Tailored Temporal Lobectomy for Medically Intractable Epilepsy

BACKGROUND:

There have been only a few large series that have used a tailored temporal lobectomy.

OBJECTIVE:

To clarify whether tailoring a temporal lobe resection will lead to equivalent epilepsy outcomes or have the same predictive factors for success when compared with standard resections.

METHODS:

Retrospective analysis of 222 patients undergoing a tailored temporal lobe resection. Demographic measures and typical factors influencing outcome were evaluated.

RESULTS:

Pathology included 222 cases. With a mean follow-up of 5.4 years, 70% of patients achieved Engel class I outcome. A significant factor predicting Engel class I outcome on multivariate analysis was lesional pathology (P = .04). Among patients with hippocampal sclerosis, extent of lateral neocortical resection and hippocampal resection were not statistically associated with Engel class I outcome (P = .93 and P = .24). However, an analysis of Engel class subgroups a to d showed that patients who had a complete hippocampectomy in the total series were more likely to achieve an Engel class Ia outcome (P = .04). This was also true among patients with hippocampal sclerosis (P = .03). Secondarily, generalized seizure (P = .01) predicted outcome less than Engel class I. Predictive of poor outcome was the need for preoperative electrodes (P = .02). Complications included superior quadrant visual field defects, 2 cases of permanent dysphasia, and 3 wound infections.

CONCLUSION:

Predictors of successful seizure outcome for a tailored temporal lobectomy are similar to standard lobectomy. Patients with secondarily generalized epilepsy and cases in which preoperative subdural electrodes were thought necessary were less likely to achieve class I outcome. Among Engel class I cases, those who had a complete hippocampectomy were more likely to achieve Engel class Ia outcome.

Temporal lobe gangliogliomas associated with chronic epilepsy: long-term surgical outcomes

OBJECTIVE

To review the clinical features and surgical outcome in patients with temporal lobe gangliogliomas associated with intractable chronic epilepsy.

METHODS

The Rush University Surgical Epilepsy Database was queried to identify patients with chronic intractable epilepsy who underwent resection of temporal lobe gangliogliomas at Rush University Medical Center. Medical records were reviewed for age of seizure onset, delay to referral for surgery, seizure frequency and characteristics, pre-operative MRI results, extent of resection, pathological diagnosis, complications, length of follow-up, and seizure improvement.

RESULTS

Fifteen patients were identified. Average duration between seizure onset and surgery was 14.3 years. Complex partial seizures were the most common presenting symptom. Detailed operative data was available for 11 patients - of these, 90.9% underwent complete resection of the amygdala and either partial or complete resection of the hippocampus, in addition to lesionectomy. Average follow-up was 10.4 years (range 1.6-27.5 years), with 14 patients improving to Engel's class I and one patient to Engel's class III. There were no recurrences, and permanent complications were noted in one patient.

CONCLUSIONS

Long-term follow-up of patients with temporal lobe gangliogliomas associated with chronic intractable epilepsy demonstrates excellent results in seizure improvement with surgery and increasingly low incidence of complications with improvements in microsurgical techniques.

Abstract 5618: Tumor suppressor genes? The status of genes PAX 5&6 in primary and secondary gliomas and glioblastoma multiforme tumors

