Author: cba

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Surgical Treatment of Giant Intracranial Arteriovenous Malformations

Neurosurgery 67:1359–1370, 2010 DOI: 10.1227/NEU.0b013e3181eda216

The treatment of giant arteriovenous malformations (AVMs) remains a challenge in the neurosurgical field. Microsurgery is one of the most effective ways for eliminating giant cerebral AVMs.

OBJECTIVE: To review surgical outcomes in treating the disease, and form conclusions regarding the indications for and outcomes of surgical treatment in giant intracranial AVMs.

METHODS: We studied 40 consecutive cases of giant AVMs treated in Beijing Tiantan Hospital between 2000 and 2008. The radiologic and clinical features were analyzed. The Spetzler-Martin grading system was used to classify the patients. All patients were surgically treated, and the final outcomes of the patients were gathered for analysis.

RESULTS: The major presenting symptoms were seizures, headaches, hemorrhage, and neurological deficits. The mean AVM diameter was 6.3 cm. According to the Spetzler- Martin grading system, 5 patients had grade III lesions, 21 had grade IV lesions, and 14 had grade V lesions. Out of the total 40 patients, 31 (77.5%) demonstrated excellent or good outcome. Complications included hemiparalysis, aphasia, hemianopia, cranial nerve dysfunction, and seizures. After follow-up, 27 of 30 (90%) surviving patients presented normal function or minimal symptoms.

CONCLUSION: Presurgical evaluation of every candidate and treatment choice is the determining factor in therapy for giant AVMs. For giant cerebral AVMs located superficially or not involving critical components, a good outcome can be expected through surgical resection. The obliteration and recurrence rates were satisfying, and the complication rate was acceptable.

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Clival chordomas: clinical management, results, and complications in 71 patients

J Neurosurg 113:1059–1071, 2010. DOI: 10.3171/2009.9.JNS08596

Chordomas are rare malignant neoplasms arising predominantly at the sacrum and skull base. They are uniformly lethal unless treated with aggressive resection and proton beam irradiation. The authors present results of the surgical management of a large number of patients with clivus chordomas. Factors that influence the surgeon’s ability to achieve radical tumor resection are also evaluated.

Methods. Between 1991 and 2005, 71 patients with clivus chordomas underwent surgery. The average followup was 66 months (median 60 months, range 3–189 months). Sixty-five patients had complete records that were analyzed in the present report. Thirty-five percent of them had undergone surgery before being treated by the authors. They were evaluated with MR imaging and CT scanning and underwent surgery utilizing a variety of skull base techniques aimed at achieving radical excision. Many also underwent postoperative radiation, usually in the form of proton beam therapy. The patients were followed up with serial imaging at regular intervals as well as with neurological evaluation.

Results. Radical tumor resection was achieved in 58% of the group. The overall 5-year survival rate was 75%. Radical resection had a positive impact on survival. The ability to achieve radical resection was dependent on the preoperative tumor volume and the number of anatomical areas involved by the tumor. Cranial nerve impairment and CSF leakage were the most frequent postoperative complications.

Conclusions. Radical excision is the ideal surgical goal in the treatment of clival chordomas and can be achieved with reasonable risks. Several different surgical approaches may be necessary to accomplish this.

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Neuroendoscopic treatment of arachnoid cysts of the quadrigeminal cistern: a series of 14 cases

J Neurosurg Pediatrics 6:000–000, 2010. DOI: 10.3171/2010.8.PEDS08491

In this paper, the authors’ goal was to evaluate the role of neuroendoscopy in the treatment of arachnoid cysts of the quadrigeminal cistern.

Methods. Between March 1995 and February 2008, 14 patients affected by arachnoid cysts of the quadrigeminal cistern were treated endoscopically. The cysts were classified according to their anatomical and radiological appearance. The most frequent form (Type I) extended infratentorially and supratentorially with a dumbbell shape. Type II cysts were confined to the infratentorial space and were associated with the most severe and acute form of hydrocephalus. Type III cysts presented a significant asymmetric expansion toward the temporal fossa. Ten patients underwent an endoscopic procedure as primary treatment and 4 as an alternative to shunt revision. In 6 cases, the first endoscopic procedure was ventriculocystostomy (VC) together with endoscopic third ventriculostomy (ETV). In the other 8 cases, the first endoscopic procedure was VC alone.

Results. In the 6 cases in which VC was performed with an ETV, the procedure was successful, and the patients did not require further surgery. Of the 8 cases in which the first endoscopic procedure performed was VC without ETV, 7 underwent reoperation. Four of these patients underwent endoscopic procedures (by reopening the obstructed VC and performing ETV or cystocisternostomy) 2, 4, 4, and 5 months later with final success in all cases. Three patients (all of whom were previously treated using ventriculo- or cystoperitoneal shunts) required shunt reimplantation (complete failure). Subdural collection developed in 1 case, which was managed by transient insertion of a subduroperitoneal shunt. Neurological and developmental outcomes were good except for 1 patient who did not show improvement in preoperative developmental delay. No transient or permanent morbidity or mortality was observed.

