Author: cba

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Anatomic features of glioblastoma and their potential impact on survival

Anatomic features of glioblastoma and their potential impact on survival

Acta Neurochir (2015) 157:179–186

Many reports on glioblastoma multiforme discuss the prognostic impact of anatomical features such as cysts, necrotic changes, extent of edema or subependymal spread of tumor cells. In the present study, we examined different growth patterns and their possible relations to patient survival.

Methods To analyze whether anatomical characteristics are related to prognosis, we reviewed the prospectively collected pre- and postoperative MRIs of 83 patients in the 5-ALA study, provided by the 5-ALA Glioma Study Group. Following a standardized analytic work flow, the tumor volume and site, presence of necrosis or cysts, and perifocal edema were assessed preoperatively. In the same way, postoperative MRI and the MRI at first recurrence were analyzed. In addition, survival time of the patients was documented.

Results Median survival time of all 83 patients was 15.1 months (range 1.5 to 70.1, mean 18). The site or volume of glioblastoma, as well as the presence of intratumoral necrosis or cysts, did not exert a significant effect on survival time; 96.4 % of recurrences occurred within the former resection margin. Tumors with initial contact with the subependymal zone had multifocal or ventricular recurrences significantly more often. In patients with residual tumor on early postoperative MRI, the follow-up images displayed enlargement of the remnants in 91.9 % of these cases.

Conclusions A merely anatomical analysis of the glioblastoma growth pattern cannot reliably provide prognostic information. The occurrence of most recurrences next to the resection margin and the high percentage of growing residual tumors underline the importance of complete resections.

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Incidence and Clinical Implications of Carotid Branch Occlusion Following Treatment of Internal Carotid Artery Aneurysms With the Pipeline Embolization Device

Incidence and Clinical Implications of Carotid Branch Occlusion Following Treatment of Internal Carotid Artery Aneurysms With the Pipeline Embolization Device

Neurosurgery 76:173–178, 2015

The use of flow diverters such as the pipeline embolization device (PED) for treatment of intracranial aneurysms carries the risk of side branch occlusion.

OBJECTIVE: To determine the incidence and clinical outcomes associated with supraclinoid internal carotid artery (ICA) branch occlusion after deployment of PEDs for ICA aneurysms.

METHODS: We reviewed patients who underwent endovascular treatment with PEDs for ICA aneurysms between June 2011 and March 2013. Forty-nine patients (43 women, mean age 56.36 1.8 years, 68 aneurysms) in whom PEDs traversed the origin of supraclinoid ICA branches (ophthalmic [OA], posterior communicating [PcommA], and anterior choroidal artery [AChA]) were selected for this study. Follow-up angiograms (mean follow-up, 12.8 6 0.8 months) were studied to determine the location of PEDs and the patency of ICA branches.

RESULTS: PEDs were placed across the ostia of 49 OAs, 14 PcommAs, and 11 AChAs. Multiple PEDs were deployed in 16 patients. Rate of branch occlusion was 4% (2/49) for the OA, 7.1% (1/14) for the PcommA, and 0% for the AChA. Patients with branch occlusion did not endure new neurological deficits. ICA branch occlusion was not associated with the number of PEDs covering the ostia (P = .76) or the origin of ICA branches from the aneurysm (P = .24).

CONCLUSION: The incidence of major supraclinoid ICA branch occlusion after treatment with PEDs was low. These events were not associated with new neurological deficits nor were they related to the number of PEDs deployed or the origin of ICA branches from the aneurysm.

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Intraoperative 3D imaging control during subthalamic Deep Brain Stimulation procedures using O-arm® technology

Intraoperative 3D imaging control during subthalamic Deep Brain Stimulation procedures using O-arm® technology- Experience in 15 patients

Neurochirurgie 60(2014)276–282

O-arm® now gives us the opportunity not only to perform 2D but also 3D scans during deep brain stimulation (DBS) procedures. We present our experience with the intraoperative use of this device. Our objective was to measure the geometrical accuracy of electrode placement during surgical procedures driven under O-arm® control.

Methods. Fifteen patients underwent STN-DBS.  For  the first 4 patients, 3D  scans were performed at the end of the procedure. We  calculated the accuracy of electrode positioning, i.e. the distance between final electrode positioning and the planned trajectory. For  the next 11  patients, who underwent both intraoperative and final 3D scan, we also calculated the accuracy of the microelectrode positioning.

