Individual memory change after anterior temporal lobectomy: a base rate analysis using regression-based outcome methodology

PURPOSE: To characterize patterns of base rate change on measures of verbal and visual memory after anterior temporal lobectomy (ATL) using a newly developed regression-based outcome methodology that accounts for effects of practice and regression towards the mean, and to comment on the predictive utility of baseline memory measures on postoperative memory outcome. METHODS: Memory change was operationalized using regression-based change norms in a group of left (n = 53) and right (n = 48) ATL patients. All patients were administered tests of episodic verbal (prose recall, list learning) and visual (figure reproduction) memory, and semantic memory before and after ATL. RESULTS: ATL patients displayed a wide range of memory outcome across verbal and visual memory domains. Significant performance declines were noted for 25-50% of left ATL patients on verbal semantic and episodic memory tasks, while one-third of right ATL patients displayed significant declines in immediate and delayed episodic prose recall. Significant performance improvement was noted in an additional one-third of right ATL patients on delayed prose recall. Base rate change was similar between the two ATL groups across immediate and delayed visual memory. Approximately one-fourth of all patients displayed clinically meaningful losses on the visual memory task following surgery. Robust relationships between preoperative memory measures and nonstandardized change scores were attenuated or reversed using standardized memory outcome techniques. CONCLUSIONS: Our results demonstrated substantial group variability in memory outcome for ATL patients. These results extend previous research by incorporating known effects of practice and regression to the mean when addressing meaningful neuropsychological change following epilepsy surgery. Our findings also suggest that future neuropsychological outcome studies should take steps towards controlling for regression-to-the-mean before drawing predictive conclusions.     

Differences between nouns and verbs after anterior temporal lobectomy.

To test the claim that lesions of left anterior and middle temporal cortical structures specifically impair processing of nouns but not verbs, 56 left-hemisphere-language-dominant patients who had undergone anterior temporal lobectomy (ATL) completed tasks assessing confrontation naming of pictured objects and actions, generation of synonyms for nouns and verbs, and semantic lexical judgments about nouns and verbs. Compared with right ATL patients left ATL patients were impaired across different tasks that assessed naming and comprehension of high-imageability as well as low-imageability nouns. These groups did not differ, however, in verb naming or comprehension on most tasks. Results are consistent with the hypothesized specialization of left temporal lobe structures for processing nouns and suggest that naming problems commonly seen after left ATL extend beyond difficulties with retrieving object names and may be related to subtle disturbances in comprehension of the meanings underlying nominal word forms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Visual angle of the mind's eye before and after unilateral occipital lobectomy.

Do mental images occur in a spatially mapped (i.e., analog, or array-format) representational medium? S. M. Kosslyn's (1978) method was used to measure the visual angle of "the mind's eye" to estimate the extent of the imagery medium before and after unilateral occipital lobectomy. It was found that the overall size of the largest possible image was reduced following the surgery. In addition, only the horizontal extent, and not the vertical extent, of the imagery medium was reduced. Finally, it was determined that the S understood the tasks, was not aware of any predictions, and was unaffected by a strong demand characteristic in a different imagery task. These results are consistent with the hypothesis that imagery occurs in a spatially mapped representational medium dependent on occipital cortex. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fulminant myasthenia gravis manifested after removal of anterior mediastinal tumor

Myasthenia gravis developed in a 35-year-old man after removal of an encapsulated anterior mediastinal tumor that was preoperatively diagnosed as a teratoma based on a computed tomographic image. Postoperative pathologic diagnosis of the excised tumor was thymoma. The patient was in crisis after the initiation of immunosuppressive treatment. The therapy was changed to immunoadsorbent perfusion therapy because of concurrent severe pneumonia and an extremely high serum concentration of anti-acetylcholine receptor antibodies. Respiratory support was necessary for 2 months after reoperation.     

