Publications by authors named "James Holsapple"

18 Publications

  • Page 1 of 1

Intracranial Hypertension Following Gunshot Wound to the Torcula: Case Report and Literature Review.

World Neurosurg 2020 05 29;137:94-97. Epub 2020 Jan 29.

Department of Neurosurgery, Boston Medical Center, Boston, Massachusetts, USA.

Background: Elevation of bone for the treatment of depressed skull fractures overlying venous sinuses is rarely required or performed. The neurosurgical literature only describes a handful of cases of surgical intervention in which the posterior two-thirds of the superior sagittal sinus was involved. Clinical course is variable, signs and symptoms suggest increased intracranial pressure, and all conservative measures should be exhausted before proceeding with the surgical route.

Case Description: A 27-year-old man presented with a self-inflicted gunshot wound to posterior head. On presentation, there were no neurologic complaints. On imaging, the bullet fragment was associated with a comminuted anteriorly displaced fracture over the torcula. Vessel imaging showed tapering of the superior sagittal sinus and transverse sinuses near the torcula, suggesting narrowing due to mass effect. The patient did not respond to initial conservative management and developed worsening diplopia and papilledema concerning for increased intracranial pressure. Occipital/suboccipital craniectomy was performed with elevation of depressed skull fracture, decompression of dural venous sinus, removal of bullet, and mesh cranioplasty. Repeat ophthalmology examination postoperatively showed improvement in optic disc edema and diplopia.

Conslusions: This case confirms that the approach of surgical management of superior sagittal venous sinus injuries associated with skull fractures described in the literature also can be used successfully for injuries over the torcula if conservative management does not help alleviate the symptoms and results in good outcome. It was felt that delayed surgery also plays an important role, as it gives time for scar tissue to form, which may help to protect the sinus from injury during surgery.
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http://dx.doi.org/10.1016/j.wneu.2020.01.170DOI Listing
May 2020

A Frequency-domain Approach to Noninvasive Intracranial Pressure Estimation.

Annu Int Conf IEEE Eng Med Biol Soc 2019 Jul;2019:5055-5058

Intracranial pressure (ICP) is a cranial vital sign, crucial in the monitoring and treatment of several neurological injuries. The clinically accepted measurement modalities of ICP are highly invasive, carrying risks of infection and limiting the benefits of ICP measurement to a small subset of critically ill patients. This work aims to take a step towards developing an accurate noninvasive means of estimating ICP, by utilizing a model-based frequency-domain approach. The mean ICP and pulse pressures of ICP are estimated from arterial blood pressure (ABP) and cerebral blood flow velocity (CBFV) waveforms, and the estimates are validated on an adult population, comprising of around two hours of data from five patients. The algorithm was shown to have an accuracy (mean error) of -1.5 mmHg and a precision (standard deviation of the error) of 4.3 mmHg in estimating the mean ICP. These results are comparable to the previously reported errors among the currently accepted invasive measurement methods, and well within the clinically relevant range.
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http://dx.doi.org/10.1109/EMBC.2019.8857042DOI Listing
July 2019

A Spectral Approach to Model-Based Noninvasive Intracranial Pressure Estimation.

IEEE J Biomed Health Inform 2020 08 25;24(8):2398-2406. Epub 2019 Dec 25.

Background: Intracranial pressure (ICP) normally ranges from 5 to 15 mmHg. Elevation in ICP is an important clinical indicator of neurological injury, and ICP is therefore monitored routinely in several neurological conditions to guide diagnosis and treatment decisions. Current measurement modalities for ICP monitoring are highly invasive, largely limiting the measurement to critically ill patients. An accurate noninvasive method to estimate ICP would dramatically expand the pool of patients that could benefit from this cranial vital sign.

Methods: This article presents a spectral approach to model-based ICP estimation from arterial blood pressure (ABP) and cerebral blood flow velocity (CBFV) measurements. The model captures the relationship between the ABP, CBFV, and ICP waveforms and utilizes a second-order model of the cerebral vasculature to estimate ICP.

Results: The estimation approach was validated on two separate clinical datasets, one recorded from thirteen pediatric patients with a total duration of around seven hours, and the other recorded from five adult patients, one hour and 48 minutes in total duration. The algorithm was shown to have an accuracy (mean error) of 0.4 mmHg and -1.5 mmHg, and a precision (standard deviation of the error) of 5.1 mmHg and 4.3 mmHg, in estimating mean ICP (range of 1.3 mmHg to 24.8 mmHg) on the pediatric and adult data, respectively. These results are comparable to previous results and within the clinically relevant range. Additionally, the accuracy and precision in estimating the pulse pressure of ICP on a beat-by-beat basis were found to be 1.3 mmHg and 2.9 mmHg respectively.

