RESUMEN
OBJECTIVE: Dens fractures are common cervical injuries in advanced aged patients. The presented study was undertaken to analyze the clinical results and risks of surgically treated patients with dens fractures over 70 years. METHODS: Data of 28 patients (17 female, 11 male) over 70 years treated from September 2004 to October 2009 were recorded. Clinical and radiological parameters were obtained including type of fracture, associated cervical and/or other injuries, comorbidities, symptoms, neurological condition, surgical strategy, postoperative course and complications. RESULTS: 89% were in a good neurological condition before surgery (ASIA E or D). In most cases, surgery was performed at an early stage after trauma (21 patients within 5 days). Ventral screw fixation was the preferred surgical strategy (64%). A slight worsening of neurological functions immediately after operation was only seen in one patient. Five patients died in the early and 2 in the late postoperative course which means a treatment mortality of 25%. Among the surviving patients two had general medical complications. CONCLUSION: Type II dens fractures are a common fracture of elderly patients. Our results are good concerning the neurological functions. Surgical and general medical complications were acceptable. However, the study also underlines that mortality rate is high and therefore treatment options should be well-considered in this high risk group.
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Vértebras Cervicales/lesiones , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/mortalidad , Apófisis Odontoides/lesiones , Fracturas de la Columna Vertebral/mortalidad , Fracturas de la Columna Vertebral/cirugía , Anciano , Anciano de 80 o más Años , Tornillos Óseos , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Neuroimagen , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Riesgo , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: The aim of this study is to report about a preliminary experience with a new minimally invasive percutaneous transpedicular dorsal stabilization system (MANTIS, Stryker, Kalamazoo, MI, USA) for thoracolumbar and lumbar spinal diseases to demonstrate the benefits of the operative technique and drawbacks. MATERIAL AND METHODS: The minimally invasive percutaneous transpedicular stabilization technique was performed in 52 patients with thoracolumbar and lumbar spinal diseases from February 2009 to August 2010. The average age of 25 male and 27 female patients was 60 years (range 15 to 81 years). Visual analog scale (VAS) was used for pre- and postoperative evaluation of pain. In all patients, preoperative magnetic resonance imaging and computed tomography (CT) scan were performed to evaluate the neuronal and bony structures. Screw position of all operated segments was controlled by postoperative CT scan. RESULTS: Indication for surgery was spondylolisthesis in 28 cases (53.8%), vertebral fracture in 15 cases (28.8%), vertebral metastasis in 8 patients (15.4%), and spondylodiscitis in 1 patient (1.9%). Decompressive laminectomy was performed in 37 cases (71.2%). An additional interbody fusion was necessary in 26 patients (50%) due to degenerative motion spondylolisthesis. All patients showed pain improvement after surgery. The average preoperative VAS score was 7.98 (minimum 5 and maximum 10) and improved after surgery to 2.15 (minimum 0 and maximum 8). The rate of screw misplacement was 4.62% (10 of 216 screws). We revised three screws (1.38%) in three different patients (5.6%) due to suboptimal screw position although these patients had no neurological deterioration. Postoperative complications include cerebrospinal fluid leakage in four cases (7.7%), which occurred during the decompressive procedure. One patient showed a postoperative hematoma located in the paravertebral muscle. CONCLUSION: Minimally invasive transpedicular screw stabilization systems such as the MANTIS lead to safe and effective procedures. They can be used for different spinal disorders and can be combined with additional surgical procedures such as intervertebral fusion or decompression, if necessary.
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Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Fusión Vertebral/métodos , Vértebras Torácicas/cirugía , Adolescente , Adulto , Anciano , Tornillos Óseos , Femenino , Humanos , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/lesiones , Masculino , Persona de Mediana Edad , Radiografía , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/cirugía , Espondilolistesis/diagnóstico por imagen , Espondilolistesis/cirugía , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/lesiones , Resultado del TratamientoRESUMEN
The treatment of spontaneous cerebellar hemorrhage is still discussed controversially. We analyzed a series of 57 patients who underwent surgical evacuation of a cerebellar hematoma at our department. Preoperative clinical and radiological parameters were assessed and correlated with the clinical outcome in order to identify factors with impact on outcome. The overall clinical outcome according to the Glasgow Outcome Scale at the last follow-up was good (GOS 4-5) in 27 patients (47%) and poor (GOS 2-3) in 16 patients (28%). Fourteen patients (25%) died. The initial neurological condition and the level of consciousness proved to be significant factors determining clinical outcome (p = 0.0032 and p = 0.0001, respectively). Among radiological parameters, brain stem compression and a tight posterior fossa solely showed to be predictive for clinical outcome (p = 0.0113 and p = 0.0167, respectively). Overall, our results emphasize the predictive impact of the initial neurological condition on clinical outcome confirming the grave outcome of patients in initially poor state as reported in previous studies. The hematoma size solely, in contrast to previous observations, showed not to be predictive for clinical outcome. Especially for the still disputed treatment of patients in good initial neurological condition, a suggestion can be derived from the present study. Based on the excellent outcome of patients with good initial clinical condition undergoing surgery due to secondary deterioration, we do not recommend preventive evacuation of a cerebellar hematoma in these patients.
