Category: Outcome

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Safety and efficacy of Gliadel wafers for newly diagnosed and recurrent glioblastoma

Acta Neurochir (2012) 154:1371–1378

Combining Gliadel wafers and radiochemotherapy with TMZ may carry the risk of increased adverse events (AE). We analyzed the efficacy and safety in patients with glioblastoma who underwent multimodal treatment with implantation of Gliadel wafers.

Methods One hundred sixty-five consecutive patients with newly diagnosed (77 patients) or recurrent (88 patients) glioblastoma were studied. Forty-seven patients underwent surgery + Gliadel. The impact of age (≥65 vs. <65), resection extent (gross total vs. partial), use of Gliadel and adjuvant treatment (TMZ vs. other schemes/no adjuvant therapy) on overall survival (OS, for patients with newly diagnosed glioblastoma) and on recurrence-survival (for patients with recurrent glioblastoma) was analyzed with Cox regression. The impact of age, history (newly diagnosed vs. recurrent glioblastoma), number of Gliadel wafers implanted (0 vs. <8 vs. 8), resection extent (gross-total vs. partial) and adjuvant treatment (TMZ vs. other schemes/no adjuvant therapy) on the occurrence of AE and on the occurrence of implantation site-related AE (ISAE) was analyzed with the logistic regression model. Significance was set at p<0.05.

Results Multivariate analysis showed the only factor associated with longer survival, both for newly diagnosed and for recurrent GBM, was resection extent. Both patients with a higher number of wafers implanted and patients with recurrent tumors were significantly at risk for AE and ISAE. Patients with eight Gliadel wafers implanted had a 3-fold increased risk of AE and a 5.6-fold increased risk of ISAE, and patients with recurrent tumor had a 2.8-fold increased risk of AE and a 9.3-fold increased risk of ISAE.

Conclusions Adding Gliadel to standard treatment did not significantly improve the outcome. The toxicity after Gliadel use was significantly higher, both for patients with newly diagnosed and patients with recurrent glioblastoma.

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Long-term visual outcome after microsurgical removal of occipital lobe cavernomas

J Neurosurg 117:295–301, 2012

Cavernomas in the occipital lobe are relatively rare. Because of the proximity to the visual cortex and incoming subcortical tracts, microsurgical removal of occipital cavernomas may be associated with a risk of visual field defects. The goal of the study was to analyze long-term outcome after operative treatment of occipital cavernomas with special emphasis on visual outcome.

Methods. Of the 390 consecutive patients with cavernomas who were treated at Helsinki University Central Hospital between 1980 and 2011, 19 (5%) had occipital cavernomas. Sixteen patients (4%) were surgically treated and are included in this study. The median age was 39 years (range 3–59 years). Seven patients (56%) suffered from hemorrhage preoperatively, 5 (31%) presented with visual field deficits, 11 (69%) suffered from seizures, and 4 (25%) had multiple cavernomas. Surgery was indicated for progressive neurological deterioration. The median follow-up after surgery was 5.25 years (range 0.5–14 years).

Results. All patients underwent thorough neuroophthalmological assessment to determine visual outcome after surgery. Visual fields were classified as normal, mild homonymous visual field loss (not disturbing the patient, driving allowed), moderate homonymous visual field loss (disturbing the patient, driving prohibited), and severe visual field loss (total homonymous hemianopia or total homonymous quadrantanopia). At the last follow-up, 4 patients (25%) had normal visual fields, 6 (38%) had a mild visual field deficit, 1 (6%) complained of moderate visual field impairment, and 5 (31%) had severe homonymous visual field loss. Cavernomas seated deeper than 2 cm from the pial surface carried a 4.4-fold risk of postoperative visual field deficit relative to superficial ones (p = 0.034). Six (55%) of the 11 patients presenting with seizures were seizure-free postoperatively. Eleven (69%) of 16 patients had no disability during the long-term follow-up.

Conclusions. Surgical removal of occipital cavernomas may carry a significant risk of postoperative visual field deficit, and the risk is even higher for deeper lesions. Seizure outcome after removal of these cavernomas appeared to be worse than that after removal in other supratentorial locations. This should be taken into account during preoperative planning.

 

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Efficacy and Safety of Endoscopic Transventricular Lamina Terminalis Fenestration for Hydrocephalus

Neurosurgery 71:464–473, 2012 DOI: 10.1227/NEU.0b013e31825b1e8d

Endoscopic third ventriculostomy (ETV) has become the procedure of choice in the treatment of obstructive hydrocephalus. In certain cases, standard ETV might not be technically possible or may engender significant risk.

