Bio

Clinical Focus


  • Neurological Surgery
  • Neurosurgery, Pediatric
  • Neurosurgery

Academic Appointments


Administrative Appointments


  • Associate Chair, Stanford University School of Medicine - Neurosurgery (2004 - Present)
  • Associate Dean for Graduate Medical Education, Stanford School of Medicine (1996 - 2011)
  • Chief of Staff, Stanford Hospital and Clinics (1996 - 2008)

Professional Education


  • Residency:Stanford University School of Medicine (1984) CA
  • Board Certification: Neurological Surgery, American Board of Neurological Surgery (1986)
  • Internship:Stanford University School of Medicine (1979) CA
  • Medical Education:University of Michigan School of Medicine (1978) MI
  • B.A., Univeristy of Michigan, Biomedical Sciences (1975)
  • M.D., University of Michigan, Medicine (1978)

Research & Scholarship

Current Research and Scholarly Interests


I have clinical research interests in the surgical treatment of epilepsy. I am also interested in new developments in the treatment of craniosynostosis a congenital abnormality of infant's skulls

Teaching

2013-14 Courses


Publications

Journal Articles


  • Rehospitalization and emergency department use rates before and after vagus nerve stimulation for epilepsy: use of state databases to provide longitudinal data across multiple clinical settings. Neuromodulation Kalanithi, P. S., Arrigo, R. T., Tran, P., Gephart, M. H., Shuer, L., Fisher, R., Boakye, M. 2014; 17 (1): 60-65

    Abstract

    OBJECTIVES: Data regarding rehospitalization and emergency department (ED) visits following vagus nerve stimulation (VNS) present data analysis challenges. We present a method that uses California's multiple databases to more completely assay VNS efficacy. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project's California Inpatient and Ambulatory Surgery databases were assayed for all VNS surgeries from 2005 to 2009. Patients were selected by epilepsy diagnosis codes and VNS procedure codes. Patients (total N = 629) were tracked across multiple databases using unique identifiers. Thirty-day and one-year post-implantation rates of VNS complication and healthcare visits were abstracted, along with one-year preoperative hospital and ED use. Statistics included correction for multiple comparisons. RESULTS: The one-year reoperation rate for adult patients (N = 536) was 3.9%; during the second year, an additional 3.2% of patients had reoperations. Within the first 30 days, <2% of patients experienced a complication. Four percent of patients were readmitted to a hospital, and 11.6% of patients visited an ED. The most common reason for rehospitalization or ED visit was seizure. In the first year after VNS, total seizure-related visits (hospitalization and ED) were 17% lower (2.12 visits per year to 1.71; p = 0.03). In the second year following VNS, seizure-related visits were 42% lower (2.21 visits per year to 1.27, p = 0.01). Pediatric patients (N = 93) had comparable results. CONCLUSIONS: VNS surgery has low rates of complications and reoperations and is associated with reduced incidence of seizure-related ED visits and hospital admissions in the first and second postoperative years.

    View details for DOI 10.1111/ner.12051

    View details for PubMedID 23551457

  • Neurosurgical interventions for spondyloepiphyseal dysplasia congenita: clinical presentation and assessment of the literature. World neurosurgery Veeravagu, A., Lad, S. P., Camara-Quintana, J. Q., Jiang, B., Shuer, L. 2013; 80 (3-4): 437 e1-8

    Abstract

    BACKGROUND: Spondyloepiphyseal dysplasia (SED) is a rare disease that causes vertebral abnormalities and short-trunk dwarfism. The two forms of SED are congenita and tarda. Each form arises in a genetically distinct fashion and manifests with a different set of complications. SED congenita is more severe, and patients usually display atlantoaxial instability and odontoid hypoplasia. Patients often have various neurologic deficits caused by compression of the spinal cord. The region most affected is the craniovertebral junction (CVJ). METHODS: A review of the PubMed Database, 1970 to the present, was performed using the search term "spondyloepiphyseal dysplasia" and limited to English-language articles. The search identified 22 articles discussing COL2A1 gene mutations and 10 clinical articles describing patients with SED and associated spinal abnormalities. RESULTS: Findings from the literature concerning diagnosis, presenting symptoms, and intervention taken are discussed. Additionally, a patient with a diagnosis of SED congenita who presented with bilateral hand numbness is described. The patient underwent a suboccipital craniotomy; posterior decompression of the foramen magnum, the arch of C1, and the lamina of C2; and instrumented fusion of C1-3 to relieve his symptoms. CONCLUSIONS: In this article, the authors survey the current literature surrounding neurosurgical interventions and present an algorithm for treatment.