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Enfermedades Cerebelosas/cirugía , Hemorragias Intracraneales/cirugía , Procedimientos Neuroquirúrgicos , Adulto , Anciano , Anciano de 80 o más Años , Craneotomía , Análisis Factorial , Femenino , Escala de Coma de Glasgow , Humanos , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/etiología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: The natural history of cerebral arteriovenous malformations (AVMs) is yet to be determined. It has been shown that angiogenic factors are involved in the pathogenesis of AVMs, in particular in partially embolized lesions. This study was conducted to investigate the expression of angiogenic and proliferative factors in relation to different clinical conditions and treatment modalities. METHODS: Immunohistochemistry was performed for 145 consecutive cases of cerebral AVMs. The specimens were stained with antibodies against VEGF, bFGF, Ki 67, CD 34 and CD 31. Expression was correlated with clinical presentation (haemorrhage, seizures or other symptoms), AVM localization, size, eloquence and venous drainage, as well as with preoperative AVM embolization. RESULTS: Whereas no correlation was found between the expression of angiogenic factors and different clinical conditions, we observed a significantly increased proliferation activity as shown by Ki 67 expression in patients with intracerebral haemorrhage (p = 0.02) and in patients with preoperative embolization (p = 0.02). CONCLUSIONS: Increased proliferation activity in partially embolized AVMs supports a 'no-touch' strategy and clinical observation in high-risk AVMs and demands complete AVM elimination in treatable lesions.
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Proliferación Celular , Malformaciones Arteriovenosas Intracraneales/patología , Embolia Intracraneal/patología , Adolescente , Adulto , Anciano , Antígenos CD34/metabolismo , Estudios de Casos y Controles , Niño , Femenino , Factor 2 de Crecimiento de Fibroblastos/metabolismo , Humanos , Malformaciones Arteriovenosas Intracraneales/metabolismo , Embolia Intracraneal/metabolismo , Antígeno Ki-67/metabolismo , Masculino , Persona de Mediana Edad , Molécula-1 de Adhesión Celular Endotelial de Plaqueta/metabolismo , Estudios Retrospectivos , Factor A de Crecimiento Endotelial Vascular/metabolismo , Adulto JovenRESUMEN
PURPOSE: Genotypes of the C825T polymorphism of the GNB3 gene encoding the G protein beta3 subunit were recently associated with the prognosis of different malignomas. We investigated potential associations of GNB3 genotypes with survival of patients with glioblastoma multiforme (GBM). METHODS: One hundred and sixty-one patients suffering from GBM were retrospectively investigated. Inclusion criteria were availability of DNA and a follow-up of at least 24 months. The results were evaluated with respect to the basic clinical data, type of surgical intervention, MGMT promoter methylation, adjuvant therapy, and survival. RESULTS: After 2 years of first diagnosis, 128 (79.5%) of the 161 patients had died, 33 (20.5%) were alive. Kaplan-Meier curves revealed a significant higher rate of survival for homo- and heterozygous T-allele carriers (P = 0.019) with 38.5 and 25.3%, respectively, but only 11.6% for homozygous C-allele carriers. Multivariable Cox regression identified the heterozygous (hazard ratio 3.3, 95% CI 1.3-8.0, P = 0.010), as well as homozygous GNB3 825 C-allele (hazard ratio 3.7, 95% CI 1.5-9.1, P = 0.004) as an independent negative prognostic factor for 2-year survival according to the GNB3 825 TT genotype reference group. CONCLUSIONS: Our data suggest an association of the GNB3 825TT genotype and better survival in patients with GBM.
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Glioblastoma/genética , Proteínas de Unión al GTP Heterotriméricas/genética , Alelos , Metilación de ADN , Metilasas de Modificación del ADN/genética , Enzimas Reparadoras del ADN/genética , Femenino , Genotipo , Glioblastoma/diagnóstico , Glioblastoma/terapia , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Pronóstico , Regiones Promotoras Genéticas/genética , Estudios Retrospectivos , Tasa de Supervivencia , Proteínas Supresoras de Tumor/genéticaRESUMEN
A subgroup of patients initially treated by radiosurgery underwent surgical resection because of recurrent hemorrhage or neurological deterioration. In a retrospective study, we want to analyze the clinical features of these patients and evaluate the effect of microneurosurgery in such rare constellations. Moreover, we hope to find answers about failure of radiation therapy in these cases by correlation of radiobiological and histopathological data. Over a 16-year-period, eight patients with cerebral arteriovenous malformation (AVM) underwent surgical resection, who previously were treated by radiosurgery. The mean duration between radiation therapy and final resection was 7 years. Preoperative evaluation revealed Spetzler-Martin grade III (n=5) and IV (n=3) AVMs. Histological examination was achieved in all resected lesions. Mean neurological follow-up was 14 months. Indications for surgical resection were intracerebral hematoma, progressive neurological deficit, and epilepsy. In comparison to the initial angiographic study before radiation therapy, preoperative angiography revealed newly developed "en passant" feeding vessels and stenosis of the main venous drainage in some patients. The mean Rankin score for all patients was 2.75 before and 3.25 after surgical resection. Postoperatively, three patients (38%) developed neurological deterioration. Histological examination of the resected tissue revealed significant radiation-induced pathology in six patients. We did not see correlation between radiation doses and severity of histolopathological radiation-induced changes. Postoperative angiography confirmed total AVM resection in all patients. AVMs insufficiently treated by radiation bear an increased surgical risk. Often, angiographic studies revealed a more complicated morphology. Microsurgical resection was extremely challenging and led to unfavorable outcomes in many of the patients.