OBJECTIVE: To present an alternative through the lamina terminalis (LT) by a transventricular, transforaminal approach with flexible neuroendoscopy and to discuss the indications, technique, neuroendoscopic findings, and outcomes.

METHODS: Between 1994 and 2010, all patients who underwent endoscopic LT fenestration as an alternative to ETV were analyzed and prospectively followed up. The decision to perform an LT fenestration was made intraoperatively.

RESULTS: Twenty-five patients, ranging in age from 7 months to 76 years (mean, 28.1 years), underwent endoscopic LT fenestration. Patients had obstructive hydrocephalus secondary to neurocysticercosis (11 patients), neoplasms (6 patients), congenital aqueductal stenosis (3 patients), and other (5 patients). Thirteen patients (52%) had had at least 1 ventriculoperitoneal shunt that malfunctioned; 6 patients (24%) had undergone a previous endoscopic procedure. Intraoperative findings that led to an LT fenestration were the following: ETV not feasible to perform, basal subarachnoid space not sufficient, or adhesions in the third ventricle. No perioperative complications occurred. The mean follow-up period was 63.76 months. Overall, 19 patients (76%) had resolutions of symptoms, had no evidence of ventriculomegaly, and did not require another procedure. Six (24%) required a ventriculoperitoneal shunt.

CONCLUSION: Endoscopic transventricular transforaminal LT fenestration with flexible neuroendoscopy is feasible with a low incidence of complications. It is a good alternative to standard ETV. Adequate intraoperative assessment of ETV success is necessary to identify patients who will benefit.

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Predictors of meningioma consistency: A study in 243 consecutive cases

Acta Neurochir (2012) 154:1383–1389 DOI 10.1007/s00701-012-1427-9

Meningioma is a common neoplasm primarily arising in the central nervous system. Its consistency is considered to be one of the critical prognostic factors for determining surgical resectability. The present study endeavored to investigate predictive factors associated with the tumor consistency.

Methods Two hundred and forty-three consecutive participants who underwent resective surgery of meningioma were examined. The authors designed an objective grading system for meningioma consistency and utilized it for assessing consistency among all cases. We focused on the relationship between preoperative tumor characteristics on neuroimaging studies and the consistency.

Results The tumor attributes on T2-weighted image (T2WI) and fluid attenuated inversion recovery (FLAIR) image were significantly correlated with the tumor consistency (p=0.004 and 0.045, respectively). The hypointense tumors on both MRI sequences tended to be hard, whereas the tumors showing hypersignal intensity were associated with soft consistency. There was no correlation between the consistency and age, gender, duration of neurologic symptoms, tumor location, size, calcification, cystic portion, en plague appearance, tumor-brain contact interface expressed by cerebrospinal fluid (CSF) cleft, perilesional vasogenic edema, bony status, features on T1-weighted image (T1WI) and pattern of contrast enhancement. In multiple logistic regression analysis, the tumor characteristics on T2WI and FLAIR image were independent factors significantly correlated with the tumor consistency (p=0.005 and 0.041, respectively). The tumor consistency was also correlated with operative radicalness as evaluated by the Simpson criteria.

Conclusions Signal intensity on T2WI and FLAIR image can be used for insinuating meningioma consistency. Presurgical prediction of the consistency is highly valuable in operative planning, particularly in arduous cases.

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Long-term Results of Enterprise Stent-Assisted Coiling of Cerebral Aneurysms

Neurosurgery 71:239–244, 2012 DOI: 10.1227/NEU.0b013e3182571953

The Enterprise Vascular Reconstruction Device and Delivery System (Cordis; the Enterprise stent) was approved for use in conjunction with coiling of wide-necked aneurysms in 2007. No published long-term aneurysm occlusion or complication data exist for the Enterprise system.

OBJECTIVE: We compiled data on consecutive patients treated with Enterprise stent-assisted coiling of aneurysms from 9 high-volume neurointerventional centers.

METHODS: A 9 center registry was created to evaluate large volume data on the delayed safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution prior to May 2009.

RESULTS: Two-hundred twenty-nine patients with 229 aneurysms, 32 of which were ruptured aneurysms, were included in the study. Mean clinical and angiographic follow-up was 619.6 ± 26.4 days and 655.7 ± 25.2 days, respectively. Mean aneurysm size was 9.2 ± 0.4 mm. Fifty-nine percent of patients demonstrated 100% coil obliteration and 81% had 90% or higher occlusion at last follow-up angiography. A total of 19 patients (8.3%) underwent retreatment of their aneurysms during the follow-up period. Angiographic in-stent stenosis was seen in 3.4% and thromboembolic events occurred in 4.4%. Overall, 90% of patients who underwent Enterprise-assisted coiling had a modified Rankin Scale score of 2 or less at last follow-up. A poor modified Rankin Scale score was strongly associated with rupture status (P < .001).