Background: Gliomas are the most common brain tumors, and glioblastoma multiforme (GBM) tumors have the poorest prognosis, and due to their molecular heterogeneity, these tumors remain incurable and highly resistant to treatments, in most cases. The PAX (paired box) family of genes is comprised of are nine members that are subdivided based on the products of their protein domain structures. PAX5 and PAX6 are developmental genes that are vital during embryonic stages of development, and their transcription factors have supportive, if not, key functions in tumorigenesis. Interestingly, gene PAX6 has been reported to be over and under expressed in high grade gliomas, GBMs, and glioma cell lines. However, these results could be an effect of upstream or downstream manipulation of other transcription factor(s), the origin of the tissue (PAX6 expression is restricted to the forebrain, optic cup, hindbrain, and spinal cord, lens placode, and nasal epithelium), and the epigenetic regulation of some other gene. In addition, there are no reported mutations in either gene PAX5 or PAX6 in the cells from GBMs. Therefore, confusion exists as to role these genes have in tumorigenesis, and whether either gene has the properties or characteristics of a tumor suppressor gene. Study Objective: The overall study objective was to determine if either PAX5 or PAX6 are tumor suppressor genes, and can be silenced or over-expressed to inhibit the progression of cultured human adult primary glioma tissue samples, by employing small interfering RNA (siRNA) methodology. Methods: Primary cell cultures were incubated in reduced serum conditions for at least 1 month prior to transfections and cells were passed every 7 to 10 days or when flask was 90% confluent. To investigate and measure true inhibition of cell proliferation or progression of the cells, several techniques were used, such as, real-time quantitative reverse transcription PCR, enzyme-linked immunosorbent assays, and immunohistochemistry. Results: The high grade (IV) primary glioma tissue samples and their respective cell cultures showed relatively high expression levels for the gene PAX6 and lower levels of expression for gene PAX5 when compared to GAPDH gene and standard controls. Our initial transfections for knocking down of PAX6 using siRNA (TriFECTA, IDT) showed 90% of control samples were transfected, and our primary cells were knockdown by 82%, 70%, and 65% for each of PAX6 isoforms (N000280.21.1-S, 2-S, and 3-S) respectively. We are currently analyzing the rest of the PAX6 data and all of the PAX5 data.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5618. doi:1538-7445.AM2012-5618

Major intratumoral hemorrhage of a petroclival atypical meningioma: case report and review of literature

Spontaneous intratumoral hemorrhage associated with a meningioma is an extremely rare event and has a very high rate of morbidity and mortality. We report a patient with a history of subtotal resection of a petroclival meningioma followed by gamma knife radiosurgery who presented with sudden neurological deterioration following intratumoral hemorrhage after 4 asymptomatic years. The patient underwent early resection of this atypical meningioma and evacuation of hematoma via a retrosigmoid transpetrosal approach and had rapid neurological improvement.

The gestural repertoire of the wild chimpanzee

Great ape gestural communication is known to be intentional, elaborate and flexible; yet there is controversy over the best interpretation of the system and how gestures are acquired, perhaps because most studies have been made in restricted, captive settings. Here, we report the first systematic analysis of gesture in a population of wild chimpanzees. Over 266 days of observation, we recorded 4,397 cases of intentional gesture use in the Sonso community, Budongo, Uganda. We describe 66 distinct gesture types: this estimate appears close to asymptote, and the Sonso repertoire includes most gestures described informally at other sites. Differences in repertoire were noted between individuals and age classes, but in both cases, the measured repertoire size was predicted by the time subjects were observed gesturing. No idiosyncratic usages were found, i.e. no gesture type was used only by one individual. No support was found for the idea that gestures are acquired by 'ontogenetic ritualization' from originally effective actions; moreover, in detailed analyses of two gestures, action elements composing the gestures did not closely match those of the presumed original actions. Rather, chimpanzee gestures are species-typical; indeed, many are 'family-typical', because gesture types recorded in gorillas, orangutans and chimpanzee overlap extensively, with 24 gestures recorded in all three genera. Nevertheless, chimpanzee gestures are used flexibly across a range of contexts and show clear adjustment to audience (e.g. silent gestures for attentive targets, contact gestures for inattentive ones). Such highly intentional use of a species-typical repertoire raises intriguing questions for the evolution of advanced communication.

Local traditions in gorilla manual skill: evidence for observational learning of behavioral organization

Elaborate manual skills of food processing are known in several species of great ape; but their manner of acquisition is controversial. Local, "cultural" traditions show the influence of social learning, but it is uncertain whether this includes the ability to imitate the organization of behavior. Dispute has centered on whether program-level imitation contributes to the acquisition of feeding techniques in gorillas. Here, we show that captive western gorillas at Port Lympne, Kent, have developed a group-wide habit of feeding on nettles, using two techniques. We compare their nettle processing behavior with that of wild mountain gorillas in Rwanda. Both populations are similar in their repertoires of action elements, and in developing multi-step techniques for food processing, with coordinated asymmetric actions of the hands and iteration of parts of a process as "subroutines". Crucially, however, the two populations deal in different ways with the special challenges presented by nettle stings, with consistently different organizations of action elements. We conclude that, while an elaborate repertoire of manual actions and the ability to develop complex manual skills are natural characteristics of gorillas, the inter-site differences in nettle-eating technique are best explained as a consequence of social transmission. According to this explanation, gorillas can copy aspects of program organization from the behavior of others and they use this ability when learning how to eat nettles, resulting in consistent styles of processing by most individuals at each different site; like other great apes, gorillas have the precursor abilities for developing culture.

