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Risks and benefits of CT angiography in spontaneous intracerebral hemorrhage

ct_spot_sign

Acta Neurochir (2014) 156:911–917

Few studies have examined the risk of computed tomography angiography (CTA) during the acute phase of spontaneous intracerebral hemorrhage (ICH), while the benefits of CTA in ICH have been well-documented. The present study investigated both the benefits of identifying spot signs, which are supposed to indicate hematoma enlargement after admission, and risks of CTA performed during the acute phase of ICH.

Methods We retrospectively assessed 323 consecutive patients with spontaneous ICHs admitted to our hospital between April 2009 and March 2012 and who underwent CTA on admission.

Results In 80 patients (24.7 %), spot signs were demonstrated on CTA source images. Multivariate analysis revealed two independent factors correlated with presence of the spot sign: age and hematoma volume (p<0.05 each). The presence of spot sign was associated with unfavorable outcomes at discharge and hematoma growth after admission (p<0.05 each). Adverse events related to CTA occurred in 17 patients (5.2 %), including transient renal dysfunction in 16 patients and allergy to contrast medium in one patient. All adverse events completely resolved within 1 week.

Conclusions Presence of the spot sign indicated the possibility of hematoma growth and unfavorable outcomes. A small number of adverse events occurred in association with CTA, but without any permanent deficits. Given the potential benefits and risks, we believe that CTA performed at admission in all patients with ICH is beneficial to improve the outcomes.

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Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms: results after clipping versus coiling in a single-center series

Recovery from oculomotor nerve palsy due to posterior communicating artery aneurysms- results after clipping versus coiling in a single-center series

Acta Neurochir (2014) 156:879–884

Oculomotor nerve palsy (ONP) is a common clinical manifestation of ruptured or unruptured posterior communicating artery (PcomA) aneurysms. Although microsurgical clip ligation has been proven a safe and durable treatment, endovascular management is emerging as an increasingly popular alternative. The aim of our study is to compare the recovery rate from ONP and assess the safety and long-term durability of both techniques.

Methods We have reviewed the retrospective data concerning twenty-two patients treated at our institution between 2004 and 2012 for PcomA aneurysms with ONP. Seven patients were operated on via a standard pterional approach, and fourteen were treated by endovascular occlusion with coils. One patient was managed conservatively. Pre-treatment and post-treatment severity of ONP was recorded, as well as the duration of symptoms before admission and treatment-related complications.

Results All seven patients who underwent surgery improved, with six total recoveries and one partial recovery. Among the fourteen patients treated by embolization, thirteen initially recovered, but long-term follow-up revealed three cases of exacerbation of ONP after refilling of the aneurysms. Two of them were clipped, and one embolized. Also, one partially resolved patient underwent a second embolization. No severe complications occurred in either group.

Conclusions Despite the small number of patients, our study suggests that both surgical clipping and embolization are safe and effective methods in regards to functional recovery (complete ONP recovery in about 85 % of the cases). However, coiling may lead to delayed recurrence of third cranial nerve (CN) palsy at long-term follow-up, requiring additional treatment. Keywords

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Inducing transient language disruptions by mapping of Broca’s area with modified patterned repetitive transcranial magnetic stimulation protocol

Mapping Broca’s area

J Neurosurg 120:1033–1041, 2014

Until now there has been no reliable stimulation protocol for inducing transient language disruptions while mapping Broca’s area. Despite the promising data of only a few studies in which speech arrest and language disturbances have been induced, certain concerns have been raised. The purpose of this study was to map Broca’s area by using event-related navigated transcranial magnetic stimulation (nTMS) to generate a modified patterned nTMS protocol.

Methods. Eleven right-handed subjects underwent nTMS to Broca’s area while engaged in a visual object-naming task. Navigated TMS was triggered 300 msec after picture presentation. The modified patterned nTMS protocol consists of 4 stimuli with an interstimulus interval of 6 msec; 8 or 16 of those bursts were repeated with a burst repetition rate of 12 Hz. Prior to mapping of Broca’s area, the primary motor cortices (M1) for hand and laryngeal muscles were mapped. The Euclidian distance on MRI was measured between cortical points eliciting transient language disruptions and M1 for the laryngeal muscle.

Results. On stimulating Broca’s area, transient language disruptions were induced in all subjects. The mean Euclidian distance between cortical spots inducing transient language disruptions and M1 for the laryngeal muscle was 17.23 ± 4.73 mm.