CONCLUSION: Although this study is limited by its retrospective nature, the Enterprise stent system appears to be an effective, safe, and durable treatment for intracranial aneurysms when used in conjunction with coiling.

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Subdural Hematoma in Patients With Cancer

Neurosurgery 71:74–79, 2012 DOI: 10.1227/NEU.0b013e3182517938

Subdural hematoma (SDH) in patients with cancer is poorly described, and its frequency and causes may have changed with recent oncologic advances.

OBJECTIVE: We conducted an analysis of the clinical and radiographic features, etiologies, treatments, and outcomes of patients with SDHs and cancer.

METHODS: We retrospectively identified patients at Memorial Sloan-Kettering Cancer Center with a diagnosis of SDH and cancer from January 2000 to December 2007. We analyzed clinical and radiographic data; multivariate Cox regression was performed to associate tumor type and etiology with survival outcome.

RESULTS: There were 90 patients; 66 had acute or subacute SDHs, 9 chronic SDHs, 11 subdural hygromas, and 4 SDHs of unclear chronicity. Gliomas (16%), leukemias (14%), and prostate cancers (14%) were the most frequent malignancies. The most common single etiologies were coagulopathy (27%) and trauma (11%). SDHs with multiple etiologies occurred in 25 patients (28%) with the combination of coagulopathy and trauma occurring in 15. Sixty patients (67%) were either completely or partially independent after SDH, and 1-year survival was 43% (95% confidence interval: 32.1-52.9). Overall survival correlated with etiology (P , .0001) and whether the malignancy was in remission (P = .005). Trauma was associated with the best overall survival compared with coagulopathy.

CONCLUSION: Leukemia and prostate cancer are the most common systemic cancers associated with SDH, and gliomas may predispose to SDH more often than previously recognized. Coagulopathy is common and associated with the worst outcome, but many patients experience good functional outcome and survival.

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Surgical management of ventral and ventrolateral foramen magnum meningiomas

Neurosurg Rev (2012) 35:359–368

Foramen magnum meningioma poses a challenge for neurosurgeons. Prognosis has generally improved with diagnostic and surgical advances over the past two decades; however, it may ultimately depend more on the surgeon’s ability to tailor the approach and interpret intraoperative risks in single cases.

The series comprised 64 patients operated on for ventral and ventrolateral foramen magnum meningioma. All patients underwent preoperative magnetic resonance imaging and received surgery via the dorsolateral route, rendering the series homogeneous in neuroradiological workup and surgical treatment. Particular to this series was that the majority of patients were of advanced age (n=29; age, >65 years), had serious functional impairment (n=30, Karnofski score <70), and large tumors (mean diameter, 3.5 cm).

Total tumor removal was achieved in 52 (81 %) patients; operative mortality was nil. Early outcome varied depending on difficulties encountered at surgery (cranial nerve position and type of involvement in particular) and type of preoperative dysfunction. Long-tract signs and cerebellar deficits improved in 74 and 77 % of cases, respectively, but only 27 % of cranial nerve deficits did so. Surgical complications most often involved the cranial nerves: cranial nerve impairment, especially of the 9th through the 12th cranial nerves, due to stretching or encasement was noted in 44 cases. At final outcome assessment, two thirds of the cranial nerve deficits cleared, and all but two patients returned to a normal productive life. One patient was reoperated on during the follow-up period.

Foramen magnum meningiomas behave like clival or spinal tumors depending on their prevalent extension. A dorsolateral approach tailored to tumor position and extension and meticulous surgical technique allow for definitive control of surgical complications. Scrupulous postoperative care may prevent dysphagia, a major persistent complication of surgery. Long-term observation of indolent tumor behavior at follow-up suggests that incomplete resection may be a viable surgical treatment option.

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Results and complications after 2-level axial lumbar interbody fusion with a minimum 2-year follow-up

J Neurosurg: Spine / July 17, 2012. DOI: 10.3171/2012.6.SPINE11915

Axial lumbar interbody fusion (AxiaLIF) is a minimally invasive presacral surgical technique that damages neither the anulus fibrosus nor the anterior or posterior longitudinal ligaments. The technique was initially designed and used for L5–S1 interbody fusions and recently was extended to 2-level fusions (L4–5 and L5–S1). Until now, only biomechanical and radiological studies have discussed the feasibility of this new indication, and no clinical study has been published. The purpose of this article is to report results and complications associated with 2-level presacral AxiaLIF with a minimum of 24 months of follow-up.

