Citations

ABSTRACT Introduction The optimal approach for identification and evaluation of the sexual problems in men and women in primary care or general medicine practice has not been consensed. Aim To provide recommendations/guidelines concerning state-of-the-art knowledge for clinical evaluation and management strategies in the evaluation and treatment of sexual dysfunction in men and women, emphasizing evidence-based medicine and a patient-centered framework. Methods An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Clinical Evaluation and Management Strategies Committee, there were 12 experts from five countries. Main Outcome Measure Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. Results Three concepts underlie sexual medicine management: (i) adoption of a patient-centered framework for evaluation and treatment; (ii) application of the principles of evidence-based medicine in diagnostic and treatment planning; and (iii) use of a unified management approach in men and women. When taken together, these three principles provide a balanced and integrated approach to sexual dysfunction management. Common algorithms for diagnosis and management of men and women with sexual dysfunction, brief sexual symptom checklists, basics in history and physical examination, indications for specialized referral and development of a follow-up strategy are presented. Conclusions More research is needed in understanding the role of evidence-based and patient-centered medicine in the clinical evaluation and management strategies of men and women with sexual dysfunction.

Abstract OBJECTIVE The purpose of this study was to better define the management of intracranial infectious aneurysms. METHODS We present a retrospective review of the management of 16 patients with intracranial infectious aneurysms. The mean follow-up period was 86 months. RESULTS None of the patients had a rehemorrhage during antibiotic treatment. The mortality and long-term outcome from ruptured intracranial infectious aneurysms may be better than previously thought. There was no significant difference in long-term outcome between patients with single or multiple infectious aneurysms or between patients who underwent surgical resection and those who were treated only with antibiotics. CONCLUSION Operative treatment should be pursued for patients with ruptured infectious aneurysms. Patients with unruptured intracranial infectious aneurysms should be observed during antibiotic therapy and followed up with cerebral angiography. Surgical resection should be considered if the aneurysm enlarges and the patient's general medical condition allows general anesthesia to be tolerated.

Abstract OBJECTIVE AND IMPORTANCE Heterotopic ossification (“neuritis ossificans”) is among the least frequently encountered reactive lesions in peripheral nerves. Only two cases have been described previously, one in the median nerve of a 34-year-old man, and the other in the ulnar nerve of an adult woman. The architecture of this lesion is distinctly zonal. Consisting of a central fibroblastic core, an intervening zone of osteoid production, and a peripheral layer of ossification, the pattern is remarkably similar to that of myositis ossificans. This similarity and the occurrence of the process in superficial nerves have led to speculation that trauma plays a role in its pathogenesis; this hypothesis remains unproved. We describe two additional cases of neuritis ossificans. CLINICAL PRESENTATION One patient, a 41-year-old man, experienced pain and numbness in the left leg for several months but had no history of local trauma. A mass was detected in the saphenous nerve. The second patient, a 16-year-old boy, noted subacute onset of pain in the popliteal fossa and decreased sensation in the distribution of the lateral sural cutaneous nerve. A mass was found within the tibial nerve at the knee level. INTERVENTION In each patient, resection of the mass required sacrifice of a segment of the nerve. CONCLUSION In each patient, the mass was composed of fibrovascular tissue with osteoid and bone deposition arranged in a zonal pattern. The ossifying process was intraneural but encased rather than directly involving nerve fascicles. These exceptionally intact examples of neuritis ossificans underscore its resemblance to myositis ossificans. Nerve-sparing resection of such masses is not always possible.

