Preliminary Experience With 3-Tesla MRI and Cushing\u27s Disease

Because radiographic visualization of a pituitary microadenoma is frequently difficult, we hypothesized that microadenomas associated with Cushing\u27s disease may be better resolved and localized via acquisition with 3-Tesla (3T) compared with standard 1.5-Tesla (1.5T) magnetic resonance imaging (MRI). Five patients (four females, one male; age range, 14 to 50 years old) with endocrine and clinical confirmation of Cushing\u27s disease underwent 1.5T and 3T MRI and corticotropin-releasing hormone stimulation/inferior petrosal sinus sampling (IPSS) as part of their preoperative evaluation. All patients underwent a transnasal trans-sphenoidal pituitary adenomectomy. In two cases, tumor could not be localized on either 1.5T or 3T MRI on the initial radiologist\u27s review. In two other cases, the 1.5T images delineated the tumor location, but it was more clearly defined on 3T MRI. In a fifth case, the 1.5T MRI showed a probable right-sided adenoma. However, on both 3T MRI and at surgical exploration the tumor was localized on the left side. Therefore, in three of five cases, 3T MRI either more clearly defined tumors seen on 1.5T MRI or predicted the location of tumor contrary to the 1.5T images. IPSS identified the correct side of the tumor in two patients, an incorrect location in two patients, and was indeterminate in one patient. In certain cases 3T MRI is a new tool that may ameliorate imaging difficulties associated with adrenocorticotrophic hormone-secreting pituitary adenomas. Its role in the diagnostic evaluation of Cushing\u27s disease will be better defined with further experience. Copyright © 2007 by Thieme Medical Publishers, Inc

Intra-Orbital Meningioma Causing Loss of Vision in Neurofibromatosis Type 2: Case Series and Management Considerations

Objectives: Little evidence exists regarding the management of orbital meningioma causing vision loss in the setting of neurofibromatosis Type 2 (NF2). We review here our experience with patients at risk for blindness due to intra-orbital meningioma.Design/Setting/Participants/Main Outcome Measures: The charts of patients with NF2 presenting for evaluation of intra-orbital meningioma and vision impairment between 2008 and 2013 were retrospectively reviewed in accordance with institutional IRB policies. Patients with primarily extra-orbital tumors and minimal intra-orbital extension were excluded. Charts were analyzed for the presence and/or imaging progression of intra-orbital tumor, presence of other optic apparatus pathology, presence and/ or progression of vision impairment, and intervention performed (if any).Results: Seven patients with intra-orbital meningioma on MRI and bilateral vision loss and/or unilateral visual impairment due to tumor and contralateral blindness of any etiology were identified. Patients without salvageable vision in either eye were excluded (n = 3). Diagnosis of meningioma was obtained either by biopsy or based on imaging assessment.Conclusion: Conservative management of orbital tumors in NF2 may be preferred in asymptomatic patients but may not be acceptable in patients with progressive visual decline. Radiation is a reasonable option for meningiomas of the orbit and optic nerve sheath. Finally, although the benefit of cranial nerve decompression in NF2 for preservation of facial nerve and hearing has previously been established, the role of optic nerve decompression for preservation of vision in NF2 remains poorly defined

Synaptic currents mediating efferent inhibition in the turtle cochlea.

Synaptic currents mediating efferent inhibition in the turtle cochlea

Multi-Disciplinary Approach to Skull Base Paragangliomas

The treatment of skull base paragangliomas has moved towards the use of cranial nerve preservation strategies, using radiation therapy and subtotal resection in instances when aiming for gross total resection would be expected to cause increased morbidity compared to the natural history of the tumor itself. The goal of this study was to analyze the role of surgery in patients with skull base paragangliomas treated with CyberKnife stereotactic radiosurgery (SRS) for definitive tumor control. A retrospective review identified 22 patients (median age 65.5 years, 50% female) treated with SRS from 2010–2022. Fourteen patients (63.6%) underwent microsurgical resection. Gross total resection was performed in four patients for tympanic paraganglioma (n = 2), contralateral paraganglioma (n = 1), and intracranial tumor with multiple cranial neuropathies (n = 1). Partial/subtotal resection was performed for the treatment of pulsatile tinnitus and conductive hearing loss (n = 6), chronic otitis and otorrhea (n = 2), intracranial extension (n = 1), or episodic vertigo due to perilymphatic fistula (n = 1). Eighteen patients had clinical and imaging follow-up for a mean (SD) of 4.5 (3.4) years after SRS, with all patients having clinical and radiological tumor control and no mortalities. Surgery remains an important component in the multidisciplinary treatment of skull base paraganglioma when considering other outcomes besides local tumor control