Gastric emptying after gastric interposition for esophageal carcinoma: comparison between the anterior and posterior mediastinal approaches

BACKGROUND/AIMS: Close observation and evaluation of the function of the transposed stomach after esophagectomy is essential. The present study uses the sulfamethizole capsule meal test to evaluate differences in gastric emptying between the anterior and posterior mediastinal approaches in patients undergoing esophagectomy. METHODOLOGY: Thirty-eight patients who underwent the esophagectomy and esophagogastrostomy for esophageal cancer were randomly divided into 2 groups: Group 1: anterior mediastinal approach, and Group 2: posterior mediastinal approach. Gastric emptying was studied using the sulfamethizole capsule meal test. Patients received sulfamethizole food capsules, 65 g of bread, and 150 ml of water. Plasma sulfamethizole levels were determined by high performance liquid chromatography (HPLC). RESULTS: Gastric emptying in both groups was significantly accelerated compared to healthy volunteers. Gastric emptying did not differ significantly between groups 1 and 2. CONCLUSIONS: The present data show that the sulfamethizole capsule meal test is an effective means of evaluating the emptying of the transposed stomach. Furthermore, when the stomach is used as an esophageal substitute following esophagectomy, gastric emptying does not differ according to the access route.     

Factors associated with work outcome after anterior temporal lobectomy for intractable epilepsy

PURPOSE: Whereas the effect of anterior temporal lobectomy on seizure frequency is well recognized, less is known about its impact on work status. METHODS: One hundred thirty-four of 190 consecutive patients with temporal lobectomy participated in this study. Eligibility criteria were developed to ensure that only patients with the potential of achieving specific outcomes were included in the corresponding analyses. RESULTS: After surgery, significantly more patients were independent in activities of daily living (p < 0.001) or able to drive (p < 0.001). Income from work also increased (p < 0.01). Nearly one fifth of the patients who were eligible for analysis had either a gain (8%) or a loss (11%) of full- or of part-time work. Univariate analyses revealed the following factors to be associated with full-time work after surgery: student or full-time work within a year before surgery, full-time work experience before surgery, full- or part-time employment experience before surgery, no disability benefits before surgery, low postsurgical seizure frequency, improved postsurgical seizure control, excellent postsurgical seizure control, driving after surgery, and further education after surgery (p < 0.05). Significant factors on multivariate analysis were being a student or having full-time work within a year before surgery [odds ratio, 16.2 (95% CI, 4.3-60.5)], driving after surgery [15.2 (3.2-72.0)], and obtaining further education after surgery [9.2 (2.2-53.0)]. CONCLUSIONS: Anterior temporal lobectomy for intractable epilepsy improves activities of daily living and the ability to drive. Work outcome of this surgery is influenced by presurgical work experience, successful postsurgical seizure control especially to allow driving, and obtaining further education after surgery.     

Gait adaptations before and after anterior cruciate ligament reconstruction surgery

Gait analyses of rehabilitated individuals with anterior cruciate ligament (ACL) deficiency and reconstruction have identified the final adaptations of increased hip extensor torque and hamstring electromyography (EMG) and decreased knee extensor torque and quadriceps EMG during stance. The initial adaptations to injury and surgery are, however, unknown as are the factors that influence the development of the adaptations. Identification of the initial response to injury would provide a basis for determining whether the final adaptations are learned automatically or if they are the result of a lengthy training period in which various factors may affect their development. The purpose of the study was to evaluate the initial effects of ACL injury and reconstruction surgery on joint kinematics, kinetics, and energetics, during walking. Injured limbs from nine subjects with ACL injury were tested 2 wk after injury, and 3 and 5 wk after surgery. Ten healthy subjects were tested. Kinematic and ground reaction data were collected and combined with inverse dynamics to calculate the joint torques and powers. A knee extensor torque throughout most of stance was observed in the injured limbs at all test sessions. This result was in conflict with previous observations of reduced extensor torque or a flexor torque in rehabilitated patients with ACL reconstruction and patients with ACL deficiency. This result also differed from the typical midstance extensor then flexor torque in healthy control subjects. Trend analysis showed a significant (P < 0.001) change in average position at the hip and knee, extensor angular impulse at the hip, and positive work done at the hip 3 wk after surgery followed by a partial rehabilitation at 5 wk after surgery. Power and work produced at the knee were reduced fivefold (P < 0.001) after 5 wk of rehabilitation and did not recover to pre-surgical levels. The existence of a long-lasting knee extensor torque 2 wk after injury indicated that the adaptation process to ACL deficiency is lengthy, requiring many gait cycles, and that numerous factors could be involved in learning the adaptations.     

