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Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Section I Intracranial Pathology Brain Tumors Phacomatosis Case 1

Vestibular Schwannoma in Neurofibromatosis Type 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Burak Sade and Joung H. Lee

Case 2

Subependymal Giant Cell Astrocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Remi Nader

Case 3

Sturge–Weber Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Remi Nader

Case 4

Von Hippel–Lindau Disease—Hemangioblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Ramez Malak and Robert Moumdjian

Meningioma Case 5

Parasagittal Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Remi Nader

Case 6

Olfactory Groove Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Stephen J. Hentschel and Lissa Marie Ogieglo

Case 7

Sphenoid Wing Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Remi Nader

Case 8

Hemangiopericytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Burak Sade and Joung H. Lee

Case 9

Clinoidal Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Burak Sade and Joung H. Lee

Case 10

Velum Interpositum Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Michel W. Bojanowski and Denis Klironomos

Pituitary Tumors Case 11

Pituitary Apoplexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Michel W. Bojanowski and Denis Klironomos

Case 12

Pituitary Adenoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Remi Nader and Marc-Elie Nader

Case 13

Craniopharyngioma: Endoscopic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Daniel M. Prevedello, Amin B. Kassam, Paul Gardner, Arlan H. Mintz, Carl H. Snyderman, and Ricardo L. Carrau

Gliomas Case 14

High-grade Glioma: Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Ramez Malak and Robert Moumdjian


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Case 15

High-grade Glioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Remi Nader and Abdulrahman J. Sabbagh

Case 16

Eloquent Cortex Low-grade Glioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 John Winestone and Allen K. Sills Jr.

Malignant Intracranial Neoplasms Case 17

Single Brain Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Joseph A. Shehadi and Brian Seaman

Case 18

Multiple Brain Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Ramez Malak and Robert Moumdjian

Case 19

Meningeal Carcinomatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Ramez Malak and Robert Moumdjian

Case 20

Primary Central Nervous System Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 John Winestone and Allen K. Sills Jr.

Case 21

Posterior Fossa Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Julius July and Eka Julianta Wahjoepramono

Other Intracranial Tumors Case 22

Fibrous Dysplasia of the Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Burak Sade and Joung H. Lee

Case 23

Orbital Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Michel Lacroix

Case 24

Multiple Ring-enhancing Cerebral Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Kevin Petrecca and Rolando Del Maestro

Case 25

Paraganglioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Nazer H. Qureshi and Ossama Al-Mefty

Case 26

Colloid Cyst of the Third Ventricle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Remi Nader

Vascular Neurosurgery Arteriovenous Malformations Case 27

Dural Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Nancy McLaughlin and Michel W. Bojanowski

Case 28

Cerebral Arteriovenous Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Pascal M. Jabbour and Erol Veznedaroglu

Case 29

Cavernous Angioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Julius July and Eka Julianta Wahjoepramono

Intracranial Aneurysms Case 30

Subarachnoid Hemorrhage and Vasospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Qasim Al-Hinai, Claude-Edouard Chatillon, David Sinclair, and Dennis J. Sirhan

Case 31

Unruptured Anterior Communicating Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Yasser I. Orz

Case 32

Posterior Communicating Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Pascal M. Jabbour and Erol Veznedaroglu


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Case 33

Familial Cerebral Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Hossam Al-Jehani and Richard Leblanc

Case 34

Blister Carotid Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Nancy McLaughlin and Michel W. Bojanowski

Case 35

Concomitant Arteriovenous Malformation and Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Julius July and Eka Julianta Wahjoepramono

Case 36

Middle Cerebral Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Julius July and Eka Julianta Wahjoepramono

Intracerebral Hemorrhage Case 37

Hypertensive Putaminal Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Remi Nader

Case 38

Intraventricular Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Hosam Al-Jehani, Dennis J. Sirhan, and Abdulrahman J. Sabbagh

Case 39

Cerebellar Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Julius July and Eka Julianta Wahjoepramono

Ischemic Cerebral Disease Case 40

Moyamoya Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Abdulrahman J. Sabbagh, Jean-Pierre Farmer, Jie Ma, Ahmad I. Lary, and JosĂŠ Luis Montes

Extracranial Vascular Disease Case 41

Amaurosis Fugax with Carotid Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Glenn C. Hunter and Alwin Camancho

Case 42

In Tandem Extracranial and Intracranial Carotid Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Glenn C. Hunter

Case 43

Vertebral Artery Stenosis with Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Glenn C. Hunter and Rudiger Von Ritschl