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Malformaciones Arteriovenosas Intracraneales/radioterapia , Malformaciones Arteriovenosas Intracraneales/cirugía , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Adulto , Angiografía Cerebral , Femenino , Escala de Consecuencias de Glasgow , Humanos , Malformaciones Arteriovenosas Intracraneales/patología , Imagen por Resonancia Magnética , Masculino , Microcirugia , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/etiología , Examen Neurológico , Radiocirugia , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: The aim of the study was to evaluate patients with multisegmental cervical spondylotic myelopathy (MCM) surgically treated via a dorsal approach. Two different laminoplasty techniques were compared by assessment of enlargement of the spinal canal and the neurological outcome. METHODS: Thirteen patients (mean age 49 years, 11 males) underwent decompressive laminoplasty over a 7-year period. The average duration of symptoms was 21 months. The pre- and postoperative degree of myelopathy was assessed by both the Nurick grading and the Japanese Orthopaedic Association myelopathy score (JOA score). Preoperatively, the mean Nurick grade was 3.1 and the mean JOA score was 11. Two different techniques of expansive laminoplasty were used. Six patients underwent a bilateral cutting (BL) technique with retropositioning of the laminae and bilateral mini-plating (BL group). Seven patients were operated on by simple open-door (OD) laminoplasty with unilateral mini-plating (OD group). Postoperatively, CT scans were obtained for all patients to measure the sagittal diameter of the spinal canal. The mean clinical and radiological follow-up was 33 months. RESULTS: Four to five laminae were involved in all patients.The mean operation time was 180 min. Complications occurred in two patients of BL group, with immediate postoperative neurological deterioration due to ventral displacement of the laminae. Overall, the average sagittal diameter (SD) of the spinal canal increased from 9.2 +/- 1.3 mm to 12.4 +/- 1.3 mm after surgery. The average enlargement of SD was significantly higher for the OD group (p < 0.0075 ). In total, the improvement rate was 38% according to the Nurick grading and 69% according to the JOA score. For the OD group, improvement rates were 57% (Nurick) and 71% (JOA). CONCLUSIONS: Decompressive laminoplasty is comparable with anterior surgery in neurological outcome. The OD technique seems to be superior to our BL technique regarding both the enlargement of SD and complication rate.
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Vértebras Cervicales/cirugía , Descompresión Quirúrgica/métodos , Laminectomía/métodos , Compresión de la Médula Espinal/cirugía , Espondilosis/cirugía , Anciano , Anciano de 80 o más Años , Placas Óseas/estadística & datos numéricos , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/patología , Femenino , Lateralidad Funcional/fisiología , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Radiografía , Radiología/métodos , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Canal Medular/diagnóstico por imagen , Canal Medular/patología , Canal Medular/cirugía , Compresión de la Médula Espinal/etiología , Compresión de la Médula Espinal/patología , Fusión Vertebral/instrumentación , Fusión Vertebral/métodos , Espondilosis/complicaciones , Espondilosis/patología , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECT: In this study, the authors' goal was to analyze a series of patients treated microsurgically for an anterior clinoid process (ACP) meningioma in regard to long-term functional outcome. METHODS: The authors retrospectively analyzed clinical data in a consecutive series of 106 patients who underwent microsurgical treatment for an ACP meningioma at 2 neurosurgical institutions between 1987 and 2005. The main presenting symptoms of the 84 female and 22 male patients (mean age 56 years) were visual impairment in 54% and headache in 28%. Physical examination revealed decreased visual acuity in 49% and a visual field deficit in 26%. Tumors were primarily resected via a pterional approach. Meningioma extensions invading the cavernous sinus, present in 29% of the patients, were not removed. Complete tumor resection (Simpson Grade I and II) was achieved in 59% of the cases. RESULTS: Postoperatively, visual acuity improved in 40%, was unchanged in 46%, and deteriorated in 14%. A new oculomotor palsy was observed in 8 patients (8%). Clinical and MR imaging data were available in 95 patients for a mean postsurgical period of 6.9 years (1.5-18 years) and revealed tumor recurrence in 10% and tumor progression after subtotal resection in 38%. Clinical deterioration on long-term follow-up consisting primarily of ophthalmological deficits was observed in 14% of the cases. CONCLUSIONS: Acceptable functional results can be achieved after microsurgical resection of ACP meningiomas; however, long-term treatment remains challenging due to a high tumor recurrence and progression rate.