Conclusions. The analysis of this series suggests that arachnoid cysts of the quadrigeminal cistern and the associated hydrocephalus can be effectively treated by endoscopy; this approach allows the patient to be shunt independent in more than 78% of the cases. If endoscopy is used as first option, the success rate of endoscopic procedures observed in this series was 90%. Endoscopic third ventriculostomy should be associated with a VC to offer the highest success rate with a single procedure.

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Surgical management of giant pediatric craniopharyngiomas

J Neurosurg Pediatrics 6:000–000, 2010.DOI: 10.3171/2010.8.PEDS09385

Prior work by the authors’ group and reports of other authors suggest worse functional outcomes and decreased survival in children with larger craniopharyngiomas. The purpose of this study was to assess the oncological, endocrinological, and functional outcomes in children who underwent radical resection of giant craniopharyngiomas (defined as 5 cm or greater in largest diameter).

Methods. Between 1986 and 2006, 26 children under the age of 18 (14 boys, 12 girls; mean age 10.5 years) underwent radical resection of giant craniopharyngiomas performed by the senior author. Data were retrospectively collected to assess the outcome of surgical treatment.

Results. Twenty (77%) of 26 patients underwent gross-total resection (GTR) confirmed by intraoperative inspection and postoperative imaging. All primary tumors (17 of 17) and 3 (33%) of 9 recurrent tumors were treated with GTR. There was no operative mortality, and 18 of 26 patients (69%) were alive at a mean follow-up of 8.9 years (median 9.3 years). Disease control was achieved in 21 (84%) of the 25 patients followed up for more than 6 months and was more successful in patients who underwent GTR (95%) than in those who underwent STR (50%, p = 0.03). New-onset diabetes insipidus (DI) occurred in 63.2% of patients (73% of patients had DI postoperatively). New or worsened deficits in visual acuity and visual fields occurred in 16% and 28%, respectively, of the 25 patients for whom postoperative visual data were available. Five patients (19%) experienced significant, permanent neurological deficits, and 5 (19%) had mild to moderate deficits. New or worsened hypothalamic disturbance occurred in 35% and 22% of patients, respectively, but obesity developed in only 15%.

Conclusions. In this retrospective series, radical resection of giant craniopharyngiomas in children was found to lead to excellent rates of disease control with acceptable or good functional outcomes but slightly higher rates of neurological complications compared with rates in patients with smaller tumors. Radical resection is less successful in recurrent tumors that reach very large sizes, especially previously irradiated tumors, with resultant diminished survival.

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Trigeminal neurinomas with extracranial extension: analysis of 28 surgically treated cases

J Neurosurg 113:1079–1084, 2010.DOI: 10.3171/2009.10.JNS091149

The object of this paper was to review the authors’ experience with 28 cases of trigeminal neurinomas having an extracranial extension.

Methods. The authors analyzed 28 cases of trigeminal neurinoma in which there was an extracranial extension of the tumor. All patients were treated in their department between the years 1989 and 2009.

Results. There was tumor extension along the ophthalmic division of the nerve in 4 cases, along the maxillary division in 5, and along the mandibular division in 13. In 6 tumors there was diffuse extracranial extension and the exact extracranial division of nerve involvement could not be ascertained. In 10 cases, the tumor had a multicompartmental location—in the posterior fossa, the middle fossa, and the extracranial compartment. Tingling paraesthesiae, numbness, and diffuse pain in the distribution of the trigeminal nerve were common symptoms and were present in 90% of patients. The extracranial component had a well-defined perineural/meningeal membrane cover that was continuous with the middle fossa dura mater and isolated the tumor tissue from the adjoining critical structures. In 7 out of 10 cases, even the posterior fossa component of the tumor was entirely “interdural” (within the confines of the dura). The maximum dimension of the tumor was > 4 cm in 22 cases. A limited “transcranial” approach with (12 cases) or without (16 cases) zygomatic osteotomy was found suitable for resection of these tumors. In 4 cases a lateral orbitotomy was performed. Total tumor resection was performed in 20 cases and partial resection in 8. The duration of follow-up ranged from 6 months to 19 years. Two patients required additional surgery for symptomatic recurrence.

Conclusions. Extracranial extensions of trigeminal neurinomas have a well-defined meningeal covering. In most cases resection was performed via a minimally invasive cranial avenue (a “reverse skull base approach”). Radical resection was associated with an excellent long-term outcome.

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The clinical significance and optimal timing of postoperative computed tomography following cranial surgery

J Neurosurg 113:1021–1025, 2010. DOI: 10.3171/2009.11.JNS081048

This study was conducted to evaluate the value of postoperative CT scans in determining the probability of return to the operating room (OR) and the optimal time to obtain such scans to determine the effects of surgery.