METHODS
In this prospective, nonrandomized, single-center study, 27 patients underwent presacral AxiaLIF surgery at the L4–5 and L5–S1 levels. Clinical outcomes were assessed using the visual analog scale for back and leg symptoms and the Oswestry Disability Index. Radiographic parameters, such as disc height, segmental lordosis, and bone fusion, were analyzed using radiographs and CT scans. Complications and revision surgeries were recorded as needed. The minimum follow-up was 24 months (up to 72 months).

RESULTS
There were no intraoperative complications. One major complication was observed: a patient developed septicemia that resolved after proper care. Clinical outcomes scores showed overall improvement in pain and physical function. During follow-up, the following complications were observed in the construct: screw breakage (14.8%), proximal/distal transsacral rod detachment (11.1%), radiolucency around the transsacral rod (52%), and cephalic rod migration (24%). Disc height gain was reported early after surgery, but at the 24-month follow-up the disc space was diminished in comparison with the preoperative status. Compared with preoperative values, the 24-month results showed loss of segmental lordosis. Only 22% of all treated levels were considered to have solid fusion at the 24-month radiological evaluation.

CONCLUSIONS
Patients undergoing presacral 2-level AxiaLIF experienced satisfactory short-term clinical outcomes; however, complications were commonly seen on imaging studies obtained 24 months postoperatively. Additional studies are required to better understand the 2-level indications for this technique.

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Significance of Simpson grading system in modern meningioma surgery

J Neurosurg 117:121–128, 2012. http://thejns.org/doi/abs/10.3171/2012.3.JNS111945

Techniques for the surgical treatment of meningioma have undergone many improvements since Simpson established the neurosurgical dogma for meningioma surgery in his seminal paper published in 1957. This study aims to assess the clinical significance and limitations of the Simpson grading system in relation to modern surgery for WHO Grade I benign meningiomas and to explore the potential of the cell proliferation index to complement the limitations in predicting their recurrence.

Methods. The surgical records of patients who underwent resection of intracranial meningiomas at the University of Tokyo Hospital between January 1995 and August 2010 were retrospectively analyzed. The authors investigated the relationships between recurrence-free survival (RFS) and Simpson grade or MIB-1 labeling index value.

Results. A total of 240 patients harboring 248 benign meningiomas were included in this study. Simpson Grade IV resection was associated with a significantly shorter RFS than Simpson Grade I, II, or III resection (p < 0.001), while no statistically significant difference was noted in RFS between Simpson Grades I, II, and III. Among meningiomas treated by Simpson Grade II and III resections, however, multivariate analysis revealed that an MIB-1 index of 3% or higher was associated with a significantly shorter time to recurrence.

Conclusions. The clinical significance of the different management strategies related to Simpson Grade I–III resection may have been diluted in the modern surgical era. The MIB-1 index can differentiate tumors with a high risk of recurrence, which could be beneficial for planning tailored optimal follow-up strategies. The results of this study appear to provide a significant backing for the recent shift in meningioma surgery from attempting aggressive resection to valuing the quality of the patient’s life.

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Clip ligation of unruptured intracranial aneurysms: a prospective midterm outcome study

Acta Neurochir (2012) 154:1135–1144. DOI 10.1007/s00701-012-1397-y

We conducted a prospective study to investigate the clinical and radiological outcome in a surgical case series of 176 patients with 203 unruptured intracranial aneurysms (UIA).

Methods The success of aneurysm obliteration was assessed within 2 weeks after surgery by digital subtraction angiography (DSA). Patients also underwent angiography 5 years after surgery. Clinical outcomes were assessed using the modified Rankin Scale (mRS). All predictors of poor surgical outcomes were assessed using an exact logistic regression.

Results Overall, 83%of the patients had a good outcome (mRS score 0 or 1); 10.8 % of the patients had a slight disability (mRS score 2), and 6.2 % of the patients had a moderate or moderatesevere disability (mRS score 3 or 4). The mortality rate was 0% overall. The most important predictors of outcome were presence of history of ischemic cerebrovascular disease and postoperative stroke. Complete aneurysm occlusion was achieved in 93.5 % of all aneurysms. Sixty percent of treated aneurysms were checked with late follow-up DSA. No cases of hemorrhage from a surgically obliterated UIA were documented in this series during the 7.3±1.4 (SD)-year follow-up period.

Conclusions If patients are carefully selected and individually assigned to their optimum treatment modality, IUAs can be obliterated by surgery with a low percentage of unfavorable outcomes.