    View details for DOI 10.1016/j.wneu.2012.01.030

    View details for PubMedID 22381876

  • Fungal infection of a ventriculoperitoneal shunt: histoplasmosis diagnosis and treatment. World neurosurgery Veeravagu, A., Ludwig, C., Camara-Quintana, J. Q., Jiang, B., Lad, N., Shuer, L. 2013; 80 (1-2): 222 e5-222 e13

    Abstract

    BACKGROUND: Histoplasmosis is a fungal disease caused by Histoplasma capsulatum, commonly found in the Americas, and Histoplasma duboisii, located in Africa. In the United States, H. capsulatum is prevalent in the Ohio and Mississippi river valleys. In rare circumstances, central nervous system (CNS) histoplasmosis infection can be caused by shunt placement. We present a case report of a 45-year-old woman in whom CNS histoplasmosis developed after having a ventriculoperitoneal (VP) shunt placed for communicating hydrocephalus. A review of the literature on fungal infections after CNS shunt placement as well as treatment options for this subset of patients was undertaken. METHODS: The PubMed database current to 1958 was filtered and limited to English-language articles. Fifty-eight articles were selected for review based on evidence of information regarding the fungal organism responsible for shunt infection, symptoms, treatment, and/or outcomes. Also included in this review is our case study. RESULTS: A thorough analysis of the PubMed database revealed 58 reported cases of CNS shunt-related fungal infections in the English-language medical literature as well as 7 therapeutic agents used to treat patients in whom postshunt fungal infections developed. CONCLUSIONS: We describe the steps in diagnosis of histoplasmosis after shunt placement, provide an effective therapeutic regimen, and review the present understanding of CNS fungal infections. The medical literature was surveyed to compare and analyze various CNS fungal infections that can arise from shunt placement as well as treatments rendered.

    View details for DOI 10.1016/j.wneu.2012.12.016

    View details for PubMedID 23247021

  • Predictors of Clinical and Angiographic Outcome After Surgical or Endovascular Therapy of Very Large and Giant Intracranial Aneurysms NEUROSURGERY Darsaut, T. E., Darsaut, N. M., Chang, S. D., Silverberg, G. D., Shuer, L. M., Tian, L., Dodd, R. L., Do, H. M., Marks, M. P., Steinberg, G. K. 2011; 68 (4): 903-915

    Abstract

    Risk factors for poor outcome in the treatment of very large (?20-24 mm) and giant (?25 mm) intracranial aneurysms remain incompletely defined.To present an aggregate clinical series detailing a 24-year experience with very large and giant aneurysms to identify and assess the relative importance of various patient, aneurysm, and treatment-specific characteristics associated with clinical and angiographic outcomes.The authors retrospectively identified 184 aneurysms measuring 20 mm or larger (85 very large, 99 giant) treated at Stanford University Medical Center between 1984 and 2008. Clinical data including age, presentation, and modified Rankin Scale (mRS) score were recorded, along with aneurysm size, location, and morphology. Type of treatment was noted and clinical outcome measured using the mRS score at final follow-up. Angiographic outcomes were completely occluded, occluded with residual neck, partly obliterated, or patent with modified flow.After multivariate analysis, risk factors for poor clinical outcome included a baseline mRS score of 2 or higher (odds ratio [OR], 0.23; 95% confidence interval [CI]: 0.08-0.66; P = .01), aneurysm size of 25 mm or larger (OR, 3.32; 95% CI: 1.51-7.28; P < .01), and posterior circulation location (OR, 0.18; 95% CI: 0.07-0.43; P < .01). Risk factors for incomplete angiographic obliteration included fusiform morphology (OR, 0.25; 95% CI: 0.10-0.66; P < .01), posterior circulation location (OR, 0.33; 95% CI: 0.13-0.83; P = .02), and endovascular treatment (OR, 0.14; 95% CI: 0.06-0.32; P < .01). Patients with incompletely occluded aneurysms experienced higher rates of posttreatment subarachnoid hemorrhage and had increased mortality compared with those with completely obliterated aneurysms.Our results suggest that patients with poor baseline functional status, giant aneurysms, and aneurysms in the posterior circulation had a significantly higher proportion of poor outcomes at final follow-up. Fusiform morphology, posterior circulation location, and endovascular treatment were risk factors for incompletely obliterated aneurysms.

