Brain metastases are the leading cause of morbidity and mortality among cancer patients, and are ... more Brain metastases are the leading cause of morbidity and mortality among cancer patients, and are reported to occur in about 40% of cancer patients with metastatic disease in the United States of America. Primary tumor cells appear to detach from the parent tumor site, migrate, survive and pass through the blood brain barrier in order to establish cerebral metastases. This complex process involves distinct molecular and genetic mechanisms that mediate metastasis from these primary organs to the brain. Furthermore, an interaction between the invading cells and cerebral milieu is shown to promote this process as well. Here, we review the mechanisms by which primary cancer cells metastasize to the brain via a mechanism called epithelial-to-mesenchymal transition, as well as the involvement of certain microRNA and genetic aberrations implicated in cerebral metastases from the lung, breast, skin, kidney and colon. While the mechanisms governing the development of brain metastases remain a...
Tension pneumocephalus is a rare complication of head trauma and neurosurgical procedures, amongs... more Tension pneumocephalus is a rare complication of head trauma and neurosurgical procedures, amongst other causes. It is defined by the combination of intracranial air, increased intracranial pressure, and mass effect. Although it often presents soon after surgery, it can also rarely present in a delayed fashion. We present a case of delayed tension pneumocephalus, occurring approximately 16 weeks after bifrontal craniectomy for a self-inflicted gunshot wound. Following a month of rhinorrhea, postnasal drip, and cough, the patient presented with a sensation of expansion in the area of the right forehead. As tension pneumocephalus is an emergency that can be fatal, this patient was treated expediently and avoided severe neurological deficits. The case recounted here is important as a demonstrative example that tension pneumocephalus does not always follow a defined course immediately after trauma or neurosurgery but rather can develop insidiously without obvious signs.
Traumatic spinal subdural hematoma (SDH) is an exceedingly rare condition, with those occurring i... more Traumatic spinal subdural hematoma (SDH) is an exceedingly rare condition, with those occurring in the absence of intracranial pathology being particularly uncommon. To date, only 13 such cases have been reported. While theories exist to describe the pathophysiology of traumatic spinal SDH, the precise mechanism and guidelines for management still remain unclear. This report describes a 37-year-old female that suffered a traumatic assault who developed progressive low back pain with radicular symptoms two days after presentation. Magnetic resonance imaging revealed a lumbar subdural hematoma extending from L1 to L5. No intracranial pathology was detected on imaging. Definitive guidelines for management of this condition are uncertain, however reports present successful use of conservative management, lumbar drainage and surgical evacuation. This patient underwent a lumbar laminectomy with evacuation of the hematoma resulting in immediate pain relief and resolution of symptoms within...
We have determined whether the nitroxide antioxidant, tempol, can oppose tissue loss and improve ... more We have determined whether the nitroxide antioxidant, tempol, can oppose tissue loss and improve recovery of locomotor function following contusion injury of the spinal cord. Contusion injury was produced in rats at the level of T10 with a weight-drop device and locomotor recovery was determined with the 21-point Basso, Beattie and Bresnahan (BBB) scale. Locomotor function recovered progressively during the 6-week postinjury observation period and was significantly greater in tempol-treated (275 mg/kg i.p., 20 min postinjury) compared to vehicle-treated rats (final BBB scores: 9.1 versus 6.4). Similarly enhanced locomotor recovery was observed with doses of tempol in the range of 138-550, but not 69 mg/kg, and with injection at 48 h postinjury indicating a therapeutic time-window of at least several days. The extent of recovery correlated with measurements of sparing of spinal cord white matter in a region several millimeters in length extending rostrally from the contusion epicenter. In contrast, loss of gray matter was unaffected by tempol treatment. Since tempol acts by scavenging reactive oxygen species (ROS) such as superoxide and hydroxyl radicals, the improved locomotor recovery and spared spinal cord tissue following contusion injury provides evidence of a direct role of ROS-mediated neurodegeneration in spinal cord injury.
Rivaroxaban is an oral factor Xa inhibitor used for stroke prevention in atrial fibrillation. The... more Rivaroxaban is an oral factor Xa inhibitor used for stroke prevention in atrial fibrillation. There are currently no evidence-based guidelines for the treatment of hemorrhagic side effects of factor Xa inhibitors. We report a case of a thalamic hemorrhage in an 84 year-old right-handed female on rivaroxaban for treatment of atrial fibrillation. The patient had fallen down steps and became unresponsive. She was found to have diffuse scattered acute subarachnoid hemorrhage as well as intraventricular hemorrhage. Neurosurgical intervention was not required in this case, but controversy over decision making to pursue pro-coagulant therapy in the setting of worsening hemorrhage requiring emergent surgery is discussed.