Case 44

High-grade Carotid Stenosis and Intracranial Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Glenn C. Hunter and Remi Nader

Cranial Trauma Closed Head Injuries Case 45

Chronic Subdural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Remi Nader

Case 46

Mild Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Judith Marcoux and Abdulrazag Ajlan

Case 47

Epidural Hematoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Abdulrazag Ajlan and Judith Marcoux

Case 48

Traumatic Acute Subdural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Abdulrazag Ajlan and Judith Marcoux

Intensive Care Management Case 49

New Trends in Neurotrauma Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Judith Marcoux and Abdulrazag Ajlan

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Case 50

Intracranial Pressure Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Abdulrazag Ajlan and Judith Marcoux

Other Cranial Trauma Case 51

Gunshot Wound to the Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Remi Nader

Case 52

Other Penetrating Intracranial Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Domenic P. Esposito

Pediatric and Developmental Disorders Hydrocephalus Case 53

Aqueductal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Jeffrey Atkinson

Case 54

Cerebrospinal Fluid Shunt Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Jeffrey Atkinson

Case 55

Slit Ventricle Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Jeffrey Atkinson

Case 56

Mega-hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Maqsood Ahmad and Abdulrahman J. Sabbagh

Pediatric Brain Tumors Case 57

Cerebellar Medulloblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Ali Raja, Ian F. Pollack, and Nazer H. Qureshi

Case 58

Brainstem Glioma 1: Pons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Abdulrahman J. Sabbagh, Ayman Abdullah Albanyan, Mahmoud A. Al Yamany, Reem Bunyan, Ahmed T. Abdelmoity, and Lahbib B. Soualmi

Case 59

Brainstem Glioma 2: Medulla Oblongata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Jean-Pierre Farmer, Abdulrahman J. Sabbagh, and Ahmad Al-Jishi

Case 60

Pineal Region Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Claude-Edouard Chatillon, José Luis Montes, and Jean-Pierre Farmer

Case 61

Endoscopic Treatment of Hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Jeffrey Atkinson

Case 62

Neurofibromatosis Type 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Jean-Pierre Farmer and Abdulrahman J. Sabbagh

Case 63

Epidermoid of the Sella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Abdulrahman J. Sabbagh and Jean-Pierre Farmer

Case 64

Frontal Abscess with Sinus Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Ramez Malak and Robert Moumdjian

Case 65

Hypothalamic Hamartoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Abdulrahman J. Sabbagh, Sandeep Mittal, Fahad Eid Alotaibi, and José Luis Montes

Pediatric Neurovascular Disease Case 66

Vein of Galen Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Samer K. Elbabaa and Sten Solander


Contents

Pediatric Cranial Trauma Case 67

Pediatric Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Jeffrey Atkinson, José Luis Montes, and Abdulrahman J. Sabbagh

Developmental Brain Disorders Case 68

Scaphocephaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Abdulrahman J. Sabbagh, Jeffrey Atkinson, Jean-Pierre Farmer, and José Luis Montes

Case 69

Spontaneous Cerebrospinal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Jeffrey Atkinson, José Luis Montes, and Abdulrahman J. Sabbagh

Case 70

Cerebral Palsy and Selective Dorsal Rhizotomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Jean-Pierre Farmer and Abdulrahman J. Sabbagh

Case 71

Neural Tube Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Abdulrahman J. Sabbagh, Abdulrahman Yaqub Alturki, José Luis Montes, Jean-Pierre Farmer, and Jeffrey Atkinson

Stereotactic and Functional Neurosurgery Neuralgias Case 72

Tic Douloureux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Burak Sade and Joung H. Lee

Case 73

Trigeminal Neuropathic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Melanie Hood and Christopher J. Winfree

Case 74

Hemifacial Spasm and Microvascular Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Bassem Sheikh

Case 75

Postherpetic Neuralgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 Isaac Chan and Christopher J. Winfree

Pain Disorders Case 76

Complex Regional Pain Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Christopher P. Kellner and Christopher J. Winfree

Case 77

Central Poststroke Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 Deepa Danan and Christopher J. Winfree

Other Stereotactic and Functional Procedures Case 78

Stereotactic Radiosurgery Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 Carmina M. Angeles and Dennis G. Vollmer

Case 79

Spasticity after Cord Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Remi Nader

Case 80

Neuronavigation and Intraoperative Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Lahbib B. Soualmi and Abdulrahman J. Sabbagh

Section II Spinal and Peripheral Nerve Pathology Spine Spinal Trauma Case 81

Lower Cervical Fracture Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Joseph A. Shehadi and Brian Seaman