Conclusion: These contributions take a step towards realizing the goal of implementing a real-time noninvasive ICP estimation modality in a clinical setting, to enable accurate clinical-decision making while overcoming the drawbacks of the invasive ICP modalities.
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http://dx.doi.org/10.1109/JBHI.2019.2961403DOI Listing
August 2020

Neural Crest Cell Failure as Embryogenesis for Fusiform Aneurysm of the Anterior Communicating Artery: Case Report and Review of the Literature.

World Neurosurg 2019 Sep 13;129:232-236. Epub 2019 Jun 13.

Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Background: Pure fusiform aneurysms of the anterior communicating artery (AcomA) are rare. We report a unique case of a patient with an AComA fusiform aneurysm in the setting of several unusual cranial neurocristopathies, including a hypoplastic internal carotid artery (ICA), persistent craniopharyngeal canal, transsphenoidal encephalocele, and ectopic, duplicated pituitary gland. We also review the literature on cranial base neurocristopathies and AComA fusiform aneurysms.

Case Description: This 46-year-old patient had a history of short stature, osteoporosis, obesity, cleft lip, decreased libido, congenital left eye blindness, headaches, and chronic nasal congestion. Magnetic resonance imaging revealed a 25 × 25 × 33 mm heterogenous soft tissue mass with an ectopic pituitary gland extending transsphenoidally and a duplicated pituitary stalk. A hormone panel revealed undetectable insulin-like growth factor 1 and growth hormone, central hypogonadism, and elevated prolactin. Before presentation, computed tomography angiography (CTA) had revealed a congenitally hypoplastic right ICA and 4.7 × 10.7 mm fusiform aneurysm of the AComA. Digital subtraction angiography confirmed stable morphology after 9 years. Nonoperative management of aneurysm and cephalocele was elected, with repeat CTA in 1 year.

Conclusions: This case provides evidence that inherent arterial wall defects can contribute to fusiform aneurysm formation in the AComA. We propose that small AComA fusiform aneurysms without sclerotic or symptomatic features can be safely observed by describing the longest reported conservative management for this type of aneurysm. A high degree of suspicion for cerebrovascular anomalies should be maintained in patients who present with cranial neurocristopathy.
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http://dx.doi.org/10.1016/j.wneu.2019.06.011DOI Listing
September 2019

A Waveform Archiving System for the GE Solar 8000i Bedside Monitor.

Acta Neurochir Suppl 2018 ;126:173-177

Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA.

Objectives: Our objective was to develop, deploy, and test a data-acquisition system for the reliable and robust archiving of high-resolution physiological waveform data from a variety of bedside monitoring devices, including the GE Solar 8000i patient monitor, and for the logging of ancillary clinical and demographic information.

Materials And Methods: The data-acquisition system consists of a computer-based archiving unit and a GE Tram Rac 4A that connects to the GE Solar 8000i monitor. Standard physiological front-end sensors connect directly to the Tram Rac, which serves as a port replicator for the GE monitor and provides access to these waveform signals through an analog data interface. Together with the GE monitoring data streams, we simultaneously collect the cerebral blood flow velocity envelope from a transcranial Doppler ultrasound system and a non-invasive arterial blood pressure waveform along a common time axis. All waveform signals are digitized and archived through a LabView-controlled interface that also allows for the logging of relevant meta-data such as clinical and patient demographic information.

Results: The acquisition system was certified for hospital use by the clinical engineering team at Boston Medical Center, Boston, MA, USA. Over a 12-month period, we collected 57 datasets from 11 neuro-ICU patients. The system provided reliable and failure-free waveform archiving. We measured an average temporal drift between waveforms from different monitoring devices of 1 ms every 66 min of recorded data.

Conclusions: The waveform acquisition system allows for robust real-time data acquisition, processing, and archiving of waveforms. The temporal drift between waveforms archived from different devices is entirely negligible, even for long-term recording.
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http://dx.doi.org/10.1007/978-3-319-65798-1_36DOI Listing
July 2018

Intraocular Silicone Oil Migration into the Ventricles Resembling Intraventricular Hemorrhage: Case Report and Review of the Literature.

