Neurosurgery Blog

J Neurosurg 112:681–688, 2010. DOI: 10.3171/2009.4.JNS081377

The object of this study was to determine the efficacy of methylprednisolone in reducing symptomatic vasospasm and poor outcomes after subarachnoid hemorrhage (SAH).

Methods. Ninety-five patients with proven SAH were recruited into a double-blind, placebo-controlled, random- ized trial. Starting within 6 hours after angiographic diagnosis of aneurysm rupture, placebo or methylprednisolone, 16 mg/kg, was administered intravenously every day for 3 days to 46 and 49 patients, respectively. Deterioration, defined as development of a focal sign or decrease of more than 1 point on the Glasgow Coma Scale for more than 6 hours, was investigated by using clinical criteria and transcranial Doppler ultrasonography, cerebral angiography, or CT when appropriate. The end points were incidence of symptomatic vasospasm (delayed ischemic neurological deficits associated with angiographic arterial narrowing or accelerated flow on Doppler ultrasonography, or both) and outcome 1 year after entry into the study according to a simplified Rankin scale (Functional Outcome Scale [FOS]) in living patients and the Glasgow Outcome Scale in all patients included.

Results. All episodes of deterioration and all living patients with a 1-year outcome were assessed by a review committee. In patients treated with methylprednisolone, the incidence of symptomatic vasospasm was 26.5% com- pared with 26.0% in those given placebo. Poor outcomes according to FOS were significantly reduced in the Meth- ylprednisolone Group at 1 year of follow-up; the risk difference was 19.3% (95% CI 0.5–37.9%). The outcome was poor in 15% (6/40) of patients in the Methylprednisolone Group versus 34% (13/38) in the Placebo Group.

Conclusions. A safe and simple treatment with methylprednisolone did not reduce the incidence of symptomatic vasospasm but improved ability and functional outcome at 1 year after SAH.

Acta Neurochir (2010) 152:417–42.DOI10.1007/s00701-009-0525-9

Between 15 and 30 % of patients with subarachnoid hemorrhage (SAH) have no bleeding source and usually have a benign clinical course and outcome. The objectives of this study were to classify the pattern of blood distribution on initial computed tomography (CT) and to correlate it with clinical outcome in aneurysmal (ASAH) and SAH of unknown origin (SAHuO).

Methods We reviewed 112 CTs of SAHuO and 104 CTs of ASAH patients. Blood distribution was classified according to a new grading system (type 0–4) and correlated to Hunt and Hess (H&H) grade and modified Rankin scores (MRS) at short- and long-term follow-up.

Results Fifty percent of 112 SAHuO patients were classified as type 0 (no visible blood on CT) or 1 (blood restricted to prepontine cisterns). Most ASAH patients presented with bleeding into the lateral Sylvian fissure (66%; type 3) or with intracerebral hemorrhage (27%; type 4) whereas types 0 and 1 were not observed. SAHuO patients were in better clinical condition on admission than ASAH patients (p<0.0001). H&H grades of SAHuO patients correlated with the amount of subarachnoid blood according to the new classification (p=0.004). Short-term outcome was obtained from 100% and long-term outcome from 95% patients (follow-up 29±31 months). Short- and long-term MRS correlated with blood distribution in SAHuO patients (p=0.012) and was significantly better than in ASAH patients (p<0.0001). No correlation was observed between blood distribution, H&H grade, and short- and long-term outcome in aneurysmal patients.

Conclusions In SAH of unknown origin, a new classification allows to predict outcome based on the extent of blood on CT.

Neurosurgery: February 2010 – Volume 66 – Issue 2 – p 368–375. doi: 10.1227/01.NEU.0000363858.17782.82

Microsurgical and endoscopic colloid cyst excision differ with regard to operative time, length of hospital stay, and extent of resection.

METHODS: A retrospective review of a single surgeon’s microsurgical colloid cyst resection in 10 consecutive patients was performed. Cyst size, hydrocephalus, symptoms, operative time, postoperative stay, complications, and objective testing of memory, concentration, calculation, and attention (cognition), along with performance at job, were noted.

RESULTS: All 10 patients had complete excision. Mean cyst size, mean operative time, and median postoperative stay were 1.6 cm, 124 minutes, and 3.5 days respectively. The mean operative time from cyst visualization to complete excision was 18 minutes. Follow-up ranged from 6 to 111 months (mean, 49.5 months). There were no recurrences; symptoms (headache, visual and balance problems) improved significantly in 70%. Postoperative cognitive performance, including memory, was the same in 8 patients (5 of whom had preoperative memory problems) and worse in 2 patients who had no preoperative memory problems. The bone flap was removed in 1 patient for wound dehiscence. Hemiparesis in another patient, seen immediately after surgery, completely resolved before discharge. One patient with loculated ventricles and multiple previous shunt revisions had unresolved hydrocephalus after cyst excision.