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Meningioma/cirugía , Procedimientos Neuroquirúrgicos , Neoplasias Craneales/cirugía , Adolescente , Adulto , Anciano , Angiografía Cerebral , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Masculino , Meningioma/diagnóstico por imagen , Meningioma/patología , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Complicaciones Posoperatorias/epidemiología , Neoplasias Craneales/diagnóstico por imagen , Neoplasias Craneales/patología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Trastornos de la Visión/epidemiología , Trastornos de la Visión/etiología , Adulto JovenRESUMEN
This study was undertaken to analyze the functional outcome of surgically treated spinal meningiomas and to determine factors for surgical morbidity. Between January 1990 and December 2006 a total of 131 patients underwent surgical resection of a spinal menigioma. There were 114 (87%) female and 17 (13%) male patients. Age ranged from 17 to 88 years (mean 69 years). The mean follow-up period was 61 months (range 1-116 months) including a complete neurological examination and postoperative MRI studies. The pre- and postoperative neurological state was graded according to the Frankel Scale. Surgery was performed under standard microsurgical conditions with neurophysiological monitoring. In 73% the lesion was located in the thoracic region, in 16% in the cervical region, in 5% at the cervico-thoracic junction, in 4.5% at the thoraco-lumbar junction and in 1.5% in the lumbar region. Surgical resection was complete in 127 patients (97%) and incomplete in 4 patients (3%). At the last follow-up the neurological state was improved or unchanged in 126 patients (96.2%) and worse in 4 patients (3%). Permanent operative morbidity and mortality rates were 3 and 0.8%, respectively. Extensive tumour calcification proved to be a significant factor for surgical morbidity (P < 0.0001). Radical resection of spinal meningiomas can be performed with good functional results. Extensive tumor calcification, especially in elderly patients proved to harbor an increased risk for surgical morbidity.
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Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Procedimientos Neuroquirúrgicos , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Calcinosis/patología , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Neoplasias Meníngeas/patología , Meningioma/patología , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos Neuroquirúrgicos/métodos , Complicaciones Posoperatorias/epidemiología , Recuperación de la Función , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: We retrospectively analyzed a series of patients harboring a FT meningioma with regard to clinical presentation, surgical technique, and follow-up results. METHODS: Clinical data in a consecutive series of 13 patients treated for a meningioma of the FT junction were retrospectively reviewed. Tumors were classified into 4 types according to their dural origin and tumor extent as depicted from preoperative MRI. RESULTS: Main presenting symptom in 9 women and 4 men (mean age, 56 years) was headache (69%) and gait disturbance (54%). Clinical examination revealed gait ataxia in 62% of the patients. The tumor displaced the vein of Galen inferiorly in 6 patients, superiorly in 2, and medially in 5 cases. The main surgical approach to the meningioma was via an occipital interhemispheric route (10 patients). Additional resection of the falx and/or incision of the tentorium was performed in 6 cases each. A complete resection (Simpson grade 1 and 2) was achieved in 85% of patients. Permanent surgical morbidity was 23%. One tumor recurrence in an atypical meningioma was observed after the mean follow-up period of 6.2 years (range, 1-14 years) with clinical and MRI examination and had to be reoperated. Eighty-five percent of the patients regained full daily activity on follow-up. CONCLUSIONS: The surgical approach should be tailored to the dural origin and extent of the tumor as depicted from preoperative MRI. Preservation of the straight sinus and Galenic venous system is recommended.
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Craneotomía , Neoplasias Meníngeas/patología , Neoplasias Meníngeas/cirugía , Meningioma/patología , Meningioma/cirugía , Microcirugia , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Neoplasias Meníngeas/diagnóstico por imagen , Meningioma/diagnóstico por imagen , Persona de Mediana Edad , Hueso Occipital , Radiografía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECT: The authors retrospectively analyzed a consecutive series of patients with cranial vault primary extradural meningioma (PEM), with particular regard to the tumor's dural involvement. The pertinent literature was reviewed. METHODS: Clinical data were retrospectively obtained in a consecutive series of 16 patients treated for a PEM at two institutions between 1992 and 2004. The authors created a classification system based on dural involvement of the tumors. Nine women and six men (mean age 55 years) presented with a painless, slowly progressive swelling. Preoperative magnetic resonance (MR) imaging revealed dural enhancement at the site of tumor in 11 patients. On surgical inspection, the tumor infiltrated the dura in all but three patients. Histological examination of tissue samples demonstrated tumor infiltration of the dura in all 14 patients in whom the dura had been resected. Three recurrent tumors were observed on follow-up examination during a mean period of 5.8 years (range 1.5-13 years) and required extirpation. In addition to one patient in whom there was histological evidence of malignancy, the other two cases involved two patients in whom no apparent dural involvement was observed during the first surgery. In a review of the literature, the authors found that histological examination showed dural involvement in 22%; the dura was not histologically evaluated in the remaining patients (78%). Postoperative follow-up data exceeding 2 years were only provided in two of the reported cases. CONCLUSIONS: Tumor infiltration of the dura should be assumed in PEMs of the cranial vault, and resection of the dura at the site of craniotomy is recommended to prevent tumor recurrence.