Naming decline after left anterior temporal lobectomy correlates with pathological status of resected hippocampus

PURPOSE: To evaluate the determinants of postoperative change in visual confrontation naming ability and the differential sensitivity of two common tests of confrontation naming. METHODS: In a group of 99 patients undergoing lobectomy of the left, language-dominant anterior temporal lobe, we examined naming ability using two measures: the 60 item Boston Naming Test (BNT), and the Visual Naming (VN) subtest of the Multilingual Aphasia Examination (MAE). ATL entailed resection of lateral temporal lobe followed by microsurgical complete removal of hippocampus. Language mapping was not performed. The status of the resected hippocampus was graded on a scale 0-4 of hippocampal sclerosis (HS). A dichotomous grouping HS- (grades 0 and 1, n = 34) and HS+ (grades 3 and 4, n = 61) was effected. Age at surgery, age of epilepsy onset, sex, extent of lateral temporal resection, Full-Scale IQ (FSIQ), and preoperative naming scores were also examined as potential predictors of pre- versus postoperative naming change. RESULTS: Preoperative BNT and VN scores were significantly worse for HS+ than for HS- (BNT, p < 0.05; VN, p = 0.001). Postoperatively, BNT and VN scores significantly declined for HS- as compared with HS+ patients (p < 0.001). For individual risk, the 90th centile of reliable change index (RCI) was used. By this criterion, of the total sample, 39% evidenced decline on the BNT and 17% evidenced decline on the VN. Logistic regression analysis with backward elimination showed HS to be the only predictor of decline in BNT and HS and sex to be the only predictors of VN decline. Males were more at risk than females. Age, age at onset, extent of lateral resection, preoperative scores, and FSIQ were not predictors. Using age at onset as a proxy for HS+/HS- we calculated probabilities for naming decline for given onset age. CONCLUSIONS: Both preoperative and postoperative change in naming ability are associated with the pathological status of the hippocampus. The potential interpretations and implications of these findings are discussed.     

Shed mediastinal blood transfusion after cardiac operations: a cost-effectiveness analysis

BACKGROUND: Cardiac surgical patients consume a significant fraction of the annual volume of allogeneic blood transfused. Scavenged autologous blood may serve as a cost-effective means of conserving donated blood and avoiding transfusion-related complications. METHODS: This study examines 834 patients after cardiac operations at the University of Alabama Hospital. Data were collected on patients receiving unwashed, filtered, autologous transfusions from shed mediastinal drainage and those receiving allogeneic transfusions. The data were incorporated into clinical decision models; confidence intervals for parameters were estimated by bootstrapping sample statistics. Costs were estimated for transfusing both allogeneic and autologous blood. RESULTS: The study found a 54% reduction in transfusion risk or a mean reduction of 1.41 allogeneic units per case (95% confidence interval, 1.04 to 1.79 units). The process saved between $49 and $62 per case. CONCLUSIONS: The use of autologous blood has the potential to significantly reduce the costs and risks associated with transfusing allogeneic blood after cardiac operations.     

Prediction of postoperative pulmonary hemodynamics for the second lobectomy after the contralateral lobectomy