Conclusions. The stimulation paradigm with the modified patterned nTMS protocol was shown to be promising and might gain more widespread use in speech localization in clinical and research applications.

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Can unilateral-approach minimally invasive transforaminal lumbar interbody fusion attain indirect contralateral decompression?

Can unilateral-approach minimally invasive transforaminal lumbar interbody fusion attain indirect contralateral decompression?

Eur Spine J (2014) 23:1144–1149

Few studies have measured the amount of indirect decompression at the contralateral neural foramen after unilateral-approach minimally invasive transforaminal lumbar interbody fusion (MITLIF). This study examined the amount of intraoperative indirect decompression at the contralateral neural foramen after a unilateral-approach MITLIF in patients with bilateral foraminal stenosis.

Methods From February 2009 to October 2012, 66 consecutive patients with bilateral foraminal stenosis underwent unilateral-approach MITLIF and postoperative magnetic resonance imaging (MRI). Direct decompression was performed at the central canal and approach-side neural foramen, while indirect decompression using cage distraction was pursued at the contralateral neural foramen. Qualitative parameters of the central canal (dural sac morphology) and neural foramen (foramen morphology) were analyzed using pre- and post-operative MRI. Quantitative measurement on the central canal (dural sac crosssectional area) and neural foramen (foramen height and width) were also measured.

Results A total of 69 intervertebral levels in the 66 patients were analyzed. Qualitative parameters of the central canal and contralateral neural foramen improved significantly after unilateral-approach MITLIF (both P<0.001). The mean dural sac cross-sectional area increased from 51.1 ± 28.8 to 84.8 ± 30.2 mm2 (P<0.001). The mean preoperative contralateral foramen height, maximum foramen width, and minimum foramen width were 11.8 ± 2.0, 4.9 ± 1.5, and 1.5 ± 0.7 mm, respectively, and these values increased postoperatively to 14.7 ± 2.5, 6.5 ± 1.8, and 2.4 ± 1.0 mm, respectively (all P<0.001).

Conclusion Quantitative and qualitative parameters of the central canal and contralateral neural foramen increased significantly after unilateral-approach MITLIF.

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Long-term natural history of incidentally discovered cavernous malformations in a single-center cohort

cavmal2_600

J Neurosurg 120:1188–1192, 2014

The aim of this study was to determine the prospective hemorrhage rate in a group of retrospectively identified patients in whom symptoms had an unclear relationship to an intracerebral cavernous malformation (ICM) or the malformation itself was an incidental finding.

Methods. Patients with incidentally discovered ICMs diagnosed between 1989 and 1999 were identified from a previously published cohort. Those with ICMs having an unclear relationship with existing symptoms were also eligible for analysis. Updated clinical and radiographic data pertaining to symptomatic intracerebral hemorrhage related to the ICM or new seizures were obtained through medical chart review and mail survey. In select patients, phone calls were made and death certificates were obtained when possible. The prospective hemorrhage rate was calculated as the number of prospective hemorrhages divided by the number of patient-years of follow-up.

Results. There were 1311 patient-years of follow-up among the 107 patients (49.5% male; mean age at diagnosis 52 years) eligible for this study. Forty-four patients died in the follow-up period, and the cause of death could be determined in 34 (77%). Two patients had a prospective hemorrhage, which was definitively related to the ICM in only one. Thus, the definitive prospective bleed rate was 0.08% per patient-year. No new seizures developed in any of the patients during the follow-up period.

Conclusions. The risk of prospective hemorrhage in patients presenting asymptomatically with ICM is very low. This information can be useful in managing such patients and may be most applicable to those with a single ICM.

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Revascularization and Aneurysm Surgery: Techniques, Indications, and Outcomes in the Endovascular Era

Revascularization and Aneurysm Surgery

Neurosurgery 74:482–498, 2014

Given advances in endovascular technique, the indications for revascularization in aneurysm surgery have declined.

OBJECTIVE: We sought to define indications, outline technical strategies, and evaluate the outcomes of patients treated with bypass in the endovascular era.

METHODS: We retrospectively reviewed all aneurysms treated between September 2006 and February 2013.