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Duramadre/patología , Neoplasias Meníngeas/patología , Meningioma/patología , Neoplasias Craneales/patología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Meningioma/diagnóstico por imagen , Meningioma/cirugía , Persona de Mediana Edad , Invasividad Neoplásica , Radiografía , Estudios Retrospectivos , Neoplasias Craneales/diagnóstico por imagen , Neoplasias Craneales/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to analyze a series of patients harboring a tuberculum sellae meningioma with regard to clinical presentation and long-term functional outcome. METHODS: Data in a consecutive series of 62 patients harboring a tuberculum sellae meningioma treated microsurgically between 1990 and 2003 were retrospectively reviewed. RESULTS: The mean age of the 46 women and 16 men enrolled in the study was 53 years (range = 29-81 years). The presenting symptom was visual compromise in 87.1% of the patients, and examination revealed decreased visual acuity in 79% and impaired visual fields in 64.5% of the patients. In addition, 14.5% of the patients had preoperative hormonal abnormalities. Simpson grades I and II resections, usually via a pterional approach, were achieved in 90.3% of the patients. Postoperatively, vision improved in 53.2%, remained unchanged in 29.8%, and deteriorated in 17.0% of the patients. The intraoperative finding predicting an unfavorable visual outcome was a thin atrophic optic nerve, encasement of the nerve, or tumor adhesion to its undersurface. Of the patients, 12.9% required permanent postoperative hormonal replacement. After a mean follow-up period of 6.0 years (range = 18 months-14 years), 88.7% of the patients resumed normal life activity and 2 recurrent tumors were observed (3.2%) and reoperated. CONCLUSIONS: Preoperative magnetic resonance imaging provides reliable information with regard to dislocation of critical vascular structures. However, the relationship between optic nerves and tumors (eg, adhesion and encasement) affected postoperative results and can only be fully appreciated during microsurgery. Visual outcome may be improved by preserving the microvasculature supplying the optic apparatus.
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Fosa Craneal Anterior/cirugía , Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Procedimientos Neuroquirúrgicos/métodos , Quiasma Óptico/cirugía , Silla Turca/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Fosa Craneal Anterior/patología , Duramadre/patología , Duramadre/fisiopatología , Duramadre/cirugía , Femenino , Humanos , Hipopituitarismo/etiología , Hipopituitarismo/fisiopatología , Hipopituitarismo/cirugía , Imagen por Resonancia Magnética , Masculino , Neoplasias Meníngeas/diagnóstico , Neoplasias Meníngeas/fisiopatología , Meningioma/diagnóstico , Meningioma/fisiopatología , Microcirugia/métodos , Microcirugia/estadística & datos numéricos , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico , Recurrencia Local de Neoplasia/prevención & control , Recurrencia Local de Neoplasia/cirugía , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Quiasma Óptico/patología , Quiasma Óptico/fisiopatología , Hipófisis/patología , Hipófisis/fisiopatología , Hipófisis/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Estudios Retrospectivos , Silla Turca/patología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Trastornos de la Visión/etiología , Trastornos de la Visión/fisiopatología , Trastornos de la Visión/cirugíaRESUMEN
OBJECTIVE: We analyzed a consecutive series of patients operated for a foramen magnum (FM) meningioma located on the ventral aspect of the medulla oblongata via a posterolateral suboccipital retrocondylar approach with regard to long-term surgical outcome. METHODS: Clinical data in a consecutive series of 25 patients experiencing a meningioma attached to dura of the anterior or anterolateral FM rim were retrospectively reviewed. RESULTS: The most common symptoms of the 19 women and six men (mean age, 59.2 yr) was cervico-occipital pain (72%) and gait disturbance (32%). Clinical examination revealed gait ataxia in 48% of the patients. As depicted from preoperative magnetic resonance imaging (MRI), dural attachment of the meningioma at the FM rim was anterior in 36% and anterolateral in 64% of cases. Tumor removal was accomplished via a posterolateral suboccipital retrocondylar approach in all patients. A Simpson Grade 2 resection was achieved in 96% of the patients. Permanent surgical morbidity and mortality rates were 8 and 4%, respectively. No tumor recurrence was observed after a mean follow-up period of 6.1 years (range, 1-14 yr) with clinical and MRI examination, and 80% of the patients have regained full daily activity. CONCLUSION: Anterior and anterolateral FM meningiomas that displace the medulla/spinal cord can be safely and completely resected via a posterolateral suboccipital retrocondylar approach. A tumor remnant should be left on critical neurovascular structures in cases with poor arachnoid dissection planes.