Frontal sinus schwannoma: case report and review of literature

Although schwannomas are frequently found in the head and neck region, sinonasal tract involvement is extremely rare, especially those of the frontal sinus. We report a patient with an incidentally found right frontal sinus lesion. The patient underwent resection of the tumor via a right craniotomy. The histological diagnosis was consistent with a schwannoma. There has been no radiographic recurrence on 2-year follow-up.

Neuro-critical care skills training using a human patient simulator

BACKGROUND

Neurosurgical trainees regularly encounter critical care situations. Traditionally, education was accomplished through lecture and experience. Increasingly, human patient simulators (HPS) are employed, allowing trainees to sharpen skills in a safe and realistic environment. We describe our experience using HPS in neurosurgical training.

METHODS

We developed a critical care training program for residents and medical students using HPS. We used a hi-fidelity, lifelike Human Patient Simulator™ (HPS™) produced by Medical Education Technologies, Inc.™ to simulate realistic scenarios for trainee education. Topics included spinal shock, closed head injury, and cerebral vasospasm. A three-way evaluation model was employed to test validity, including pre- and post-exercise testing, survey feedback, and videotaped replay. The simulation exercises were conducted by a neuro-critical care attending, a senior neurosurgical resident, and a HPS technician.

RESULTS

We currently have 29 participants. On a 20-point critical care multiple-choice exam for these participants, average improvement has been 4.5 points or 25%. In subgroup analysis, average improvement was 4.75 points (24%) amongst neurosurgery residents, 3.07 points (18%) amongst neurology residents, 7 points (38%) amongst general surgery residents, and 7 points (38%) amongst senior medical students. Post-exercise evaluations were overwhelmingly positive.

CONCLUSIONS

Neurosurgical critical care education is important for safe and effective care for patients. Clinical experience and didactic lectures help trainees obtain a solid knowledge base, but do not provide the benefit for learning in a fail-safe environment. Through the use of HPS, we have enhanced the critical care education of our trainees.

The history of neurological surgery at rush university medical center

The history of neurosurgery at Rush University is tightly linked to the emergence of neurological surgery in the city of Chicago. Rush Medical College (RMC) was chartered in 1837 and in 1898 began an affiliation with the newly founded University of Chicago (UC), which proceeded to full union in 1923 as the Rush Medical College of the University of Chicago (RMC/UC). Percival Bailey founded neurosurgery at the RMC/UC and started a neurosurgery training program at the South Side campus in 1928. In 1935, Adrien Ver Brugghen started the first neurosurgical training program at the West Side campus at the Presbyterian Hospital/RMC. The major alliances with RMC have involved the Cook County Hospital, the Presbyterian Hospital, the UC, the University of Illinois, and St. Luke's Hospital. Those affiliations significantly shaped Rush neurosurgery. The RMC/UC union was dissolved in 1941, and an affiliation was formed with the University of Illinois in Chicago (UI). In 1959, Eric Oldberg, the founder and Chairman of Neurosurgery at the UI, became the next chairman of neurosurgery at Presbyterian-St. Luke's Hospital, incorporating it into the UI program. He was succeeded in 1970 by Walter Whisler, who founded the first independent and board-approved neurosurgery residency program in 1972 at the newly reactivated Rush Medical College. Whisler was chairman until 1999, when Leonard Cerullo, founder of the Chicago Institute of Neurosurgery and Neuroresearch, became chairman at Rush. Richard Byrne, appointed in 2007, is the current chairman of the Rush University neurosurgery department.

