Author: cba

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Does aqueductal stenosis influence the lumbar infusion test in normal-pressure hydrocephalus?

Acta Neurochir (2016) 158:2305–2310

Late-onset idiopathic aqueductal stenosis may present with clinical features indistinct from idiopathic normal-pressure hydrocephalus (NPH). Moreover, aqueductal stenosis (AS) is not always detected by conventional magnetic resonance imaging (MRI). The aim of this study was to compare the hydrodynamic pattern among NPH patients according to the patency of the aqueduct.

Methods Fifty-six consecutive lumbar infusion tests were performed in patients with NPH syndrome. Precipitating causes of hydrocephalus were excluded, and aqueductal patency was examined through high-resolution, T2-weighted 3D MRI. Patients were classified into two groups: non-patent aqueduct and patent aqueduct. Mean values of pressure and pulse amplitude were obtained from basal and plateau stages of infusion studies.

Results Twelve of 56 patients with NPH-like symptoms presented with morphological AS (21.4 %). Patent aqueduct and non-patent aqueduct groups had similar values of mean opening lumbar pressure (8.2 vs. 8.1 mmHg), and mean opening pulse amplitude (3.1 vs. 2.9 mmHg). Mean pressure in the plateau stage (28.6 vs. 23.2 mmHg), and mean pulse amplitude in the plateau stage (12.5 vs. 10.6 mmHg) were higher in the patent aqueduct group. These differences were not statistically significant. Only Rout was significantly higher in the patent aqueduct group (13.6 vs. 10.1 mmHg/ml/min). One-third of NPH patients with AS presented Rout >12 mmHg/ ml/min.

Conclusions No differences in mean pressure or pulse amplitude during basal and plateau epochs of the lumbar infusion test in NPH patients were detected, regardless of aqueductal patency. However, Rout was significantly higher in patients with patent aqueduct.

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Outcomes in craniotomy vs endoscopic craniopharyngioma resection

Neurosurg Focus 41 (6):E6, 2016

Craniopharyngiomas have historically been resected via transcranial microsurgery (TCM). In the last 2 decades, the extended endoscopic endonasal (transtuberculum) approach to these tumors has become more widely accepted, yet there remains controversy over which approach leads to better outcomes. The purpose of this study is to determine whether differences in outcomes were identified between TCM and extended endoscopic endonasal approaches (EEEAs) in adult patients undergoing primary resection of suprasellar craniopharyngiomas at a single institution.

Methods A retrospective review of all patients who underwent resection of their histopathologically confirmed craniopharyngiomas at the authors’ institution between 2005 and 2015 was performed. Pediatric patients, revision cases, and patients with tumors greater than 2 standard deviations above the mean volume were excluded. The patients were divided into 2 groups: those undergoing primary TCM and those undergoing a primary EEEA. Preoperative patient demographics, presenting symptoms, and preoperative tumor volumes were determined. Extent of resection, tumor histological subtype, postoperative complications, and additional outcome data were obtained. Statistical significance between variables was determined utilizing Student t-tests, chi-square tests, and Fisher exact tests when applicable.

Results After exclusions, 21 patients satisfied the aforementioned inclusion criteria, 12 underwent TCM for resection while 9 benefitted from the EEEA. There were no significant differences in patient demographics, presenting symptoms, tumor subtype, or preoperative tumor volumes, no tumors had significant lateral or prechiasmatic extension. The extent of resection was similar between these 2 groups, as was the necessity for additional surgery or adjuvant therapy. CSF leakage was encountered only in the EEEA group (2 patients). Importantly, the rate of postoperative visual improvement was significantly higher in the EEEA group than in the TCM group (88.9% vs 25.0%, p = 0.0075). Postoperative visual deterioration only occurred in the TCM group (3 patients). Recurrence was uncommon, with similar rates between the groups. Other complication rates, overall complication risk, and additional outcome measures were similar between these groups as well.

Conclusions Based on this study, most outcome variables appear to be similar between TCM and EEEA routes for similarly sized tumors in adults. The multidisciplinary EEEA to craniopharyngioma resection represents a safe and compelling alternative to TCM. The authors’ data demonstrate that postoperative visual improvement is statistically more likely in the EEEA despite the increased risk of CSF leakage. These results add to the growing evidence that the EEEA may be considered the approach of choice for resection of select confined primary craniopharyngiomas without significant lateral extension in centers with experienced surgeons. Further prospective, multiinstitutional collaboration is needed to power studies capable of fully evaluating indications and appropriate approaches for craniopharyngiomas.