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Morbidity and Mortality of C2 Fractures in the Elderly- Surgery and Conservative Treatment

Neurosurgery 70:1055–1059, 2012 DOI: 10.1227/NEU.0b013e3182446742

Closed C2 fractures commonly occur after falls or other trauma in the elderly and are associated with significant morbidity and mortality. Controversy exists as to best treatment practices for these patients.

OBJECTIVE: To compare outcomes for elderly patients with closed C2 fractures by treatment modality.

METHODS: We retrospectively reviewed 28 surgically and 28 nonsurgically treated cases of closed C2 fractures without spinal cord injury in patients aged 65 years of age or older treated at Stanford Hospital between January 2000 and July 2010. Comorbidities, fracture characteristics, and treatment details were recorded; primary outcomes were 30-day mortality and complication rates; secondary outcomes were length of hospital stay and long-term survival.

RESULTS: Surgically treated patients tended to have more severe fractures with larger displacement. Charlson comorbidity scores were similar in both groups. Thirty-day mortality was 3.6% in the surgical group and 7.1% in the nonsurgical group, and the 30-day complication rates were 17.9% and 25.0%, respectively; these differences were not statistically significant. Surgical patients had significantly longer lengths of hospital stay than nonsurgical patients (11.8 days vs 4.4 days). Long-term median survival was not significantly different between groups.

CONCLUSION: The 30-day mortality and complication rates in surgically and nonsurgically treated patients were comparable. Elderly patients faced relatively high morbidity and mortality regardless of treatment modality; thus, age alone does not appear to be a contraindication to surgical fixation of C2 fractures.

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Long-Term Surgical Outcomes of Spinal Meningiomas

Spine 2012 ; 37 : E617 – E623 

Although previous studies have demonstrated favorable surgical outcomes for spinal meningioma, with a low incidence of tumor recurrence, few have examined longterm surgical outcomes.

Methods. The influence of patient age, surgical margin status (Simpson grade), tumor location, and histological subtype on tumor recurrence were examined retrospectively. In addition, the resected dura mater from Simpson grade I cases was examined for invasive tumor cells and compared with the presence or absence of a dural tail sign on magnetic resonance image.

Results. Complete resection (Simpson grades I and II) was performed in 62 patients. Among them, the tumor recurrence rate was 9.7%, all in patients who underwent grade II resection for ventral spinal lesions. The mean duration to reoperation in these patients was 12.2 ± 5.2 years. Of the 6 patients who underwent incomplete resection (Simpson grade III/IV), all required reoperation for tumor recurrence or regrowth, 5 years later on average. Patients younger than 50 years at the initial surgery had a significantly higher recurrence rate than those aged 50 years or older. Histologic examination of 43 dura mater specimens from Simpson grade I-resection patients revealed tumor cell invasion between the inner and outer layers in 15 patients. This invasion was noted in 8 (29%) of 28 patients who were negative for the dural tail sign on magnetic resonance image, and in 7 (47%) of 15 patients who showed a positive dural tail sign. The MIB-1 index reached about 10% for dumbbell-type meningiomas invading the vertebral body; these were associated with repeated recurrence and unfavorable prognosis.

Conclusion. Long-term follow-up after surgery for meningiomas indicated that Simpson grade I resection should be selected whenever practicable when treating younger patients or dumbbelltype meningiomas. Tumors recurred at 12 years, on average, in approximately 30% of patients who underwent grade II resection.

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Surgical results of an endoscopic endonasal approach for clival chordomas

Acta Neurochir (2012) 154:879–886. DOI 10.1007/s00701-012-1317-1

The surgical approaches for clival chordomas remain controversial, although the extent of resection is one of the most important factors for long survival rates. Recently an endoscopic endonasal approach in good collaboration with otolaryngologists has attracted major attention as a surgical approach for clival chordomas. We describe our experience with the endoscopic endonasal approach and provide a review of the literature.

Methods Between 2008 and 2011, six operations were performed via the endoscopic endonasal approach for clivus chordomas. The mean tumor size was 35 mm in diameter. The tumor location was mainly from the upper to middle clivus. The tumor extended into the cavernous sinus in five cases and intradurally in three cases. A binostril approach was performed in four cases, while a one nostril approach was performed in two cases.

Results Gross total removal was achieved in three cases. The analysis of cases with incomplete resection suggested that residual tumors were observed epidurally and subdurally. The residual on the epidura was observed from the posterior clinoid to the posterior compartment of the cavernous sinus. On the other hand, the residual on the subdural was observed behind the upper part of the pituitary gland. There was no postoperative cerebrospinal fluid (CSF) leakage using vascularized nasoseptal flaps in any of the cases.

