RESUMO
OBJECTIVE: To learn about the effects of cranial base surgery. DESIGN: Cohort study with a mean follow-up of 30 months. SETTING: Population-based. PATIENTS: A consecutive sample of 183 patients who underwent cranial base surgery; 118 patients had malignant skull base tumors, the majority of which were previously treated; 50 had benign tumors; 9 had congenital malformations of the skull base; 3 had inflammatory lesions, and 3 had traumatic defects of the skull base. MAIN OUTCOME MEASURES: Disease-free interval, overall survival, and rate of complications and functional status. INTERVENTION: Cranial base surgery was followed by radiotherapy (in previously untreated patients). RESULTS: After completion of follow-up (mean, 30 months), 30 (25.4%) patients had died of their malignant tumors and 8 (6.8%) had died of other causes. One patient (0.84%) was lost to follow-up. The overall cancer survival rate without regard to histologic type was 67% (63% with no evidence of disease). Among the patients who were treated for benign neoplasm, 72% had no evidence of disease at a mean follow-up of 39 months. The group of patients with congenital malformations and inflammatory and traumatic lesions demonstrated successful correction of their presurgical problem with skull base surgery. One patient (who had invasive aspergillosis) died of disease. The overall surgical-medical mortality rate was 2%; the complication rate was 33%, and the Karnofsky performance score was improved or unchanged after surgery in 83% of patients. The average duration of surgery, number of blood transfusions used, and length of the hospital stay were 10 hours, 3 units, and 15 days, respectively. CONCLUSIONS: Cranial base surgery is a valid surgical technique for treatment of cranial base afflictions. In this study it was found to be beneficial in controlling benign and malignant disease and to be the treatment of choice for selected congenital malformations, trauma, and inflammatory lesions.
Assuntos
Neoplasias Cranianas/cirurgia , Crânio/cirurgia , Adolescente , Adulto , Criança , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Crânio/anormalidades , Neoplasias Cranianas/mortalidade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
PURPOSE: To evaluate stable xenon-enhanced CT cerebral blood flow with balloon test occlusion as a predictor of stroke risk in internal carotid artery sacrifice. METHODS: Abrupt internal carotid artery occlusion was performed by surgical or endovascular means below the origin of the ophthalmic artery in 31 normotensive patients who were assessed preoperatively by a 15-minute clinical balloon test occlusion followed by an internal carotid artery-occluded xenon CT cerebral blood flow study. RESULTS: One patient, who passed the clinical test occlusion but exhibited regions of cerebral blood flow less than 30 mL/100 g per minute on the occlusion xenon CT cerebral blood flow study went on to have a fatal stroke corresponding exactly to the region of reduced blood flow. Thirty patients passed both components of the preoperative stroke-risk assessment. Neuroimaging demonstrated possible flow-related infarctions, which subsequently developed in three patients. Two patients were asymptomatic, and one patient was left with a mild residual hemiparesis. CONCLUSIONS: Our protocol provided a statistically significant reduction in subsequent infarction rate and infarction-related death rate when compared with a control group of normotensive abrupt internal carotid artery occlusion patients who did not undergo any preoperative stroke-risk assessment (reported in the literature). The estimated false-negative rate for our preoperative assessment protocol ranged from 3.3% to 10% depending on the assessment of the cause of the three potentially flow-related infarctions. Although life-threatening major vascular territory infarctions have been avoided, our protocol is less sensitive to changes predicting smaller, often minimally symptomatic, vascular border zone infarctions and does not predict postoperative thromboembolic strokes.
Assuntos
Encéfalo/irrigação sanguínea , Doenças das Artérias Carótidas/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Cateterismo , Seio Cavernoso/diagnóstico por imagem , Infarto Cerebral/diagnóstico por imagem , Meios de Contraste , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Aneurisma Intracraniano/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Xenônio , Adolescente , Adulto , Idoso , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/cirurgia , Velocidade do Fluxo Sanguíneo/fisiologia , Mapeamento Encefálico , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Interna/cirurgia , Seio Cavernoso/cirurgia , Infarto Cerebral/prevenção & controle , Dominância Cerebral/fisiologia , Feminino , Seguimentos , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Complicações Pós-Operatórias/diagnóstico por imagem , Fluxo Sanguíneo Regional/fisiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
This study reviewed 124 patients who required facial nerve manipulation during cranial base surgery. Most of them underwent only nerve displacement or selective transection for improved surgical access to the cranial base (70 and 34, respectively). Fourteen patients had the facial nerve resected for oncologic reasons and repaired with primary nerve grafting. Most patients regained quite satisfactory facial function with quality correlating with the degree of nerve injury. Six patients had facial nerve resected as part of oncologic palliation and had the facial deficit rehabilitated with regional tissue. A correlation between preoperative facial nerve weakness and the quality of nerve graft function was not found. An oncologic correlation, however, is suggested (patients with preoperative weakness had less favorable prognosis). Overall, patients who require facial nerve resection for oncologic reasons do not do as well as those with normal preoperative function.