Methods. Between January and December 2006 (12 months), all postoperative head CT scans obtained for 3 individual surgeons were reviewed. Scans were divided into 3 groups, which were determined by the preference of each surgeon: Group A (early scans—scheduled between 0 and 7 hours); Group B (delayed scans—scheduled between 8 and 24 hours); and Group C (urgent scans—ordered because of a new neurological deficit). The initial scans were reviewed and analyzed in 2 different fashions. The first was to analyze the efficacy of the scans in predicting return to the OR. The second was to determine the optimal time for obtaining a scan. The second analysis was a review of serial postoperative scans for expected versus unexpected findings and changes in the acuity of these findings over time.

Results. In 251 (74%) of 338 cases, the patients had postoperative head CT scans within 24 hours of surgery. Analysis 1 determined the percent of patients returning to the OR for emergency treatment based on postoperative scans: Group A (early)—133 patients, with 0% returning to the OR; Group B (delayed)—108 patients, with 0% returning to the OR; and Group C (urgent)—10 patients, with 30% returning to the OR (p < 0.05). Analysis 2 determined the optimal timing of postoperative scans and changes in scan acuity: Group A (early scan) had an 11% incidence of change in acuity on subsequent scans. Group B (delayed scan) had a 3% incidence of change in acuity on follow-up scans (p < 0.05).

Conclusions. Routine postoperative scans at 0–7 hours or at 8–24 hours are not predictive of return to the OR, whereas patients with a new neurological deficit in the postoperative period have a 30% chance of emergency reoperation based on CT scans. In addition, early postoperative scans (0–7 hours) fail to predict CT changes, which might evolve over time and may influence postoperative medical management.

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Utility of diffusion tensor-imaged (DTI) motor fiber tracking for the resection of intracranial tumors near the corticospinal tract

Acta Neurochir. DOI 10.1007/s00701-010-0817-0

Treatment of intracranial tumors near the corticospinal tract remains a surgical challenge. Several technical tools to map and monitor the motor tract have been implemented. The present study aimed to assess the utility of diffusion tensor imaging (DTI) fiber tracking in the surgical treatment of motor eloquent tumors at our institution.

Methods Patients operated for intracranial tumors close to the motor tract with the use of intraoperative image guidance including DTI fiber tracking of the corticospinal tract and intraoperative motor evoked potential (MEP) monitoring were analyzed. The intraoperative utility of fiber tracking data was analyzed. Furthermore, preoperative MRI scans with and without motor fiber tracking were reevaluated post hoc for tumor relation to the motor tract, estimated resectability, and best approach. Thereby, the utility of fiber tracking in surgical planning was assessed.

Results Nineteen patients were analyzed. The estimation of tumor localization in relation to the motor tract and of resectability was not influenced by fiber tracking in any of the cases. Only in one single case did evaluating surgeons change their surgical approach after the addition of the fiber tracking data. In all cases, fiber tracking included in image guidance did not change the intraoperative strategy, while MEP monitoring did.

Conclusions DTI fiber tracking did not influence the surgical planning or the intraoperative course. However, it is still used at our institution due to its ease in acquisition and its potential impact in a larger series. Furthermore, more experience with this technique is required to lead to a technical improvement.

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A Multicenter Multinational Registry for Assessing Ventriculoperitoneal Shunt Infections for Hydrocephalus

Neurosurgery 67:1303–1310, 2010 DOI: 10.1227/NEU.0b013e3181f07e76

Reported infection rates after ventriculoperitoneal shunt surgery vary from 1 to 25%. Antibiotic-impregnated (AI) catheters may reduce shunt infection rates, but this is uncertain.

OBJECTIVE: To establish a prospective shunt registry to evaluate short-term (3-month) infection rates associated with ventriculoperitoneal shunts and standard or AI catheters during surgical treatment of hydrocephalus.

METHODS: A prospective, multicenter, noncontrolled, open-label registry investigated patients with de novo catheter implantation or catheter replacement of an existing ventriculoperitoneal shunt. The primary outcome was shunt infection.

RESULTS: A total of 440 patients were entered into the registry at 10 sites: 3 in North America, 2 in Singapore, 4 in China and 1 in India. Seven patients were excluded. Of the 433 remaining patients, 314 had new shunts and 119 were revisions. Shunt infections occurred in 14 of 433 patients (3.2%) overall and in 2 of 37 infants (5.2%) younger than 1 year. AI catheters were used in 46 of 433 patients at 7 centers. The shunt infection rate was 0 of 46 for shunts with AI catheters and 14 of 387 (3.6%) without AI catheters. Infection rates were similar with AI catheters, adjusting for age and catheter type.