    View details for DOI 10.1227/NEU.0b013e3182098ad0

    View details for Web of Science ID 000288123100038

    View details for PubMedID 21221025

  • Episodic encephalopathy due to an occult spinal vascular malformation complicated by superficial siderosis CLINICAL NEUROLOGY AND NEUROSURGERY Gonella, M. C., Fischbein, N. J., Lane, B., Shuer, L. M., Greicius, M. D. 2010; 112 (1): 82-84

    Abstract

    Superficial siderosis (SS) of the central nervous system is a rare condition caused by chronic subarachnoid hemorrhage. Clinical manifestations typically include sensorineural hearing loss and cerebellar ataxia. Recurrent episodic encephalopathy in the setting of SS has not been reported. We describe a unique case of SS in a 67-year-old man with an 8-year history of episodic encephalopathy associated with headache and vomiting. The patient also had a history of progressive dementia, ataxia, and myelopathy. A diagnosis of superficial siderosis was made after magnetic resonance gradient-echo images showed diffuse hemosiderin staining over the cerebellum and cerebral convexities. No intracerebral source of hemorrhage was identified. The patient therefore underwent gadolinium-enhanced spinal MRI which suggested a possible vascular malformation. A therapeutic laminectomy subsequently confirmed an arteriovenous fistula which was resected. In SS, there are often long delays between symptom onset and definitive diagnosis. Early identification is facilitated by magnetic resonance imaging with gradient-echo sequences. When no source of hemorrhage is identified intracranially, then total spinal cord imaging is indicated to assess for an occult source of hemorrhage as occurred in our case.

    View details for DOI 10.1016/j.clineuro.2009.09.005

    View details for Web of Science ID 000273933700017

    View details for PubMedID 19857921

  • Two-year-old girl with cervicomedullary junction stenosis and an unknown type of skeletal dysplasia JOURNAL OF NEUROSURGERY-PEDIATRICS Cheshier, S. H., Kalani, M. Y., Pendakaur, A., Higgins, D., Kahn, D., Shendel, S., Shuer, L. 2008; 2 (3): 200-202

    Abstract

    The authors present a novel case of skeletal dysplasia in a 2.8-year-old girl. The patient presented with progressive lower cranial nerve palsy and myelopathy due to constriction at the cervicomedullary junction caused by overgrowth of the occipital bone of the foramen magnum and the C-1. She also had prominent bone overgrowth of the superior orbital ridges, resulting in excessive stretching of periorbital skin and an inability to fully close her eyes.

    View details for DOI 10.3171/PED/2008/2/9/200

    View details for Web of Science ID 000258903800010

    View details for PubMedID 18759602

  • Intracerebral hemorrhage caused by cerebral amyloid angiopathy in a 53-year-old man JOURNAL OF NEUROLOGY Campbell, D. M., Bruins, S., Vogel, H., Shuer, L. M., Wijman, C. A. 2008; 255 (4): 597-598

    View details for DOI 10.1007/s00415-008-0742-9

    View details for Web of Science ID 000255255300021

    View details for PubMedID 18227992

  • Primary paraspinal leiomyosarcoma invading the cervical spinal canal successfully treated with surgery, radiotherapy, and chemotherapy - Case report JOURNAL OF NEUROSURGERY-SPINE Lehman, N. L., Jacobs, C. D., Holsten, P. A., Jaikumar, S., Lehman, T. D., Gibbs, I. C., Shuer, L. M. 2007; 6 (5): 441-446

    Abstract

    A primary paraspinal leiomyosarcoma invading the spine is an exceedingly rare neoplasm that may clinically mimic a schwannoma. The authors report a case involving a 45-year-old man with a primary leiomyosarcoma of the cervical paraspinal musculature that invaded the spinal canal at C1-2 and subsequently metastasized to the lungs and pancreas. Aggressive treatment consisting of resection of the primary tumor, adjunctive radiation therapy and chemotherapy, and surgical debulking of metastatic disease resulted in local tumor control at the primary site and long-term survival of the patient.