Conclusions The endoscopic endonasal transclival approach allows an appropriate extent of resection with acceptable complication rates in comparison with other approaches. In our series, the accomplishment of gross total removal was associated with the relationship between the tumors and surrounding structures, such as the pituitary gland and the cavernous portion of the intracranial carotid artery (ICA).

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Predictive Value and Safety of Intraoperative Neurophysiological Monitoring With Motor Evoked Potentials in Glioma Surgery

Neurosurgery 70:1060–1071, 2012 DOI: 10.1227/NEU.0b013e31823f5ade

Resection of gliomas in or adjacent to the motor system is widely performed with intraoperative neuromonitoring (IOM). Despite the fact that data on the safety of IOM are available, the significance and predictive value of the procedure are still under discussion. Moreover, cases of false-negative monitoring affect the surgeon’s confidence in IOM.

OBJECTIVE: To examine cases of false-negative IOM to reveal structural explanations.

METHODS: Between 2007 and 2010, we resected 115 consecutive supratentorial gliomas in or close to eloquent motor areas using direct cortical stimulation for monitoring of motor evoked potentials (MEPs). The monitoring data were reviewed and related to new postoperative motor deficit and postoperative imaging. Clinical outcomes were assessed during follow-up.

RESULTS: Monitoring of MEPs was successful in 112 cases (97.4%). Postoperatively, 30.3% of patients had a new motor deficit, which remained permanent in 12.5%. Progression- free follow-up was 9.7 months (range, 2 weeks-40.6 months). In 65.2% of all cases, MEPs were stable throughout the operation, but 8.9% showed a new temporary motor deficit, whereas 4.5% (5 patients) presented with permanently deteriorated motor function representing false-negative monitoring at first glance. However, these cases were caused by secondary hemorrhage, ischemia, or resection of the supplementary motor area.

CONCLUSION: Continuous MEP monitoring provides reliable monitoring of the motor system, influences the course of operation in some cases, and has to be regarded as the standard for IOM of the motor system. In our series, we found no false-negative MEP results.

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Staged resection of large vestibular schwannomas

J Neurosurg 116:1126–1133, 2012.(http://thejns.org/doi/abs/10.3171/2012.1.JNS111402)

Staged resection of large vestibular schwannomas (VSs) has been proposed as a strategy to improve facial nerve outcomes and morbidity. The authors report their experience with 2-stage resections of large VSs and analyze the indications, facial nerve outcomes, surgical results, and complications. The authors compare these results with those of a similar cohort of patients who underwent a single-stage resection.

Methods. A retrospective review of all patients (age > 18 years) who underwent surgery from 2002 to 2010 for large (≥ 3 cm) VSs at the authors’ institution with a minimum of 6 months follow-up was undertaken. A first-stage retrosigmoid approach (without meatal drilling) was performed to remove the cerebellopontine angle portion of the tumor and to decompress the brainstem. A decision to stage the operation was made intraoperatively if there was cerebellar or brainstem edema, excessive tumor adherence to the facial nerve or brainstem, a poorly stimulating facial nerve, or a thinned or splayed facial nerve. A second-stage translabyrinthine approach was performed at a later date to remove the remaining tumor. The single-stage resection consisted of a retrosigmoid approach with meatal drilling. Patient charts were evaluated for tumor size, extent of resection, tumor recurrence, House-Brackmann facial nerve function grade, and complications.

Results. Twenty-eight and 19 patients underwent 2- or single-stage resection of a large VS, respectively. The average tumor size was 3.9 cm (range 3.2–7 cm) in the 2-stage group and 3.9 cm (range 3.1–5 cm) in the single-stage group. The mean follow-up was 36 ± 19 months in the 2-stage group versus 24 ± 14 months in the single-stage group. Gross-total or near-total resection was achieved in 27 (96.4%) of 28 patients in the 2-stage group and 15 (79%) of 19 patients in the single-stage group (p < 0.01). Anatomical facial nerve preservation was achieved in all but 1 patient (94.7%), and there were no recurrences on follow-up imaging in the 2-stage group. Good facial nerve functional outcome (House-Brackmann Grades I and II) at last follow-up was achieved in 23 (82%) of 28 patients in the 2-stage group and 10 (53%) of 19 patients in the single-stage group (p < 0.01). Cerebrospinal fluid leak–related complications (intracranial hypotension, blood patch, and lumboperitoneal shunt for pseudomeningocele) were more common in the 2-stage group. There were no postoperative strokes, hemorrhages, or deaths in either group.