RESULTS: We identified 54 consecutive patients (16 males and 39 females) with 56 aneurysms. Aneurysms were located along the cervical internal carotid artery (ICA) (n = 1), petrous/cavernous ICA (n = 1), cavernous ICA (n = 16), supraclinoid ICA (n = 7), posterior communicating artery (n = 2), anterior cerebral artery (n = 4), middle cerebral artery (MCA) (n = 13), posterior cerebral artery (PCA) (n = 3), posterior inferior cerebellar artery (n = 4), and vertebrobasilar arteries (n = 5). Revascularization was performed with superficial temporal artery (STA) to MCA bypass (n = 25), STA to superior cerebellar artery (SCA) (n = 3), STA to PCA (n = 1), STA-SCA/STA-PCA (n = 1), occipital artery (OA) to PCA (n = 2), external carotid artery/ICA to MCA (n = 15), OA to MCA (n = 1), OA to posterior inferior cerebellar artery (n = 1), and in situ bypasses (n = 8). At a mean clinical follow-up of 18.5 months, 45 patients (81.8%) had a good outcome (Glasgow Outcome Scale 4 or 5). There were 7 cases of mortality (12.7%) and an additional 9 cases of morbidity (15.8%). At a mean angiographic follow-up of 17.8 months, 14 bypasses were occluded. Excluding the 7 cases of mortality, the majority of aneurysms (n = 42) were obliterated. We identified 7 cases of residual aneurysm and recurrence in 6 patients at follow-up.

CONCLUSION: Given current limitations with existing treatments, cerebral revascularization remains an essential technique for aneurysm surgery.

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Intraoperative Contrast-Enhanced Ultrasound for Brain Tumor Surgery

INTRAOPERATIVE CEUS FOR BRAIN SURGERY

Neurosurgery 74:542–552, 2014 

Contrast-enhanced ultrasound (CEUS) is a dynamic and continuous modality that offers a real-time, direct view of vascularization patterns and tissue resistance for many organs. Thanks to newer ultrasound contrast agents, CEUS has become a wellestablished, live-imaging technique in many contexts, but it has never been used extensively for brain imaging. The use of intraoperative CEUS (iCEUS) imaging in neurosurgery is limited.

OBJECTIVE: To provide the first dynamic and continuous iCEUS evaluation of a variety of brain lesions.

METHODS: We evaluated 71 patients undergoing iCEUS imaging in an off-label setting while being operated on for different brain lesions; iCEUS imaging was obtained before resecting each lesion, after intravenous injection of ultrasound contrast agent. A semiquantitative, offline interobserver analysis was performed to visualize each brain lesion and to characterize its perfusion features, correlated with histopathology.

RESULTS: In all cases, the brain lesion was visualized intraoperatively with iCEUS. The afferent and efferent blood vessels were identified, allowing evaluation of the time and features of the arterial and venous phases and facilitating the surgical strategy. iCEUS also proved to be useful in highlighting the lesion compared with standard B-mode imaging and showing its perfusion patterns. No adverse effects were observed.

CONCLUSION: Our study is the first large-scale implementation of iCEUS in neurosurgery as a dynamic and continuous real-time imaging tool for brain surgery and provides the first iCEUS characterization of different brain neoplasms. The ability of CEUS to highlight and characterize brain tumor will possibly provide the neurosurgeon with important information anytime during a surgical procedure.

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Is the 4 mm height of the vertebral artery groove really a limitation of C1 pedicle screw insertion?

VA groove and C1 pedicle screw insertion

Eur Spine J (2014) 23:1109–1114

To explore the feasibility and effectiveness of C1 pedicle screw fixation in patients whose atlas vertebral artery groove (defined as the C1 pedicle) height is less than 4 mm, but with a medullary canal.

Methods From January 2010 to January 2013, 7 patients (6 males, 1 female) with atlantoaxial instability whose C1 pedicle height was less than 4.0 mm on one or both sides were treated by C1 pedicle screw fixation at our institution. Thirteen of the 14 C1 pedicles were less than 4.0 mm in height, but all had a medullary canal. Patients were followed up at regular intervals. Postoperative computed tomography (CT) scans were performed to assess if C1 pedicle screw placement was successful. Clinical outcomes were evaluated according to postoperative complications, the American Spinal Injury Association grading system, and bone graft status.

Results Thirteen C1 pedicles with a height less than 4.0 mm were inserted by 13 3.5- or 4.0-mm-diameter pedicle screws, and one C1 pedicle whose height was 4.1 mm was inserted by a 4.0-mm-diameter pedicle screw. In addition, 14 pedicle screws were inserted in the axis. The mean follow-up period was 23 (range 8–38) months. No neurologic or vascular complications occurred in any of the seven patients. Postoperative CT three-dimensional reconstruction images showed that all 14 pedicle screws were inserted in the C1 pedicles without destruction of the atlas pedicle cortical bone. All patients demonstrated bony fusion 6 months postoperatively.