Results. Average stimulation-induced improvement of UPDRS-III  score was 52.5 ± 15%. For  the first 4 patients, the mean electrode positioning accuracy was 1.46 ± 0.56 mm. For the 11  patients who underwent intraoperative 3D scan, the mean microelectrodes positioning accuracy was 1.59 ± 1.1 mm. Aberrant positioning was detected in two cases, and was analyzed by fusing 3D scan with preoperative MR images. The definite electrodes positioning accuracy was 1.05 ± 0.54 mm.

Conclusion. Intraoperative 3D scan is feasible, and can help us detect and correct early aberrant trajectories.

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Frameless robotic stereotactic biopsies: a consecutive series of 100 cases

Frameless robotic stereotactic biopsies- a consecutive series of 100 cases

J Neurosurg 122:342–352, 2015

Stereotactic biopsy procedures are an everyday part of neurosurgery. The procedure provides an accurate histological diagnosis with the least possible morbidity. Robotic stereotactic biopsy needs to be an accurate, safe, frameless, and rapid technique. This article reports the clinical results of a series of 100 frameless robotic biopsies using a Medtech ROSA device.

Methods The authors retrospectively analyzed their first 100 frameless stereotactic biopsies performed with the robotic ROSA device: 84 biopsies were performed by frameless robotic surface registration, 7 were performed by robotic bone fiducial marker registration, and 9 were performed by scalp fiducial marker registration. Intraoperative flat-panel CT scanning was performed concomitantly in 25 cases. The operative details of the robotic biopsies, the diagnostic yield, and mortality and morbidity data observed in this series are reported.

Results A histological diagnosis was established in 97 patients. No deaths or permanent morbidity related to surgery were observed. Six patients experienced transient neurological worsening. Six cases of bleeding within the lesion or along the biopsy trajectory were observed on postoperative CT scans but were associated with transient clinical symptoms in only 2 cases. Stereotactic surgery was performed with patients in the supine position in 93 cases and in the prone position in 7 cases. The use of fiducial markers was reserved for posterior fossa biopsy via a transcerebellar approach, via an occipital approach, or for pediatric biopsy.

Conclusions ROSA frameless stereotactic biopsies appear to be accurate and safe robotized frameless procedures.

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Combined use of 18 F-FDG PET and corticosteroid for diagnosis of deep-seated primary central nervous system lymphoma without histopathological confirmation

Combined use of 18 F-FDG PET and corticosteroid for diagnosis of deep-seated primary central nervous system lymphoma without histopathological confirmation

Acta Neurochir (2015) 157:187–194

Although histological diagnosis is indispensable in treating primary central nervous system lymphoma (PCNSL), we sometimes face an intractable situation in which tissue can be obtained only from a deep-seated brain lesion. In place of a histological diagnosis, the diagnostic adequacy of the combined use of 18 F-FDG PET and corticosteroid administration for PCNSL located in a deep-seated brain structure is reported.

Methods Patients with a deep-seated tumor were treated as having PCNSL without histological confirmation, based on the following criteria: (1) there was no evidence of systemic malignancy; (2) the tumor showed an extremely high FDG uptake relative to normal gray matter on pretreatment 18 FFDG PET;

(3) the tumor decreased in size 1 week after diagnostic therapy by corticosteroid administration on contrast-enhanced T1-weighted magnetic resonance imaging (MRI). FDG uptake of the lesion was evaluated by the maximum of standardized uptake values (SUVmax) and tumor-tonormal ratio of the SUV (T/N ratio). The extent of the tumor reduction was calculated by volumetric analysis for the treatment response to corticosteroid administration.

Results Ten patients (4 males and 6 females) matched these criteria. On pretreatment 18 F-FDG PET, mean SUVmax in the tumor was 24.8 (8.75–60.75), and mean T/N ratio was 3.24 (2.17–5.12). The extent of tumor volume reduction was shown to be 21 to 68 % 1 week after diagnostic therapy by corticosteroids. Mean total dose and duration of corticosteroids were 719 mg as prednisolone and 6.5 days, respectively. Nine patients achieved complete response and one patient achieved partial response on MRI after standard treatment for PCNSL with high-dose methotrexate and/or whole-brain irradiation.