CONCLUSION: The overall shunt infection rate was lower than in previous multicentered studies. The low infection rate and low rate of AI catheter use precludes any meaningful statement regarding the value of AI catheters in reducing the infection rate. Consideration should be given to performing a well designed, adequately powered, prospective randomized controlled trial to determine whether AI catheters reduce shunt infection rates.

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Repeat Transsphenoidal Surgery for the Treatment of Remaining or Recurring Pituitary Tumors in Acromegaly

Neurosurgery 67:949–956, 2010 DOI: 10.1227/NEU.0b013e3181ec4379

Acromegaly is a disorder characterized by hypersecretion of growth hormone caused by a growth hormone–secreting pituitary adenoma.

OBJECTIVE: To evaluate the long-term efficacy and safety of repeat transsphenoidal surgery for persistent or recurrent acromegaly.

METHODS: We retrospectively reviewed records for 53 acromegalic patients who underwent repeat transsphenoidal surgery for persistent or progressive acromegaly at Toranomon Hospital between 1987 and 2006. Multivariate logistic regression was performed to evaluate preoperative factors influencing the surgical outcome.

RESULTS: Thirty-one patients (58.5%) met the criteria for cure on long-term follow-up endocrine findings. Furthermore, 17 patients were well controlled with normal insulinlike growth factor I levels without (2 patients) or with medication (15 patients), whereas insulin-like growth factor I levels were still above normal in 5 patients after postoperative adjuvant therapy. Only 1 patient was undergoing additional hormonal replacement after surgery, although transient cerebrospinal fluid leak, transient abducens nerve palsy, severe nasal bleeding, and pituitary abscess occurred in each patient, respectively. Multivariate analysis clarified that a favorable surgical outcome was achieved in patients without cavernous sinus invasion (hazard ratio 12.56), tumor segmentation (hazard ratio 5.82), or in those older than 40 years old (hazard ratio 3.21).

CONCLUSION: Repeat surgery can be performed safely with an approximately 60% long-term cure rate in this series. Reoperation should therefore be considered for persistent or recurrent disease in acromegalic patients in whom adjuvant therapy is not effective enough or cannot be accepted. The careful study of initial or preoperative magnetic resonance imaging and the use of micro-Doppler, endoscope, and eye movement monitoring device during surgery can help increase cure rate with a lower complication rate.

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Bilateral Deep Brain Stimulation for Cervical Dystonia: Long-term Outcome in a Series of 10 Patients

Neurosurgery 67:957–963, 2010 DOI: 10.1227/NEU.0b013e3181ec49c7

Bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) was shown to be effective in cervical dystonia refractory to medical treatment in several small short-term and 1 long-term follow-up series. Optimal stimulation parameters and their repercussions on the cost/benefit ratio still need to be established.

OBJECTIVE: To report our long-term outcome with bilateral GPi deep brain stimulation in cervical dystonia.

METHODS: The Toronto Western Spasmodic Torticollis Rating Scale was evaluated in 10 consecutive patients preoperatively and at last follow-up. The relationship of improvement in postural severity and pain was analyzed and stimulation parameters noted and compared with those in a similar series in the literature.

RESULTS: The mean (standard deviation) follow-up was 37.6 (16.9) months. Improvement in the total Toronto Western Spasmodic Torticollis Rating Scale score as evaluated at latest follow-up was 68.1% (95% confidence interval: 51.5-84.6). In 4 patients, there was dissociation between posture severity and pain improvement. Prevalently bipolar stimulation settings and high pulse widths and amplitudes led to excellent results at the expense of battery life.

CONCLUSION: Improvement in all 3 subscale scores of the Toronto Western Spasmodic Torticollis Rating Scale with bilateral GPi deep brain stimulation seems to be the rule. Refinement of stimulation parameters might have a significant impact on the cost/ benefit ratio of the treatment. The dissociation of improvement in posture severity and pain provides tangible evidence of the complex nature of cervical dystonia and offers interesting insight into the complex functional organization of the GPi.

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Glioblastoma multiforme of the elderly: the prognostic effect of resection on survival

J Neurooncol. DOI 10.1007/s11060-010-0429-9

According to recent developments the best treatment options for glioblastoma (GBM) consist in maximum safe resection and additional adjuvant treatment with radiotherapy (RT) and alkylating chemotherapy (CHX).

These options have been evaluated for populations with a median age of approximately 58 years. We therefore addressed the issue of whether elderly patients ([65years) could also benefit from cytoreductive surgery (CS) and adjuvant treatment using alkylating chemotherapy.