Abstract OBJECTIVE AND IMPORTANCE We report the case of a 29-year-old man with Gardner syndrome and an isolated, giant cerebellopontine angle craniopharyngioma. Our description of this patient is only the second case report of a craniopharyngioma arising primarily in the cerebellopontine angle. CLINICAL PRESENTATION The patient presented with a 1-year history of progressive neurological impairment and headache. On the basis of the patient's history of multiple dermal fibromas, a cranial osteoma, familial adenomatous polyposis (FAP), a total abdominal colectomy, and an adenoma of the ampulla of Vater, we diagnosed the patient's condition as Gardner syndrome. INTERVENTION Magnetic resonance imaging showed a large cerebellopontine angle tumor, which was removed through a suboccipital retromastoid craniotomy. The pathological features were those of an adamantinomatous craniopharyngioma. The patient has done well postoperatively and has no new neurological deficits. A careful retrospective review of the preoperative imaging shows that this tumor was located exclusively in the posterior fossa and was not an extension of a sellar, suprasellar, or clival craniopharyngioma. CONCLUSION We present the second reported case of FAP and craniopharyngioma. There is no known genetic link between FAP and craniopharyngioma. Now that the patient has manifested a primary tumor of the central nervous system with FAP, it is unclear whether he should be classified as having Turcot syndrome. For this patient, we recommended vigilant follow-up imaging and forgoing external beam radiotherapy unless there is a documented recurrence of his craniopharyngioma.

Abstract OBJECTIVE AND IMPORTANCE: Optic nerve choristoma is a rare lesion composed of adipose tissue and smooth muscle involving the optic nerve. Few cases have been reported. CLINICAL PRESENTATION: A 20-year-old woman presented with a history of slowly progressive visual loss in the left eye. On T1-weighted magnetic resonance imaging studies, after frequency-selective fat saturation, an optic nerve mass was detected at the level of the optic canal with signal characteristics suggesting the diagnosis of optic nerve lipoma. INTERVENTION: At left frontotemporal craniotomy, the intracranial optic nerve appeared thin and atrophic proximally and was covered by abundant adipose tissue distally. Because no cleavage plane could be identified between the fatty lesion and the optic nerve, which appeared splayed within the adipose tissue, the nerve was resected after an intraoperative biopsy. The presence of two heterotopic mesodermal elements, a rim of adipose tissue admixed with bundles of mature smooth muscle, extending into the nerve septa, warranted a diagnosis of optic nerve choristoma. CONCLUSION: Optic nerve choristoma is an uncommon optic nerve lesion. Even if imaging studies are highly suggestive of the diagnosis, pathological confirmation is required because of the high adipose tissue content in the majority of cases. The lesion, most likely malformative and nonneoplastic in nature, can be the cause of progressive visual loss.

Abstract OBJECTIVE To report presenting clinical symptoms, previous medical history, and survival rates for people with saccular intracranial aneurysms (IAs), in a defined population. METHODS The medical records of all residents of Olmsted County, Minnesota, with possible IAs were reviewed. Clinical manifestations at the time of diagnosis, previous medical history, demographic factors, and survival rates after diagnosis were determined. RESULTS Of 270 people with IAs detected between 1965 and 1995, 188 exhibited symptoms at the time of diagnosis, including 74% of women and 63% of men (P = 0.054). Intracranial hemorrhage (ICH) was the most common presenting symptom (60% of all patients and 86% of patients who exhibited symptoms), followed by cranial nerve palsy, transient ischemic attacks, and seizures. Survival rates after detection (with the exclusion of cases that were first detected during autopsies) were dependent on the occurrence of ICH; 23% of patients who presented with ICH died by 1 day after diagnosis, compared with 5% of those who did not exhibit symptoms or exhibited symptoms but without ICH at presentation. At 5 years, 44.7% of patients with hemorrhage had died, compared with 29.4% of patients with symptoms other than hemorrhage. After the first 24 hours after detection, survival rates did not differ significantly for those presenting with or without hemorrhage. Predictors of better survival rates also included lower age and later calendar year of presentation. CONCLUSION This study provides the first data on aneurysm characteristics, clinical symptoms, and survival rates among people with IAs in a defined population. During the study period, most aneurysms were detected in the context of an aneurysm-related symptom (particularly among women), with a large proportion of patients presenting with ICH. After the acute phase of hemorrhage, long-term survival rates among people with IAs were similar for those presenting with or without ICH.