Malignant carotid body tumors are rare, with spread of the tumor mostly noted in regional lymph n... more Malignant carotid body tumors are rare, with spread of the tumor mostly noted in regional lymph nodes. Vertebral metastases are an exceedingly rare presentation, only reported in isolated case reports, and present a diagnostic and management challenge. A case of widespread vertebral metastasis, presenting with myelopathy, from a carotid body tumor is discussed in this paper, along with management strategies.
Stereotactic radiosurgery (SRS) is a widely used therapy for multiple brain lesions, and studies ... more Stereotactic radiosurgery (SRS) is a widely used therapy for multiple brain lesions, and studies have clearly established the safety and efficacy of single-dose SRS. However, as patient survival has increased, the recurrence of tumors and the development of metastases to new sites within the brain have made it desirable to repeat treatments over time. The cumulative toxicity of multi-isocenter, multiple treatments has not been well defined. We have retrospectively studied 10 patients who received multiple SRS treatments for multiple brain lesions to assess the cumulative toxicity of these treatments. In a retrospective review of all patients treated with SRS using the X-knife (Radionics, Burlington, MA) at Westchester Medical Center/New York Medical College between December 1995 and December 2000, 10 patients were identified who received at least two treatments to at least 3 isocenters and had a minimum follow-up period of 6 months. Image fusion technique was used to determine cumul...
Spinal cord involvement by perineural spread of malignant mesothelioma is rare. We report a case ... more Spinal cord involvement by perineural spread of malignant mesothelioma is rare. We report a case of malignant mesothelioma that spread locally to invade the bony spine with both extradural and intradural perineural spread into the spinal canal that resulted in spinal cord compression. A 61-year-old man with a history of malignant mesothelioma presented with progressive leg weakness and right-sided arm weakness. Magnetic resonance imaging showed an enhancing lesion in the apex of the right lung with extension through the C7-T1 foramina with right hemicord enhancement. The patient underwent a C7-T1 laminectomy and right-sided C7-T1 and T1-T2 foraminotomies for neural decompression and biopsy of the lesion. Intraoperatively, tumor extended epidurally, and intradural perineural tumor spread along the C8 and T1 nerve roots into the spinal cord. Because it adhered to the spinal cord, no dissectible plane could be identified that would allow for safe total removal of the tumor. The epidura...
Brain metastases are the leading cause of morbidity and mortality among cancer patients, and are ... more Brain metastases are the leading cause of morbidity and mortality among cancer patients, and are reported to occur in about 40% of cancer patients with metastatic disease in the United States of America. Primary tumor cells appear to detach from the parent tumor site, migrate, survive and pass through the blood brain barrier in order to establish cerebral metastases. This complex process involves distinct molecular and genetic mechanisms that mediate metastasis from these primary organs to the brain. Furthermore, an interaction between the invading cells and cerebral milieu is shown to promote this process as well. Here, we review the mechanisms by which primary cancer cells metastasize to the brain via a mechanism called epithelial-to-mesenchymal transition, as well as the involvement of certain microRNA and genetic aberrations implicated in cerebral metastases from the lung, breast, skin, kidney and colon. While the mechanisms governing the development of brain metastases remain a...
Tension pneumocephalus is a rare complication of head trauma and neurosurgical procedures, amongs... more Tension pneumocephalus is a rare complication of head trauma and neurosurgical procedures, amongst other causes. It is defined by the combination of intracranial air, increased intracranial pressure, and mass effect. Although it often presents soon after surgery, it can also rarely present in a delayed fashion. We present a case of delayed tension pneumocephalus, occurring approximately 16 weeks after bifrontal craniectomy for a self-inflicted gunshot wound. Following a month of rhinorrhea, postnasal drip, and cough, the patient presented with a sensation of expansion in the area of the right forehead. As tension pneumocephalus is an emergency that can be fatal, this patient was treated expediently and avoided severe neurological deficits. The case recounted here is important as a demonstrative example that tension pneumocephalus does not always follow a defined course immediately after trauma or neurosurgery but rather can develop insidiously without obvious signs.
Traumatic spinal subdural hematoma (SDH) is an exceedingly rare condition, with those occurring i... more Traumatic spinal subdural hematoma (SDH) is an exceedingly rare condition, with those occurring in the absence of intracranial pathology being particularly uncommon. To date, only 13 such cases have been reported. While theories exist to describe the pathophysiology of traumatic spinal SDH, the precise mechanism and guidelines for management still remain unclear. This report describes a 37-year-old female that suffered a traumatic assault who developed progressive low back pain with radicular symptoms two days after presentation. Magnetic resonance imaging revealed a lumbar subdural hematoma extending from L1 to L5. No intracranial pathology was detected on imaging. Definitive guidelines for management of this condition are uncertain, however reports present successful use of conservative management, lumbar drainage and surgical evacuation. This patient underwent a lumbar laminectomy with evacuation of the hematoma resulting in immediate pain relief and resolution of symptoms within...