Onehundred and three patients suffering from newly diagnosed, primary supratentorial glioblastoma multiforme[65 years (median 70.8 years) were identified in our single-center glioma database (2002–2007) and retrospectively divided into group A (n = 31) treated with surgery alone (biopsy, BY, n = 21, CS n = 10), group B (n = 37) surgery plus radiation (BY n = 18, CS n = 19), and group C (n = 35) surgery, RT and CHX (BY n = 4, CS n = 31). Progression- free survival (PFS) and overall survival (OAS) were determined in each group and correlated to age, Karnofsky performance score (KPS), and extent of resection (biopsy (BY), partial (PR), and complete resection (CR)). Progression was defined according the Macdonald criteria. For all patients PFS and OAS were 3.2 months and 5.1 months (m) respectively. PFS and OAS for groups A/B/C were 1.8/ 3.2/6.4 m (P = 0.000) and 2.2/4.4/15.0 m (P = 0.000), respectively. Median age for groups A/B/C was 74.4/70.6/ 68.5 years and median KPS was 60/70/80. Age (\75, C75) was inversely correlated with OAS (5.8/2.5 m, P = 0.01). KPS (\70, C70) was correlated with OAS 2.4/6.5 m (P = 0.000). Extent of resection (BY, PR, or CR) correlated with PFS (2.1/3.4/6.4 m, P = 0,000) and OS (2.2/7.0/ 13.9 m, P = 0,000), respectively.

Our study shows that elderly GBM patients can benefit from maximum treatment procedures with cytoreductive microsurgery, radiation therapy, and chemotherapy. Treatment options are obviously affected by KPS and age. The most impressive outcome predictor in this population was the extent of microsurgical resection for patients treated with adjuvant radiotherapy and chemotherapy. To conclude, elderly GBM patients should not be per se excluded from intensive treatment procedures.

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Surgical treatment of cervical kyphosis

Eur Spine J. DOI 10.1007/s00586-010-1602-8

Cervical kyphosis is an uncommon but potentially debilitating and challenging condition.

We reviewed the etiology, presentation, clinical and radiological evaluation, and treatment of cervical kyphosis. Based on the current controversy as to the ideal mode of surgical management, we paid particular attention to the available surgical strategies.

There are three approaches for cervical kyphosis: the anterior, posterior or combined procedures. The principal indication for the posterior strategy is a flexible kyphosis or kyphosis caused by ankylosing spondylitis.

The main point of debate is between the choice of the anterior or the combined strategy. The two strategies were compared with regard to clinical outcome, correction of deformity, rate of fusion, complications, revision surgery, and mortality. The combined strategy appears to result in a greater degree of correction than the anterior-alone strategy, and it is more likely to improve the cervical alignment to achieve a lordosis. However, the procedure carries a higher rate of postoperative neurological deterioration, complications, revision surgery, and mortality. Although the anterior alone strategy achieves a smaller reduction of cervical kyphosis, it has a lower rate of postoperative neurological deterioration, complications, revision surgery, and mortality.

We recommend that the surgical treatment of cervical kyphosis should be planned on an individual basis.

A multicenter, prospective, randomized controlled study would be necessary to determine the ideal mode of treatment for complex cervical kyphosis.

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Capillary telangiectasias: clinical, radiographic, and histopathological features

J Neurosurg 113:709–714, 2010. DOI: 10.3171/2009.9.JNS09282

Brain capillary telangiectasias (BCTs) are small, clinically benign, angiographically occult lesions that are usually incidental findings. Large capillary telangiectasias have not been reported previously as most BCTs are very small. Symptomatic BCTs are also rare, with few reports in the literature. The authors review the clinical manifestations, imaging, and histopathological characteristics of BCTs to further elucidate the diagnostic and clinical features of these vascular malformations.

Methods. The authors completed a retrospective radiological review of all cases of BCTs in the neuroradiology database at the University of Utah involving patients treated between January 1993 and December 2007. The MR imaging scans were reviewed, and the BCT was measured in 2 dimensions. They arbitrarily chose > 1 cm to define a large BCT as a majority of these lesions were smaller than that. The medical chart and the electronic database were used to gather each patient’s clinical information.

Results. One hundred thirty patients were identified in the archived neuroradiology database of capillary telangiectasias. Cases involving 105 patients with definite capillary telangiectasias were reviewed, and from these, 7 patients were identified to have a large capillary telangiectasia measuring > 1 cm. Upon further review, 2 of these patients were identified as having symptoms likely related to their capillary telangiectasia. These 2 cases are reported in the article. No patients with smaller BCTs were found to have symptoms related to their lesion.

Conclusions. Brain capillary telangiectasias are small vascular malformations that rarely cause symptoms. They are often overlooked on imaging because of their clinically benign nature; however, they have been misdiagnosed as glial tumors in the past. Specific MR imaging sequences (T1-weighted postcontrast and gradient refocused echo) are valuable in aiding diagnosis, as histopathological diagnosis is often not possible. These cases highlight that BCTs can cause symptoms, a finding that may actually be related to the size of the lesion (28.6% of large BCTs in this series were symptomatic, whereas none of the small ones were).