Able-bodied wild chimpanzees imitate a motor procedure used by a disabled individual to overcome handicap

Chimpanzee culture has generated intense recent interest, fueled by the technical complexity of chimpanzee tool-using traditions; yet it is seriously doubted whether chimpanzees are able to learn motor procedures by imitation under natural conditions. Here we take advantage of an unusual chimpanzee population as a 'natural experiment' to identify evidence for imitative learning of this kind in wild chimpanzees. The Sonso chimpanzee community has suffered from high levels of snare injury and now has several manually disabled members. Adult male Tinka, with near-total paralysis of both hands, compensates inability to scratch his back manually by employing a distinctive technique of holding a growing liana taut while making side-to-side body movements against it. We found that seven able-bodied young chimpanzees also used this 'liana-scratch' technique, although they had no need to. The distribution of the liana-scratch technique was statistically associated with individuals' range overlap with Tinka and the extent of time they spent in parties with him, confirming that the technique is acquired by social learning. The motivation for able-bodied chimpanzees copying his variant is unknown, but the fact that they do is evidence that the imitative learning of motor procedures from others is a natural trait of wild chimpanzees.

Chronic epilepsy associated with temporal tumors: long-term surgical outcome

Object

The authors undertook a study to review the clinical features and outcome in patients who underwent surgery for intractable chronic epilepsy caused by temporal lobe tumors.

Methods

The Rush Surgical Epilepsy Database was queried to identify patients with chronic intractable epilepsy who underwent resection of temporal lobe tumors between 1981 and 2005 at Rush University Medical Center. Medical records were reviewed for age of the patient at seizure onset, delay to referral for surgery, seizure frequency and characteristics, preoperative MR imaging results, extent of resection, pathological diagnosis, complications, duration of follow-up period, and seizure improvement.

Results

Thirty-eight patients were identified, all with low-grade tumors. Gangliogliomas were the most common (36.8%), followed in descending order by dysembryoplastic neuroepithelial tumors (26.3%) and low-grade diffuse astrocytoma (10.5%). The mean duration between seizure onset and surgery was 15.4 years. Complex partial seizures were the most common presenting symptom. Detailed operative data were available for 28 patients; of these, 89.3% underwent complete resection of the amygdala, and 82.1% underwent partial or complete resection of hippocampus, in addition to lesionectomy. The mean follow-up duration was 7.7 years (range 1.0–23.1 years), with 78.9% of patients having seizure status that improved to Engel Class I, 15.8% to Engel Class II, and 5.3% to Engel Class III. Permanent complications were noted in 2.6% of patients.

Conclusions

The authors' examination of the long-term follow-up data in patients with temporal lobe tumors causing chronic intractable epilepsy demonstrated excellent results in seizure improvement after surgery.

Occult cervical (C1-2) dural tear causing bilateral recurrent subdural hematomas and repaired with cervical epidural blood patch

The authors report the case of a 56-year-old previously healthy man who presented with a 4-month history of postural headache accompanied by nausea and vomiting. The results of initial imaging studies of the brain were normal. Repeated MR imaging demonstrated bilateral subdural hematomas which were drained and reaccumulated over a period of time. Spinal myelography revealed a cerebrospinal fluid leak at the C1-2 level. A cervical epidural blood patch, with repeated injections of 10 ml autologous blood at the site of the leak, dramatically improved the headache within 24 hours and eliminated the recurrent subdural hematomas. The results of follow-up computed tomography of the brain at 1, 4, 8, and 16 weeks were normal, and at 1-year follow-up the patient was completely free of symptoms and working.

Epidural cylinder electrodes for presurgical evaluation of intractable epilepsy: technical note

BACKGROUND

This is a technical report describing a different technique for the insertion of epidural electrodes in the preoperative evaluation of epilepsy surgery. Our experience in 67 cases using this technique is analyzed.

METHODS

Cylinder electrodes with multiple recording nodes spaced 1 cm apart along a Silastic core are placed into the epidural space under general anesthesia through single or multiple burr holes. We reviewed the data on 67 cases of medically intractable epilepsy requiring intracranial monitoring that had epidural cylinder electrodes placed. The electrodes were placed bilaterally or contralateral to subdural grids in 64 of the 67 cases. Continuous monitoring was performed from 1 to 3 weeks.

RESULTS

This method was most useful when used bilaterally or contralateral to subdural grids. Definitive surgery was rendered in 48 of 67 cases. After monitoring, all electrodes were removed at bedside or upon return to the operating room for definitive surgery. There were no mortalities, infections, cerebrospinal fluid leaks, neurologic deficits, or electrode malfunctions. Two patients (2/67, 3%) did develop subdural hematomas early in our series after dural injury near the pterion; however, these patients did not sustain permanent deficit.