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Comparison between electric-field-navigated and line-navigated TMS for cortical motor mapping in patients with brain tumors

Acta Neurochir (2016) 158:2277–2289

For the navigation of transcranial magnetic stimulation (TMS), various techniques are available. Yet, there are two basic principles underlying them all: electric-fieldnavigated transcranial magnetic stimulation (En-TMS) and line-navigated transcranial magnetic stimulation (Ln-TMS). The current study was designed to compare both methods.

Methods To explore whether there is a difference in clinical applicability, workflow, and mapping results of both techniques, we systematically compared motor mapping via EnTMS and Ln-TMS in 12 patients suffering from brain tumors.

Results The number of motor-positive stimulation spots and the ratio of positive spots per overall stimulation numbers were significantly higher for En-TMS (motor-positive spots: EnTMS vs. Ln-TMS: 128.3 ± 35.0 vs. 41.3 ± 26.8, p < 0.0001; ratio of motor-positive spots per number of stimulations: EnTMS vs. Ln-TMS: 38.0 ± 9.2 % vs. 20.0 ± 14.4 %, p = 0.0031). Distances between the En-TMS and Ln-TMS motor hotspots were 8.3 ± 4.4 mm on the ipsilesional and 8.6 ± 4.5 mm on the contralesional hemisphere (p = 0.9124).

Conclusions The present study compares En-TMS and LnTMS motor mapping in the neurosurgical context for the first time. Although both TMS systems tested in the present study are explicitly designed for application during motor mapping in patients with brain lesions, there are differences in applicability, workflow, and results between En-TMS and Ln-TMS, which should be distinctly considered during clinical use of the technique. However, to draw final conclusions about accuracy, confirmation of motor-positive Ln-TMS spots by intraoperative stimulation is crucial within the scope of upcoming investigations.

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One-year outcome in patients with idiopathic normal-pressure hydrocephalus: comparison of lumboperitoneal shunt to ventriculoperitoneal shunt

J Neurosurg 125:1483–1492, 2016

Idiopathic normal pressure hydrocephalus (iNPH) is treated with cerebrospinal fluid shunting, and implantation of a ventriculoperitoneal shunt (VPS) is the current standard treatment. The objective of this study was to compare the efficacy and safety of VPSs and lumboperitoneal shunts (LPSs) for patients with iNPH.

Methods The authors conducted a prospective multicenter study of LPS use for patients with iNPH. Eighty-three patients with iNPH (age 60 to 85 years) who presented with ventriculomegaly and high-convexity and medial subarachnoid space tightness on MR images were recruited from 20 neurological or neurosurgical centers in Japan between March 1, 2010, and October 19, 2011. The primary outcome was the modified Rankin Scale (mRS) score 1 year after surgery, and the secondary outcome included scores on the iNPH grading scale (iNPHGS). A previously conducted VPS cohort study with the same inclusion criteria and primary and secondary end points was used as a historical control.

Results: The proportion of patients who achieved a favorable outcome (i.e., improvement of at least 1 point in their mRS score) was 63% (95% CI 51%–73%) and was comparable to values reported with VPS implantation (69%, 95% CI 59%–78%). Using the iNPHGS, the 1-year improvement rate was 75% (95% CI 64%–84%) and was comparable to the rate found in the VPS study (77%, 95% CI 68%–84%). The proportion of patients experiencing serious adverse events (SAEs) and non-SAEs did not differ signi cantly between the groups at 1 year after surgery (SAEs: 19 [22%] of 87 LPS patients vs 15 [15%] of 100 VPS patients, p = 0.226; non-SAEs: 24 [27.6%] LPS patients vs 20 [20%] VPS patients, p = 0.223). However, shunt revisions were more common in LPS-treated patients than in VPS-treated patients (6 [7%] vs 1 [1%]).

Conclusions The efficacy and safety rates for LPSs with programmable valves are comparable to those for VPSs for the treatment of patients with iNPH. Despite the relatively high shunt failure rate, an LPS can be the treatment of choice because of its minimal invasiveness and avoidance of brain injury.