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Contents

Case 82

Atlantoaxial Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 Eric P. Roger and Edward Benzel

Case 83

Type 2 Odontoid Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 Joseph A. Shehadi and Brian Seaman

Case 84

Basilar Invagination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 Michel Lacroix

Case 85

Compression Fracture of the Thoracolumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Eric P. Roger and Edward Benzel

Case 86

Lumbar Burst Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Ahmed Jaman Alzahrani and Khalid N. Almusrea

Degenerative Spine Disease Case 87

Cervical Spondylotic Myelopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 Remi Nader

Case 88

Anterior versus Posterior Approach to the Cervical Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Amgad S. Hanna and Remi Nader

Case 89

Lower Back Pain—Conservative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Hashem Al Hashemi, Remi Nader, and Abdulrahman J. Sabbagh

Case 90

Neurogenic versus Vascular Claudications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Eric P. Roger and Edward Benzel

Case 91

Cauda Equina Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Cristian Gragnaniello and Remi Nader

Case 92

Thoracic Disk Herniation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330 Remi Nader

Spinal Neoplasms Case 93

Intradural Spinal Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Adam Sauh Gee Wu and Stephen J. Hentschel

Case 94

Intramedullary Spinal Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 Amgad S. Hanna and William E. Krauss

Case 95

Spinal Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Brian Seaman and Joseph A. Shehadi

Spinal Vascular Pathology Case 96

Spinal Arteriovenous Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Bassem Sheikh

Case 97

Spinal Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352 Pascal M. Jabbour and Erol Veznedaroglu

Case 98

Lumbar Epidural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354 Remi Nader

Spinal Infections Case 99

Spinal Epidural Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 Cristian Gragnaniello and Remi Nader


Contents

Developmental Spinal Disorders Case 100

Chiari I Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361 Mahmoud A. Al Yamany, Homoud Aldahash, and Abdulrahman J. Sabbagh

Peripheral Nerve Pathology Upper Extremity Peripheral Nerve Disease Case 101

Median Nerve Entrapment at the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 Gaetan Moise and Christopher J. Winfree

Case 102

Brachial Plexus Injury and Horner Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 Stephen M. Russell

Case 103

Neurogenic Thoracic Outlet Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372 Stephen M. Russell

Case 104

Right Axillary Mass with Tinel Sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Deepa Danan and Christopher J. Winfree

Case 105

Ulnar Nerve Compression at the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378 Stephen M. Russell

Lower Extremity Peripheral Nerve Disease Case 106

Lower Extremity Peripheral Nerve Sheath Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 Robert L. Tiel

Case 107

Foot Drop and Peroneal Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 Robert L. Tiel

Section III Neurology Epilepsy Case 108

Temporal Lobe Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 Abdulrahman J. Sabbagh, Lahbib B. Soualmi, Fawziah A. Bamogaddam, Khurram A. Siddiqui, and Shobhit Sinha

Case 109

Corpus Callosotomy for Drop Attacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 Abdulrahman J. Sabbagh, Jerey Atkinson, Jean-Pierre Farmer, and JosÊ Luis Montes

Case 110

Vagal Nerve Stimulator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404 Nazer H. Qureshi

Dementias and White Matter Diseases Case 111

Progressive Multifocal Leukoencephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 Ravi Pande, Maya Nader, and Remi Nader

Case 112

Neuromyelitis Optica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 Xiaohong Si and Robert Herndon

Case 113

Normal Pressure Hydrocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 Remi Nader

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

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Case 65 Hypothalamic Hamartoma

Case 65

225

Hypothalamic Hamartoma

Abdulrahman J. Sabbagh, Sandeep Mittal, Fahad Eid Alotaibi, and José Luis Montes

A

B

Fig. 65.2 T1-weighted sagittal magnetic resonance images of the brain showing depth electrode within the hypothalamic hamartoma.

C

Fig. 65.1 T1-weighted magnetic resonance images of the brain with contrast, relevant (A) axial, (B) sagittal, and (C) coronal slices are shown.

Clinical Presentation

• A 16-year-old boy is referred to you by an epileptologist. He presents with a history of progressive epilepsy that is refractory to medication. • The seizures are described as episodes of short bouts of emotionless laughter with loss of awareness that last only a few seconds at a time and occur several times during the day now. ■

• He also suffers from generalized tonic-clonic seizures several times a month. • Other pertinent findings include cognitive delay. He is able to speak. The remainder of his neurologic exam is normal (including motor, sensory, cerebellar, and gait examination). • A magnetic resonance imaging (MRI) scan is obtained and shown in Fig. 65.1.