Conclusion If there is a medullary canal in the C1 pedicle, a 3.5- or 4.0-mm-diameter pedicle screw can be safely inserted into the atlas and C1 pedicle screw fixation can be performed without any impact on fixation stability and clinical efficacy, even if the C1 pedicle height is less than 4.0 mm.

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Continuous dynamic mapping of the corticospinal tract during surgery of motor eloquent brain tumors

Continuous dynamic subcortical mapping

J Neurosurg 120:1015–1024, 2014

The authors developed a new mapping technique to overcome the temporal and spatial limitations of classic subcortical mapping of the corticospinal tract (CST). The feasibility and safety of continuous (0.4–2 Hz) and dynamic (at the site of and synchronized with tissue resection) subcortical motor mapping was evaluated.

Methods. The authors prospectively studied 69 patients who underwent tumor surgery adjacent to the CST (< 1 cm using diffusion tensor imaging and fiber tracking) with simultaneous subcortical monopolar motor mapping (short train, interstimulus interval 4 msec, pulse duration 500 μsec) and a new acoustic motor evoked potential alarm. Continuous (temporal coverage) and dynamic (spatial coverage) mapping was technically realized by integrating the mapping probe at the tip of a new suction device, with the concept that this device will be in contact with the tissue where the resection is performed. Motor function was assessed 1 day after surgery, at discharge, and at 3 months.

Results. All procedures were technically successful. There was a 1:1 correlation of motor thresholds for stimulation sites simultaneously mapped with the new suction mapping device and the classic fingerstick probe (24 patients, 74 stimulation points; r2 = 0.98, p < 0.001). The lowest individual motor thresholds were as follows: > 20 mA, 7 patients; 11–20 mA, 13 patients; 6–10 mA, 8 patients; 4–5 mA, 17 patients; and 1–3 mA, 24 patients. At 3 months, 2 patients (3%) had a persistent postoperative motor deficit, both of which were caused by a vascular injury. No patient had a permanent motor deficit caused by a mechanical injury of the CST.

Conclusions. Continuous dynamic mapping was found to be a feasible and ergonomic technique for localizing the exact site of the CST and distance to the motor fibers. The acoustic feedback and the ability to stimulate the tissue continuously and exactly at the site of tissue removal improves the accuracy of mapping, especially at low (< 5 mA) stimulation intensities. This new technique may increase the safety of motor eloquent tumor surgery.

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Re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms

Cranio re-exploration for aneu

Acta Neurochir (2014) 156:869–877

Unplanned re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms (UIAs) is sometimes required, but the underlying causes and rates of these procedures are seldom reported. This study retrospectively analyzed the causes of such re-explorations to identify methods for decreasing their necessity.

Method From January 2000 to December 2011, 1,720 patients with a total of 1,938 UIAs underwent surgical treatment at our institution. Fromthis cohort, 26 patients (1.5 %) with 38 UIAs required re-exploration. Clinical data, aneurysm characteristics, treatment methods, and the incidence and causes of re-exploration of the craniotomy were analyzed for these 26 patients.

Results: Several causes of re-exploration were identified: compromised distal blood flow (eight patients, 0.47 %), hemorrhagic venous infarction (four patients, 0.23 %), brain retraction injury (three patients, 0.17 %), newly identified aneurysms (three patients, 0.17 %), bleeding from an incompletely clipped aneurysm (two patients, 0.12 %), epidural hematoma (two patients, 0.12%), failed aneurysm clipping (two patients, 0.12 %) and other causes (two patients, 0.12 %). Annual reexploration incidence rates ranged from 0 to 3.1 %. Annual incidence rates gradually decreased following the introduction of several intraoperative monitoring systems.

Conclusions Precise surgical planning and careful operative techniques can reduce the incidence of unplanned reexploration of the craniotomy. The introduction of various intraoperative monitoring systems can also contribute to a reduction in this incidence.