 

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Transulcal parafascicular minimally invasive approach to deep and subcortical cavernomas

J Neurosurg 125:1360–1366, 2016

Cavernomas comprise 8%–15% of intracranial vascular lesions, usually supratentorial in location and superficial. Cavernomas in the thalamus or subcortical white matter represent a unique challenge for surgeons in trying to identify and then use a safe corridor to access and resect the pathology.

Previous authors have described specific open microsurgical corridors based on pathology location, often with technical difficulty and morbidity.

This series presents 2 cavernomas that were resected using a minimally invasive approach that is less technically demanding and has a good safety profile. The authors report 2 cases of cavernoma: one in the thalamus and brainstem with multiple hemorrhages and the other in eloquent subcortical white matter. These lesions were resected through a transulcal parafascicular approach with a port-based minimally invasive technique.

In this series there was complete resection with no neurological complications. The transulcal parafascicular minimally invasive approach relies on image interpretation and trajectory planning, intraoperative navigation, cortical cannulation and subcortical space access, high-quality optics, and resection as key elements to minimize exposure and retraction and maximize tissue preservation. The authors applied this technique to 2 patients with cavernomas in eloquent locations with excellent outcomes.

 

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The Effect of Lumbar Spinal Muscle on Spinal Sagittal Alignment

Neurosurgery 79:847–855, 2016

The majority of earlier studies of the parameters of sagittal balance did not consider the influence of spinal muscles on spinal sagittal alignment.

OBJECTIVE: To analyze the relationship between the paraspinal muscle (quantity and quality) and sagittal alignment in elderly patients.

METHODS: We reviewed 50 full-spine lateral standing radiographs and lumbar magnetic resonance images of elderly patients at a single center. The radiographic parameters examined were thoracic kyphosis, lumbar lordosis (LL), sagittal vertical axis, pelvic tilt, sacral slope, and pelvic incidence (PI). The lumbar muscularity (LM; quantity) and fatty degeneration ratio (FD; quality) in the paraspinal muscle were measured at the L3 level on magnetic resonance images. The relationships between the parameters, LM, and FD were analyzed with the Pearson correlation coefficient and multiple linear regression.

RESULTS: Pearson analysis demonstrated that the FD had significant correlations with age (r = 0.393), thoracic kyphosis (r = 20.559), pelvic tilt (r = 0.430), sagittal vertical axis (r = 0.488), and PI 2 LL (r = 0.479, P , .05), and a close negative correlation was found between the FD and LL (r = 20.505, P , .01). The LM had significant correlations with the LL (r = 0.342) and PI 2 LL (r = 20.283, P , .05). Regression models that controlled for confounding factors such as body mass index confirmed the correlations between the above parameters and FD (P , .05).

CONCLUSION: The quality of the paraspinal muscle could be one of the various factors that influence sagittal balance.

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Analysis of the surgical benefits of 5-ALA–induced fluorescence in intracranial meningiomas

J Neurosurg 125:1408–1419, 2016

One of the most important causes for recurrence of intracranial meningiomas is residual tumor tissue that remains despite assumed complete resection. Recently, intraoperative visualization of meningioma tissue by 5-aminolevulinic acid (5-ALA)–induced protoporphyrin IX (PpIX) fluorescence was reported. The aim of this study was to investigate the possible surgical benefits of PpIX fluorescence for detection of meningioma tissue.

Methods 5-ALA was administered preoperatively to 190 patients undergoing resection of 204 intracranial meningiomas. The meningiomas’ PpIX fluorescence status, fluorescence quality (strong or vague), and intratumoral fluorescence homogeneity were investigated during surgery. Additionally, specific sites, including the dural tail, tumor-infiltrated bone flap, adjacent cortex, and potential satellite lesions, were analyzed for PpIX fluorescence in selected cases.