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Intramedullary high signal intensity and neurological status as prognostic factors in cervical spondylotic myelopathy

Acta Neurochir (2010) 152:1687–1694. DOI 10.1007/s00701-010-0692-8

The neurological outcome of cervical spondylotic myelopathy (CSM) may depend on multiple factors, including age, symptom duration, cord compression ratio, cervical curvature, canal stenosis, and factors related to magnetic resonance (MR) signal intensity (SI). Each factor may act independently or interactively with others. To clarify the factors in prognosis, we prospectively analyzed the outcomes of patients with myelopathy caused by soft disc herniation in correlation with magnetic resonance imaging (MRI) findings and other clinical parameters.

Materials and methods From June 2006 to July 2009, we performed surgical operations in 137 patients with CSM. Of these patients, 70 (51.1%), including 45 men and 25 women with ventral cord compression at one or two levels, underwent anterior cervical discectomy and fusion. The mean duration of follow-up was 32.7 months. We surveyed the cervical curvature index (CCI), canal stenosis (Torg–Pavlov ratio), cord compression ratio, the length of SI change on T2WI, and clinical outcome using the Japanese Orthopedic Association (JOA) score for cervical myelopathy. The MRI SI was evaluated by grade: grade 0, no change in signal intensity; grade 1, light signal change; and grade 2, bright signal change on the T2WI. Multifactorial effects were identified by regression analysis.

Results The mean preoperative and postoperative JOA scores were 10.5±2.9 and 14.9±2.1, respectively (p< 0.05). The mean recovery rate based on the JOA score was 70.0±20.1%. The respective preoperative JOA scores and recovery ratios(%) were 11.6±2.3 and 81.5±17.0% in 20 patients with SI grade 0; 10.8±2.3 and 70.1±17.3% in 25 patients with grade 1; and 9.2±3.6 and 60.7±20.9% in 25 patients with grade 2, respectively. Post-surgical neurological outcome showed no significant relationship to age, symptom duration, cervical alignment, stenosis, or cord compression.

Conclusions Among the variables tested, preoperative neurological status and intramedullary signal intensity were significantly related to neurological outcome. The better the preoperative neurological status was, the better the postoperative neurological outcome. The SI grade on the preoperative T2WI was negatively related to neurological outcome. Hence, the severity of SI change and preoperative neurological status emerged as significant prognostic factors in post-operative CSM.

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Brain surface motion imaging to predict adhesions between meningiomas and the brain surface

Neuroradiology (2010) 52:1003–1010. DOI 10.1007/s00234-010-0671-z

“Brain surface motion imaging” (BSMI) is the subtraction of pulse-gated, 3D, heavily T2-weighted image of two different phases of cerebrospinal fluid (CSF) pulsation, which enables the assessment of the dynamics of brain surface pulsatile motion. The purpose of this study was to evaluate the feasibility of this imaging method for providing presurgical information about adhesions between meningiomas and the brain surface.

Methods Eighteen cases with surgically resected meningioma in whom BSMI was presurgically obtained were studied. BSMI consisted of two sets of pulse-gated, 3D, heavily T2-weighted, fast spin echo scans. Images of the systolic phase and the diastolic phase were obtained, and subtraction was performed with 3D motion correction. We analyzed the presence of band-like texture surrounding the tumor and judged the degree of motion discrepancy as “total,” “partial,” or “none.” The correlation between BSMI and surgical findings was evaluated. For cases with partial adhesions, agreements in the locations of the adhesions were also evaluated.

Results On presurgical BSMI, no motion discrepancy was seen in eight cases, partial in six cases, and total in four cases. These presurgical predictions about adhesions and surgical findings agreed in 13 cases (72.2%). The locations of adhesions agreed in five of six cases with partial adhesions.

Conclusion In the current study, BSMI could predict brain and meningioma adhesions correctly in 72.2% of cases, and adhesion location could also be predicted. This imaging method appears to provide presurgical information about brain/meningioma adhesions.

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Intraoperative 5-aminolevulinic-acid-induced fluorescence in meningiomas

Acta Neurochir (2010) 152:1711–1719. DOI 10.1007/s00701-010-0708-4

5-aminolevulinic acid (5-ALA) has gained importance as an intraoperative photodynamic diagnostic agent for the extirpation of malignant gliomas. The application of this technique for resection of meningiomas has barely been explored. The aim of this study was to evaluate the utility of 5-ALA-induced fluorescence as a visual tool in meningioma resection and its correlation with histological findings.

Methods A total of 33 consecutive patients undergoing resection of intracranial meningiomas from December 2007 to August 2009 were included in this study. After confirmation of normal liver function, 5-ALA was administered orally (20 mg/kg) within 3–5 h prior to skin incision. All cases were operated on using standard microsurgical and neuronavigation-guided techniques. Intraoperative 440 nm fluorescence was applied periodically during and at the end of resection in order to detect tumor-infiltrated sites. The fluorescence of the tumor was evaluated intraoperatively by the surgeon and confirmed by subsequent video analysis.