CONCLUSION: We report the very short operative times and postoperative stay for microsurgery, which are comparable to some endoscopic series. We also report results of objective tests of cognitive performance. With adoption of a callosal incision of 1 cm or less, meticulous dissection around the fornix, and complete excision, acceptable long-term cognitive function and functional performance were achieved. Our results support the microsurgical approach. A larger sample size can more conclusively establish whether it should be chosen over the endoscopic technique.

Neurosurgery 66:59-65, 2010 DOI: 10.1227/01.NEU.0000362000.35742.3D

OBJECTIVE: To study the outcomes of surgery for chordomas of the craniocervical junction and upper cervical spine as well as complication rates, survival, and associated adverse factors.

METHODS: Retrospective review of patients (1982-2007) at 2 European centers who underwent transoral, transfacial, transmandibular, and anterior cervical approaches for excision of chordomas of the craniocervical junction and cervical spine. The χ2 test and Fisher exact test were used to determine significant adverse factors (P < .05), and log-rank survival analysis was used to compare outcome in different groups.

RESULTS: One hundred thirty-two operations were performed in 97 patients. The most common operations were transoral surgeries and maxillotomies. After surgery, neck pain was the same or better in 98.1% of patients. Of the 18.6% of patients who presented with myelopathy, 27.8% improved, 44.4% remained unchanged, and 27.8% deteriorated. Major complication rates were velopharyngeal incompetence, 3.1%; vertebral artery stroke, 1%; wound infection, 3.1%; dysphagia, 3.1%; failure of fixation, 2.1%; sepsis, 3.1%; meningitis, 3.1%; and cerebrospinal fluid leakage, 6.2%. Five- and 10-year overall survivals were 55% and 36%, respectively. Patients who presented to our units for revision surgery, after prior attempts at resection elsewhere, were associated with a worse survival than patients who underwent de novo surgery.

CONCLUSION: We present, to our knowledge, the largest published series of chordomas at the craniocervical junction. Complication rates for these major operations can be minimized at specialist centers, with careful patient selection and counseling. As complete or as radical an operation as possible should be performed at first presentation; the best chance for the patient is the first chance.

J Neurosurg Anesthesiol 2009;21:339–345

Objective: To assess the intracranial hemodynamic modifica- tions induced by a decompressive craniectomy (DC) after severe traumatic brain injury (TBI), using transcranial Doppler (TCD) ultrasonography and intracranial pressure (ICP) sensor. Mor- tality rate and neurological outcomes were also evaluated after this procedure.

Design: A prospective study was carried out on 26 TBI patients, measuring transcranial Doppler and ICP before, immediately after, and 48 hours after the DC, allowing for statistical analysis of hemodynamic changes. The mortality rate and the neuro- logical outcomes were assessed.

Measurements and Results: After DC, ICP decreased from 37±17 to 20±13mm Hg (P=0.0003). The global cerebral blood flow was modified with diastolic velocities rising from 23±15 to 31±13cm/s (P=0.0038) and a pulsatility index decreasing from 1.70±0.66 to 1.18±0.37 (P=0.0012). This normalization of the global cerebral hemodynamics after the DC was immediate, symmetric, and constant during the first 48 hours. Outcome was evaluated at 6 months: good recovery or moderate disability was observed in 11 patients (42%), persistent vegetative state in 7 patients (27%), and 8 patients died (31%).

Conclusions: The DC results in a significant, immediate, and durable improvement of ICP associated with a normalization of cerebral blood flow velocities in most TBI patients with refractory intracranial hypertension.

J Neurosurg Anesthesiol 2009;21:339–345

A prospective study was carried out on 26 TBI patients, measuring transcranial Doppler and ICP before, immediately after, and 48 hours after the DC, allowing for statistical analysis of hemodynamic changes. The mortality rate and the neuro- logical outcomes were assessed.

Measurements and Results: After DC, ICP decreased from 37±17 to 20±13mm Hg (P=0.0003). The global cerebral blood flow was modified with diastolic velocities rising from 23±15 to 31±13cm/s (P=0.0038) and a pulsatility index decreasing from 1.70±0.66 to 1.18±0.37 (P=0.0012). This normalization of the global cerebral hemodynamics after the DC was immediate, symmetric, and constant during the first 48 hours. Outcome was evaluated at 6 months: good recovery or moderate disability was observed in 11 patients (42%), persistent vegetative state in 7 patients (27%), and 8 patients died (31%).

Conclusions: The DC results in a significant, immediate, and durable improvement of ICP associated with a normalization of cerebral blood flow velocities in most TBI patients with refractory intracranial hypertension.