    View details for Web of Science ID 000246048100011

    View details for PubMedID 17542511

  • Comparison of endovascular and surface cooling during unruptured cerebral aneurysm repair NEUROSURGERY Steinberg, G. K., Ogilvy, C. S., Shuer, L. M., Connolly, E. S., Solomon, R. A., Lam, A., Kassell, N. F., Baker, C. J., Giannotta, S. L., Cockroft, K. M., Bell-Stephens, T. E., Allgren, R. L. 2004; 55 (2): 307-314

    Abstract

    To compare endovascular versus surface methods for the induction and reversal of hypothermia during neurosurgery in a multicenter, prospective, randomized study.Patients undergoing elective open craniotomy for repair of an unruptured cerebral aneurysm (n = 153) were randomly assigned (2:1) to undergo whole-body hypothermia to 33 degrees C, either with an endovascular cooling device placed in the inferior vena cava via the femoral vein (n = 92) or with a surface convective air blanket (n = 61). Active rewarming was accomplished using the same devices.Cooling rates in endovascular and surface blanket groups averaged 4.77 and 0.87 degrees C/h, respectively (P < 0.001). When the first temporary arterial or aneurysm clip was placed, 99% of endovascular patients and 20% of surface blanket patients had reached the target of 33 degrees C (P < 0.001). Obese patients were cooled efficiently with the endovascular approach (3.56 degrees C/h). Rewarming rates averaged 1.88 degrees C/h for endovascular patients and 0.69 degrees C/h for surface blanket patients (P < 0.001). By the end of surgery, 89 and 53% of these patients, respectively, had rewarmed to at least 35 degrees C (P < 0.001). On leaving the operating room, 14% of endovascular patients and 28% of surface blanket patients were still intubated (P = 0.035). The overall safety of the two procedures was comparable. No clinically significant catheter-related thrombotic, bleeding, or infectious complications were reported in the endovascular group.Endovascular cooling provided superior induction, maintenance, and reversal of hypothermia compared with the surface blanket, without an increase in complications. Endovascular cooling may have clinical benefit for patients undergoing cerebrovascular surgery, as well as patients with acute stroke, head injury, or acute myocardial infarction.

    View details for DOI 10.1227/01.NEU.0000129683.99430.8C

    View details for Web of Science ID 000223191500008

    View details for PubMedID 15271236

  • Current source density analysis of synaptic generators of human interictal spike Stereotactic and functional neurosurgery Heit, G., Ulbert, I., Halgren, E., Karmos, G., Shuer, L. 1999; 73 (1-4): 116

    View details for PubMedID 10853114

  • Intracranial ictal recordings in mesial frontal lobe epilepsy JOURNAL OF CLINICAL NEUROPHYSIOLOGY Toczek, M. T., Morrell, M. J., Risinger, M. W., Shuer, L. 1997; 14 (6): 499-506

    Abstract

    Localization of ictal onset in patients with medically refractory frontal lobe epilepsy is challenging even with intracranial monitoring. We present a series of nine patients with presumed mesial frontal lobe epilepsy in whom successful localization of ictal onset was achieved in most cases. Intracranial electrodes were placed over cingulate and supplementary motor cortex bilaterally, with additional electrodes placed over lateral and inferior frontal lobes as part of an evaluation for epilepsy surgery. Localization of the ictal onset was clearly defined in seven of nine patients and was characterized by a pattern of lower amplitude beta/gamma range frequencies noted in one to four adjacent electrodes arising from cingulate cortex or supplementary motor cortex in six patients. In the remaining patient, ictal onset was characterized by periodic high amplitude spike and slow-wave discharges evolving into a higher voltage faster rhythm. Electrographic onset occurred coincident with or preceded clinical findings. Ictal pattern also did not demonstrate a widespread propagation pattern in most of the recordings in which ictal onset was well localized. Precise localization of ictal onset within the mesial frontal lobe is possible. Rapid propagation to regions within and outside the frontal lobe does not always occur.