Results A total of 32 (97%) patients presented with benign meningiomas (WHO I–II). In 1 (3%) patient, histological anaplastic signs (WHO III) could be demonstrated. 5-ALAinduced fluorescence of the tumor was confirmed in a total of 31 (94%) patients. The fluorescence did not correlate with the histological findings (n=30 WHO I–II, n=1 WHO grade III) or with preoperative brain edema and administration of steroids. A total resection could be postoperatively demonstrated in 25 (76%) patients. No adverse effects attributable to 5-ALA occurred.

Conclusions 5-ALA-induced fluorescence is a useful and promising intraoperative tool for the visualization of meningioma tissue. The novel findings demonstrated in this study in terms of high fluorescence and poor correlation with histological findings highlight the usefulness of this technique as a routine visual tool to achieve optimal resection of meningiomas.

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First-line treatment of malignant glioma with carmustine implants followed by concomitant radiochemotherapy: a multicenter experience

Neurosurg Rev (2010) 33:441–449. DOI 10.1007/s10143-010-0280-7

Randomized phase III trials have shown significant improvement of survival 1, 2, and 3 years after implantation of 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU) wafers for patients with newly diagnosed malignant glioma. But these studies and subsequent non-phase III studies have also shown risks associated with local chemotherapy within the central nervous system. The introduction of concomitant radiochemotherapy with temozolomide (TMZ) has later demonstrated a survival benefit in a phase III trial and has become the current treatment standard for newly diagnosed malignant glioma patients. Lately, this has resulted in clinical protocols combining local chemotherapy with BCNU wafers and concomitant radiochemotherapy with TMZ although this may carry the risk of increased toxicity.

We have compiled the treatment experience of seven neurosurgical centers using implantation of carmustine wafers at primary surgery followed by 6 weeks of radiation therapy (59–60 Gy) and 75 mg/m2/day TMZ in patients with newly diagnosed glioblastoma followed by TMZ monochemotherapy. We have retrospectively analyzed the postoperative clinical course, occurrence and severity of adverse events, progression-free interval, and overall survival in 44 patients with newly diagnosed glioblastoma multiforme. All patients received multimodal treatment including tumor resection, BCNU wafer implantation, and concomitant radiochemotherapy. Of 44 patients (mean age 59±10.8 years) with glioblastoma who received Gliadel wafer at primary surgery, 28 patients (64%) had died, 16 patients (36%) were alive, and 15 patients showed no evidence of clinical or radiographic progression after a median follow-up of 15.6 months. At time of analysis of adverse events in this patient population, the median overall survival was 12.7 months and median progression-free survival was 7.0 months. Surgical, neurological, and medical adverse events were analyzed. Twenty-three patients (52%) experienced adverse events of any kind including complications that did not require treatment. Nineteen patients (43%) experienced grade 3 or grade 4 adverse events. Surgical complications included cerebral edema, healing abnormalities, cerebral spinal fluid leakage, meningitis, intracranial abscess, and hydrocephalus. Neurological adverse events included newly diagnosed seizures, alteration of mental status, and new neurological deficits. Medical complications were thromboembolic events (thrombosis, pulmonary embolism) and hematotoxicity.

Combination of both treatment strategies, local chemotherapy with BCNU wafer and concomitant radiochemotherapy, appears attractive in aggressive multimodal treatment schedules and may utilize the sensitizing effect of TMZ and carmustine on MGMT and AGT on their respective drug resistance genes. Our data demonstrate that combination of local chemotherapy and concomitant radiochemotherapy carries a significant risk of toxicity that currently appears underestimated. Adverse events observed in this study appear similar to complication rates published in the phase III trials for BCNU wafer implantation followed by radiation therapy alone, but further add the toxicity of concomitant radiochemotherapy with systemic TMZ. Save use of a combined approach will require specific prevention strategies for multimodal treatments.

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Postauricular, transpetrous, presigmoid approach for extensive skull base tumors in the petroclival region: the successes and the travails

Acta Neurochir (2010) 152:1633–1645.DOI 10.1007/s00701-010-0701-y

Postauricular, transpetrous, presigmoid approach combines a supra/infratentorial exposure with partial petrosectomy to access third to the twelfth cranial nerves and extraaxial lesions situated anterolateral to brainstem. It provides a shorter working distance to large petrosal, petroclival, cerebellopontine, and cerebellomedullary cisternal lesions and their extensions to the subtemporal–infratemporal areas. This study reviews the surgical technique, corridors of extension, and complications encountered utilizing this approach for excising extensive lesions in these locations.

