Tag: Brain

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The failure of preoperative ethylene-vinyl alcohol copolymer embolization to improve outcomes in arteriovenous malformation management: case series

AVM-before

J Neurosurg 118:969–977, 2013

Ethylene-vinyl alcohol copolymer embolization is increasingly used preoperatively in the resection of brain arteriovenous malformations (AVMs). However, the case for embolization improving the outcome of resection has not been evaluated. In this paper the authors set out to compare outcomes after surgery for brain AVMs in 2 consecutive periods of practice. In the first period, selective embolization was used without the use of ethylene-vinyl alcohol copolymer. In the second period, selective embolization with ethylene-vinyl alcohol copolymer was performed.

Methods. A consecutive case series (prospectively collected data) was retrospectively analyzed. Adverse outcomes were considered to be an outcome modified Rankin Scale score greater than 2 due to embolization or surgery.

Results. A total of 538 surgical cases were included. The percentages of adverse outcomes were as follows: 0.34% for Spetzler-Martin AVMs less than Grade III (1 of 297 cases); 5.23% (95% CI 2.64%–9.78%) for Grade III AVMs (9 of 172 cases); and 17% (95% CI 10%–28%) for AVMs greater than Grade III (12 of 69 cases). There was no improvement in outcomes from the first period to the second period. The adverse outcome for Grade III brain AVMs in the first period was 5.2% (7 of 135 cases) and in the second period (after ethylene-vinyl alcohol copolymer was introduced) it was 5.4% (2 of 37 cases). For AVMs greater than Grade III, the adverse outcome was 12% (6 of 49 cases) in the first period and 30% (6 of 20 cases) in the second period.

Conclusions. Outcomes for brain AVM surgery were not improved by ethylene-vinyl alcohol copolymer embolization. Preoperative embolization of high-grade AVMs with an ethylene-vinyl alcohol copolymer did not prevent those hemorrhagic complications which embolization is hypothesized to prevent based on theoretical speculations but not demonstrated in practice.

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Failed awake craniotomy: a retrospective analysis in 424 patients undergoing craniotomy for brain tumor

Awake cranio

J Neurosurg 118:243–249, 2013

Awake craniotomy for removal of intraaxial tumors within or adjacent to eloquent brain regions is a well-established procedure. However, awake craniotomy failures have not been well characterized. In the present study, the authors aimed to analyze and assess the incidence and causes for failed awake craniotomy.

Methods. The database of awake craniotomies performed at Tel Aviv Medical Center between 2003 and 2010 was reviewed. Awake craniotomy was considered a failure if conversion to general anesthesia was required, or if adequate mapping or monitoring could not have been achieved.

Results. Of 488 patients undergoing awake craniotomy, 424 were identified as having complete medical, operative, and anesthesiology records. The awake craniotomies performed in 27 (6.4%) of these 424 patients were considered failures. The main causes of failure were lack of intraoperative communication with the patient (n = 18 [4.2%]) and/or intraoperative seizures (n = 9 [2.1%]). Preoperative mixed dysphasia (p < 0.001) and treatment with phenytoin (p = 0.0019) were related to failure due to lack of communication. History of seizures (p = 0.03) and treatment with multiple antiepileptic drugs (p = 0.0012) were found to be related to failure due to intraoperative seizures. Compared with the successful awake craniotomy group, a significantly lower rate of gross-total resection was achieved (83% vs 54%, p = 0.008), there was a higher incidence of short-term speech deterioration postoperatively (6.1% vs 23.5%, p = 0.0017) as well as at 3 months postoperatively (2.3% vs 15.4%, p = 0.0002), and the hospitalization period was longer (4.9 ± 6.2 days vs 8.0 ± 10.1 days, p < 0.001). Significantly more major complications occurred in the failure group (4 [14.8%] of 27) than in the successful group (16 [4%] of 397) (p = 0.037).

Conclusions. Failures of awake craniotomy were associated with a lower incidence of gross-total resection and increased postoperative morbidity. The majority of awake craniotomy failures were preventable by adequate patient selection and avoiding side effects of drugs administered during surgery.

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A Novel Aneurysm Clip Design for Atheromatous, Thrombotic, or Previously Coiled Lesions

Neurosurgery 67[ONS Suppl 2]:ons333–ons341, 2010 DOI: 10.1227/NEU.0b013e3181f7451b

Large and giant lesions often have thicker, atheromatous walls as well as intra-aneurysmal thrombus that combine to prevent traditional clips from closing properly in some cases.

OBJECTIVE: To report the development and use of a novel clip design specifically tailored to treat atheromatous, thrombotic, or previously coiled aneurysms.

METHODS: We retrospectively reviewed the records of 6 patients with complex aneurysms not amenable to simple neck clipping and not considered appropriate for endovascular therapy who were treated using a novel ‘‘compression’’ clip design. We describe the development and use of a novel aneurysm clip design with blades that are not opposed at rest to allow direct clipping of atheromatous, thrombotic, and previously coiled aneurysms.

RESULTS: Four patients had recurrent, previously coiled aneurysms; one of these also had a large thrombotic component. Two patients had complex lesions with heavy atheroma involving a portion of their aneurysms. There were no complications related to the use of the clip, and all patients did well without neurological complications. In every case, the clip allowed straightforward obliteration of the aneurysm without the need for temporary vascular occlusion, aneurysmorrhaphy, or removal of an intra-aneurysmal coil mass. All patients underwent intraoperative angiography to confirm obliteration of the aneurysm with preservation of the normal vasculature.

CONCLUSION: Atheromatous, thrombotic, and previously coiled aneurysms may not be treatable with simple neck clipping and may not be curable with endovascular therapy. For such cases, we designed a novel ‘‘compression’’ clip that has been used safely and successfully in our experience with good short-term follow-up.

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