Questions

1. Describe the MRI (Fig. 65.1). 2. What is the term used for type of seizures this patient is experiencing? 3. How will you work up this patient? 4. Briefly describe the anatomy of the hypothalamus; enumerate its nuclei and their functions. 5. What seizure types are associated with hypothalamic hamartomas (HH)?

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6. What symptoms other than epilepsy are associated with HH? 7. If this patient has polydactyly and hypopituitarism, what syndrome would you want to confirm? 8. How do you classify HH? What class does this patient’s hamartoma belong to? 9. What treatment options can you offer to a patient with HH and intractable seizures? What are their limitations and outcomes?

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Answers

1. Describe the MRI (Fig. 65.1). • MRI shows a small nonenhancing, isointense lesion in the hypothalamic area. • The mass occupies the 3rd ventricle and does not cause hydrocephalus. • This is most consistent with a HH. 2. What is the term used for type of seizures this patient is experiencing? • Gelastic seizures 3. How will you work up this patient? • Imaging and electrophysiologic investigations include – Electroencephalogram (EEG): can show slow spike and wave EEG patterns with or without multifocal epileptiform abnormalities (typically frontal or temporal)1 – Computed tomography (CT) scan: may show an isodense nonenhancing lesion – MRI: shows an isotense to slightly hypointense lesion compared with gray matter2 – Depth electrode recording: When the diagnosis is equivocal and EEG is nonspecific, specialized centers may consider this modality for diagnosis (Fig. 65.2).3,4 – Positron emission tomography scan: reveals ictal hypermetabolism at the hamartoma site5 – Single photon emission computerized tomography (SPECT) imaging: measures regional cerebral blood flow during seizures. Ictal SPECT scans can be done after injection of the tracer technetium-99m hexamethylpropyleneamine oxime (Tc-99m-HMPAO). – Magnetoencephalography (MEG): MEG maps interictal magnetic dipole sources onto MRI to produce a magnetic source image6 – Magnetic resonance spectroscopy: decrease in N-acetyl aspartate/creatine and an increase in myoinositol/creatine (mI/Cr) ratios in tumor tissue when compared with values in normal gray matter of the amygdala. Choline/creatine ratios were also increased when compared with those in normal gray matter controls7 • Endocrinologic workup – See Case 12, Pituitary Adenoma, for details 4. Briefly describe the anatomy of the hypothalamus; enumerate its nuclei and their functions.

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• The hypothalamus is commonly subdivided into regions along its anteroposterior axis (Fig. 65.3).8 – The preoptic region extends rostrally to the optic chiasm and dorsally to the anterior commissure. – The supraoptic region resides above the optic chiasm. – The tuberal region lies above and includes the tuber cinereum. – The mammillary region includes the mammillary bodies and the posterior hypothalamic nuclei. 5. What seizure types are associated with HH? • Seizure types include – Gelastic seizures (forced bouts of emotionless laughter) are considered by most authors to be characteristic of HH. – Multiple other seizure types exist including ▪ Generalized tonic-clonic seizures ▪ Partial complex seizures ▪ Drop attacks ▪ Atypical absences 6. What symptoms other than epilepsy are associated with HH? • Other associated symptoms can include – Precocious puberty – Psychiatric manifestations9,10 ▪ Oppositional defiant disorder (83.3%) ▪ Attention deficit-hyperactivity disorder (75%) ▪ Conduct disorder (33.3%) ▪ Affective disorders (16.7%) ▪ Progressive cognitive decline 7. If this patient has polydactyly and hypopituitarism, what syndrome would you want to confirm? • Pallister–Hall syndrome (PHS)11 • The syndrome is typically characterized by the presence of a HH in association with multisystem malformations. • The spectrum of features also includes pituitary hypoplasia or dysfunction, central postaxial polydactyly, dysplastic nails, bifid epiglottis, and imperforate anus. • Additionally, cardiac anomalies, renal defects, and mild mental retardation are seen. • PHS is often diagnosed at birth. In familial cases it is inherited in an autosomal dominant pattern with variable expressivity.