    View details for Web of Science ID 000077365900006

    View details for PubMedID 9458056

  • Central neurocytoma: One associated with a fourth ventricular PNET/medulloblastoma and the second mixed with adipose tissue HUMAN PATHOLOGY Horoupian, D. S., Shuster, D. L., KAARSOOHERRICK, M., Shuer, L. M. 1997; 28 (9): 1111-1114

    Abstract

    We report two cases of central neurocytoma; one located in the right lateral ventricle and associated with a distinctly separate primitive neuroectodermal tumor (PNET)/medulloblastoma of the fourth ventricle, and the other admixed with fat cells and arising from the left lateral and third ventricles with extension into the corpus callosum. We discuss that concurrent occurrences of PNET and adipose tissue are not fortuitous events, but an evidence that neurocytomas and PNETs originate in the residual germinal pool from common progenitor cell rests recapitulating features of developing neurons and with a potential for mesenchymal differentiation.

    View details for Web of Science ID A1997XY09000017

    View details for PubMedID 9308737

  • MULTIPLE-SUTURE SYNOSTOSIS SUBSEQUENT TO VENTRICULAR SHUNTING PLASTIC AND RECONSTRUCTIVE SURGERY Schendel, S. A., Shuer, L. M. 1994; 93 (5): 1073-1077

    View details for Web of Science ID A1994ND65800028

    View details for PubMedID 8134467

  • PLEOMORPHIC GRANULAR-CELL ASTROCYTOMA OF THE PINEAL-GLAND CANCER Snipes, G. J., Horoupian, D. S., Shuer, L. M., Silverberg, G. D. 1992; 70 (8): 2159-2165

    Abstract

    Primary neoplasms of the pineal gland are uncommon. Two patients with unusual primary pineal tumors that had similar distinctive histologic features are reported.The surgically resected neoplastic pineal tissue from these patients were examined by light microscopy, immunohistochemistry, and electron microscopy and correlated with the patients' clinical course.These pineal tumors consisted of a mixture of spindle-shaped cells with fibrillated cell processes and many large lipidized and/or granular pleomorphic cells, some of which were multinucleated. These two tumors superficially resembled pleomorphic xanthoastrocytoma and granular cell tumors of the central nervous system. The pleomorphic tumor cells expressed glial fibrillary acidic protein and some also produced retinal S-antigen, a marker for retinal photoreceptor cells. Long-term follow-up (8 years) on one of these patients suggested a relatively "benign" clinical course.It is possible that this newly described tumor may be a distinct subset of pineal gland neoplasias with a favorable biologic behavior despite the histologic features that would suggest otherwise.

    View details for Web of Science ID A1992JT85900024

    View details for PubMedID 1394046

  • Maternally administered esmolol decreases fetal as well as maternal heart rate. Journal of clinical anesthesia LARSON, C. P., Shuer, L. M., Cohen, S. E. 1990; 2 (6): 427-429

    Abstract

    Fetal heart rate was monitored during the administration of esmolol 100 micrograms/kg/min to a 36-year-old, 29-week pregnant woman who was undergoing craniotomy for surgical treatment of six cerebral aneurysms. During stable general anesthesia, sodium nitroprusside was administered to induce moderate hypotension; at the same time, esmolol was infused to control maternal tachycardia. Within minutes after starting the esmolol infusion, maternal heart rate decreased from 100 beats/minute to 65 beats/minute, and fetal heart rate decreased from 160 beats/minute to 130 beats/minute. Upon termination of the infusion 3 hours later, both maternal and fetal heart rate returned to preinfusion values. No adverse effects of esmolol infusion were noted in the mother or fetus.