Results PpIX fluorescence was observed in 185 (91%) of 204 meningiomas. In the subgroup of sphenoorbital meningiomas (12 of 204 cases), the dural part showed visible PpIX fluorescence in 9 cases (75%), whereas the bony part did not show any PpIX fluorescence in 10 cases (83%). Of all fluorescing meningiomas, 168 (91%) showed strong PpIX fluorescence. Typically, most meningiomas demonstrated homogeneous fluorescence (75% of cases). No PpIX fluorescence was observed in any of the investigated 89 dural tails. In contrast, satellite lesions could be identified through PpIX fluorescence in 7 cases. Furthermore, tumor-infiltrated bone flaps could be visualized by PpIX fluorescence in all 13 cases. Notably, PpIX fluorescence was also present in the adjacent cortex in 20 (25%) of 80 analyzed cases.

Conclusions The authors’ data from this largest patient cohort to date indicate that PpIX fluorescence enables intraoperatively visualization of most intracranial meningiomas and allows identification of residual tumor tissue at specific sites. Thus, intraoperative detection of residual meningioma tissue by PpIX fluorescence might in future reduce the risk of recurrence.

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The Mini-Open Pedicle Subtraction Osteotomy for Flat-Back Syndrome and Kyphosis Correction

Operative Neurosurgery 12:309–316, 2016

The pedicle subtraction osteotomy (PSO) has been a mainstay treatment for flat-back syndrome. The morbidity of open deformity correction can be high, and minimally invasive applications may reduce such morbidity.

OBJECTIVE: To describe an operative technique of the mini-open PSO.

METHODS: Two patients underwent percutaneous fixation above and below the PSO, and the PSO was performed in a mini-open fashion. The correction was obtained by cantilever.

RESULTS: The patient who underwent the L3 PSO had a prior fusion from T11 to L4 for scoliosis 35 years ago. On presentation at 62 years of age, he had a pelvic incidence of 54, lumbar lordosis of 23, sagittal vertical axis of 114 cm, and pelvic tilt of 25. He underwent an anterior lumbar interbody fusion at L5-S1 followed by a min-open L3 PSO. He had a postoperative lumbar lordosis of 64 (correction of 41), and his sagittal vertical axis went to 13 cm. His Oswestry Disability Index and visual analog scale scores decreased after surgery. The second patient was 64 years of age and underwent an L1 PSO. He had 43 of kyphosis from T10 to L2. He had a preoperative pelvic incidence of 63, lumbar lordosis of 35, pelvic tilt of 24, and sagittal vertical axis of 3 cm. His postoperative kyphosis improved from 43 to 32.

CONCLUSION: The mini-open PSO can achieve significant lordosis, although it is heavily reliant on anterior arthrodesis. Larger studies are needed to compare this approach with an open PSO.

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Intraoperative Near-Infrared Optical Imaging Can Localize Gadolinium-Enhancing Gliomas During Surgery

Neurosurgery 79:856–871, 2016

Although real-time localization of gliomas has improved with intraoperative image guidance systems, these tools are limited by brain shift, surgical cavity deformation, and expense.

OBJECTIVE: To propose a novel method to perform near-infrared (NIR) imaging during glioma resections based on preclinical and clinical investigations, in order to localize tumors and to potentially identify residual disease.

METHODS: Fifteen patients were identified and administered a Food and Drug Administration-approved, NIR contrast agent (Second Window indocyanine green [ICG], 5 mg/kg) before surgical resection. An NIR camera was utilized to localize the tumor before resection and to visualize surgical margins following resection. Neuropathology and magnetic resonance imaging data were used to assess the accuracy and precision of NIR fluorescence in identifying tumor tissue.

RESULTS: NIR visualization of 15 gliomas (10 glioblastoma multiforme, 1 anaplastic astrocytoma, 2 low-grade astrocytoma, 1 juvenile pilocytic astrocytoma, and 1 ganglioglioma) was performed 22.7 hours (mean) after intravenous injection of ICG. During surgery, 12 of 15 tumors were visualized with the NIR camera. The mean signal-tobackground ratio was 9.5 6 0.8 and fluorescence was noted through the dura to a maximum parenchymal depth of 13 mm. The best predictor of positive fluorescence was enhancement on T1-weighted imaging; this correlated with signal-to-background ratio (P = .03). Nonenhancing tumors did not demonstrate NIR fluorescence. Using pathology as the gold standard, the technique demonstrated a sensitivity of 98% and specificity of 45% to identify tumor in gadolinium-enhancing specimens (n = 71).