Conclusion Although the value of biopsy is universal, combining 18 F-FDG PET and corticosteroid administration is an important alternative method that may lead to the diagnosis of deep-seated PCNSLs in cases with intractable histopathological confirmations.

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Fluorescent Cancer-Selective Alkylphosphocholine Analogs for Intraoperative Glioma Detection

Fluorescent_Cancer_Selective_Alkylphosphocholine

Neurosurgery 76:115–124, 2015

5-Aminolevulinic acid (5-ALA)-induced tumor fluorescence aids brain tumor resections but is not approved for routine use in the United States. We developed and describe testing of 2 novel fluorescent, cancer-selective alkylphosphocholine analogs, CLR1501 (green) and CLR1502 (near infrared), in a proof-of-principle study for fluorescence-guided glioma surgery.

OBJECTIVE: To demonstrate that CLR1501 and CLR1502 are cancer cell-selective fluorescence agents in glioblastoma models and to compare tumor-to-normal brain (T:N) fluorescence ratios with 5-ALA.

METHODS: CLR1501, CLR1502, and 5-ALA were administered to mice with magnetic resonance imaging-verified orthotopic U251 glioblastoma multiforme- and glioblastoma stem cell-derived xenografts. Harvested brains were imaged with confocal microscopy (CLR1501), the IVIS Spectrum imaging system (CLR1501, CLR1502, and 5-ALA), or the Fluobeam near-infrared fluorescence imaging system (CLR1502). Imaging and quantitative analysis of T:N fluorescence ratios were performed.

RESULTS: Excitation/emission peaks are 500/517 nm for CLR1501 and 760/778 nm for CLR1502. The observed T:N ratio for CLR1502 (9.28 6 1.08) was significantly higher (P , .01) than for CLR1501 (3.51 6 0.44 on confocal imaging; 7.23 6 1.63 on IVIS imaging) and 5-ALA (4.81 6 0.92). Near-infrared Fluobeam CLR1502 imaging in a mouse xenograft model demonstrated high- contrast tumor visualization compatible with surgical applications.

CONCLUSION: CLR1501 (green) and CLR1502 (near infrared) are novel tumor-selective fluorescent agents for discriminating tumor from normal brain. CLR1501 exhibits a tumor-to-brain fluorescence ratio similar to that of 5-ALA, whereas CLR1502 has a superior tumor-to-brain fluorescence ratio. This study demonstrates the potential use of CLR1501 and CLR1502 in fluorescence-guided tumor surgery.

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Vago-glossopharyngeal neuralgia

Vago-glossopharyngeal neuralgiaActa Neurochir (2015) 157:311–321

Glossopharyngeal neuralgia (GPN), or better named vago-glossopharyngeal neuralgia (VGPN), is a rare disorder amounting to 1 % of the incidence of trigeminal neuralgia (TN). Pain is paroxysmal, of the electrical shooting type, and mainly provoked by stimulation of the pharynx or deep throat, especially during swallowing. Due to its rarity, VGPN is often misdiagnosed. The front line of medical treatment is based on anticonvulsants. Surgery should be considered when the pain is refractory to medications. In most patients, the cause is neurovascular conflict on root entry zone (REZ) or midcistern portion, of the IXth and/or Xth cranial nerves. Compressive vessels can be evidenced by means of a high sensibility and a high specificity resolution MR imaging in most centers.

Present consensus is that the first option of neurosurgical treatment be microvascular decompression. In patients with precarious general conditions, stereotactic radiosurgery may be considered. Also, thermo-rhizotomy at the pars nervosa of foramen jugularis or tractotomy-nucleotomy at brainstem may be alternatives, but these methods entail a significant risk of deficits.

In this article, the authors reviewed the main literature series on neurosurgical treatments of this disease.

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Atlantoaxial Instability of Inflammatory Origin in Adults

Atlantoaxial Instability of Inflammatory Origin in Adults

Neurosurgery 76:E226–E232, 2015

Acquired atlantoaxial instability of inflammatory origin (Grisel syndrome) is a rare condition. It usually occurs in children with benign upper airway problems and responds well to immobilization, rarely requiring C1-2 arthrodesis. Our recent experience with 2 adult cases suggests this may not be true in an older subpopulation.