Methods The lesions (n=14) included petroclival meningiomas [(n=5), including three recurrent lesions], dumbbell lower cranial nerve schwannomas (n=2), giant acoustic schwannomas (n=2), recurrent giant trigeminal nerve schwannoma (n=1), glomus jugulare (n=3), and recurrent petrous aneurysmal bone cyst (n=1). The approach was combined with a retrosigmoid suboccipital craniectomy (n=3), with an infratemporal approach (n=2), and with an extreme lateral transcondylar approach and a translabyrinthine approach in one patient each, respectively. External auditory canal was not ligated in nine patients, superior petrosal sinus and tentorial division was performed in all patients, and sigmoid sinus–internal jugular vein was excised in three patients (with a glomus jugulare (n=1) and petroclival meningioma (n=2), respectively). Repair was performed with fat–fascia, pedicled pericranium, and temporalis muscle. Lumbar drain was placed for three to five postoperative days.

Results Total excision was performed in nine patients. Small tumor remnants were left attached to the brainstem (n=3, petroclival meningioma), carotid canal and cavernous sinus (n=1, glomus jugulare), and sigmoid sinus–jugular bulb (n=1, recurrent trigeminal schwannoma). A two-staged procedure was performed in three patients. Two patients with recurrent giant petroclival meningiomas died: one with lower cranial nerve paresis due to aspiration pneumonitis and the other with cerebrospinal fluid otorrhoea and secondary meningitis.

Conclusions The approach facilitates direct tumor decompression and its retraction away from the brainstem without initially encountering the intracisternal cranial nerves and neuraxis. It provides multiple corridors for excising extensive posterior fossa tumors. Preoperative assessment of sigmoid sinus dominance, jugular bulb height, labyrinth, vein of Labbe, and space available through Trautman’s triangle considerably helps in complication avoidance.

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The presigmoid approach to anterolateral pontine cavernomas

J Neurosurg 113:701–708, 2010. DOI: 10.3171/2010.1.JNS08413

Anterolateral cavernomas of the pons have been surgically removed via a variety of approaches, commonly retrosigmoid or transventricular. The goal in this study was to evaluate the presigmoid approach as an alternative.

Methods. Clinical data were reviewed in 9 patients presenting with anterolateral pontine cavernomas between 1999 and 2007.

Results. All patients were treated via a presigmoid approach, which provided a nearly perpendicular trajectory to the anterolateral pons. The brainstem was entered through a “safe zone” between the trigeminal nerve and the facial/ vestibulocochlear nerve complex. Complete resection was achieved in all cases. No patient experienced recurrent events during follow-up (1–24 months). The patients’ modified Rankin Scale score improved within 1 year of surgery (1.7 ± 0.4) compared with baseline (2.6 ± 0.2; p < 0.05). Only one patient experienced a new deficit (decreased hearing), which was corrected with a hearing aid.

Conclusions. The presigmoid approach is recommended for the resection of anterolateral pontine cavernomas. With this approach, the need for cerebellar retraction is nearly eliminated. The lateral “presigmoid” entry point creates a trajectory that allows complete resection of even deep lesions at this level, or anterior to the internal acoustic meatus.

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Outcomes after a purely endoscopic transsphenoidal resection of growth hormone

Neurosurg Focus 29 (4):E5, 2010. DOI: 10.3171/2010.7.FOCUS10153

Using strict biochemical remission criteria, the authors assessed surgical outcomes after endoscopic transsphenoidal resection of growth hormone (GH)–secreting pituitary adenomas and identified preoperative factors that significantly influence the rate of remission.

Methods. A retrospective review of a prospectively maintained database was performed. The authors reviewed cases in which an endoscopic resection of GH-secreting pituitary adenomas was performed. The cohort consisted of 26 patients who had been followed for 3–60 months (mean 24.5 months). The thresholds of an age-appropriate, normalized insulin-like growth factor–I concentration, a nadir GH level after oral glucose load of less than 1.0 μg/l, and a random GH value of less than 2.5 μg/l were required to establish biochemical cure postoperatively.

Results. Overall, in 57.7% of patients undergoing a purely endoscopic transsphenoidal pituitary adenectomy for acromegaly, an endocrinological cure was achieved. The mean clinical follow-up duration was 24.5 months. In patients with microadenomas (4 cases) the cure rate was 75%, whereas in patients harboring macroadenomas (22 cases) the cure rate was 54.5%. Cavernous sinus invasion (Knosp Grades 3 and 4) was associated with a significantly lower remission rate (p = 0.0068). Hardy Grade 3 and 4 tumors were also less likely to achieve biochemical cure (p = 0.013). The overall complication rate was 11.5% including 2 incidents of transient diabetes insipidus and 1 postoperative CSF leak, which were treated nonoperatively.

Conclusions. A purely endoscopic transsphenoidal approach to GH-secreting pituitary adenomas leads to similar outcome for noninvasive macroadenomas compared with traditional microsurgical techniques. Furthermore, this approach may often provide maximal visualization of the tumor, the pituitary gland, and the surrounding neurovascular structures.

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