CONCLUSION: With the use of Second Window ICG, gadolinium-enhancing tumors can be localized through brain parenchyma intraoperatively. Its utility for margin detection is promising but limited by lower specificity.

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Endoventricular Deep Brain Stimulation of the Third Ventricle: Proof of Concept and Application to Cluster Headache

Neurosurgery 79:806–815, 2016

The third ventricle (3rd V) is surrounded by centers related to satiety, homeostasis, hormones, sleep, memory, and pain. Stimulation of the wall of the 3rd V could be useful to treat disorders related to dysfunction of the hypothalamus.

OBJECTIVE: To assess safety and efficacy of endoventricular electrical stimulation of the hypothalamus using a floating deep brain stimulation (DBS) lead laid on the floor of the 3rd V to treat refractory cluster headaches (CH).

METHODS: Seven patients, aged 24 to 60 years, experiencing chronic CH (mean chronic duration 5.8 6 2.5 years) were enrolled in this pilot, prospective, open study assessing the safety and potential efficacy of chronic DBS of the 3rd V. Number of attacks was collected during baseline and was compared with those occurring at 3, 6, and 12 months postoperation. Any side effects that occurred during or after surgery were reported. Effect on mood was assessed using the Hospital Anxiety and Depression scale during baseline and at 6 and 12 months postoperation.

RESULTS: Insertion of the lead into the posterior 3rd V and chronic stimulation was feasible and safe in all patients. The voltage ranged from 0.9 to 2.3 volts. The most common side effect was transient trembling vision during stimulation. At 12 months, 3 of 7 patients were pain free, 2 had 90% improvement, 1 of 7 had 75% improvement, and 1 of 7 was not significantly improved.

CONCLUSION: This proof of concept demonstrates the feasibility, safety, and potential efficacy of 3rd V DBS using an endoventricular road that could be applied to treat various diseases involving hypothalamic areas. Continue reading “Endoventricular Deep Brain Stimulation of the Third Ventricle: Proof of Concept and Application to Cluster Headache”

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Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma

subarachnoid-hemorrhage-and-intracerebral-hematoma-caused-by-aneurysms-of-the-anterior-circulation

J Neurosurg 125:1344–1351, 2016

Intracerebral hematoma (ICH) with subarachnoid hemorrhage (SAH) indicates a unique feature of intracranial aneurysm rupture since the aneurysm is in the subarachnoid space and separated from the brain by pia mater. Broad consensus is lacking regarding the concept that ultra-early treatment improves outcome. The aim of this study is to determine the associative factors for ICH, ascertain the prognostic value of ICH, and investigate how the timing of treatment relates to the outcome of SAH with concurrent ICH.

Methods The study data were pooled from the SAH International Trialists repository. Logistic regression was applied to study the associations of clinical and aneurysm characteristics with ICH. Proportional odds models and dominance analysis were applied to study the effect of ICH on 3-month outcome (Glasgow Outcome Scale) and investigate the effect of time from ictus to treatment on outcome.

Results Of the 5362 SAH patients analyzed, 1120 (21%) had concurrent ICH. In order of importance, neurological status, aneurysm location, aneurysm size, and patient ethnicity were significantly associated with ICH. Patients with ICH experienced poorer outcome than those without ICH (OR 1.58; 95% CI 1.37–1.82). Treatment within 6 hours of SAH was associated with poorer outcome than treatment thereafter (adjusted OR 1.67; 95% CI 1.04–2.69). Subgroup analysis with adjustment for ICH volume, location, and midline shift resulted in no association between time from ictus to treatment and outcome (OR 0.99; 95% CI 0.94–1.07).

Conclusions The most important associative factor for ICH is neurological status on admission. The finding regarding the value of ultra-early treatment suggests the need to more robustly reevaluate the concept that hematoma evacuation of an ICH and repair of a ruptured aneurysm within 6 hours of ictus is the most optimal treatment path.