World Neurosurg 2017 Jun 4;102:695.e7-695.e10. Epub 2017 Apr 4.

Department of Neurosurgery, Boston Medical Center, Boston, Massachusetts, USA.

Background: Intracranial silicone migration is a rare complication of ocular silicone oil endotamponade and may resemble intraventricular hemorrhage. The etiology of the phenomenon is challenging to understand.

Case Description: In an effort to shed light on this phenomenon, we report a case of a 67-year-old woman with ocular silicone oil endotamponade on the left eye due to retinal detachment who presented with headache to the emergency department. The imaging work-up revealed intraventricular silicone oil migration.

Conclusions: The literature is reviewed through the perspective of pathophysiology. The migration of intraocular silicone oil into the ventricular system provides both an important complication for clinicians to be aware of, as well as a paradigm reminding us that cerebrospinal fluid spaces may have more extensive communications with other body compartments than previously thought.
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http://dx.doi.org/10.1016/j.wneu.2017.03.131DOI Listing
June 2017

Radiological imaging features of the basal ganglia that may predict progression to hemicraniectomy in large territory middle cerebral artery infarct.

Neuroradiology 2017 May 28;59(5):477-484. Epub 2017 Mar 28.

Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.

Purpose: Predicting which patients are at risk for hemicraniectomy can be helpful for triage and can help preserve neurologic function if detected early. We evaluated basal ganglia imaging predictors for early hemicraniectomy in patients with large territory anterior circulation infarct.

Methods: This retrospective study evaluated patients with ischemic infarct admitted from January 2005 to July 2011. Patients with malignant cerebral edema refractory to medical therapy or with herniating signs such as depressed level of consciousness, anisocoria, and contralateral leg weakness were triaged to hemicraniectomy. Admission images were reviewed for presence of caudate, lentiform nucleus (putamen and globus pallidus), or basal ganglia (caudate + lentiform nucleus) infarction.

Results: Thirty-one patients with large territory MCA infarct, 10 (32%), underwent hemicraniectomy. Infarction of the caudate nucleus (9/10 vs 6/21, p = 0.002) or basal ganglia (5/10 vs 2/21, p = 0.02) predicted progression to hemicraniectomy. Infarction of the lentiform nucleus only did not predict progression to hemicraniectomy. Sensitivity for patients who did and did not have hemicraniectomy were 50% (5/10) and 90.5% (19/21). For caudate nucleus and caudate plus lentiform nucleus infarcts, the crude- and age-adjusted odds of progression to hemicraniectomy were 9.5 (1.4-64.3) and 6.6 (0.78-55.4), respectively.

Conclusion: Infarction of the caudate nucleus or basal ganglia correlated with patients progressing to hemicraniectomy. Infarction of the lentiform nucleus alone did not.
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http://dx.doi.org/10.1007/s00234-017-1823-1DOI Listing
May 2017

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments.

J Neurotrauma 2017 02 19;34(4):861-868. Epub 2016 May 19.

3 Department of Neurosurgery, Boston University School of Medicine , Boston, Massachusetts.

Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting.
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http://dx.doi.org/10.1089/neu.2016.4475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5314982PMC
February 2017

Expanding Endovascular Therapy of Very Small Ruptured Aneurysms with the 1.5-mm Coil.

Interv Neurol 2015 Oct 18;4(1-2):59-63. Epub 2015 Sep 18.

Department of Radiology, Boston University School of Medicine, Boston Mass., USA.

Background: Very small ruptured aneurysms (≤3 mm) demonstrate a significant risk for procedural rupture with endovascular therapy. Since 2007, 1.5-mm-diameter coils have been available (Micrus, Microvention, and ev3), allowing neurointerventionalists the opportunity to offer patients with very small aneurysms endovascular treatment. In this study, we review the clinical and angiographic outcome of patients with very small ruptured aneurysms treated with the 1.5-mm coil.

Methods: This is a retrospective cohort study in which we examined consecutive ruptured very small aneurysms treated with coil embolization at a single institution. The longest linear aneurysm was recorded, even if the first coil was sized to a smaller transverse diameter. Very small aneurysms were defined as ≤3 mm. Descriptive results are presented.