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Algorithmic selection of cervical deformity surgery

An algorithmic strategy for selecting a surgical approach in cervical deformity correction

Neurosurg Focus 36 (5):E5, 2014

Adult degenerative cervical kyphosis is a debilitating disease that often requires complex surgical management. Young spine surgeons, residents, and fellows are often confused as to which surgical approach to choose due to lack of experience, absence of a systematic method of surgical management, and today’s plethora of information regarding surgical techniques. Although surgeons may be able to perform anterior, posterior, or combined (360°) approaches to the cervical spine, many struggle to rationally choose an appropriate approach for deformity correction.

The authors introduce an algorithm based on morphology and pathology of adult cervical kyphosis to help the surgeon select the appropriate approach when performing cervical deformity surgery.

Cervical deformities are categorized into 5 different prevalent morphological types encountered in clinical settings. A surgical approach tailored to each category/ type of deformity is then discussed, with a concrete case illustration provided for each.

Preoperative assessment of kyphosis, determination of the goal for surgery, and the complications associated with cervical deformity correction are also summarized. This article’s goal is to assist with understanding the big picture for surgical management in cervical spinal deformity.

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Pre- and postoptic subdivisions of the anterior choroidal artery

AChA Anatomy

J Neurosurg 120:1217–1228, 2014

The object of this study was to delineate the microsurgical anatomy of the cisternal segment of the anterior choroidal artery (AChA). The authors also propose a new classification of this segment on the basis of its complicated course within the carotid and crural cisterns in relation to important neurovascular structures, and the site of origin, course, and areas of supply of perforating arteries.

Methods. Thirty cadaveric cerebral hemispheres injected with colored latex were dissected under surgical magnification to view the cisternal segment of the AChA and its perforators. Fiber dissections using the Klingler technique were performed in two additional latex injected hemispheres to follow the penetration points, courses, and terminal areas of supply of perforating branches that arise from the cisternal segment of the AChA.

Results. The cisternal segment of the AChA was divided into pre- and postoptic parts that meet at the artery’s genu, the most medial extension point of the cisternal segment where the artery makes an abrupt turn after passing under the optic tract. The preoptic part of the AChA extended from its origin at the inferomedial side of the internal carotid artery to the artery’s genu, which is commonly located just inferomedial to the initial part of the optic tract. The postoptic part coursed within the crural cistern and extended from the genu to the inferior choroidal point. The genu of the AChA was 8 mm medial to the artery’s origin and was located medial to the optic tract in 13% of the hemispheres. The postoptic part was longer than the preoptic part in all hemispheres and had more perforating arteries supplying critical deep structures (preoptic 3.4 per hemisphere vs postoptic 4.6 per hemisphere), and these results were statistically significant (p = 0.01). At the preoptic part, perforating arteries arose from the superolateral portion of the artery and coursed laterally; at the postoptic part, perforators arose from the inferomedial portion of the artery and coursed medially. Perforating arteries from both segments passed most commonly to the optic tract, followed by the anterior segment and apex of uncus in the preoptic part and the cerebral peduncle in the postoptic part.

Conclusions. Both parts of the cisternal segment of the AChA come into surgical view during surgeries for different pathologies in and around the perimesencephalic cisterns. However, attending to the artery’s genu and defining pre- and postoptic parts during surgery may help the surgeon locate the origin and eventual course of these perforators, and even estimate the terminal areas of supply of most of the perforating arteries. The proposed classification system can prove helpful in planning any operative procedure along the crural cistern and may reduce the probability of inadvertent injury to perforating branches of the cisternal segment.

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Surgically Relevant Localization of the Central Sulcus With High-Density Somatosensory-Evoked Potentials Compared With Functional Magnetic Resonance Imaging

Surgically Relevant Localization of the Central Sulcus With High-Density Somatosensory-Evoked Potentials Compared With Functional Magnetic Resonance Imaging

Neurosurgery 74:517–526, 2014

Resection of abnormal brain tissue lying near the sensorimotor cortex entails precise localization of the central sulcus. Mapping of this area is achieved by applying invasive direct cortical electrical stimulation. However, noninvasive methods, particularly functional magnetic resonance imaging (fMRI), are also used. As a supplement to fMRI, localization of somatosensory-evoked potentials (SEPs) recorded with an electroencephalogram (EEG) has been proposed, but has not found its place in clinical practice.

OBJECTIVE: To assess localization accuracy of the hand somatosensory cortex with SEP source imaging.

METHODS: We applied electrical source imaging in 49 subjects, recorded with highdensity EEG (256 channels). We compared it with fMRI in 18 participants and with direct cortical electrical stimulation in 6 epileptic patients.