KEY WORDS intracerebral hematoma; subarachnoid hemorrhage; outcome assessment; intracranial aneurysm; vascular disorders

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Resection of highly language-eloquent brain lesions based purely on rTMS language mapping without awake surgery

resection-of-highly-language-eloquent-brain-lesions-based-purely-on-rtms-language-mapping-without-awake-surgery

Acta Neurochir (2016) 158:2265–2275

The resection of left-sided perisylvian brain lesions harbours the risk of postoperative language impairment. Therefore the individual patient’s language distribution is investigated by intraoperative direct cortical stimulation (DCS) during awake surgery. Yet, not all patients qualify for awake surgery. Non-invasive language mapping by repetitive navigated transcranial magnetic stimulation (rTMS) has frequently shown a high correlation in comparison with the results of DCS language mapping in terms of language-negative brain regions. The present study analyses the extent of resection (EOR) and functional outcome of patients who underwent left-sided perisylvian resection of brain lesions based purely on rTMS language mapping.

Methods Four patients with left-sided perisylvian brain lesions (two gliomas WHO III, one glioblastoma, one cavernous angioma) underwent rTMS language mapping prior to surgery. Data from rTMS language mapping and rTMS-based diffusion tensor imaging fibre tracking (DTI-FT) were transferred to the intraoperative neuronavigation system. Preoperatively, 5 days after surgery (POD5), and 3 months after surgery (POM3) clinical follow-up examinations were performed.

Results No patient suffered from a new surgery-related aphasia at POM3. Three patients underwent complete resection immediately, while one patient required a second rTMSbased resection some days later to achieve the final, complete resection.

Conclusions The present study shows for the first time the feasibility of successfully resecting language-eloquent brain lesions based purely on the results of negative language maps provided by rTMS language mapping and rTMS-based DTI-FT. In very select cases, this technique can provide a rescue strategy with an optimal functional outcome and EOR when awake surgery is not feasible.

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Microscopic versus endoscopic approaches for craniopharyngiomas

microscopic-versus-endoscopic-approaches-for-craniopharyngiomas

Neurosurg Focus 41 (6):E5, 2016

Resection remains the mainstay of treatment for craniopharyngiomas with the goal of radical resection, if safely possible, to minimize the rate of recurrence. Endoscopic endonasal and microscopic transcranial surgical approaches have both become standard methods for the treatment for craniopharyngiomas. However, the approach selection paradigm for craniopharyngiomas is still a point of discussion. Choosing the optimal surgical approach can play a significant role in maximizing the extent of resection and surgical outcome while minimizing the risks of potential complications.

Craniopharyngiomas can present with a variety of different sizes, locations, and tumor consistencies, and each individual tumor has distinct features that favor one specific approach over another.

The authors review standard cranial base techniques applied to craniopharyngioma surgery, using both the endoscopic endonasal approach and traditional open microsurgical approaches, and analyze factors involved in approach selection. They discuss their philosophy of approach selection based on the location and extent of the tumor on preoperative imaging as well as the advantages and limitations of each surgical corridor, and they describe the operative nuances of each technique, using a personalized, tailored approach to the individual patient with illustrative cases and videos.

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Diffusion Tensor Imaging: A Possible Biomarker in Severe Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage?

diffusion-tensor-imaging-a-possible-biomarker-in-severe-traumatic-brain-injury-and-aneurysmal-subarachnoid-hemorrhage

Neurosurgery 79:786–793, 2016

A great need exists in traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (aSAH) for objective biomarkers to better characterize the disease process and to serve as early endpoints in clinical studies. Diffusion tensor imaging (DTI) has shown promise in TBI, but much less is known about aSAH.

OBJECTIVE: To explore the use of whole-brain DTI tractography in TBI and aSAH as a biomarker and early endpoint.

METHODS: Of a cohort of 43 patients with severe TBI (n = 20) or aSAH (n = 23) enrolled in a prospective, observational, multimodality monitoring study, DTI data were acquired at approximately day 12 (median, 12 days; interquartile range, 12-14 days) after injury in 22 patients (TBI, n = 12; aSAH, n = 10). Whole-brain DTI tractography was performed, and the following parameters quantified: average fractional anisotropy, mean diffusivity, tract length, and the total number of reconstructed fiber tracts. These were compared between TBI and aSAH patients and correlated with mortality and functional outcome assessed at 6 months by the Glasgow Outcome Scale Extended.

RESULTS: Significant differences were found for fractional anisotropy values (P = .01), total number of tracts (P = .03), and average tract length (P = .002) between survivors and nonsurvivors. A sensitivity analysis showed consistency of results between the TBI and aSAH patients for the various DTI measures.