Conclusions. The authors’ results suggest that staged resection of large VSs may potentially achieve better facial nerve outcomes. There does not appear to be added neurological morbidity with staged resections

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Surgery of Insular Nonenhancing Gliomas: Volumetric Analysis of Tumoral Resection, Clinical Outcome, and Survival in a Consecutive Series of 66 Cases

Neurosurgery 70:1081–1094, 2012.  DOI: 10.1227/NEU.0b013e31823f5be5

Despite intraoperative technical improvements, the insula remains a challenging area for surgery because of its critical relationships with vascular and neurophysiological functional structures.
OBJECTIVE: To retrospectively investigate the morbidity profile in insular nonenhancing gliomas, with special emphasis on volumetric analysis of tumoral resection.

METHODS: From 2000 to 2010, 66 patients underwent surgery. All surgical procedures were conducted under cortical-subcortical stimulation and neurophysiological monitor- ing. Volumetric scan analysis was applied on T2-weighted magnetic resonance images (MRIs) to establish preoperative and postoperative tumoral volume.

RESULTS: The median preoperative tumor volume was 108 cm3. The median extent of resection was 80%. The median follow-up was 4.3 years. An immediate postoperative worsening was detected in 33.4% of cases; a definitive worsening resulted in 6% of cases. Patients with extent of resection of . 90% had an estimated 5-year overall survival rate of 92%, whereas those with extent of resection between 70% and 90% had a 5-year overall survival rate of 82% (P , .001). The difference between preoperative tumoral volumes on T2-weighted MRI and on postcontrast T1-weighted MRI ([T2 2 T1] MRI volume) was computed to evaluate the role of the diffusive tumoral growing pattern on overall survival. Patients with preoperative volumetric difference , 30 cm3 demonstrated a 5-year overall survival rate of 92%, whereas those with a difference of . 30 cm3 had a 5-year overall survival rate of 57% (P = .02).

CONCLUSION: With intraoperative cortico-subcortical mapping and neurophysiologi- cal monitoring, a major resection is possible with an acceptable risk and a significant result in the follow-up.

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Intradural spinal metastases: a surgical series of 15 patients

Acta Neurochir (2012) 154:871–877. DOI 10.1007/s00701-012-1313-5

Intradural spinal metastases are rare, and little is known regarding surgical indications and outcomes.

Methods A retrospective search identified adults with intradural spinal metastases operated on at the Mayo Clinic from 1994-2011. Data were collected regarding demographics, tumor type and location, and outcomes.

Results Fifteen patients with intradural spinal metastases were investigated. The age range was 38-74 years (mean= 55 years; ±SD=11.1). Predominant tumor location and type were lumbosacral and adenocarcinoma, respectively: 3 intramedullary and 12 extramedullary. Patients were operated on to relieve or prevent progressive/intractable neurological sequelae and/or pain. Of 13 who underwent resection, gross total removal was reported in 10; simple biopsy was performed in 2. There was one surgical complication, no medical complications, and no surgical mortality. At median follow-up of 1 month postoperatively, 10 of 15 patients were stable or improved. Of 13 patients who underwent resection, 10 were stable or improved. Of two patients who underwent biopsy, neither was stable or improved at follow-up. Using the Modified McCormick Scale, 11 of 15 patients were “functional” preoperatively and 4 went from “functional” preoperatively to “non-functional” postoperatively. Three of those four died within 60 days of surgery from systemic disease progression. Median hospital stay was 8 days. Ten of 15 patients died by the end of the study period, and the median survival of 15 patients was 5 months.

Conclusions With improved outcomes in metastatic cancer, more patients are encountered in practice. An aggressive surgical approach is warranted for extramedullary lesions, whereas caution is advised for intramedullary lesions. Postoperative functional decline is more likely due to systemic disease progression rather than surgery.

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Supratentorial and infratentorial brain abscesses: surgical treatment, complications and outcomes—a 10-year single-center study

Acta Neurochir (2012) 154:903–911. DOI 10.1007/s00701-012-1299-z

To analyze the variables determining morbidity, mortality and outcome in subjects with brain abscesses treated at a single center over a 10-year period.

Methods A retrospective study was conducted on a series of 59 patients with brain abscesses surgically treated with stereotactically guided aspiration or open craniotomy excision. Such variables as age, gender, clinical presentation, number of days to diagnosis, location, number of lesions, predisposing factors, mechanism of infection, etiological agent, and therapy were analyzed independently. Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery, and classified according to a four-point gradual severity scale. Postoperative outcome was appraised through the Glasgow Outcome Scale (GOS) 6 months after surgery, 0–4 points were considered poor outcome and 5 points good outcome.