RESULTS: Comparison of SEP source imaging with fMRI indicated differences of 3 to 8 mm, with the exception of the mesial-distal orientation, where variances of up to 20 mm were found. This discrepancy is explained by the fact that the source maximum of the first SEP peak is localized deep in the central sulcus (area 3b), where information initially arrives. Conversely, fMRI showed maximal signal change on the lateral surface of the postcentral gyrus (area 1), where sensory information is integrated later in time. Electrical source imaging and fMRI showed mean Euclidean distances of 13 and 14 mm, respectively, from the contacts where electrocorticography elicited sensory phenomena of the contralateral upper limb.

CONCLUSION: SEP source imaging, based on high-density EEG, reliably identifies the depth of the central sulcus. Moreover, it is a simple, flexible, and relatively inexpensive alternative to fMRI.

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The anterior interhemispheric approach – a safe and effective approach to anterior skull base lesions

Interhemispheric app

Acta Neurochir (2014) 156:689–696

Many approaches to the anterior skull base have been reported. Frequently used are the pterional, the unilateral or bilateral frontobasal, the supraorbital and the frontolateral approach. Recently, endoscopic transnasal approaches have become more popular. The benefits of each approach has to be weighted against its complications and limitations. The aim of this study was to investigate if the anterior interhemispheric approach (AIA) could be a safe and effective alternative approach to tumorous and non-tumorous lesions of the anterior skull base.

Methods We screened the operative records of all patients with an anterior skull base lesion undergoing transcranial surgery.We have used the AIA in 61 patients. These were exclusively patients with either olfactory groove meningioma (OGM) (n =43), ethmoidal dural arteriovenous fistula (dAVF) ( n =6) or frontobasal fractures of the anterior midline with cerebrospinal fluid (CSF) leakage ( n =12). Patient records were evaluated concerning accessibility of the lesion, realization of surgical aims (complete tumor removal, dAVF obliteration, closure of the dural tear), and approach related complications.

Results The use of the AIA exclusively in OGMs, ethmoidal dAVFs and midline frontobasal fractures indicated that we considered lateralized frontobasal lesions not suitable to be treated successfully. If restricted to these three pathologies, the AIA is highly effective and safe. The surgical aim (complete tumor removal, complete dAVF occlusion, no rhinorrhea) was achieved in all patients. The complication rate was 11.5 % (wound infection (n =2; 3.2 %), contusion of the genu of the corpus callosum, subdural hygroma, epileptic seizure, anosmia and asymptomatic bleed into the tumor cavity (n =1 each). Only the contusion of the corpus callosum was directly related to the approach (1.6 %). Olfaction, if present before surgery, was preserved in all patients, except one (1.6 %).

Conclusions The AIA is an effective and a safe approach to tumorous, vascular and traumatic pathologies of the midline anterior skull base. This approach should be part of the armamentarium of skull base surgeons.

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Transsphenoidal surgical treatment of pituitary adenomas in patients aged 80 years or older

Pituitary adenomas patients aged 80

Neurosurg Rev (2014) 37:269–277

To know the clinical characteristics of pituitary adenomas in the elderly patients aged 80 years or older who were surgically treated.

From1995 through 2012, 907 patients underwent surgery for the pituitary adenomas at Kagoshima and Hiroshima University hospitals in Japan. Ten (1.1 %) patients were aged 80 years or older. We retrospectively assessed the clinical characteristics including preoperative comorbidities, manifestations, neuroimaging findings, and endocrinologic features of these ten patients.

The subjects included eight males and two females. Their ages ranged from 80 to 86 with mean of 83.1 years. Of these, besides one case of growth hormone-producing adenoma, others were clinically nonfunctioning adenoma. Six patients had modest comorbidities such as hypertension, cardiovascular diseases, diabetes mellitus, or chronic kidney dysfunction, and all patients were classified into grade 2–3 on American Society of Anesthesiologists’ Physical Status grading. Transsphenoidal surgery was performed in all due to visual disturbance in eight, diabetes mellitus as an intercurrent illness of acromegaly in one, and for the purpose of preventing visual disturbance in one patient who had an adenoma impinging optic chiasm but still had normal visual field. The surgeries provided sufficient decompression of the optic pathways and improved visual disorder in all. In an acromegalic male, his comorbidities considerably improved. No permanent surgical morbidity ensued. More than three axes of anterior pituitary hormones were preoperatively impaired in all, which were rarely recovered.