We presented 7 cases who were performed the second lobectomy for the second lung cancer after the first successful lobectomy on the contralateral lung (3 cases for right upper lobectomy + left lower lobectomy and 4 cases for right upper lobectomy + left lower lobectomy). In 6 patients, the predicted postoperative FEV1 estimated by multiplying the preoperative FEV1 by the fraction of perfusion to the contralateral lung was less than 800 ml/m2BSA, which is our first cut-off for identifying lung resection candidates. Unilateral pulmonary arterial occlusion test (UPAO) revealed that total pulmonary vascular resistance (TPVRI) in 3 of those 6 patients was lower than 700 dyne.sec.cm-5/m2BSA, our second cut-off for lung resection. More precise postlobectomy pulmonary hemodynamics in another 3 of those 6 patients were then estimated by adapting selective pulmonary occlusion test (SPAO). Since TPVRI during SPAO was lower than the cut-off value, it was suggested that second lobectomy would be feasible with low incidence of post operative cardiopulmonary complication. There was no serious complications in all 7 cases during their postoperative course. We believe that more precise prediction of postoperative pulmonary hemodynamics by adapting UPAO and SPAO could be one of the tools to minimumize postoperative cardiopulmonary complications in those patients needed second lobectomy for the second lung cancer after the first successful lobectomy on the contralateral lung even though their impaired lung fung function.     

Uterine lymphoma: sonographic, Doppler, and CT findings before and after chemotherapy

We studied the performance of the CARDIAC STATus, a new rapid, easy to perform qualitative whole blood bedside test for detection of elevated CK-MB and myoglobin in the emergency room. Blood samples from 182 consecutive patients with chest pain were drawn on admission and at five and seven hours after the onset of symptoms. The CARDIAC STATus tests were performed by coronary care unit nurses and, independently, by a trained laboratory technician. The results were compared with quantitative assays for CK-MB mass and myoglobin. At the end of the study, a second test series using a new lot number of cartridges was performed on the same blood samples because of possible elution buffer contamination. Nurses produced more false negative results than the technician (CK-MB 43 vs. 27 %, p=0.01, myoglobin 31 vs. 13%, p<0.0001), but the technician produced more false positive myoglobin results (9.3 vs. 5.5%, p=0.0001). In the second test series, the nurses produced significantly fewer false negative tests both for CK-MB (19%, p<0.0001) and myoglobin (13%, p=0.0002). The false negative rate for the technician was not different between the first and the second test series. The CARDIAC STATus yields a substantial number of false negative results both for CK-MB and myoglobin when compared to a quantitative assay, and therefore at present has limited value for ruling out an acute myocardial infarction.     

Coronal CT of the paranasal sinuses before and after functional endoscopic sinus surgery

Coronal CT of the paranasal sinuses and the ostiomeatal complex (OMC) was performed before and 12 months after bilateral functional endoscopic sinus surgery (FESS) in 30 patients with sinusitis and 12 patients with nasal polyposis. The extent of sinus mucosal thickening was graded, and the patency of the OMC was evaluated. After FESS, the percentage of open OMCs had increased from 42% to 83% in the sinusitis group, and from 8% to 45% in the polyposis group. There was only a small improvement in mucosal score in sinuses with opened OMC, so that the overall extent of sinus opacification before and after FESS was almost the same. Despite this, 91% of the patients reported clinical relief of symptoms. Preoperative coronal CT of the paranasal sinuses serves as an anatomical map for the surgeon, but there is no benefit of routine postoperative CT.     

CT and MR findings of posterior mediastinal panniculitis

There are few reports of anterior communicating artery aneurysms causing visual symptoms, and penetration of the optic chiasm by such aneurysms has not been reported. A 40-year-old man presented with the abrupt onset of left homonymous hemianopsia, right visual acuity disturbance (finger counting), and slight headache. Angiography disclosed a 7-mm anterior communicating artery aneurysm projecting inferiorly. After the neck of the aneurysm was clipped, the dome of the aneurysm was resected. The operation confirmed that the aneurysm had penetrated the right half of the optic chiasm and the thrombosed dome had also compressed the right optic tract. Although the aneurysm was successfully clipped, the visual disturbance persisted after surgery, suggesting that the damage to the visual pathways by aneurysm penetration was irreversible in this case.     

