Month: July 2019

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Morphological Variables Associated With Ruptured Middle Cerebral Artery Aneurysms

Neurosurgery, Volume 85, Issue 1, July 2019, Pages 75–83

Geometric factors of intracranial aneurysms and surrounding vasculature could affect the risk of aneurysm rupture. However, large-scale assessments of morphological parameters correlated with intracranial aneurysm rupture in a location-specific manner are scarce.

OBJECTIVE: To investigate the morphological characteristics associated with ruptured middle cerebral artery (MCA) aneurysms.

METHODS: Five hundred sixty-one patients with 638 MCA aneurysms diagnosed between 1990 and 2016 who had available computed tomography angiography (CTA) were included in this study. CTAs were evaluated using the Vitrea Advanced Visualization software for 3-dimensional (3D) reconstruction. Morphological parameters examined in each model included aneurysm projection, wall irregularity, presence of a daughter dome, presence of hypoplastic or aplastic A1 arteries and hypoplastic or fetal posterior communicating arteries (PCoA), aneurysm height and width, neck diameter, bottleneck factor, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine the association of morphological characteristics with rupture of MCA aneurysms. Logistic regression was used to build a predictive MCA score.

RESULTS: Greater bottleneck and size ratio, and irregular, multilobed, temporally projecting MCA aneurysms are associated with higher rupture risk, whereas higher M1/M2 ratio, larger width, and the presence of an ipsilateral or bilateral hypoplastic PCoA were inversely associated with rupture. The MCA score had good predictive capacity with area under the receiver operating curve = 0.88.
CONCLUSION: These practical morphological parameters specific to MCA aneurysms are easy to assess when examining 3D reconstructions of unruptured aneurysms and could aid in risk evaluation in these patients.

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Universal fluorescence module for intraoperative fluorescein angiography

Acta Neurochirurgica (2019) 161:1343–1348

Even in specialized centers, suboptimal aneurysm clipping can be as high as 12%. Intraoperative fluorescence angiography with indocyanine green and, more recently, fluorescein sodium have been shown to be a good method for intraop- erative flow assessment. However, the cost with the apparatus it entails limits its widespread use.

We have developed a low-cost universal fluorescence module (FM) designed to visualize fluorescein and perform intraoperative angiography. The purpose of this paper is to describe this device as well as to present our early experience with its use in the treatment of cerebral aneurysms.

Method A FM was designed and built using a cyan-blue narrow bandpass (460 to 490 nm) excitation filter and a yellow-orange longpass (blocking wavelengths under 520 nm) barrier filter mounted on a 3D-printed holding tray in a specific disposition to perfectly match the light source and the objective lens of the surgical microscope. It allowed switching from white light to fluorescence mode in a simple and sterile fashion. Its perfect attachment to the microscope was possible by reusing the lens fittings extracted from used original drape sets that would otherwise be discarded. Four patients underwent aneurysm clipping using the FM at two institutions from April to September 2018.

Results A bright green fluorescence against a dark background was observed after intravenous bolus of fluorescein. Blood vessels became obviously distinct from non-contrast-filled structures such as clipped aneurysms and the brain. Vascular anatomy could be appreciated without any distortion, including perforating arteries.

Conclusions Intraoperative fluorescence angiography was successfully performed with the use of this universal FM after intra- venous injection of fluorescein sodium. This simple and low-cost device may be useful in resource-limited centers, where other sorts of intraoperative angiography are not available.

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Pediatric Supratentorial Ependymoma: Surgical, Clinical, and Molecular Analysis

Neurosurgery 85:41–49, 2019

Pediatric supratentorial ependymomas (SEs) have distinct molecular and behavioral differences from their infratentorial counterparts.

OBJECTIVE: To present our experience with pediatric SEs over a 24-yr period.

METHODS: Clinical, operative, and radiographic information was abstracted retrospectively. Our primary outcomes were progression-free survival (PFS) and overall survival (OS). Detection of C11or f95-RELA rearrangement was performed using interphase fluorescence in situ hybridization (iFISH).

RESULTS: Seventy-three patients were identified (41 female, 32 male); median age was 6.7 yrs (range, 1 mo-18.8 yr); median follow-up was 8.3 yrs (range, 2.0-26.3). Fifty-eight (79.5%) of 73 patients underwent gross total resection (GTR); no patient with subtotal resection had greater than 1 cm3 of residual tumor; 42 patients (57.5%) experienced subsequent disease progression with 17 patients ultimately dying of their disease. Median PFS was 3.7 yrs. Molecular analysis was available for 51 patients (70%). On bivariate analysis, PFS and OS were not statistically affected by age, tumor grade, or extent of resection, although there was a clinically significant trend for the latter in favor of aggressive resection on PFS (P = .061). Children with RELA fusion had significantly higher PFS (P = .013) than those without, although there was no difference in OS when compared with those with no C11orf95-RELA fusion or C11orf95 gene rearrangement alone.

CONCLUSION: In our series, GTR may be associated with better PFS, but did not impact OS. Surprisingly, RELA fusion was not found to be a negative prognostic factor, raising the possibility that the deleterious effects may be overcome by aggressive resection.

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