Transsphenoidal surgery is safe and efficient treatment way for patients aged 80 years or older with pituitary adenomas with chiasmatic symptoms when the patients’ general condition is well preserved and pituitary hormonal deficiency is adequately replaced.

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Stereotactic radiosurgery for Spetzler-Martin Grade III arteriovenous malformations

Spetzler-Martin grade III AVMs

J Neurosurg 120:973–981, 2014

The purpose of this study was to define the outcomes and risks of stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) Grade III arteriovenous malformations (AVMs).

Methods. Between 1987 and 2009, SRS was performed in 474 patients with SM Grade III AVMs. The AVMs were categorized by scoring the size (S), drainage (D), and location (L): IIIa was a small AVM (S1D1L1, N = 282); IIIb was a medium/deep AVM (S2D1L0, N = 44); and IIIc was a medium/eloquent AVM (S2D0L1, N = 148). The median target volume was 3.8 ml (range 0.1–26.3 ml) and the margin dose was 20 Gy (range 13–25 Gy). Eighty-one patients (17%) underwent prior embolization, and 58 (12%) underwent prior resection.

Results. At a mean follow-up of 89 months, the total obliteration rates documented by angiography or MRI for all SM Grade III AVMs increased from 48% at 3 years to 69% at 4 years, 72% at 5 years, and 77% at 10 years. The SM Grade IIIa AVMs were more likely to obliterate than other subgroups. The cumulative rate of hemorrhage was 2.3% at 1 year, 4.4% at 2 years, 5.5% at 3 years, 6.4% at 5 years, and 9% at 10 years. The SM Grade IIIb AVMs had a significantly higher cumulative rate of hemorrhage. Symptomatic adverse radiation effects were detected in 6%.

Conclusions. Treatment with SRS was an effective and relatively safe management option for SM Grade III AVMs. Although patients with residual AVMs remained at risk for hemorrhage during the latency interval, the cumulative 10-year 9% hemorrhage risk in this series may represent a significant reduction compared with the expected natural history.

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Spinal juvenile (Type III) extradural-intradural arteriovenous malformations

Spinal extradural-intradural AVMs

 J Neurosurg Spine 20:452–458, 2014

Owing to their rarity, demographics, natural history, and treatment, results for spinal juvenile (Type III) extradural-intradural arteriovenous malformations (AVMs) are frequently only provided in case report format.

Methods. A pooled analysis was performed utilizing the PubMed database through April 2013. Individualized patient data were extracted to elucidate demographics, hemorrhage risk, and treatment result information.

Results. Twenty-nine studies describing 51 patients were included. The mean age at presentation was 15.0 ± 10.5 years with a slight male predilection (63%, 1.7:1 sex ratio). Presentation modality included progressive deficits in 35%, hemorrhage in 31%, acute deficits not attributed to hemorrhage in 22%, and asymptomatic/incidental in 12% of patients. The annual hemorrhage rate was 2.1%; statistically significant risk factors for hemorrhage included presentation age (HR 0.39 [95% CI 0.18–0.87]) and associated aneurysms (HR 8.74 [95% CI 1.76–43.31]). Seventy-seven percent of patients underwent treatment; after a mean follow-up of 2.6 ± 3.2 years, 73% were improved, 10% were the same, and 17% were worse neurologically. Of 25 cases with described angiographic results, 8 lesions were obliterated (32%). Of these 25 patients, 8 had AVMs with associated aneurysms, and the aneurysm was obliterated in all 8 patients. Over the course of 57.9 patient-years of follow-up, including 55.3 patient-years for partially treated AVMs, no hemorrhages were described, reflecting a trend toward protection from hemorrhage after treatment (p = 0.12, likelihood ratio test).

Conclusions. Spinal juvenile (Type III) extradural-intradural AVMs commonly present symptomatically. Associated arterial aneurysms increase their hemorrhage risk, and protection from hemorrhage may be achieved from partial obliteration of these lesions, particularly if targeted toward associated aneurysms.

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Anterior trans-frontal endoscopic management of colloid cyst

Endoscopic trans-frontal approach colloid cysts

Neurosurg Rev (2014) 37:235–241

Different management options are available for the treatment of colloid cysts. Goals of those procedures are to achieve a complete resection avoiding potential long-term recurrence along with CSF pathways restoration with minimal morbidity and mortality.