    View details for PubMedID 1980197

  • OCCULT VASCULAR MALFORMATIONS OF THE OPTIC CHIASM - MAGNETIC-RESONANCE-IMAGING DIAGNOSIS AND SURGICAL LASER RESECTION NEUROSURGERY Steinberg, G. K., Marks, M. P., Shuer, L. M., SOGG, R. L., Enzmann, D. R., Silverberg, G. D. 1990; 27 (3): 466-470

    Abstract

    Angiographically occult vascular malformations of the optic nerve and chiasm are extremely rare. Before the advent of magnetic resonance imaging (MRI), it was difficult to diagnose these lesions preoperatively. We report MRI scan findings of optic chiasm cavernous angiomas in two patients with chiasmal syndrome. MRI was useful in localizing the vascular malformation and delineating its characteristics, especially chronic hemorrhage. One patient underwent biopsy of the lesion. The other patient underwent complete microsurgical resection of the malformation with the carbon dioxide laser with preservation of vision. Occult vascular malformations of the optic nerve and chiasm may be a more common cause of visual deterioration than previously recognized. The MRI scan is the imaging modality of choice for diagnosing and following these lesions. In certain patients, these vascular malformations may be amenable to complete surgical removal with stabilization or improvement of visual function.

    View details for Web of Science ID A1990DV49200023

    View details for PubMedID 2234344

  • STEREOTAXIC HEAVY-CHARGED-PARTICLE BRAGG-PEAK RADIATION FOR INTRACRANIAL ARTERIOVENOUS-MALFORMATIONS NEW ENGLAND JOURNAL OF MEDICINE Steinberg, G. K., FABRIKANT, J. I., Marks, M. P., Levy, R. P., Frankel, K. A., Phillips, M. H., Shuer, L. M., Silverberg, G. D. 1990; 323 (2): 96-101

    Abstract

    Heavy-charged-particle radiation has several advantages over protons and photons for the treatment of intracranial lesions; it has an improved physical distribution of the dose deep in tissue, a small angle of lateral scattering, and a sharp distal falloff of the dose.We present detailed clinical and radiologic follow-up in 86 patients with symptomatic but surgically inaccessible cerebral arteriovenous malformations that were treated with stereotactic helium-ion Bragg-peak radiation. The doses ranged from 8.8 to 34.6 Gy delivered to volumes of tissue of 0.3 to 70 cm3.Two years after radiation treatment, the rate of complete obliteration of the lesions, as detected angiographically, was 94 percent for lesions smaller than 4 cm3, 75 percent for those of 4 to 25 cm3, and 39 percent for those larger than 25 cm3. After three years, the rates of obliteration were 100, 95, and 70 percent, respectively. Major neurologic complications occurred in 10 patients (12 percent), of whom 8 had permanent deficits. All these complications occurred in the initial stage of the protocol, before the maximal dose of radiation was reduced to 19.2 Gy. In addition, hemorrhage occurred in 10 patients from residual malformations between 4 and 34 months after treatment. Seizures and headaches were less severe in 63 percent of the 35 and 68 percent of the 40 patients, respectively, who had them initially.Given the natural history of these inaccessible lesions and the high risks of surgery, we conclude that heavy-charged-particle radiation is an effective therapy for symptomatic, surgically inaccessible intracranial arteriovenous malformations. The current procedure has two disadvantages: a prolonged latency period before complete obliteration of the vascular lesion and a small risk of serious neurologic complications.

    View details for Web of Science ID A1990DM62600005

    View details for PubMedID 2359429

  • EFFECT OF HYPERGLYCEMIA ON NEURONAL CHANGES IN A RABBIT MODEL OF FOCAL CEREBRAL-ISCHEMIA STROKE KRAFT, S. A., Larson, C. P., Shuer, L. M., Steinberg, G. K., BENSON, G. V., Pearl, R. G. 1990; 21 (3): 447-450

    Abstract

    In clinical medicine, cerebral ischemia is frequently due to a focal, rather than global, insult. The effect of hyperglycemia in focal cerebral ischemia is not well defined. We studied the effect of hyperglycemia on neuropathologic changes in a rabbit model of focal cerebral ischemia. Rabbits were randomized to receive saline (n = 12) or glucose (n = 12) infusions. The left anterior cerebral and left internal carotid arteries were clipped after the infusion began. After 6 hours of occlusion, the area of severe ischemic neuronal damage in the left neocortex and striatum on two standard sections of brain was calculated and expressed as a percentage of the total area of the left cortex or striatum. The mean +/- SEM cortical area of severe ischemic neuronal damage was 22.1 +/- 2.8% in the glucose-treated rabbits and 34.0 +/- 4.6% in the saline-treated rabbits (p less than 0.05). The cortical area of severe ischemic neuronal damage was inversely correlated with plasma glucose concentration at the time of arterial clipping (p less than 0.05). We conclude that hyperglycemia is associated with decreased histologic neuronal injury in this model of focal cerebral ischemia and may be protective when cerebral ischemia occurs from a focal insult.