Results: From July 2007 to March 2015, 81 aneurysms were treated acutely with coils in 78 patients presenting with subarachnoid hemorrhage. There were 5 patients with 3-mm aneurysms, of which the transverse diameter was ≤2 mm in 3 patients. In all 5 patients, a balloon was placed for hemostatic prophylaxis in case of rupture, and a single 1.5-mm coil was inserted for aneurysm treatment without complication. Complete aneurysm occlusion was achieved in 1 patient, residual neck in 2, and residual aneurysm in 2 patients. Aneurysm recanalization was present in 2 patients with an anterior communicating artery aneurysm; a recoiling attempt was unsuccessful in 1 of these 2 patients due to inadvertent displacement and distal coil embolization, but subsequent surgical clipping was successful. Another patient was retreated by surgical clipping for a residual wide-neck carotid terminus aneurysm. One patient died of ventriculitis 3 weeks after presentation; all 4 other patients had an excellent outcome with no rebleed at follow-up (mean 21 months, range 1-62).

Conclusion: The advent of the 1.5-mm coil may be used in the endovascular treatment of patients with very small ruptured aneurysms, providing a temporary protection to the site of rupture in the acute phase. If necessary, bridging with elective clipping may provide definitive aneurysm treatment.
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http://dx.doi.org/10.1159/000437275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640086PMC
October 2015

Resection of Primary Brachial Plexus Tumor via a Modified Supraclavicular Approach.

J Neurol Surg Rep 2014 Aug 28;75(1):e133-5. Epub 2014 May 28.

Department of Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, United States.

Benign peripheral nerve sheath tumors are generally considered curable lesions, and surgical resection is recommended as the primary line of treatment. When these tumors occur in the brachial plexus, they are most frequently accessed via the supraclavicular approach. Traditional descriptions of this approach have included either transection of sternocleidomastoid (SCM) muscle fibers or disarticulation of the clavicular head of the SCM muscle. This report presents a simple and easy-to-adapt modification of the supraclavicular approach that offers greater preservation of the SCM muscle. The modification primarily consists of the creation of an intramuscular window between the sternal and clavicular heads of the SCM via the splitting and dilation SCM muscle fibers. This technique minimizes the disruption of SCM muscle tissue compared with previous descriptions and may be associated with improved postoperative pain and return to function.
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http://dx.doi.org/10.1055/s-0034-1376423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110154PMC
August 2014

An enigmatic brainstem posterior fossa ganglioglioma in an adult.

Int J Neurosci 2014 Sep 29;124(9):704-6. Epub 2014 Jan 29.

1Boston University School of Medicine , Boston, MA , USA.

Ganglioglioma is a rare central nervous system neoplasm representing 0.4% to 1.7% of all brain tumors and most frequently occurs in the pediatric population with an incidence of 7.6%. These tumors are usually slow-growing and well-circumscribed solid or cystic lesions. Gangliogliomatosis infrequently occurs in the frontal lobe, pineal gland, basal ganglia, hypothalamus, and optic chiasm, with very few reports of brainstem ganglioglioma. We report a case of a 35-year-old female who initially presented with headache, vertigo, ataxia, saccadic dysfunction, dysarthria, and dysmetria for several years due to an unknown etiology. Her brain imaging showed multiple lesions in the pons and the cerebellum with cystic changes and size reduction and enlargement over the next few years while her neurological symptoms continued to worsen. The patient received courses of steroid treatment that improved her neurological symptoms, suggesting an inflammatory component of her disease. Extensive workup for an inflammatory or infectious etiology was unfruitful and two brain biopsies were inconclusive. A third biopsy showed atypical glial nuclei, binucleated cells, and Rosenthal fibers and the presence of BRAF V600E mutation was detected. The diagnosis of gangliogliomatosis was consequently established. This case illustrates that gangliogliomatosis may present with the waxing-and-waning neurological signs and symptoms. It can masquerade inflammatory processes in the central nervous system on brain imaging and deserves careful consideration in the diagnosis of patients with an indolent course of neurological deterioration.
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http://dx.doi.org/10.3109/00207454.2013.877901DOI Listing
September 2014

The effect of a neurocritical care service without a dedicated neuro-ICU on quality of care in intracerebral hemorrhage.

Neurocrit Care 2013 Jun;18(3):305-12

Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA.

Background: Introduction of neurocritical care services to dedicated neuro-ICUs is associated with improved quality of care. The impact of a neurocritical care service without a dedicated neuro-ICU has not been studied.

Methods: We retrospectively identified all patients admitted to our institution with intracerebral hemorrhage (ICH) in two 12-month periods: immediately before the arrival of the first neurointensivist ("before") and after the neurocritical care service was established ("after"). There was no nursing team, ICU housestaff/physician extender team, or physical unit dedicated to the care of patients with critical neurologic illness during either period. Using an uncontrolled before-after design, we compared clinical outcomes and performance on quality metrics between groups.