The two main surgical options are endoscopic resection or direct removal by either transfrontal or transcallosal approach. The efficacy of endoscopic technique to achieve gross total colloid cyst excision has been well documented.

In the present study, authors describe a series of 29 patients who underwent surgery by a variation of the standard worldwide implemented endoscopic technique. Using a more anterior approach, it is easier to reach the roof of the cyst, its possible adherences with the tela choroidea, plexus, and the internal cerebral veins. The described approach has shown to be safe, quick, and very effective with a total cyst removal rate of 86.2 %.

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Predictive value of intraoperative 5-aminolevulinic acid–induced fluorescence for detecting bone invasion in meningioma surgery

Predictive value of intraoperative 5-aminolevulinic

J Neurosurg 120:840–845, 2014

Bone invasion is a major concern in meningioma surgery, since it is predictive of the recurrence of cranial involvement, morbidity, and mortality. Bone invasion has been reported in 20%–68% of studies with histopathologically confirmed data. Unfortunately, radical resection of bone invasion remains challenging. The aim of this study was to assess the role of 5-aminolevulinic acid (5-ALA) fluorescence in guiding the resection of bone-invading meningiomas. To this purpose, the sensitivity, specificity, and positive and negative predictive values of 5-ALA in detecting meningioma bone invasion were evaluated.

Methods. Data from 12 patients affected by bone-invading meningiomas (7 with skull base and 5 with convexity meningiomas) who had undergone surgery with the assistance of 5-ALA fluorescence and neuronavigation between July 2012 and March 2013 at the Department of Neurosurgery of Padua were retrospectively analyzed. To evaluate the sensitivity and specificity of 5-ALA fluorescence in detecting meningioma tissue, a pathologist analyzed 98 surgical bone samples under blue light, according to different fluorescence patterns. Magnetic resonance images and CT scans were obtained pre- and postoperatively to determine the extent of bone invasion resection.

Results. The rate of 5-ALA–induced fluorescence of both tumor and bone invasion was 100%. Based on the pathological examination of bone specimens, 5-ALA presented a sensitivity of 89.06% (95% CI 81.41%–96.71%) and a specificity of 100% in detecting meningioma bone invasion, while the positive and negative predictive values were 100% and 82.93% (95% CI 71.41%–94.45%), respectively. At the postoperative stage, MRI did not detect cases of meningioma bone invasion, whereas CT scans revealed residual hyperostosis in 2 cases.

Conclusions. In summary, 5-ALA fluorescence represents a suitable and reliable technique for identifying and removing bone infiltration by meningiomas. However, further studies are needed to prove the clinical consequences of this promising technique in a larger population.

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Endoscopic endonasal approach in the management of skull base chordomas

Endoscopic approach skull base chordomas

Neurosurg Rev (2014) 37:217–225

Skull base chordomas represent very interesting neoplasms, due to their rarity, biological behavior, and resistance to treatment. Their management is very challenging. Recently, the use of a natural corridor, through the nose and the sphenoid sinus, improved morbidity and mortality allowing also for excellent removal rates.

Prospective analysis of 54 patients harboring a skull base chordoma that were managed by extended endonasal endoscopic approach (EEA). Among the 54 patients treated (during a 72 months period), 21 were women and 33 men, undergoing 58 procedures. Twenty-two cases (40 %) were recurrent and 32 (60 %) newly diagnosed chordomas. Among the 32 newly diagnosed chordomas, a gross total resection was achieved in 28 cases (88%), a near total (>95%of tumor) in 2 cases (6%), a partial (>50 % of tumor) in 2 cases (6 %). Among the 22 recurrent chordomas, resection was complete in 7 cases (30 %), near total in 7 (30%), and partial in 8 (40 %). The global gross total resection rate was 65 % (35/54 cases). Four patients (11 %) recurred and 4 (11 %) progressed within a mean follow-up of 34 months (range 12–84 months). Four patients (11 %) were re-operated; one patient (1.8 %) died due to disease progression, one patient (1.8 %) died 2 weeks after surgery due to a massive bleeding from an ICA pseudo aneurysm. CSF leakage occurred in four patients (8 %), and meningitis in eight cases (14 %). No new permanent neurological deficit occurred.

The EEA management of skull base chordomas requires a long and gradual learning curve that once acquired offers the possibility of either similar or better resection rates as compared to traditional approaches while morbidity is improved.

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