    View details for Web of Science ID A1990CT20500015

    View details for PubMedID 2309269

  • HYPERGLYCEMIA DECREASES ACUTE NEURONAL ISCHEMIC CHANGES AFTER MIDDLE CEREBRAL-ARTERY OCCLUSION IN CATS STROKE ZASSLOW, M. A., Pearl, R. G., Shuer, L. M., Steinberg, G. K., LIEBERSON, R. E., Larson, C. P. 1989; 20 (4): 519-523

    Abstract

    Hyperglycemia has been reported to worsen the tolerance of the brain to ischemia, and it has therefore been recommended that patients undergoing neurosurgical procedures not receive glucose-containing solutions. However, whereas most animal studies have used global ischemia models, most neurosurgical procedures are associated with risks of focal rather than global ischemia. We therefore studied the effects of glucose administration in an animal model of focal cerebral ischemia. We anesthetized 20 cats with halothane (0.85% end tidal in oxygen), and a focal cerebral ischemic lesion was produced by clip ligation of the left middle cerebral artery using a transorbital approach. Hyperglycemia (10 cats, mean +/- SEM plasma glucose concentration 561 +/- 36 mg/dl) was established before ligation by infusion of 50% glucose in 0.45% saline; the control group (10 cats, mean +/- SEM plasma glucose concentration 209 +/- 28 mg/dl) received 0.45% saline only. Total fluid administered, mean arterial blood pressure, body temperature, and arterial blood gas values did not differ between the two groups 0, 2, and 6 hours after ligation. The cats were killed 6 hours after ligation, and the area of severe ischemic neuronal damage was determined by microscopic examination of a coronal section at the level of the optic chiasm. The mean +/- SEM area of left cortical severe ischemic neuronal damage was 12 +/- 2% of the left cortex in the hyperglycemic group compared with 28 +/- 5% in the control group (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1989U149900014

    View details for PubMedID 2929029

  • CORONARY VASOSPASM DURING PERCUTANEOUS TRIGEMINAL RHIZOTOMY ANAESTHESIA Swerdlow, B., Shuer, L., ZELCER, J. 1988; 43 (10): 861-863

    Abstract

    A case of myocardial infarction as a result of coronary vasospasm during percutaneous trigeminal rhizotomy is presented. Potential consequences of the profound sympathetic response during this procedure are discussed. Invasive haemodynamic monitoring as well as prophylaxis with nitrates and calcium antagonists may be useful in patients prone to coronary vasospasm who undergo this procedure.

    View details for Web of Science ID A1988Q368400009

    View details for PubMedID 3264468

  • PEEP DOES NOT AFFECT LEFT ATRIAL-RIGHT ATRIAL PRESSURE DIFFERENCE IN NEUROSURGICAL PATIENTS ANESTHESIOLOGY ZASSLOW, M. A., Pearl, R. G., Larson, C. P., Silverberg, G., SHUER, L. F. 1988; 68 (5): 760-763

    Abstract

    Positive end-expiratory pressure (PEEP) has been used to prevent and treat venous air embolism in patients in the seated position undergoing neurosurgical operations. However, the safety of PEEP has recently been questioned, because of concern that PEEP might increase right atrial pressure (RAP) more than left atrial pressure, thereby predisposing patients with a probe-patent foramen ovale to paradoxical air embolism. In a prior study in dogs, the authors found that to up 10 cm H2O PEEP did not affect the interatrial pressure difference. In the present study, the authors examined the effects of 0, 5, and 10 cm H2O PEEP in 12 anesthetized neurosurgical patients positioned both supine and seated prior to operation. Measurements were made of systemic arterial pressure, RAP, mean pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP), and cardiac output. PAWP was higher (average 2 mmHg) than RAP in all patients. PEEP increased RAP and PAWP in patients, both seated and supine (mean 3 mmHg at 10 cm H2O), but did not affect the PAWP-RAP difference. In an additional eight patients in the seated position, the authors examined the effects of 0, 10, and 20 cm H2O PEEP during operation. PEEP again increased PAWP and RAP, but did not significantly affect the PAWP-RAP difference. The PAWP-RAP difference became negative (-1 mmHg) in one patient with 20 cm H2O PEEP. The authors conclude that levels of PEEP up to 10 cm H2O do not alter the interatrial pressure difference in seated neurosurgical patients, and, therefore, would not predispose these patients to paradoxical air embolism.