CLINICAL PRESENTATION: A 71-year-old man developed C1-2 instability in the setting of culture-negative endocarditis. Initial immobilization was attempted for 8 weeks but new imaging revealed progressive destruction of the odontoid and worsening instability. Symptoms resolved after C1-4 arthrodesis. A 35-year-old woman developed C1-2 instability after a molar extraction and otitis media. Despite 12 weeks of immobilization and antibiotics, symptoms persisted and the atlantodental interval increased. She was successfully treated with a C1-2 arthrodesis.

CONCLUSION: A literature review revealed 13 reports (14 cases) of inflammatory atlantoaxial instability in patients aged 18 and older since 1830. Including the 2 cases reported here, 11 cases underwent initial nonoperative treatment with durable satisfactory results in only 2 of them (18.2%). Aspiration of the C1-2 phlegmon was diagnostic in only 4 of these 16 cases. Destruction of the odontoid was seen in a minority of cases (5/16, 31.3%). In this first review of the topic since the introduction of screwbased C1-2 fixation, it is suggested that nonoperative treatment is futile for inflammatory atlantoaxial instability in adults and strong consideration should be given to C1-2 arthrodesis. This procedure can reliably produce good outcomes with minimal morbidity.

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True aqueductal tumors: a unique entity

True aqueductal tumors-a unique entity

Acta Neurochir (2015) 157:169–177

Pure aqueductal tumors (ATs) differ from pineal region and tectal/tegmental tumors in that they are epicentered within the aqueduct. Nevertheless, these tumors are rarely described as a separate type of tumor, and are often grouped with other lesions located in the same vicinity. The present multicenter study focuses on our experience treating patients with pure ATs.

Methods Data from three large tertiary centers was collected retrospectively, including presenting symptoms, treatment paradigm, surgical approaches, pathology, and outcome.

Results Between 1999 and 2013, 16 patients with AT were diagnosed and treated at the three tertiary centers. Ages at presentation ranged from 5.5 to 57 years. Thirteen patients presented with hydrocephalus-related symptoms, and two were identified incidentally. Thirteen patients underwent an endoscopic third ventriculostomy, and two of these underwent a simultaneous endoscopic biopsy (one grade II ependymoma, one non-specified low-grade glioma). Two others underwent shunt placement. Three patients underwent resection due to tumor progression. Pathologies included glioblastoma multiforme, glioneural tumor, and ependymoma grade II. All non-resected tumors remained stable or grew only minimally.

Conclusions ATs are a rare entities that usually present with obstructive hydrocephalus. Treatment includes primarily cerebrospinal fluid drainage (preferably via an endoscopic third ventriculostomy). Simultaneous endoscopic biopsy may be done in selected cases. Tumor resection should be reserved for growing tumors; the trans-fourth ventricular or transchoroidal approaches are probably safer than other approaches used to reach the tectal region.

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Factors Predicting Recurrence After Resection of Clival Chordoma

Clivus chordomas

Neurosurgery 76:179–186, 2015

Clival chordomas frequently recur because of their location and invasiveness.

OBJECTIVE: To investigate clinical, operative, and anatomic factors associated with clival chordoma recurrence.

METHODS: Retrospective review of clival chordomas treated at our center from 1993 to 2013.

RESULTS: Fifty patients (56% male) with median age of 59 years (range, 8-76) were newly diagnosed with clival chordoma of mean diameter 3.3 cm (range, 1.5-6.7). Symptoms included headaches (38%), diplopia (36%), and dysphagia (14%). Procedures included transsphenoidal (n = 34), transoral (n = 4), craniotomy (n = 5), and staged approaches (n = 7). Gross total resection (GTR) rate was 52%, with 83%mean volumetric reduction, values that improved over time.While the lower third of the clivus was the least likely superoinferior zone to contain tumor (upper third = 72%/middle third = 82%/lower third = 42%), it most frequently contained residual tumor (upper third = 33%/middle third = 38%/lower third = 63%; P , .05). Symptom improvement rates were 61% (diplopia) and 53% (headache). Postoperative radiation included proton beam (n = 19), cyberknife (n = 7), intensity-modulated radiation therapy (n = 6), external beam (n = 10), and none (n = 4). At last follow-up of 47 patients, 23 (49%) remain disease-free or have stable residual tumor. Lower third of clivus progressed most after GTR (upper/mid/lower third = 32%/ 41%/75%). In a multivariate Cox proportional hazards model, male gender (hazard ratio [HR] = 1.2/P = .03), subtotal resection (HR = 5.0/P = .02), and the preoperative presence of tumor in the middle third (HR = 1.2/P = .02) and lower third (HR = 1.8/P = .02) of the clivus increased further growth or regrowth, while radiation modality did not.