CONCLUSION: DTI parameters, assessed at approximately day 12 after injury, correlated with mortality at 6 months in patients with severe TBI or aSAH. Similar patterns were found for both TBI and aSAH patients. This supports a potential role of DTI as early endpoint for clinical studies and a predictor of late mortality.

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Clipping of previously coiled cerebral aneurysms

clipping-previously-coiled-aneurysms

J Neurosurg 125:1337–1343, 2016

With the increasing number of aneurysms treated with endovascular coiling, more recurrences are beingencountered. The aim of this study was to evaluate the efficacy and safety of microsurgical clipping in the treatment ofrecurrent, previously coiled cerebral aneurysms and to identify risk factors that can affect the outcomes of this procedure.

Methods:  One hundred eleven patients with recurrent aneurysms whose lesions were managed by surgical clipping between January 2002 and October 2014 were identified. The rates of aneurysm occlusion, retreatment, complications,and good clinical outcome were retrospectively determined. Univariate and multivariate logistic regressions were performed to identify factors associated with these outcomes.

Results:  The mean patient age was 50.5 years, the mean aneurysm size was 7 mm, and 97.3% of aneurysms were located in the anterior circulation. The mean follow-up was 22 months. Complete aneurysm occlusion, as assessed by intraoperative angiography, was achieved in 97.3% of aneurysms (108 of 111 patients). Among patients, 1.8% (2 of 111 patients) had a recurrence after clipping. Retreatment was required in 4.5% of patients (5 of 111) after clipping. Major complications were observed in 8% of patients and mortality in 2.7%. Ninety percent of patients had a good clinical outcome. Aneurysm size (OR 1.4, 95% CI 1.08–1.7; p = 0.009) and location in the posterior circulation were significantly associated with higher complications. All 3 patients who had coil extraction experienced a postoperative stroke. Aneurysm size (OR 1.2, 95% CI 1.02–1.45; p = 0.025) and higher number of interventions prior to clipping (OR 5.3, 95% CI 1.3–21.4; p = 0.019) were significant predictors of poor outcome. An aneurysm size > 7 mm was a significant predictor of incomplete obliteration and retreatment (p = 0.018).

Conclusions:  Surgical clipping is safe and effective in treating recurrent, previously coiled cerebral aneurysms. Aneurysm size, location, and number of previous coiling procedures are important factors to consider in the management of these aneurysms. http://thejns.org/doi/abs/10.3171/2015.10.JNS151544

aneurysm, clipping, previously coiled, Recurrence, vascular disorders

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Emerging Applications of Therapeutic Ultrasound in Neuro-oncology

emerging_applications_of_therapeutic_ultrasound_in

Neurosurgery 79:643–654, 2016

Transcranial focused ultrasound (FUS) can noninvasively transmit acoustic energy with a high degree of accuracy and safety to targets and regions within the brain. Technological advances, including phased-array transducers and real-time temperature monitoring with magnetic resonance thermometry, have created new opportunities for FUS research and clinical translation.

Neuro-oncology, in particular, has become a major area of interest because FUS offers a multifaceted approach to the treatment of brain tumors. FUS has the potential to generate cytotoxicity within tumor tissue, both directly via thermal ablation and indirectly through radiosensitization and sonodynamic therapy; to enhance the delivery of therapeutic agents to brain tumors by transiently opening the blood-brain barrier or improving distribution through the brain extracellular space; and to modulate the tumor microenvironment to generate an immune response.

In this review, we describe each of these applications for FUS, the proposed mechanisms of action, and the preclinical and clinical studies that have set the foundation for using FUS in neuro-oncology.

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Electrical stimulation of the parahippocampal gyrus for prediction of posthippocampectomy verbal memory decline

provocative-test-for-verbal-memory-decline

J Neurosurg 125:1053–1060, 2016

Epilepsy surgery is of known bene t for drug-resistant temporal lobe epilepsy (TLE); however, a certain number of patients suffer signi cant decline in verbal memory after hippocampectomy. To prevent this disabling compli- cation, a reliable test for predicting postoperative memory decline is greatly desired. Therefore, the authors assessed the value of electrical stimulation of the parahippocampal gyrus (PHG) as a provocation test of verbal memory decline after hippocampectomy on the dominant side.