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Case 65 Hypothalamic Hamartoma

â–

227

Answers (continued)

Fig. 65.3 Hypothalamic nuclei and regions. Medial and lateral areas are illustrated in shades of red/purple or green, respectively. n, nucleus; ADH, antidiuretic hormone; CRH, corticotrophin-releasing hormone; TRH, thy-

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rotropin-releasing hormone; LHRH, luteinizing hormone release hormone; A, anterior; P, posterior; M, medial; L, lateral. (Courtesy of the Pan Arab Journal of Neurosurgery.)

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â–

Answers (continued)

Fig. 65.4 Classification of hypothalamic hamartomas (Coronal section). (A) Normal; (B) peduncular, Delalande & Fohlen type I (horizontal insertion); (C) parahypothalamic, sessile Delalande & Fohlen type II (vertical insertion); (D) intrahypothalamic, sessile, Delalande & Fohlen type III (vertical insertion); (E) intrahypothalamic, Delalande & Fohlen type III

(horizontal and vertical insertion); (F) intrahypothalamic, Delalande & Fohlen type IV (giant). (Adapted from Delalande O, Fohlen M. Disconnecting surgical treatment of hypothalamic hamartoma in children and adults with refractory epilepsy and proposal of a new classification. Neurol Med Chir (Tokyo) 2003;43(2):61-68.)

Fig. 65.5 Intraoperative endoscopic view of a hypothalamic hamartoma (H).

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Case 65 Hypothalamic Hamartoma

229

Answers (continued)

8. How do you classify HH? What class does this patient’s hamartoma belong to? • Several classification schemes have been described. • The most recent and most widely used is the classification of Delalande and Fohlen (Fig. 65.4).12 • The present patient’s lesion is classified as intrahypothalamic (3E) according to Delalande and Fohlen’s classification. 9. What treatment options can you offer to a patient with HH and intractable seizures? What are their limitations and outcomes? • Microsurgical resection: Seizure outcome is related to completeness of resection.13,14 – Pterional and frontotemporal approach14 ▪ Advantage: shortest, most direct route to the suprasellar cistern and hamartoma ▪ Disadvantage: Surgical corridor may be narrowed by the internal carotid artery, optic nerve and tracts, oculomotor nerve, and pituitary stalk. ▪ Outcome: 23% of patients are seizure free, 87% have significant seizure reduction (in a study of 13 patients). – Transcallosal interforniceal approach15 ▪ Advantage: provides a wide exposure to the 3rd ventricle and an excellent view of the hamartoma from above; avoidance of cranial nerves and blood vessels in the suprasellar cistern and interpeduncular fossa may further reduce the risk of stroke and oculomotor nerve injury ▪ Disadvantage: risk of short-term memory deficits because of potential septal, forniceal, or mammillary body injury ▪ Outcome: 52% are seizure free, 24% have significant improvement (in a series of 29 patients)15 ▪ Complications: thalamic infarct in 7%, increased appetite in 33% (this is permanent in 16%), and short-term memory deficits in 50% – Transcallosal, subchoroidal approach: alternative to the transcallosal interforniceal route; lower risk of short-term memory deficits – Endoscopic transventricular approach (Fig. 65.5 for an endoscopic view) ▪ Outcome: 31% were able to sustain complete resection (14 of 44 patients), of whom 90% were seizure free.16 ▪ Complications: short-term memory difficulties (three patients) and hemiparesis (one patient).16

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• Disconnection procedure (open or endoscopic)17 – Outcome: 58% seizure free – Complications (in a series of 18 patients)17: stroke (2 patients), diabetes insipidus (2 patients), meningitis (1 patient) • Stereotactic radiosurgery18 – Gamma knife radiosurgery: good treatment for small- and medium-size hamartomas. The median dose recommended at the marginal isodose is 17 Gy (range is 13–26 Gy). ▪ Outcome: 37% seizure free. Most had cognitive and behavioral improvement. ▪ Complications: 15% transient worsening of seizures; no permanent complications mentioned. – Linear acceleration-based radiosurgery – Stereotactic brachytherapy • Stereotactic radiofrequency ablation – Outcome: 25% seizure free, 25% significant improvement (12 patients)19 – Complications: 8% mortality (1 patient), 16% memory deficits • Vagal nerve stimulation: limited role; palliative and seizure freedom is not expected.20 • Corpus callosotomy: limited role