Results: We included 74 patients with primary supratentorial ICH. Mortality, length of stay (LOS), proportion of patients with modified Rankin Score 0-3, and destination on discharge did not differ between groups when adjusted for confounders. Time to first two consecutive systolic blood pressure (SBP) measurements <180 mmHg was shorter in the "after" cohort (mean 4.5 vs. 3.2 h, p = 0.001). Area under the curve measurement for change in SBP from baseline over the first 24 h after ED arrival demonstrated greater, sustained SBP reduction in the "after" cohort (mean -187.9 vs. -720.9, p = 0.04). A higher proportion of patients were fed without passing a dysphagia screen in the "before" group (45 vs. 0%, p < 0.001).

Conclusions: Introduction of a neurocritical service without a neuro-ICU at our institution was associated with a trend toward longer ICU LOS and improvement in some key metrics of quality of care for patients with ICH.
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http://dx.doi.org/10.1007/s12028-013-9818-1DOI Listing
June 2013

Postpartum trifecta: simultaneous eclamptic intracerebral hemorrhage, PRES, and herniation due to intracranial hypotension.

Neurocrit Care 2012 Dec;17(3):434-8

Department of Neurology, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, C-3, Boston, MA 02118, USA.

Background: In the postpartum patient, sudden depression of consciousness may be caused by a number of etiologies and can result in serious consequences. Rapid, accurate diagnosis allows for specific treatments that optimize outcome, but diagnosis can be challenging in this population. We present a case of postpartum herniation due to intracranial hypotension in a patient with eclampsia, posterior reversible encephalopathy syndrome (PRES), and intracerebral hemorrhage (ICH).

Methods: Case report.

Results: A 26-year-old woman developed headache on postpartum day (PD) 1 after cesarean section with epidural anesthesia. Over the next 3 days, she developed progressively worsening headache and hypertension. On PD 5, she had a generalized seizure, leading to endotracheal intubation, propofol infusion, and transfer to our institution. By PD 6, she opened her eyes to voice, followed commands, moved all extremities, and had briskly reactive 4 mm pupils. MRI showed L parasagittal ICH with minimal mass effect, edema consistent with PRES, and brain descent with obliteration of the basal cisterns and tonsillar herniation. Later on PD 6, after diuresis for pulmonary edema, she became unresponsive with a dilated and nonreactive left pupil. She was laid flat for transport to CT, with improvement in arousal and pupil reactivity within 5 min. Intravascular volume was repleted with normal saline and albumin, and she was placed in the Trendelenburg position. Over the subsequent 8 h, she developed a dilated and nonreactive left pupil whenever her head was raised to horizontal. Her head position was gradually successfully raised over 48 h without need for a lumbar epidural blood patch. She was discharged home on PD 13 with only mild left arm dysmetria.

Conclusions: Intracranial hypotension may coexist with other potential causes of cerebral herniation in the postpartum period. Establishing this diagnosis is crucial because its treatment is opposite that of other causes of herniation.
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http://dx.doi.org/10.1007/s12028-012-9742-9DOI Listing
December 2012

Deep hypothermic circulatory arrest for treatment of renal carcinoma.

J Clin Anesth 2009 May;21(3):217-9

Department of Anesthesiology Upstate Medical University, Syracuse, NY 13210, USA.

The case of a 67-year-old woman with multiple medical problems who presented for resection of a metastatic renal cell carcinoma involving the posterior fossa, is presented. Anesthetic management of the patient, who suffered metastasis to the brain, and who required deep hypothermic circulatory arrest, is discussed.
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http://dx.doi.org/10.1016/j.jclinane.2008.06.041DOI Listing
May 2009

Aggressive pediatric meningioma with soft tissue and lymph node metastases: a case report.

Pediatr Dev Pathol 2009 May-Jun;12(3):244-8

Department of Pathology, SUNY Upstate Medical University, Syracuse, NY, USA.