Influence of head trauma on outcome following anterior temporal lobectomy

BACKGROUND: There is controversy in the literature regarding the importance of risk factors in developing epilepsy and seizure outcome following anterior temporal lobectomy. Some of the existing studies may be biased because of patient selection and limitations in determining predisposition. OBJECTIVE: To investigate the role of risk factors for epilepsy in determining outcome following anterior temporal lobectomy. PATIENTS AND METHODS: We identified 102 patients in a consecutive surgery series for epilepsy from a tertiary center with a minimum of 1-year postoperative follow-up. Risk factors for epilepsy were determined prospectively on at least 3 occasions before anterior temporal lobectomy. Risk factors investigated were a history of febrile convulsions, family history of epilepsy, significant head trauma, history of meningitis, history of encephalitis, or significant perinatal insult. Foreign tissue lesions on magnetic resonance imaging was also included if an anterior temporal lobectomy was performed for presumed dual pathologic findings (hippocampus and lesion). Outcome was determined using Engel's classification. For statistical analysis we used successive logistic regression analysis, chi(2) test, Fisher exact test, and t test. RESULTS: Of the 102 patients, 13 had no identified risk factor for epilepsy, 49 had 1 identified risk factor, and 40 had more than 1. Frequencies were 39 febrile convulsions (15 complex febrile convulsions), 29 head trauma, 22 with lesions seen on magnetic resonance imaging, 12 history of meningitis, 2 history of encephalitis, 19 family history of epilepsy, and 4 perinatal insult. Seventy-one (70%) were classified as Engel's class I, with 56 patients continuously free of seizures at follow-up. Those without risk factor were as likely to be rendered free of seizures following anterior temporal lobectomy as those with a risk factor (P = .27). No risk factor alone or in combination was correlated with complete freedom from seizures following anterior temporal lobectomy, but the presence of head trauma, alone or in combination, was correlated with continued seizures following anterior temporal lobectomy (P = .03; odds ratio, 2.6). Better outcomes were not seen in those with head trauma before the age of 5 years (P = .57). These findings did not change if all those with lesions on magnetic resonance imaging were excluded in the analysis. Those with a history of head trauma were as likely to have pathologic evidence of mesial temporal sclerosis as others (P = .82). CONCLUSIONS: Patients with a history of significant head trauma are less likely to become free of seizures following anterior temporal lobectomy. No other risk factor correlated with a statistically significant greater or lesser chance of freedom from seizures. This information may be used in preoperative counseling of patients.     

CT evaluation of the anterior mediastinum: spectrum of disease

Computed tomography (CT) is the study of choice for evaluating disease in the anterior mediastinum. Mediastinal CT is usually performed with intravenously administered contrast material, and spiral CT is the preferred technique for evaluating a mediastinal mass. CT demonstrates thymic hyperplasia and thymic cysts and can help differentiate thymoma and thymic Hodgkin lymphoma. It is also useful in staging Hodgkin lymphoma and non-Hodgkin lymphoma. In thyroid malignancy, CT can depict mediastinal extension and lymphadenopathy; it also allows detection of goiter and ectopic parathyroid glands. Germ cell tumors such as teratoma and seminoma have characteristic appearances at CT. CT can also demonstrate miscellaneous mediastinal masses, such as lymphangioma, hematoma, those due to fibrosing mediastinitis, and pericardial cysts. Adenopathy due to tuberculosis or sarcoidosis is evident at CT, as is osteomyelitis due to a postsurgical abscess. Finally, CT features can suggest the pathologic origin of metastasis in the anterior mediastinum.     

Imaging of mediastinal lymph nodes: CT, MR, and FDG PET

The evaluation of mediastinal lymph nodes is an important aspect of staging in patients with non-small cell lung cancer. Anatomic imaging of lymph nodes with computed tomography (CT) and magnetic resonance (MR) imaging has been limited by the relatively low sensitivity and specificity of these techniques. Advances in physiologic imaging of mediastinal lymph nodes with 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) have resulted in improved diagnostic accuracy in the determination of nodal status. Despite the limitations of CT, this technique still plays an important role by aiding in the selection of the most appropriate procedure for staging, by guiding biopsy, and by providing anatomic information for visual correlation with FDG PET images. At present, anatomic MR imaging of lymph nodes is primarily a problem-solving tool for cases with inconclusive CT results. Physiologic MR imaging with iron oxide is an exciting area of investigation, and the accuracy of this technique is being assessed in clinical trials. Anatomic and physiologic imaging techniques should be considered complementary rather than competitive imaging strategies.     