Hearing Improvement after Resection of a Large Jugular Foramen Schwannoma: Case Report

Although hearing improvement after surgery for small tumors of the cerebellopontine angle has been reported, the mechanism by which surgery leads to the improvement in hearing remains controversial. We report a patient who sought treatment for progressive tinnitus and hearing loss. Magnetic resonance imaging showed a large (5-cm) schwannoma in the cerebellopontine angle. At surgery the lesion was found to originate from rootlets of cranial nerve X at the jugular foramen. The patient underwent gross total resection of the tumor. Immediately after surgery, his hearing improved dramatically. We believe that our patient represents an example of hearing impairment at least in part referable to direct compression of the brainstem. Importantly, the patient's hearing deficit was completely reversible. Some authors claim that surgery to preserve hearing may be contraindicated in patients with speech discrimination scores below 50%. However, when extrinsic brainstem compression may contribute to the cause of such a hearing decrement, postoperative improvement in hearing may be a reasonable expectation

Intraoperative Rupture of Brainstem Cavernous Malformation: Case Report

Although cavernous malformations (CMs) are an important cause of intracranial hemorrhage, the natural history of these lesions is controversial. Both retrospective and prospective studies undertaken to define risk factors for hemorrhage from CMs have consistently identified the location of a lesion as a factor that has a significant impact on the rate of rupture, and brainstem CMs consistently have a higher rate of symptomatic hemorrhage than those at other locations. The mechanism underlying this disparity in rupture rates, however, remains obscure. Most authors attribute the difference, at least partially, to the sensitivity of the brainstem to hemorrhage. Regardless, the specific factors that cause a given CM to rupture are unknown. The authors report their first encounter with an intraoperative rupture of a CM in the brainstem. This case underscores the risks encountered during the surgical approach to brainstem CMs and may provide insight into the pathophysiological mechanisms underlying the rupture of these lesions

Treatment Modality and Quality Benchmarks of Aneurysmal Subarachnoid Hemorrhage at a Comprehensive Stroke Center

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) is the most severe type of stroke. In 2012, the Joint Commission, in collaboration with the American Heart Association/American Stroke Association (AHA/ASA), launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification was designed to promote higher standard of care for patients with complex stroke.ObjectiveThe goal of this study was to examine the treatment modality and quality benchmarks of aSAH at one of the first five certified CSCs in the United States.MethodsConsecutive patients with aSAH at Cedars-Sinai Medical Center between April 1, 2012 and May 30, 2014 were included for this retrospective study. The ruptured aneurysm was treated with coiling or clipping within 24 h. All patients were managed per AHA guidelines. Discharge outcomes were assessed using modified Rankin Scale (mRS). The rate of aneurysm treatment, door-to-treatment time, rate of posttreatment rebleed, hospital length of stay (LOS), discharge outcome, and mortality rates were evaluated as quality indicators.ResultsThe median age (interquartile range) of the 118 patients with aSAH was 55 (19). Among them, 84 (71.2%) were females, 94 (79.7%) were transfers from outside hospitals, and 74 (62.7%) had Hunt and Hess grades 1–3. Sixty patients (50.8%) were treated with coiling, 52 (44.1%) with clipping, and 6 (5.1%) untreated due to ictal cardiac arrest or severe comorbidities. The rate of aneurysm treatment was 95% (112/118) with median door-to-treatment time at 12.5 (8.5) h and 0.9% (1/112) posttreatment rebleed. The median ICU and hospital LOS were 12.5 (7) and 17.0 (14.5) days, respectively. Coiling was associated with significantly shorter LOS than clipping. There were 59 patients (50%) with favorable outcome and 19 deaths (16.1%) at hospital discharge. There was no significant difference in discharge outcome between coiling and clipping.ConclusionCare of aSAH at one of the early CSCs in the United States was associated with high rate of aneurysm treatment, fast door-to-treatment time, low posttreatment rebleed, excellent outcome, and low mortality rate. Coiling was associated with significant shorter LOS than clipping. There was no significant difference in discharge outcomes between treatment modalities