Month: October 2019

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Bypass surgery of complex middle cerebral artery aneurysms—technical aspects and outcomes

Acta Neurochirurgica (2019) 161:1981–1991

The main challenge of bypass surgery of complex MCA aneurysm is not the selection of the bypass type, but the initial decision making of how to exclude the affected vessel segment from circulation. The aim of our study was to review our experience with the treatment of complex MCA aneurysms using revascularization and parent artery sacrifice techniques. Based on this, we aimed at categorizing these aneurysms according to specific surgical aspects in order to facilitate preoperative planning for these challenging surgical pathologies.

Methods We reviewed 50 patients with complex MCA aneurysms that were not clippable but required revascularization and parent artery sacrifice. We report the individual variations of surgical techniques, highlight the technical aspects, and categorize the aneurysms based on their location and orientation.

Results Of the 50 aneurysms, 56% were giant, 16% large, and 28% < 10 mm, but fusiform. Fourteen percent were previously treated endovascular. Four percent presented with SAH. Ten percent were prebifurcational, 60% involved the bifurcation, and 30% were postbifurcational. Both parent artery sacrifice and bypass strategies were tailored to the individual localization and anatomical relationship of the aneurysm and inflow/outflow arteries (38% proximal inflow occlusion, 42% aneurysm trapping, 20% distal outflow occlusion; 14% STA-MCA bypass, 48% interposition graft, 36%, combined/complex revascularization with reimplantation/in situ techniques). Good outcome (mRS 0–2) rates at discharge and at follow-up were 64% and 84%. Based on our analysis of individual cases, we categorized complex MCA aneurysms into six types and provide individual recommendations for their surgical exploration and treatment by revascularization and parent artery sacrifice.

Conclusion Complex MCA aneurysms are among the most challenging vascular lesions and afford highly individualized treatment strategies. Revascularization and parent artery sacrifice provide durable results that are superior to the natural history. Our classification provides a tool for planning and pre-surgical assessment of the intraoperative anatomy of complex MCA aneurysms, helping to assume possible pitfalls.

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Accuracy and safety of 1-day external lumbar drainage of CSF for shunt selection in patients with idiopathic normal pressure hydrocephalus

J Neurosurg 131:1011–1017, 2019

Three to five days of external lumbar drainage (ELD) of CSF is a test for ventriculoperitoneal shunt (VPS) selection in idiopathic normal pressure hydrocephalus (iNPH). The accuracy and complication rates of a shorter (1-day) ELD procedure were analyzed.

METHODS Data of patients with iNPH who underwent 1-day ELD to be selected to undergo VPS placement with a programmable valve in the period from 2005 to 2015 were reviewed. Patients experiencing VPS complications, valve malfunctioning, or with less than 1 year of follow-up were excluded. The ability of 1-day ELD to predict VPS outcome at 1- and 12-month follow-up was assessed by calculating sensitivity, specificity, and positive and negative predictive values.

RESULTS Of 93 patients who underwent 1-day ELD, 3 did not complete the procedure. Of the remaining 90 patients, 2 experienced transient nerve root irritation. Twenty-four patients had negative test outcomes and 66 had positive test out- comes. Nine negative-outcome patients had intraprocedural headache, which showed 37.5% sensitivity (95% confidence interval [CI] 19.5%–59.2%) and 100% specificity (95% CI 93.1%–100%) as predictors of negative 1-day ELD outcome. Sixty-eight patients (6 with negative and 62 with positive outcomes) underwent VPS insertion, which was successful in
0 and 58 patients, respectively, at 1-month follow-up. Test sensitivity and specificity in predicting surgical outcome at 1-month follow-up were 100% (95% CI 92.3%–100%) and 60% (95% CI 27.4%–86.3%), respectively, with 94.1% accu- racy (95% CI 85.6–98.4%). Among the 1-day ELD–positive patients, 2 showed no clinical benefit at 12 months follow-up. Test sensitivity and specificity in predicting surgical outcome at 12-month follow-up was 100% (95% CI 92.5%–100%) and 75.0% (95% CI 35.6%–95.5%), respectively, with 97.1% (95% CI 89.8%–99.6%) accuracy.

CONCLUSIONS One-day ELD is a reliable tool in iNPH management, with low complication risk and short trial duration. The test is very consistent in predicting who will have a positive outcome with VPS placement, given the high chance of successful outcome at 1- and 12-month follow-up; negative-outcome patients have a high risk of unsuccessful surgery. Intraprocedural headache is prognostic of 1-day ELD negative outcome.

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Stereotactic Lesion in the Forel’s Field H: A Two-Years Prospective Open-Label Study on Motor and Nonmotor Symptoms, Neuropsychological Functions and Quality of Life in Parkinson Disease

Neurosurgery, Volume 85, Issue 4, October 2019, Pages E650–E659

Stereotactic lesion in the Forel’s field H (campotomy) was proposed in 1963 to treat Parkinson disease (PD) symptoms. Despite its rationale, very few data on this approach have emerged. Additionally, no study has assessed its effects on nonmotor symptoms, neuropsychological functions and quality of life.

OBJECTIVE: To provide a prospective 2-yr assessment of motor, nonmotor, neuropsychological and quality of life variables after unilateral campotomy.

METHODS: Twelve PD patients were prospectively evaluated using the Unified Parkinson’s Disease Rating Scale (UPDRS), the Dyskinesia Rating Scale and the Parkinson’s disease quality of life questionnaire (PDQ39) before campotomy, and after 6 and 24 mo. Nonmotor, neuropsychiatric, neuropsychological and quality of life variables were assessed. The impact of PD on global health was also rated.

RESULTS: A significant reduction in contralateral rest tremor (65.7%, P < .001), rigidity (87.8%, P < .001), bradykinesia (68%, P < .001) and axial symptoms (24.2%, P < .05) in offmedication condition led to a 43.9% reduction in UPSDRS III scores 2 yr after campotomy (P < .001). Gait improved by 31.9% (P < .05) and walking time to cover 7 m was reduced by 43.2% (P< .05). Pain decreased by 33.4% (P< .01), while neuropsychiatric and neuropsychological functions did not change. Quality of life improved by 37.8% (P < .05), in line with a 46.7% reduction of disease impact on global health (P < .001).

CONCLUSION: A significant 2-yr improvement of motor symptoms, gait performance and pain was obtained after unilateral campotomy without significant changes to cognition. Quality of life markedly improved in parallel with a significant reduction of PD burden on global health.

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