Metastatic meningioma is extremely rare, occurring in an estimated 0.1% of cases. We report a case of pediatric meningioma metastatic to cervical soft tissue and lymph nodes. An 8-year-old boy presented with headaches, dizziness, and involuntary eye flickering. Magnetic resonance imaging (MRI) revealed a 7.5-cm parasagittal, dural-based mass with venous sinus encasement. Therapeutic embolization was followed by bilateral craniotomy, achieving subtotal resection. Histopathologic examination revealed an atypical meningioma with regions of hypercellularity, small cell morphology, sheeting architecture, increased mitoses, and brain invasion. Surveillance MRI studies showed growth of residual tumor and enlarging cervical soft tissue masses with posterior triangle lymphadenopathy. Radiation and surgical resection were employed for the intracranial tumor burden; resection of the soft tissue masses revealed metastatic meningioma, with soft tissue infiltration and metastasis to 8 lymph nodes. This case demonstrates the aggressive biologic potential of pediatric meningiomas, with potential for distant spread via cerebrospinal fluid leakage and lymphatic invasion.
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http://dx.doi.org/10.2350/08-07-0501.1DOI Listing
September 2009

Training for fitness: reconsidering the 80-hour work week.

Perspect Biol Med 2008 ;51(1):134-43

Center for Bioethics and Humanities, Department of Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USa.

The medical literature is replete with articles about the Accreditation Council for Graduate Medical Education's 2003 resident duty hour restrictions. Most of these papers describe creative and thoughtful responses to the new system. However, others express concern that the "80-hour work week" could hamper continuity of care and educational activities. Nevertheless, if fatigue impairs resident learning and medical care quality, then work hour restrictions seem worthwhile. We add our voices to the critics' for additional reasons. Data support that fatigue occurs even with reasonable work schedules, and residents do not reliably use time off from work to rest. Regulated work schedules can interfere with adequate rehearsal of the physical and mental stamina required in certain specialties, yet patients have a right to expect their physicians to be trained in the particular demands of those specialties. Similarly, residents have a right to a realistic understanding of authentic clinical practice. Further, while self-sacrifice need not be routine, trainees should feel that occasional self-sacrifice is appropriate and acceptable for a physician. We reject uniform, arbitrary duty hour limits for all specialties. Rather, we propose that a subspecialty-based system can foster the development of the endurance, skills, and reasoning that patients and colleagues expect.
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http://dx.doi.org/10.1353/pbm.2008.0000DOI Listing
April 2008

Ventral thoracic spinal cord herniation: frequently misdiagnosed entity.

Spine (Phila Pa 1976) 2006 Aug;31(17):E600-5

Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, NY 13210, USA.

Study Design: Case report with review of the literature.

Objective: Symptomatic spinal cord herniation through ventral aspect of dura is frequently misdiagnosed because this condition is rare. The most frequent misdiagnosis was that of dorsal arachnoid cyst. The purpose of this article is to provide insight on clinical presentation, diagnosis, and surgical treatment of this entity. Results of our cases were compared with that of the reported literature.

Summary Of Background Data: Eighty-six cases reported in the literature were reviewed and data are presented in this article.

Methods: We had 3 patients diagnosed with spinal cord herniation through the ventral aspect of the dural sac. All 3 cases were misdiagnosed initially and later successfully operated. The dura was repaired primarily with suture in 1 case and with surgical graft in the other 2 cases.

Results: Reduction of spinal cord herniation reverses some of the signs and symptoms that have been present for years. Two of our patients had remarkable recovery in motor strength and bladder function. The third patient improved but remained with residual myelopathy.

Conclusion: Ventral herniation of the thoracic spinal cord is a partially treatable cause of myelopathy, when recognized promptly and treated surgically. Recognizing this infrequent cause of myelopathy prevents misdiagnosis. Delay in diagnosis may impair recovery at a later date.
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http://dx.doi.org/10.1097/01.brs.0000229247.69171.a1DOI Listing
August 2006

Magnetic resonance imaging characteristics of hyperacute hemorrhage in the brain and spine.

Clin Imaging 2002 Sep-Oct;26(5):330-7

Department of Radiology, Upstate Medical University, 750 East Adams St, Syracuse, NY 13210, USA.

Five distinct stages have been defined for the magnetic resonance (MR) appearance of intraparenchymal hematomas in the brain: hyperacute, acute, early subacute, late subacute and chronic. Despite the extensive study of the evolution of hematomas there has been little attention given to the MR appearance of the posthemorrhagic state within the initial hours after the hemorrhage occurs. We discuss and illustrate the MR imaging characteristics of hyperacute hemorrhage. Five cases of hyperacute intraparenchymal hemorrhage, one intracranial subdural and one intraspinal lumbar epidural hemorrhage are presented.
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http://dx.doi.org/10.1016/s0899-7071(02)00444-8DOI Listing
January 2003