    View details for Web of Science ID A1988N243200014

    View details for PubMedID 3285733

  • REDUCTION CRANIOPLASTY AND SEVERE HYPOTENSION ANESTHESIOLOGY Parsons, D., SAMUELS, S. I., Steinberg, G., Shuer, L. 1988; 68 (1): 145-146

    View details for Web of Science ID A1988L597700028

    View details for PubMedID 3337371

Conference Proceedings


  • Idiopathic giant-cell granulomatous hypophysitis - Report of a case with autopsy follow-up Wilson, J. D., Jacobs, M., Shuer, L., Atlas, S., Horoupian, D. S. DUSTRI-VERLAG DR KARL FEISTLE. 2000: 300-304

    Abstract

    Idiopathic granulomatous inflammation of the pituitary gland occurs rarely, and is usually identified as an incidental finding at autopsy. However, it may present during life as a mass lesion that clinically mimics other more common pituitary gland lesions. We report a 54-year-old woman presenting with acute onset diabetes insipidus whose MRI showed a 1.1 cm pituitary mass, with infundibular thickening and meningeal enhancement. Biopsy demonstrated granulomatous hypophysitis with multinucleate histiocytes. Special studies for infectious organisms were negative. The patient's disease progressed following biopsy, causing complete loss of vision in the right eye. This responded to high-dose steroids and local lowdose radiation. She later developed an acute inferior myocardial infarction. Laboratory tests failed to demonstrate an underlying autoimmune process. While recovering from this myocardial infarction, she succumbed to pulmonary embolism. Autopsy revealed moderate residual chronic infundibular inflammation. No evidence of systemic or residual pituitary granulomatous disease was identified. To the best of our knowledge, this is the first case of idiopathic granulomatous hypophysitis initially diagnosed by biopsy to have post-mortem neuropathologic examination.

    View details for Web of Science ID 000165329800007

    View details for PubMedID 11128623

  • STEREOTAXIC HELIUM ION BRAGG PEAK RADIOSURGERY FOR INTRACRANIAL ARTERIOVENOUS-MALFORMATIONS - DETAILED CLINICAL AND NEURORADIOLOGICAL OUTCOME Steinberg, G. K., FABRIKANT, J. I., Marks, M. P., Levy, R. P., Frankel, K. A., Phillips, M. H., Shuer, L. M., Silverberg, G. D. KARGER. 1991: 36-49

    Abstract

    89 patients with angiographically documented arteriovenous malformations were treated with helium ion Bragg peak radiation. The rate of complete angiographic obliteration 2 years after radiation was 94% in those lesions smaller than 4 cm3 (2.0 cm in diameter), 75% for those 4-25 cm3 and 39% for those larger than 25 cm3 (3.7 cm in diameter); at 3 years after radiation, the corresponding obliteration rates were 100, 95 and 70%. Major clinical complications occurred in 10 patients (8 permanent, 2 transient) between 3 and 21 months after treatment; all were in the initial stage of the protocol (higher radiation doses). 10 patients bled from residual malformation between 4 and 34 months after treatment. Seizures were improved in 63% and headaches in 68% of patients. Excellent or good clinical outcome was achieved in 94% of patients. Compared to the natural history and risks of surgery for these difficult malformations, we consider these results encouraging. Heavy-charged-particle radiation is a valuable therapy for surgically inaccessible symptomatic cerebral arteriovenous malformations. The current procedure has two disadvantages: the prolonged latent period before complete obliteration and the small risk of serious neurological complications.

    View details for Web of Science ID A1991HG99200005

    View details for PubMedID 1808653

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