CONCLUSION: Our findings underscore long-standing support for GTR as reducing chordoma recurrence. The lower third of the clivus frequently harbored residual or recurrent tumor, despite staged approaches providing mediolateral (transcranial 1 endonasal) or superoinferior (endonasal 1 transoral) breadth. There was no benefit of proton-based over photonbased radiation, contradicting conventional presumptions.

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Utility of postmortem imaging system for anatomical education in skull base surgery

Utility of postmortem imaging system for anatomical education in skull base surgery

Neurosurg Rev (2015) 38:165–170

Although cadaver dissections are important for skull base surgeons to acquire anatomical knowledge and techniques, their opportunities are limited in Japan. The Autopsy Imaging Center of the University of Fukui Hospital has both a CT scanner and an MR unit solely for deceased patients.

The authors applied the postmortemimaging to cadaver dissections and evaluated its usefulness in surgical education. Ten sides of five formalin-fixed cadaver heads were dissected by ten neurosurgeons. Five neurosurgeons were young, three were moderately experienced, and two were experts in skull base surgery. They performed orbitozygomatic, anterior transpetrosal, posterior transpetrosal, and transcondylar approaches. CT bone images were taken before and after dissections, and MR images were taken before dissection to merge with the CT bone images. The usefulness of the images for each neurosurgeon and for each skull base approach was evaluated.

The postmortem imaging system was useful for all neurosurgeons, especially in anterior transpetrosal, posterior transpetrosal, and transcondylar approaches. They could find the insufficiency or excessiveness of their drilling of specific bony structures with the images. Even the experts in skull base surgery could identify regions in which they could add drilling safely to widen the surgical field more.

The postmortem imaging system was useful for skull base cadaver dissections. This system is expected to be utilized for education and research on surgical anatomy.

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Mapping p53 Mutations in Low-Grade Glioma: A Voxel-Based Neuroimaging Analysis

Mapping p53 Mutations in Low-Grade Glioma

AJNR Am J Neuroradiol 36:70–76

Brain tumor location has proved to be a prognostic factor that may be associated with features of neoplastic origin. Mutation of p53 is an atypical genetic change that occurs during tumorigenesis. Thus, a potential correlation may exist between tumor location and p53 status. The purpose of the current study was to identify anatomic characteristics of mutant p53 expression by using quantitative neuroimaging analyses.

MATERIALS AND METHODS: Preoperative MR images from 182 patients with histologically confirmed low-grade gliomas were retrospectively analyzed. All tumors were manually marked and registered to the standard space. Using a voxel-based lesion-symptom mapping analysis, we located brain regions associated with a high occurrence of p53 mutation and corrected them by using a permutation test. The acquired clusters were further included as a factor in survival analyses.

RESULTS: Statistical analysis demonstrated that the left medial temporal lobe and right anterior temporal lobe were specifically associated with high expression of mutant p53. Kaplan-Meier curves showed that tumors located in these regions were associated with significantly worse progression-free survival compared with tumors occurring elsewhere.

CONCLUSIONS: Our voxel-level imaging analysis provides new evidence that genetic changes during cancer may have anatomic specificity. Additionally, the current study suggests that tumor location identified on structural MR images could potentially be used for customized presurgical outcome prediction.

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Reconstruction of the anterior skull base after major trauma or extensive tumour resection

Reconstruction of the anterior skull base after major trauma or extensive tumour resectionActa Neurochir (2015) 157:139–144

The authors describe their experience with the reconstruction of complex anterior skull base defects after trauma or tumour resection using a “sandwich” technique with pericranial flap, titanium mesh and TachoSil.

Methods Description of surgical anatomy, surgical technique, indications, limitations, complications, specific perioperative considerations and specific information to give to the patient about surgery and potential risks. A summary of ten key points is given.