Results Eighty abscesses were diagnosed and surgically managed in 59 patients. The mean age was 44.69 years (range: 0.16-77); 59.3% were female. The median number of days to diagnosis was 7. Most frequent clinical presentations included fever (52.5%), headache (42.4%), and focal neurologic deficits (39%). Mechanism of infection was mainly hematogenous spread (32.2%). Stereotactically guided aspiration was the treatment of choice for 74.6% of the patients, whereas 25.4% of the cases were managed through open craniotomy excision. Outcome was favorable in 81.35% (n048) of the subjects. General morbidity was 27.1%, and mortality stood at 10.16%. Out of a total 38.98% (n023) of complications, two-thirds were due to medical causes. The analysis of variables revealed that only age (p00.02), immunosuppression (OR 5.83; p00.012) and hematogenous spread (p<0.01) were associated with poor outcomes.

Conclusions Immunosuppression, hematogenous spread and advanced age were predictors of poor prognosis. Most of the complications following brain abscess management were not directly related to surgery or surgical technique.

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Can Elderly Patients Recover Adequately After Laminoplasty?

Spine 2012 ; 37 : 667 – 671 

This was a prospective clinical comparative study of surgical outcomes for patients with cervical spondylotic myelopathy (CSM).

Objective. The purpose of this study was to compare the surgical outcomes between nonelderly and elderly patients with CSM who underwent laminoplasty.

Summary of Background Data. Age at the time of surgery influences the surgical outcome. We designed a large-scale study of the surgical outcome for CSM from a single operative procedure used exclusively in elderly patients.

Methods. A total of 520 consecutive patients with CSM (331 men; 189 women) who underwent double-door laminoplasty were included. Mean age was 62 years (range, 23–93), and mean duration of disease was 20.1 ± 32.0 months. Average postoperative followup period was 33.3 ± 15.7 months. Patients were divided into 3 groups by age: nonelderly ( < 65 years), young-old (65–74 years), and old-old ( ≥ 75 years). The number of patients in each group was 287, 143, and 90. Pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score).

Results. Mean pre- and postoperative JOA scores in nonelderly, young-old, and old-old groups were 11.0 and 14.4, 10.2 and 13.2, and 8.7 and 11.8 points, respectively. The elderly group showed significantly low recovery rates of JOA scores compared with the nonelderly group ( P < 0.0001). However, mean achieved JOA scores (postoperative JOA score − preoperative JOA score) were 3.4, 3.0, and 3.1 in nonelderly, young-old, and old-old groups, respectively, with no significant difference among these groups ( P = 0.17).

Conclusion. Pre- and postoperative JOA scores were low in elderly patients. However, the achieved JOA score was almost similar among the 3 groups. Thus, elderly patients could obtain reasonable recovery after cervical laminoplasty.

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Complications of endoscopic microdiscectomy using the EASYGO! system

Acta Neurochir DOI 10.1007/s00701-012-1321-5.

Microendoscopic discectomy (MED) is emerging as a minimally invasive alternative to conventional microsurgical discectomy (MSD). EASYGO! is a new system for spinal endoscopy that claims smooth transition from MSD to MED, with a reduced learning curve period. The aims of this study were to describe the complications that appeared during the learning curve period of MED and to compare their incidence with the rate and type of complications that occurred during a simultaneous non-randomised series of standard MSDs.

Methods Between July 2009 and December 2010, 138 patients underwent scheduled first-time discectomy in our institution, 37 using an MED approach and 101 by a conventional MSD. A MED learning curve was obtained by plotting every case with its respective operative time. Complications, length of hospital stay, need of further surgery and outcome were prospectively recorded in both groups.

Results The mean operative time was 66 min for the MSD group and 100 min for the MED group, although for the last 14 cases of the latter group the time was reduced. Curvefitting techniques showed that the inverse equation, ƒ(x)= 122.12/x+73.05, had the best correlation between case number and operative time. The learning curve was overcome after the 30th case. Complications occurred in 9.8 % of the MSD group and 8.1 % of the MED group (P=0.49). Average length of hospital stay was 2.36 days for the MED group and 3.36 days for the MSD group (P=0.01). The procedure successfully relieved patient symptoms in 68.63 % of the MSD group and 89.92 % of the MED group. No revision surgery was required in the MED group, but it was necessary in ten patients of the MSD group.

Conclusions Between 25 and 30 cases are needed to reach the learning curve’s asymptote of MED. Even during this initial learning period MED is a safe procedure, with comparable results to those obtained with conventional MSD and with a similar complication rate. The key points for reducing intraoperative complications are an adequate expertise in MSD, a precise selection of initial cases, a proper surgical planning and a careful technique, which are mandatory to avoid unnecessary neurological injury in an otherwise secure surgical approach.

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