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Craneotomía/métodos , Foramen Magno/cirugía , Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Microcirugia/métodos , Hueso Occipital/cirugía , Adulto , Anciano , Vértebras Cervicales/patología , Vértebras Cervicales/cirugía , Femenino , Humanos , Masculino , Neoplasias Meníngeas/patología , Meningioma/patología , Persona de Mediana Edad , Hueso Occipital/patología , Resultado del TratamientoRESUMEN
OBJECTIVE: Intradural nonneoplastic cysts compressing the spinal cord are rare lesions. We retrospectively analyzed a series of patients harboring this entity with regard to clinical and radiological features, surgical management, and follow-up results. METHODS: In a retrospective study, we reviewed the medical charts, radiological investigations, and follow-up data of 11 women and 10 men (mean age, 43.6 yr) with intradural juxtamedullary spinal cysts, which were consecutively treated microsurgically at our institutions between January 1995 and January 2003. All lesions were approached via a laminectomy, hemilaminectomy, or laminoplasty at the corresponding vertebral levels and histopathologically verified. The patients were routinely scheduled for clinical follow-up 2 and 6 months after surgery. Baseline postoperative magnetic resonance imaging (MRI) was ordered 6 months after surgery. Thereafter, follow-up was performed at 1-year intervals, with neurological examination and MRI. RESULTS: According to presenting symptomatology, two main patient groups could be differentiated: one group with a myelopathic syndrome (10 patients) and another group with a predominant radicular pain syndrome (8 patients). Histopathological examination revealed 16 arachnoid cysts, 4 neuroepithelial cysts, and 1 cervical nerve root cyst. Most arachnoid cysts (12 cases) were located on the dorsal aspect of the thoracic spinal cord. The mean craniocaudal extension of these cysts was 3.7 vertebral levels, and complete resection was performed. In four patients, the arachnoid cyst was situated ventral to the spinal cord and involved up to 17 vertebral levels. These patients had a history of major spinal trauma, and the cyst was generously fenestrated at its greatest circumference as depicted on preoperative MRI scans. The four neuroepithelial cysts and the cervical nerve root cyst were located on the ventral or ventrolateral aspect of the spinal cord, and their maximum sagittal extension was two spinal vertebral levels. Symptoms in all but two patients demonstrated major improvement; in particular, radiating pain disappeared immediately after surgery. There was no cyst recurrence on MRI after a mean follow-up period of 3.2 years. CONCLUSION: Intradural cysts should be considered in the differential diagnosis of lesions causing myelopathy and/or a radicular pain syndrome. Microsurgical resection or generous fenestration in cysts with large craniocaudal extensions effectively ameliorated patients' symptomatology. A description of the first documented case of a surgically treated intradural cervical nerve root cyst is provided.
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Quistes Aracnoideos/cirugía , Enfermedades de la Médula Espinal/cirugía , Médula Espinal/patología , Médula Espinal/cirugía , Adulto , Anciano , Quistes Aracnoideos/diagnóstico por imagen , Femenino , Humanos , Laminectomía/métodos , Imagen por Resonancia Magnética/métodos , Masculino , Microcirugia/métodos , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Enfermedades de la Médula Espinal/diagnóstico por imagen , Traumatismos de la Médula Espinal/complicaciones , Traumatismos de la Médula Espinal/diagnóstico por imagen , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/patología , Vértebras Torácicas/cirugíaRESUMEN
OBJECT: The aim of this study was to analyze a subgroup of patients harboring cerebellopontine angle meningiomas originating from the posterior petrous bone in regard to clinical presentation, surgical anatomy, complications, and long-term functional postoperative results. METHODS: Data in a series of 51 patients with meningiomas of the posterior petrous bone who had undergone microsurgical treatment at the authors' institution between 1989 and 2002 were retrospectively reviewed. The patient population consisted of 46 women and five men with a mean age of 53 years (range 22-70 years). The main symptom on first admission was impaired hearing in 41%, dizziness in 20%, and tinnitus in 18% of the patients. Results of physical examination and audiological testing revealed hypacusis in 65% of patients, cerebellar ataxia in 31%, and impairment of the fifth cranial nerve in 26%. All patients underwent surgical treatment via a lateral suboccipital approach. Intraoperatively, the tumor was found to be attached to the postmeatal dura in 37%, the premeatal dura in 27.5%, the suprameatal dura in 19.6%, the inframeatal dura in 7.8%, and centered on the porus acusticus in 5.9% of cases. Tumor extension into the internal acoustic meatus was present in seven patients. Tumor resection was categorized as Grade I in 14 patients, Grade II in 29, Grade III in six, and Grade IV in two patients, according to the Simpson classification system. The site of displacement of the cranial nerves was predictable in up to 84% of patients, depending on the dural origin of the tumor as depicted on preoperative magnetic resonance (MR) imaging studies. Postoperatively, a new and permanent facial paresis was observed in five patients (9.8%). In 38 patients in whom both pre- and postoperative audiological data were available, hearing function deteriorated after surgery in 18.4% and improved in 7.9%. Clinical and MR imaging postsurgical data from a mean period of 5.8 years (range 13 months-13 years) were available in all patients. Forty-four patients (86%) resumed normal daily activity. Tumor recurrence was observed in two patients (3.9%), and both underwent a second surgery. CONCLUSIONS: Preoperative detailed analysis of MR imaging data gives the surgeon a clue about the dislocation of critical neurovascular structures, particularly the cranial nerves. Nonetheless, the exact relationship of the cranial nerves to the tumor (dislocation, adherence, infiltration, and splaying of nerves) can only be fully appreciated during surgery.