We have determined whether the nitroxide antioxidant, tempol, can oppose tissue loss and improve ... more We have determined whether the nitroxide antioxidant, tempol, can oppose tissue loss and improve recovery of locomotor function following contusion injury of the spinal cord. Contusion injury was produced in rats at the level of T10 with a weight-drop device and locomotor recovery was determined with the 21-point Basso, Beattie and Bresnahan (BBB) scale. Locomotor function recovered progressively during the 6-week postinjury observation period and was significantly greater in tempol-treated (275 mg/kg i.p., 20 min postinjury) compared to vehicle-treated rats (final BBB scores: 9.1 versus 6.4). Similarly enhanced locomotor recovery was observed with doses of tempol in the range of 138-550, but not 69 mg/kg, and with injection at 48 h postinjury indicating a therapeutic time-window of at least several days. The extent of recovery correlated with measurements of sparing of spinal cord white matter in a region several millimeters in length extending rostrally from the contusion epicenter. In contrast, loss of gray matter was unaffected by tempol treatment. Since tempol acts by scavenging reactive oxygen species (ROS) such as superoxide and hydroxyl radicals, the improved locomotor recovery and spared spinal cord tissue following contusion injury provides evidence of a direct role of ROS-mediated neurodegeneration in spinal cord injury.
Rivaroxaban is an oral factor Xa inhibitor used for stroke prevention in atrial fibrillation. The... more Rivaroxaban is an oral factor Xa inhibitor used for stroke prevention in atrial fibrillation. There are currently no evidence-based guidelines for the treatment of hemorrhagic side effects of factor Xa inhibitors. We report a case of a thalamic hemorrhage in an 84 year-old right-handed female on rivaroxaban for treatment of atrial fibrillation. The patient had fallen down steps and became unresponsive. She was found to have diffuse scattered acute subarachnoid hemorrhage as well as intraventricular hemorrhage. Neurosurgical intervention was not required in this case, but controversy over decision making to pursue pro-coagulant therapy in the setting of worsening hemorrhage requiring emergent surgery is discussed.
Malignant carotid body tumors are rare, with spread of the tumor mostly noted in regional lymph n... more Malignant carotid body tumors are rare, with spread of the tumor mostly noted in regional lymph nodes. Vertebral metastases are an exceedingly rare presentation, only reported in isolated case reports, and present a diagnostic and management challenge. A case of widespread vertebral metastasis, presenting with myelopathy, from a carotid body tumor is discussed in this paper, along with management strategies.
Stereotactic radiosurgery (SRS) is a widely used therapy for multiple brain lesions, and studies ... more Stereotactic radiosurgery (SRS) is a widely used therapy for multiple brain lesions, and studies have clearly established the safety and efficacy of single-dose SRS. However, as patient survival has increased, the recurrence of tumors and the development of metastases to new sites within the brain have made it desirable to repeat treatments over time. The cumulative toxicity of multi-isocenter, multiple treatments has not been well defined. We have retrospectively studied 10 patients who received multiple SRS treatments for multiple brain lesions to assess the cumulative toxicity of these treatments. In a retrospective review of all patients treated with SRS using the X-knife (Radionics, Burlington, MA) at Westchester Medical Center/New York Medical College between December 1995 and December 2000, 10 patients were identified who received at least two treatments to at least 3 isocenters and had a minimum follow-up period of 6 months. Image fusion technique was used to determine cumul...
Spinal cord involvement by perineural spread of malignant mesothelioma is rare. We report a case ... more Spinal cord involvement by perineural spread of malignant mesothelioma is rare. We report a case of malignant mesothelioma that spread locally to invade the bony spine with both extradural and intradural perineural spread into the spinal canal that resulted in spinal cord compression. A 61-year-old man with a history of malignant mesothelioma presented with progressive leg weakness and right-sided arm weakness. Magnetic resonance imaging showed an enhancing lesion in the apex of the right lung with extension through the C7-T1 foramina with right hemicord enhancement. The patient underwent a C7-T1 laminectomy and right-sided C7-T1 and T1-T2 foraminotomies for neural decompression and biopsy of the lesion. Intraoperatively, tumor extended epidurally, and intradural perineural tumor spread along the C8 and T1 nerve roots into the spinal cord. Because it adhered to the spinal cord, no dissectible plane could be identified that would allow for safe total removal of the tumor. The epidura...
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