Neurosurg Focus 27 (5):E3, 2009. DOI: 10.3171/2009.8.FOCUS09167

Cerebral venous sinus thrombosis (CVST) is a rare clinicopathological entity. The incidence of CVST in chil- dren and neonates has been reported to be as high as 7 cases per million people, whereas in adults the incidence is 3–4 cases per million. The predisposing factors to this condition are mainly genetic and acquired prothrombotic states and infection. The clinical picture of CVST is nonspecific, highly variable, and can mimic several other clinical conditions. Diagnosis of CVST is established with the implementation of neuroimaging studies, especially MR imaging and venography. Identification and elimination of the underlying cause, anticoagulation, proper management of intracranial hypertension, and anticonvulsant prophylaxis constitute cornerstones of CVST treatment. Newer treatment strategies such as endovascular thrombolysis and decompressive craniectomy have been recently used in the treatment of patients with CVST with variable success rates. Further clinical research must be performed to delineate the exact role of these newer treatments in the management of severe cases of CVST. The recent advances in the diagnosis and treatment of patients with CVST have significantly lowered the associated mortality and morbidity and have improved the outcome of these patients.

Journal of Clinical Oncology. DOI:10.1200/JCO.2008.19.8721

Purpose

We evaluated the efficacy of bevacizumab (Avastin TM), alone and in combination with irinotecan, in patients with recurrent glioblastoma in a phase II, multicenter, open-label, noncomparative trial.

Patients and Methods

One hundred sixty-seven patients were randomly assigned to receive bevacizumab 10 mg/kg alone or in combination with irinotecan 340 mg/m2 or 125 mg/m2 (with or without concomitant enzyme-inducing antiepileptic drugs, respectively) once every 2 weeks. Primary end points were 6-month progression-free survival and objective response rate, as determined by independent radiology review. Secondary end points included safety and overall survival.

Results

In the bevacizumab-alone and the bevacizumab-plus-irinotecan groups, estimated 6-month progression-free survival rates were 42.6% and 50.3%, respectively; objective response rates were 28.2% and 37.8%, respectively; and median overall survival times were 9.2 months and 8.7 months, respectively. There was a trend for patients who were taking corticosteroids at baseline to take stable or decreasing doses over time. Of the patients treated with bevacizumab alone or bevacizumab plus irinotecan, 46.4% and 65.8%, respectively, experienced grade  3 adverse events, the most common of which were hypertension (8.3%) and convulsion (6.0%) in the bevacizumab-alone group and convulsion (13.9%), neutropenia (8.9%), and fatigue (8.9%) in the bevacizumab-plus-irinotecan group. Intracranial hemorrhage was noted in two patients (2.4%) in the bevacizumab-alone group (grade 1) and in three patients (3.8%) patients in the bevacizumabplus-irinotecan group (grades 1, 2, and 4, respectively).

Conclusion

Bevacizumab, alone or in combination with irinotecan, was well tolerated and active in recurrent glioblastoma.

J Neurosurg Pediatrics 4:199-216, 2009. DOI: 10.3171/2009.3.PEDS08459

Object. The authors undertook this study to review their experience with cortical resections in the rolandic region in children with intractable  epilepsy.
Methods. The authors retrospectively reviewed the medical records obtained in 22 children with intractable epilepsy arising from the rolandic region. All patients underwent preoperative   electroencephalography (EEG), MRimaging, prolonged video-EEG recordings, functional MR imaging, magnetoencephalography, and in some instances PET/SPECT studies. In 21 patients invasive subdural grid and depth electrode monitoring was performed. Resection of the epileptogenic zones in the rolandic region was undertaken in all cases. Seizure outcome was graded according to the Engel classification. Functional outcome was determined using validated outcome scores.
Results. There were 10 girls and 12 boys, whose mean age at seizure onset was 3.2 years. The mean age at surgery was 10 years. Seizure duration prior to surgery was a mean of 7.4 years. Nine patients had preoperative hemiparesis.
Neuropsychological testing revealed impairment in some domains in 19 patients in whom evaluation was possible. Magnetic resonance imaging abnormalities were identified in 19 patients. Magnetoencephalography was performed in all patients and showed perirolandic spike clusters on the affected side in 20 patients. The mean duration of invasive monitoring was 4.2 days. The mean number of seizures during the period of invasive monitoring was 17. All patients underwent resection that involved primary motor and/or sensory cortex. The most common pathological entity encountered was cortical dysplasia, in 13 children. Immediately postoperatively, 20 patients had differing degrees of hemiparesis, from mild to severe. The hemiparesis improved in all affected patients by 3–6 months postoperatively. With a mean follow-up of 4.1 years (minimum 2 years), seizure outcome in 14 children (64%) was Engel Class I and seizure outcome in 4 (18%) was Engel Class II. In this series, seizure outcome following perirolandic resection was intimately related to the child’s age at the time of surgery. By univariate logistic regression analysis, age at surgery was a statistically significant factor predicting seizure outcome (p < 0.024).
Conclusions. Resection of rolandic cortex for intractable epilepsy is possible with expected morbidity. Accurate mapping of regions of functional cortex and epileptogenic zones may lead to improved seizure outcome in children with intractable rolandic epilepsy. It is important to counsel patients and families preoperatively to prepare them for possible worsened functional outcome involving motor, sensory and/or language pathways.

Acta Neurochirurgica DOI: 10.1007/s00701-009-0492-1

Conclusion The extent and duration of visual symptoms, size of the tumor and vascular adherence were prognostic factors affecting visual recovery after microsurgical resection of suprasellar meningiomas.