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Neoplasias Meníngeas/patología , Neoplasias Meníngeas/cirugía , Meningioma/patología , Meningioma/cirugía , Microcirugia/métodos , Hueso Petroso/patología , Hueso Petroso/cirugía , Complicaciones Posoperatorias , Neoplasias Craneales/patología , Neoplasias Craneales/cirugía , Adulto , Anciano , Nervios Craneales/anatomía & histología , Traumatismos Craneocerebrales/etiología , Parálisis Facial/etiología , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Even during the microsurgical era, tentorial meningiomas present a formidable surgical challenge when tumor involves critical neurovascular structures. We report our experience with tentorial meningioma with regard to clinical presentation, diagnostic workup, microsurgical technique, complications, and follow-up results. METHODS: In a retrospective study, we reviewed the medical charts, neuroimaging data, and follow-up data of patients treated microsurgically for tentorial meningioma in our department between January 1989 and June 2002. Patients were routinely scheduled for clinical and radiological follow-up 6 months and 1 year after surgery. Thereafter, follow-up was performed every 1 or 2 years on the basis of the results of each follow-up examination. RESULTS: The main presenting symptoms of the patients (69 women and 12 men) were headache (75%), dizziness (49%), and gait disturbance (46%). The leading neurological signs were gait ataxia (52%) and cranial nerve deficits (28%). Extent of tumor resection was Simpson Grade I in 29 patients, Grade II in 45 patients, Grade III in 1 patient, Grade IV in 4 patients, and unknown in 2 patients. Permanent surgical morbidity and mortality were 19.8 and 2.5%, respectively. Clinical and magnetic resonance imaging follow-up was available in 74 patients for a period ranging from 1 to 13 years (mean, 5.9 yr). Of these, 64 patients (86%) have resumed normal life activity. Seven patients had tumor recurrence and four underwent reoperation. CONCLUSION: Careful preoperative planning of the surgical approach tailored to tumor location and extent is a prerequisite to achieve radical microsurgical tumor resection with minimal morbidity and mortality. Resection of an infiltrated but patent venous sinus is not recommended.
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Neoplasias Infratentoriales/cirugía , Meningioma/cirugía , Microcirugia/efectos adversos , Microcirugia/métodos , Complicaciones Posoperatorias , Neoplasias Supratentoriales/cirugía , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Most entities in and around the anterior two-thirds of the supratentorial ventricles can be reached via transcortical or transcallosal approach. This study examined the effect of surgical approach on the postoperative neurological outcome. Thirty-eight patients with intra- and periventricular supratentorial lesions were operated on by either frontal transcortical or anterior transcallosal approach. Postoperative diencephalic damage occurred in 22% of patients in the transcortical group and in 36% in the transcallosal group; transient mutism was virtually equivalent in the two groups. Postoperative epilepsy (26%) and subdural fluid collections (30%) occurred only in the transcortical group. The incidence of postoperative hemiparesis was higher in the transcallosal group. There was a high correlation between postoperative Glasgow Outcome Score of 5 and preoperative severity of neurological disease but no correlation between postoperative Glasgow Outcome Score of 5 and location of the lesion or between postoperative clinical course and surgical approach. Surgical outcome of ventricle-associated lesions depends mainly on the severity of preoperative symptoms and not on surgical approach. Additionally, the incidence of postoperative seizures and subdural fluid collections after transcortical surgery is high.
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Corteza Cerebral/cirugía , Neoplasias del Ventrículo Cerebral/cirugía , Cuerpo Calloso/cirugía , Enfermedades del Sistema Nervioso/etiología , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias , Adolescente , Adulto , Anciano , Corteza Cerebral/diagnóstico por imagen , Corteza Cerebral/patología , Neoplasias del Ventrículo Cerebral/diagnóstico por imagen , Neoplasias del Ventrículo Cerebral/patología , Niño , Preescolar , Cuerpo Calloso/diagnóstico por imagen , Cuerpo Calloso/patología , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/diagnóstico por imagen , Enfermedades del Sistema Nervioso/patología , Pronóstico , Radiografía , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
Recurrent hemorrhage in the case of incompletely treated aneurysms is well known. The authors present a series of patients in whom rebleeding occurred in spite of totally occluded aneurysms. During a period of 12 years, 1170 patients with intracranial aneurysms were treated using either clipping (n=727) or coiling (n=443). In 11 of them, intracranial rebleeding occurred, in seven of whom routine post-treatment angiography revealed total aneurysm occlusion before the appearance of rehemorrhage. Further analysis focused on these seven patients. Their recurrent aneurysm ruptures happened with a mean latency of 9.5 months (range 21 h-48 months) from initial treatment. All aneurysms belonged to the anterior circulation. Three patients underwent primary clipping, and four experienced coiling first. The intracranial hemorrhages appeared mainly as intracerebral hematomas. The angiographically documented recurrent aneurysm configurations were caused by clip slippage (n=2), coil compaction (n=3), or coil migration/dislocation (n=1). In one case with primary surgery, clip slippage was possible but not confirmed by intraoperative view, because the patient died before therapeutic intervention. Two patients did not undergo therapy because of their poor clinical condition and died. Four of the remaining patients underwent clipping of the recurrent lesions, and one had recoiling. Final outcome was excellent/good in only two patients. The mainly poor outcome after rebleeding was caused by the high incidence of intracerebral hemorrhage.