CONCLUSIONS

Epidural cylinders are another option for preoperative monitoring, useful for determining lobe or laterality of seizure genesis. They offer an alternate method to EPEs in cases where epidural recording is desirable. The cylinder electrodes are easy to place and can be removed without a return to the operating theater. The electrodes' minimal mass effect allows them to be safely placed bilaterally or contralateral to subdural grids. The epidural cylinders can monitor cortex with a greater density of nodes and can access regions not amenable to EPEs.

Postoperative acute disseminated encephalomyelitis after exposure to microfibrillar collagen hemostat

Microfibrillar collagen hemostat, known by its trade name Avitene, has been used in neurosurgery for decades. Complications with this product have been documented in other surgical specialties and described as mostly immune-mediated foreign-body reactions that can lead to a granulomatous reaction. There has never been a case of disseminated encephalomyelitis associated with this topical hemostatic agent. In this report the authors present a case of postoperative acute disseminated encephalomyelitis after exposure to Avitene. Possible pathophysiological mechanisms are discussed and the pertinent literature is reviewed.

Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study

OBJECTIVE

The absence of surgical subspecialty emergency care in the United States is a growing public health concern. Neurosurgery is a field lacking coverage in many areas of the country; however, this is generally thought to be of greater concern in rural areas. Because of decreasing numbers of neurosurgeons, medical malpractice, and liability concerns, neurosurgery coverage is becoming a public health crisis in urban areas. Our objective was to quantify neurosurgical emergency transfers to academic medical centers in Cook County, IL, including patient demographics, reasons for transfer, time lapse in transfer, and effects on patient condition.

METHODS

Data on neurosurgery emergency transfers was gathered prospectively by all five of the academic neurosurgery departments in Cook County, IL, over a 2-month period. Patient demographics devoid of identifiers, diagnosis, transfer origin, time lapse of transfer, and patient condition at the time of transfer and at the receiving hospital were recorded.

RESULTS

Two-hundred thirty emergent neurosurgical transfers occurred during the study period. The most common diagnoses were parenchymal intracerebral hemorrhage (33%) and subarachnoid hemorrhage (28%). Sixty-six percent of neurosurgical transfers to academic medical facilities originated at hospitals without full-time neurosurgery coverage. The mean time to transfer for all patients was 5 hours 10 minutes (standard deviation, 3 h 42 min; range, 1-20 h 12 min). A decline in Glasgow Coma Scale score was seen in 29 patients. A shortage of neurosurgical intensive care unit beds occurred on 55% of the days in the study. Only 19% of the emergency cases were related to cranial trauma, and only 3% of transfers came from Level 1 trauma centers.

CONCLUSION

A combination of factors has led to decreases in availability of neurosurgical coverage in Cook County community hospital emergency departments. This has placed an increased burden on neurosurgical departments at academic centers, and, in some cases, delays led to a decline in patient condition. Eighty-one percent of the cases were not related to cranial trauma; thus, acute care trauma surgeons would be of little use. Coordinated efforts among local governments, medical centers, and emergency medical services to regionalize subspecialty services will be necessary to manage this problem.

African elephants have expectations about the locations of out-of-sight family members

Monitoring the location of conspecifics may be important to social mammals. Here, we use an expectancy-violation paradigm to test the ability of African elephants (Loxodonta africana) to keep track of their social companions from olfactory cues. We presented elephants with samples of earth mixed with urine from female conspecifics that were either kin or unrelated to them, and either unexpected or highly predictable at that location. From behavioural measurements of the elephants' reactions, we show that African elephants can recognize up to 17 females and possibly up to 30 family members from cues present in the urine-earth mix, and that they keep track of the location of these individuals in relation to themselves.