Methods Eleven right-handed, Japanese-speaking patients with medically intractable left TLE participated in the study. Before surgery, they underwent provocative testing via electrical stimulation of the left PHG during a verbal en- coding task. Their pre- and posthippocampectomy memory function was evaluated according to the Wechsler Memory Scale-Revised (WMS-R) and/or Mini-Mental State Examination (MMSE) before and 6 months after surgery. The rela- tionship between postsurgical memory decline and results of the provocative test was evaluated.

Results Left hippocampectomy was performed in 7 of the 11 patients. In 3 patients with a positive provocative rec- ognition test, verbal memory function, as assessed by the WMS-R, decreased after hippocampectomy, whereas in 4 patients with a negative provocative recognition test, verbal memory function, as assessed by the WMS-R or MMSE, was preserved.

Conclusions Results of the present study suggest that electrical stimulation of the PHG is a reliable provocative test to predict posthippocampectomy verbal memory decline.

 

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Maximizing safe resection of low- and high-grade glioma

dti-gliomas

J Neurooncol (2016) 130:269–282

Surgical resection plays a central role in the management of gliomas. In this study, we review the evidence in support of extent of resection to improve survival, symptom management, and time to malignant transformation in low- and high-grade gliomas, and summarize the findings from our literature search regarding the role of extent of resection and intraoperative practices to maximize safety.

There is a growing body of evidence supporting improved overall survival, improved progression-free survival, and superior quality of life with greater extent of resection.

Additionally, a better understanding of central nervous system plasticity allows for a staged approach to the surgical management of low- and intermediate-grade gliomas.

A number of intraoperative techniques have been utilized to offer safer glioma surgery with greater extent of resection. Approaches such as awake brain tumor surgery can be safely performed with low failure rates and excellent long-term functional outcomes.

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Hydrocephalus: an underrated long-term complication of microvascular decompression for trigeminal neuralgia

External lumbar drain- A pragmatic test for prediction of shunt outcomes in idiopathic normal pressure hydrocephalus

Acta Neurochir (2016) 158:2203–2206

Hydrocephalus is a common complication of posterior fossa surgery, but its real incidence after microvascular decompression (MVD) for idiopathic trigeminal neuralgia (TN) still remains unclear. The aim of this study was to focus on the potential association between MVD and hydrocephalus as a surgery-related complication.

Methods All patients who underwent MVD procedure for idiopathic TN at our institute between 2009 and 2014 were reviewed to search for early or late postoperative hydrocephalus.

Results There were 259 consecutive patients affected by idiopathic TN who underwent MVD procedure at our institution between 2009 and 2014 (113 men, 146 women; mean age 59 years, range 30–87 years; mean follow-up 40.92 months, range 8–48 months). Nine patients (3.47 %) developed communicating hydrocephalus after hospital discharge and underwent standard ventriculo-peritoneal shunt. No cases of acute hydrocephalus were noticed.

Conclusions Our study suggests that late communicating hydrocephalus may be an underrated potential long-term complication of MVD surgery.

 

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Surgical excision of symptomatic sacral perineurial Tarlov cyst

tarlov-cysts

Eur Spine J (2016) 25:3385–3392

Symptomatic sacral perineural cysts are extremely rare. The aim of this retrospective study is to investigate the outcome of 15 consecutive patients treated by microsurgical resection of the cyst and to review the literature.

Methods The authors retrospectively reviewed their clinical data archive from 2002 to 2014. Fifteen patients who were operated on due to symptomatic sacral perineural cysts were enrolled in the study. Patients’ symptoms, radiographs, intra-operative findings, and clinical results were evaluated. All 15 patients underwent microsurgical excision of the cyst. The literature on this topic available in PubMed was also reviewed.

Results There were 5 men and 10 women included in the study, with a mean age of 31 years (range 7–60 years). Preoperative symptoms include low back pain, coccydynia, buttock pain, perianal pain and radicular pain. All of the patients underwent surgical resection. The mean follow-up was 54 months (range 3–160 months). All the patients experienced complete or substantial resolution of the preoperative local and radicular pain after surgery.

Conclusions Cyst excision is an effective and safe technique for symptomatic sacral perineural (Tarlov) cysts. Careful patient selection is vital to the management and treatment of this difficult and controversial pathology.

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