Responses of mechanoreceptor neurons in the cat knee joint capsule before and after anterior cruciate ligament transection

It is known that afferent neurons play a protective role in knees made unstable by transection of the anterior cruciate ligament. However, it is not known whether cutting the anterior cruciate ligament has an effect on the response of the sensory neurons that innervate the joint. In this study, the responsiveness (activation threshold and position sensitivity) of single, mechanically sensitive afferent neurons from the cat knee was evaluated by a series of extension, internal, and external rotations. The anterior cruciate ligament then was cut and the same procedure was repeated. Transection of the ligament increased joint laxity for all types of rotation. The responsiveness of the neurons was not changed significantly by cutting the ligament (p > 0.05). Therefore, capsule afferents continue to behave normally in joints in which the anterior cruciate ligament has been transected.     

Sonographic guidance of mediastinal biopsy: an effective alternative to CT guidance

OBJECTIVE: Our objective was to determine the diagnostic and cost efficacy of sonographically guided mediastinal biopsy as an alternative to CT-guided mediastinal biopsy and to review our biopsy triage experience in switching from CT to sonography. CONCLUSION: Sonography is as safe and accurate as CT and is 25% less costly than CT. Sonography proved particularly valuable for identifying vessels and perfused tissue and for permitting upright biopsy positions in dyspneic patients. When using our triage criteria, radiologists should find sonographically guided mediastinal biopsy to be an attractive alternative to CT-guided mediastinal biopsy in most patients.     

Visual confrontation naming following left anterior temporal lobectomy: A comparison of surgical approaches.

Change in visual confrontation naming was examined following left (speech dominant) anterior temporal lobectomy (ATL) as a function of surgical technique and patient characteristics. Two hundred seventeen patients with intractable left temporal lobe epilepsy were selected according to standard criteria across 8 centers, and combined into 4 surgical approaches to ATL: (a) tailored resections with intraoperative mapping of eloquent cortex, (b) tailored resections with extraoperative mapping, (c) standard resections with sparing of superior temporal gyrus, and (d) standard resections including excision of superior temporal gyrus. Changes in visual confrontation naming were examined with an index of reliable change derived from an independent sample of 90 nonsurgical patients with complex partial seizures. Results showed significant decline in visual confrontation naming following left ATL, regardless of surgical technique. Across surgical approaches, the risk for decline in visual confrontation naming was associated with a later age of seizure onset and more extensive resection of lateral temporal neocortex. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Severe amnesia: an usual late complication after temporal lobectomy

A patient developed the severe amnesic syndrome 8 years after temporal lobe surgery for epilepsy. He underwent left temporal lobectomy (6 cm, 43.5 g; hippocampal sclerosis) aged 19, and remained seizure free for 8 years until a convulsion followed a head injury. He became severely amnesic after a fourth convulsion 16 months later. He was right-handed, pre-operative IQ was average, verbal memory poor and non-verbal memory normal. Post-operatively, these were unchanged. After the first post-operative seizure he began professional training. After onset of amnesia IQ was unchanged, anterograde memory severely impaired and retrograde amnesia dense for at least 16 months. He died 2 years later. Magnetic resonance imaging before amnesia showed absence of anterior left temporal lobe, atrophy of left fornix and mamillary body, and normal right temporal lobe. Four months after onset of amnesia, right hippocampal volume had reduced by 36%. Autopsy showed: previous left temporal lobectomy with absence of left amygdala and hippocampus, atrophy of fornix and mamillary body; neuronal loss in the right hippocampus, severe in CA1 and CA4; intact right amygdala and parahippocampal gyrus; recent diffuse damage associated with cause of death. A convulsion can cause severe hippocampal damage in adult life. Hippocampal zones CA1 and/or CA4 are critical for maintaining memory and the amygdala and parahippocampal gyrus cortex alone cannot support acquisition of new memories.