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References

1. Berkovic SF, Andermann F, Melanson D, Ethier RE, Feindel W, Gloor P. Hypothalamic hamartomas and ictal laughter: evolution of a characteristic epileptic syndrome and diagnostic value of magnetic resonance imaging. Ann Neurol 1988;23(5):429–439 2. Hahn FJ, Leibrock LG, Huseman CA, Makos MM. The MR appearance of hypothalamic hamartoma. Neuroradiology 1988;30(1):65–68 3. MunariC, KahaneP, FrancioneS, . Role of the hypothalamic hamartoma in the genesis of gelastic fits (a video-stereo-EEG study). Electroencephalogr Clin Neurophysiol 1995;95(3):154–160 4. Palmini A, Chandler C, Andermann F, et al. Resection of the lesion in patients with hypothalamic hamartomas and catastrophic epilepsy. Neurology 2002;58(9):1338–1347 5. Palmini A, Van Paesschen W, Dupont P, Van Laere K, Van Driel G. Status gelasticus after temporal lobectomy: ictal FDG-PET findings and the question of dual pathology involving hypothalamic hamartomas. Epilepsia 2005;46(8):1313–1316 6. Tovar-Spinoza ZS, Ochi A, Rutka JT, Go C, Otsubo H. The role of magnetoencephalography in epilepsy surgery. Neurosurg Focus 2008;25(3):E16 7. Amstutz DR, Coons SW, Kerrigan JF, Rekate HL, Heiserman JE. Hypothalamic hamartomas: correlation of MR imaging and spectroscopic findings with tumor glial content. AJNR Am J Neuroradiol 2006;27(4):794–798 8. Parent A. Carpenter’s Human Neuroanatomy. Baltimore: Williams & Wilkins; 1996 9. Savard G, Bhanji NH, Dubeau F, Andermann F, Sadikot A. Psychiatric aspects of patients with hypothalamic hamartoma and epilepsy. Epileptic Disord 2003;5(4):229–234 10. Weissenberger AA, Dell ML, Liow K, et al. Aggression and psychiatric comorbidity in children with hypothalamic hamartomas and their unaffected siblings. J Am Acad Child Adolesc Psychiatry 2001;40(6):696–703 11. Hall JG, Pallister PD, Clarren SK, et al. Congenital hypothalamic hamartoblastoma, hypopituitarism, imperforate anus and post-

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12.

13.

14.

15.

16.

17.

18.

19. 20.

axial polydactyly–a new syndrome? Part I: clinical, causal, and pathogenetic considerations. Am J Med Genet 1980;7(1):47–74 Delalande O, Fohlen M. Disconnecting surgical treatment of hypothalamic hamartoma in children and adults with refractory epilepsy and proposal of a new classification. Neurol Med Chir (Tokyo) 2003;43(2):61–68 Mittal S, Montes JL, Farmer JP, Sabbagh AJ. Surgical management of epilepsy related to hypothalamic hamartomas. In: Villemure JG, Baltuch G, eds. Operative Techniques in Epilepsy Surgery. New York: Thieme Medical Publishers; 2009:81–98 Palmini A, Paglioli-Neto E, Montes J, Farmer JP. The treatment of patients with hypothalamic hamartomas, epilepsy and behavioural abnormalities: facts and hypotheses. Epileptic Disord 2003;5(4):249–255 Harvey AS, Freeman JL, Berkovic SF, Rosenfeld JV. Transcallosal resection of hypothalamic hamartomas in patients with intractable epilepsy. Epileptic Disord 2003;5(4):257–265 Rekate HL, Feiz-Erfan I, Ng YT, Gonzalez LF, Kerrigan JF. Endoscopic surgery for hypothalamic hamartomas causing medically refractory gelastic epilepsy. Childs Nerv Syst 2006;22(8):874–880 Fohlen M, Lellouch A, Delalande O. Hypothalamic hamartoma with refractory epilepsy: surgical procedures and results in 18 patients. Epileptic Disord 2003;5(4):267–273 Régis J, Scavarda D, Tamura M, et al. Epilepsy related to hypothalamic hamartomas: surgical management with special reference to gamma knife surgery. Childs Nerv Syst 2006;22(8):881–895 Kuzniecky RI, Guthrie BL. Stereotactic surgical approach to hypothalamic hamartomas. Epileptic Disord 203;5(4):275–280 Feiz-Erfan I, Horn EM, Rekate HL, et al. Surgical strategies for approaching hypothalamic hamartomas causing gelastic seizures in the pediatric population: transventricular compared with skull base approaches. J Neurosurg 2005; 103(4, Suppl):325–332

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Neurosurgery Case Review: Questions and Answers  

An ideal resource for board exam preparation, this review distills the essentials of neurosurgery in a user-friendly question and answer for...