Orangutans modify their gestural signaling according to their audience's comprehension

When people are not fully understood, they persist with attempts to communicate, elaborating their speech in order to better convey their meaning [1]. We investigated whether captive orangutans (Pongo pygmaeus and Pongo abelii) would use analogous communicative strategies in signaling to a human experimenter, and whether they could distinguish different degrees of misunderstanding. Orangutans' behavior varied according to how well they had apparently been understood. When their aims were not met, they persisted in communicative attempts. However, when the interlocutor appeared partially to understand their meaning, orangutans narrowed down their range of signals, focusing on gestures already used and repeating them frequently. In contrast, when completely misunderstood, orangutans elaborated their range of gestures, avoiding repetition of failed signals. It is therefore possible, from communicative signals alone, to determine how well an orangutan's intended goal has been met. This differentiation might function under natural conditions to allow an orangutan's intended goals to be understood more efficiently. In the absence of conventional labels, communicating the fact that an intention has been somewhat misunderstood is an important way to establish shared meaning.

Spider monkey ranging patterns in Mexican subtropical forest: do travel routes reflect planning?

Although it is well known that frugivorous spider monkeys (Ateles geoffroyi yucatanensis) occupy large home ranges, travelling long distances to reach highly productive resources, little is known of how they move between feeding sites. A 11 month study of spider monkey ranging patterns was carried out at the Otochma'ax Yetel Kooh reserve, Yucatán, Mexico. We followed single individuals for as long as possible each day and recorded the routes travelled with the help of a GPS (Global Positioning System) device; the 11 independently moving individuals of a group were targeted as focal subjects. Travel paths were composed of highly linear segments, each typically ending at a place where some resource was exploited. Linearity of segments did not differ between individuals, and most of the highly linear paths that led to food resources were much longer than the estimate visibility in the woodland canopy. Monkeys do not generally continue in the same ranging direction after exploiting a resource: travel paths are likely to deviate at the site of resource exploitation rather than between such sites. However, during the harshest months of the year consecutive route segments were more likely to retain the same direction of overall movement. Together, these findings suggest that while moving between feeding sites, spider monkeys use spatial memory to guide travel, and even plan more than one resource site in advance.

Mental maps in chacma baboons (Papio ursinus): using inter-group encounters as a natural experiment

Encounters between groups of wild chacma baboons (Papio ursinus) can be viewed as a natural experiment to investigate the nature of these primates' mental representations of large-scale space. During a 16-month field study in a high population density habitat we recorded the foraging routes and the most important resources of a group of 25 individuals. Also, we estimated the locations of additional baboon groups relative to the study group. Routes were less linear, travel speed was higher, and inter-resource distances were larger when other groups were present within 500 m of the focal group; thus, the study group avoided others by taking detours. We predicted that evasive manoeuvres would be characteristic of different possible orientation mechanisms, and compared them with our observations. We analysed 34 evasive manoeuvres in detail. In an area that lacked prominent landmarks, detours were small; larger detours occurred when resources were directly visible, or in the vicinity of a hill offering conspicuous landmarks. In areas without prominent landmarks, detours were along familiar routes and waiting bouts of up to 60 min occurred; on one occasion the study group aborted their entire day's journey. We discuss these findings in the light of time and energy costs and suggest that the baboons lack the ability to compute Euclidean relations among locations, but use network maps to find their way to out-of-sight locations.

Ape Society: Trading Favours

An alpha-male chimpanzee allots mating opportunities with receptive females in return for support from potential competitors. Although ubiquitous among humans and apparently rare among animals, exchange of one currency for another -- in this case sex for power -- may not be cognitively demanding.

Sociality, Evolution and Cognition

Variations in brain size and proportions can be linked to the cognitive capacities of different animal species, and correlations with ecology may give clues to the evolutionary origins of these specializations. Much recent evidence has implicated the social domain as a major challenge driving increases in problem-solving abilities of mammals. However, the methods of measurement available to researchers are often indirect and sometimes appear to give conflicting answers, and other intellectual challenges may also have been influential in cognitive evolution. While the cause of an evolutionary increase in intelligence may be domain-specific (sociality, for example), and the brain specialization that results may largely implicate a single perceptual system, such as vision, the intelligence shown in consequence can be very 'general-purpose' (as in primates and some avian taxa). Future research needs to get beyond vague ascription of 'greater intelligence' or 'faster learning' towards a precise account of the cognitive mechanisms that underlie particular mental skills in different species; that will allow theory-testing against data from complex, natural situations as well as from the laboratory, on a common metric.