Conclusions After a bifrontal craniotomy and a subfrontal approach, it is possible to achieve a reliable reconstruction of the anterior skull base in a watertight manner by fixing a pericranial flap or a fascia lata graft to the orbital roofs and planum sphenoidale with an individually tailored titanium mesh and closing the frontobasal dura lesion with TachoSil.

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Gamma Knife radiosurgery for meningiomas arising from the tentorium

Gamma Knife radiosurgery for meningiomas arising from the tentorium- a 22-year experienceJ Neurooncol (2015) 121:129–134

In order to evaluate long term clinical and imaging outcomes, the authors retrospectively reviewed our 22-year experience using stereotactic radiosurgery (SRS) for tentorial meningiomas.

Thirty-nine patients with tentorial meningiomas underwent SRS using various Gamma Knife technologies between 1988 and 2010. The most common presenting symptoms were headache, dizziness or disequilibrium, and ataxia. The median tumor volume was 4.6 cm3 (range 0.5–36.6 cm3) and the median radiation dose to the tumor margin was 14 Gy (range 8.9–18 Gy). The median follow-up period was 41 months (range 6–183 months).

At the last imaging follow-up, tumor volumes decreased in 22 patients (57 %), remained stable in 13 patients (33 %), and increased in 4 patients (10 %). The progression-free survival after SRS was 97 % at 1 year, and 92 % at 5 years. At the last clinical followup, 35 patients (90 %) showed no change in symptoms, 1 patient (2 %) showed improvement of their neurologic symptom, and 3 patients (8 %) demonstrated worsening symptoms. The rate of symptom worsening after SRS was 5 % at 1 year, and 10 % at 5 years. Asymptomatic peritumoral edema after SRS occurred in 2 patients (5 %). Symptomatic adverse radiation effect developed in 2 patients (5 %).

SRS for tentorial meningiomas provided long-term effective tumor control and a low risk of radiation related complications.

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Syrinx resolution is correlated with the upward shifting of cerebellar tonsil following posterior fossa decompression in pediatric patients with Chiari malformation type I

Sirinx resolution

Eur Spine J (2015) 24:155–161

Chiari malformation type I (CMI) is characterized by deformed hindbrain. This study aimed to quantitatively evaluate the alterations in position of hindbrain after Posterior fossa decompression (PFD), and to identify the factors associated with syrinx resolution in pediatric patients with CMI.

Methods Eighty-seven patients, aged from 5 to 18 years, who underwent PFD for CMI between September 2006 and September 2012 were retrospectively reviewed. On midsagittal MR images, the position of medulla oblongata and cerebellum was quantitatively evaluated preoperatively and at follow-up. The maximal syrinx/cord (S/C) ratio and syrinx length were also measured. Significant improvement of syrinx was defined as a more than 20 % decrease in maximal S/C ratio or length on follow-up MRI.

Results Neurological deficits were found in 51 of the 87 patients preoperatively and 37 (72.4 %) of them obtained improvement of their symptoms at the last visit. Overall, upward shifting of the tip of cerebellar tonsil was observed in 66 (75.9 %) patients at the last follow-up. Moreover, the mean longitudinal distance of the tip of cerebellar tonsil changed from 16.47 ± 5.00 to 13.89 ± 4.38 mm (P<0.001) at final follow-up. Significant syrinx resolution was noticed in 79 (90.8 %) cases. Pointed cerebellar tonsils were found in 85 (97.7 %) of our patients preoperatively and 78 (91.8 %) of them acquired round cerebellar tonsils after PFD. The improvement of maximal S/C ratio was significantly correlated with upward shifting of the tip of cerebellar tonsil (P = 0.023).

Conclusions Following PFD for CMI, position and morphology of the cerebellar tonsil could revert to normal in most of the pediatric patients, and the upward shifting of the tip of cerebellar tonsil is significantly correlated with syrinx improvement. From this study, PFD without shunting may be effective for syrinx secondary to CMI in pediatric population.

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Endovascular Treatment of 346 Middle Cerebral Artery Aneurysms

MCA aneurysmNeurosurgery 76:54–61, 2015

The endovascular treatment of middle cerebral artery (MCA) aneurysms has been controversial because of the frequency of complex anatomy and the relative ease of surgical clipping in this location.

OBJECTIVE: To present a large single-center experience with the endovascular treatment of MCA aneurysms.