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Aneurisma Roto/complicaciones , Aneurisma Roto/cirugía , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/cirugía , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/cirugía , Adulto , Anciano , Aneurisma Roto/diagnóstico por imagen , Angiografía Cerebral , Femenino , Escala de Consecuencias de Glasgow , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Hemorragias Intracraneales/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Recurrencia , Reoperación , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
OBJECTIVE: Both cortical oxygen saturation (SaO(2)) and cortical blood volume (BV) are related to regional cerebral blood flow. Among a series of patients with cerebral arteriovenous malformations, we examined the problem of hyperemia after embolization/resection or resection with the intraoperative application of near-infrared spectroscopy. METHODS: Cortical SaO(2) and BV (intracapillary total hemoglobin concentrations) were measured, with near-infrared spectroscopy, in areas adjacent to the arteriovenous malformation for 20 patients, before and after resection. The absolute values for both parameters and postexcision/preexcision ratios (P-P ratios) were determined. Data were correlated with multiple clinical and preoperative angiographic parameters. RESULTS: Before resection, the mean SaO(2) was 49 +/- 16% and the mean BV was 12.65 +/- 7.41 mg/ml. After resection, SaO(2) increased for 17 of 20 patients and BV increased for 18 of 20 patients. The differences between pre- and postexcision values for both parameters were observed to be statistically significant (P < 0.01). The average P-P ratios were 1.5 +/- 0.4 for SaO(2) and 1.7 +/- 0.4 for BV. Correlation between the P-P ratios for the two parameters was good. The initial BV and the P-P ratios for both SaO(2) and BV were exclusively dependent on the extent of preoperative embolization. Postoperatively, two patients developed intracerebral hemorrhage or severe edema. Both demonstrated high P-P ratios for SaO(2) (2.3 and 2.1) and BV (1.6 and 2.1). CONCLUSION: Intraoperative near-infrared spectroscopy is able to detect the hyperemic status of adjacent cortex after arteriovenous malformation resection. However, staged therapy with embolization and surgery results in less hyperemia after resection. While two patients with hyperemic complications exhibited very large increases in SaO(2) and BV, we cannot refute the normal-perfusion pressure breakthrough theory.
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Volumen Sanguíneo/fisiología , Corteza Cerebral/química , Corteza Cerebral/fisiopatología , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/métodos , Hiperemia/etiología , Hiperemia/fisiopatología , Malformaciones Arteriovenosas Intracraneales/fisiopatología , Malformaciones Arteriovenosas Intracraneales/terapia , Monitoreo Intraoperatorio/métodos , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos Neuroquirúrgicos/métodos , Oxígeno/análisis , Complicaciones Posoperatorias , Espectroscopía Infrarroja Corta/métodos , Adolescente , Adulto , Anciano , Corteza Cerebral/cirugía , Circulación Cerebrovascular/fisiología , Embolización Terapéutica/instrumentación , Femenino , Humanos , Hiperemia/diagnóstico , Malformaciones Arteriovenosas Intracraneales/diagnóstico , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/instrumentación , Procedimientos Neuroquirúrgicos/instrumentación , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Espectroscopía Infrarroja Corta/instrumentaciónRESUMEN
OBJECT: The authors present a series of patients in whom partially occluded aneurysms were retreated using complementary surgical or endovascular therapy. METHODS: During a period of 18 months, 301 patients with intracranial aneurysms were treated using either clip application (171 patients) or endovascular embolization with Guglielmi Detachable Coils ([GDCs] 130 patients). Routine posttreatment angiography studies revealed residual aneurysms in 21 of these patients, nine of whom were retreated using an endovascular or surgical method, with a mean treatment latency of 1.2 months. Four patients underwent primary surgical clip application, whereas five patients experienced GDC packing first. Among patients in the surgical group, the residual aneurysm neck was small and total elimination of the aneurysm was achieved by packing in GDCs. In patients in the endovascular group the authors incompletely packed the aneurysm because of its wide neck or fusiform component in two patients, perforation of a very small aneurysm in one patient, and coil dislocation in another patient. Typical coil compaction occurred in one case. Complete clip application was achieved in all patients. There was no complication in any patient due to the second treatment modality. Final outcome was excellent or good in six and fair in three. CONCLUSIONS: Following clip application or endovascular embolization of intracranial aneurysms, the use of complementary surgical or endovascular management is successful and associated with low morbidity.