METHODS: The neurointerventional database at our institution was reviewed for all endovascular treatments of MCA aneurysms. Demographics, aneurysm characteristics, treatment modality, intraprocedural hemorrhagic and thromboembolic events, 30-day neurological events, and follow-up angiographic studies were recorded.

RESULTS: From December 1996 to April 2013, 292 patients underwent endovascular treatment of 346 MCA aneurysms. Of these, 341 (98.6%) were successfully completed. Balloon neck remodeling was used in 230 procedures (66.5%). Ninety-five procedures (27.4%) were for ruptured aneurysms. The rate of intraprocedural hemorrhage was 2.6% (9 of 346). The overall rate of intraprocedural thromboembolic events was 13.6% (47 of 346), significantly more common in patients with acute subarachnoid hemorrhage (27.4%; P, .001). The 30-day major (modified Rankin Scale score . 2) neurological event rate was 2.9% (10 of 346), significantly more common in patients with subarachnoid hemorrhage (8.4%) compared with those without (0.8%; P , .001). The rate of complete or near-complete aneurysm occlusion at was 90.6% $ 6 months and 91.8% at $ 2 years, with an average of 24 months of follow-up available for 247 procedures.

CONCLUSION: Endovascular treatment of MCA aneurysms can be safe and effective. However, it is associated with a high asymptomatic thromboembolic event rate that is more frequent in the setting of acute subarachnoid hemorrhage.

KEY WORDS:

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Extended endoscopic transsphenoidal approach infrachiasmatic corridor

EE transsphenoidal approach infrachiasmatic corridor

Neurosurg Rev (2015) 38:137–147

An extended endoscopic transsphenoidal approach is required for skull base lesions extending to the suprasellar area. Inferior approach using the infrachiasmatic corridor allows access to the lesions through the tumor growth that is favorable for the extended transsphenoidal approaches. Infrachiasmatic corridor is a safer route for the inferior approaches that is made up by basal arachnoid membrane and Liliequist’s membrane with its leaves (diencephalic and mesencephalic leaf). This area extends from the optic canal and tuberculum sella to the corpus mamillare.

We performed extended endoscopic approach using the infrachiasmatic corridor in 52 cases, including tuberculum sella meningiomas (n:23), craniopharyngiomas (n:16), suprasellar Rathke’s cleft cyst (n:6), pituitary adenoma (n:2), fibrous dysplasia (n:1), infundibular granulosa cell tumor (n:2), and epidermoid tumor (n:2). Total resection was achieved in 17 of 23 (74 %) with tuberculum sellae meningioma using infrachiasmatic approach. Twenty patients presented with visual disorders and 14 of them improved. There were two postoperative cerebrospinal fluid (CSF) leakages and one transient diabetes insipidus and one permanent diabetes insipidus. Sixteen patients were operated on by the infrachiasmatic approach for craniopharyngiomas. Improvement was reached in seven of eight patients presented with visual disorders. Complete tumor resection was performed in 10 of 16 cases and cyst aspiration in 4 cases, and there were remnants in two cases. Postoperative CSF leakage was seen in two patients.

Infrachiasmatic corridor provides an easier and safer inferior route for the removal of middle midline skull base lesions in selected cases.

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Effect of postural changes on ICP in healthy and ill subjects

ICP

Acta Neurochir (2015) 157:109–113

Reference values and physiological measurements of intracranial pressure (ICP) are primarily reported in the supine position, while reports of ICP in the vertical position are surprisingly rare considering that humans maintain the vertical position for the majority of the day. In order to distinguish normal human physiology from disease entities such as idiopathic intracranial hypertension and normal pressure hydrocephalus, we investigated ICP in different body postures in both normal and ill subjects.

Methods Thirty-one patients were included: four normal patients following complete removal of a solitary clearly demarcated small brain tumour and fitted with a telemetric ICP monitoring device for long-term ICP monitoring; 27 patients requiring invasive ICP monitoring as a part of their diagnostic work-up or monitoring of shunt treatment effect. ICP was recorded in the following body positions: upright standing, sitting in a chair, supine and right lateral lumbar puncture position.

Results Linear regression of median ICP based on patient posture, group, and purpose of monitoring presented a significant model (p<0.001), but could not distinguish between patient groups (p=0.88). Regression of differences in median ICP between body postures and supine ICP as the baseline, presented a highly significant model (p<0.001) and adjusted R2=0.86. Both body posture (p<0.001) and patient group (p<0.001) were highly significant factors.

Conclusions Differences in ICP between body postures enabled us to distinguish the normal group from patient groups. Normal patients appear able to more tightly regulate ICP when switching body postures.

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Management of complex intracranial aneurysms with bypass surgery


 Complex aneurysms bypass surgery_93 patients

Neurosurg Rev (2015) 38:109–120

Despite advances in microsurgery and the development of new endovascular techniques, the treatment of complex intracranial aneurysms remains a daunting challenge for neurosurgeons. In the present study, we retrospectively reviewed our experience of bypass surgery in the treatment of 93 cases of complex intracranial aneurysms.

A series of 93 consecutive cases of complex intracranial aneurysms were treated with bypass surgery between April 2004 and July 2013. Radial artery (RA) grafts were used in 58 cases, saphenous vein (SV) grafts in 16 cases, and occipital artery (OA) grafts in 6 cases, while the remaining 13 cases were managed with superficial temporal artery (STA) grafts. In this series, the aneurysms were excised after trapping in 32 cases with mass effect and neural compression. Proximal occlusion of the parent artery was performed in 22 cases of fusiform or giant dissecting aneurysms with subsequent retrograde flow to avoid compromise of the perforators nearby. Trapping was performed after bypass surgery in the remaining 39 cases. Postoperative angiographies were performed in 91 patients and patency of the bypass graft and obliteration of the aneurysms were confirmed in 89 patients. Patency of the bypass could not be confirmed in the remaining two patients, of which one presented with cerebral infarction due to graft occlusion, and the other remained asymptomatic. Within 1 month after surgery, 88 patients had good outcome, four patients needed assistance for daily living, and one death occurred due to brainstem infarction. In 77 patients with a mean follow-up of 3.0 years, 72 patients had good outcome, 4 patients needed assistance for daily living, and 1 death occurred unrelated to surgery.

Complex intracranial aneurysms present unique therapeutic challenges that require thorough surgical planning, individualized treatment strategies, and refined neurovascular techniques for successful outcome. Proper use of bypass surgery is imperative in preserving the parent artery and its major perforators. The internal maxillary artery, used as a donor in a bypass, is an effective method due to its shorter distance from the recipient vessels and relatively large diameter with resulting higher flow rate.

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Anterior cervical discectomy versus corpectomy for multilevel cervical spondylotic myelopathy: a meta-analysis

Anterior cervical discectomy versus corpectomy for multilevel cervical spondylotic myelopathy

Eur Spine J (2015) 24:31–39

This is a meta-analysis to compare the results between anterior cervical discectomy fusion (ACDF) and anterior cervical corpectomy fusion (ACCF) for the patients with multilevel cervical spondylotic myelopathy (MCSM).

Methods Systematic review and meta-analysis of cohort studies between ACDF with plate fixation and ACCF with plate fixation for the treatment of MCSM. An extensive search of literature was performed in PubMed, Mediline, Embase and the Cochrane library. The following outcome measures were extracted: JOA scores, fusion rate, cervical lordosis (C2–7), complications, blood loss and operation time. Data analysis was conducted with RevMan 5.0.

Results Four cohorts (six studies) involving 258 patients were included in this study. The pooled analysis showed that there was no significant difference in the postoperative JOA score [WMD = -0.14 (-1.37, 1.10), P = 0.83], fusion rate [OR = 0.84 (0.15, 4.86), P = 0.85] between two group. However, there was significant difference in the cervical lordosis [WMD = 3.38 (2.52, 4.23), P<0.00001], surgical complication rate and instrument related complication rate (P = 0.01, 0.005 respectively), blood loss [WMD = -52.53 (-73.53, -31.52), P<0.00001], and operation time [WMD = -14.10 (-20.27, -7.93), P<0.00001].

Conclusions As compared with ACCF with plate fixation, ACDF with plate fixation showed no significant differences in terms of postoperative JOA score, fusion rate, but better improved cervical lordosis, lower complication and smaller surgical trauma. As the limitations of small sample and short follow-up in this study, it still could not be identified whether ACDF with plate fixation is more effective and safer than ACCF with plate fixation.

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