Assuntos
Nervo Facial/anatomia & histologia , Nervo Facial/cirurgia , Crânio/cirurgia , Estimulação Elétrica , Expressão Facial , Músculos Faciais/inervação , Músculos Faciais/fisiopatologia , Nervo Facial/fisiopatologia , Feminino , Seguimentos , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Contração Muscular/fisiologia , Regeneração Nervosa , Transferência de Nervo , Crânio/inervação , Neoplasias Cranianas/patologia , Neoplasias Cranianas/cirurgia , Nervo Sural/transplante , Osso Temporal/inervação , Osso Temporal/cirurgiaRESUMO
During the last 7 years, approximately 170 neoplasms, and 35 vascular lesions involving the cavernous sinus were treated by the first two authors. During the treatment of such lesions, the direct vein graft reconstruction of the internal carotid artery from the petrous to the supraclinoid or infraclinoid ICA was performed in 23 patients. Graft occlusion occurred in 3 patients and in one of these, it was successfully salvaged by placing a long venous graft from the extracranial ICA to the M3 segment of the middle cerebral artery. The latter 3 patients were neurologically normal. One patient with significant atherosclerotic disease suffered the dissection of the distal internal carotid artery with the graft being patent. The suturing technique. This patient eventually died. Two patients with severely compromised collateral circulation suffered minor strokes due to the temporary occlusion of the ICA. This has been avoided in the more recent patients by the adoption of brain protection techniques such as moderate hypothermia, induced hypertension, and barbiturate coma. Low dose heparin therapy during grafting and high dose intravenous steroids prior to the grafting also appear to be beneficial. Direct vein graft reconstruction of the intracavernous carotid artery is a valuable tool during the management of cavernous sinus lesions. The advantages and disadvantages of this technique as well as the pros and cons of other revascularization techniques will be discussed. During microsurgical removal of cavernous sinus lesions, the cranial nerves III-VI were reconstructed by direct resuture or by nerve grafting in 16 patients. In the majority of these patients, recovery of cranial nerve function was observed, which was very encouraging.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Artérias Carótidas/transplante , Seio Cavernoso/cirurgia , Nervos Cranianos/transplante , Humanos , Estudos Retrospectivos , Doenças Vasculares/cirurgiaRESUMO
The computed tomography scans and magnetic resonance imaging films of 57 patients who underwent anterior or anterolateral cranial base surgery from January 1987 to August 1989 were retrospectively reviewed to ascertain the significance of early and late postoperative intracranial imaging changes. Extra-axial changes (air, blood, cerebrospinal fluid collection) were found in 96% of patients; axial changes (brain edema, contusion) were seen in 30% of patients in the first postoperative period (72 hours). Subsequently, extra-axial changes began to resolve but axial changes became more prevalent. After 6 months, only axial changes persisted (encephalomalacia). It was encouraging to find a low correlation of imaging abnormalities with clinically significant findings.
Assuntos
Imageamento por Ressonância Magnética , Crânio/cirurgia , Tomografia Computadorizada por Raios X , Encefalomalacia/diagnóstico por imagem , Encefalomalacia/etiologia , Humanos , Projetos Piloto , Complicações Pós-Operatórias , Período Pós-Operatório , Estudos Retrospectivos , Crânio/diagnóstico por imagem , Crânio/patologia , Fatores de TempoRESUMO
In an effort to isolate and characterize the emission of acoustic signals from saccular aneurysms, we made a series of invasive microphone recordings from experimental aneurysms created on the common carotid arteries of dogs using the vein pouch technique. Using a modified probe microphone, we compared recordings from the common carotid artery before creation of the aneurysm to recordings from the aneurysmal surface, both before and after clip occlusion. We then performed spectral analysis, band-pass filtering, and spectrographic analysis to compare the dominant frequency and width of the frequency range of both the aneurysmal and carotid recorded signals. The aneurysmal signals had a significantly higher dominant frequency (p less than or equal to 0.05) and a significantly wider frequency range (p less than or equal to 0.05) than the carotid signals. Aneurysmal signals recorded under conditions of systemic hypotension had a significantly lower frequency (p less than or equal to 0.05) than aneurysmal signals recorded under conditions of hypertension. Our results support the assumptions that acoustic signals from experimental saccular aneurysms are distinct from those of the parent vessel and that the aneurysmal signal can be characterized using passive microphone recordings.
Assuntos
Doenças das Artérias Carótidas/fisiopatologia , Aneurisma Intracraniano/fisiopatologia , Som , Animais , Artérias Carótidas/fisiopatologia , Doenças das Artérias Carótidas/patologia , Cães , Eletricidade , Aneurisma Intracraniano/patologia , Análise Espectral , VibraçãoRESUMO
A patent internal carotid artery (ICA) is essential in most patients. Management of skull base lesions often requires translocation, balloon embolization, or resection of this vessel. Preoperative tests to assess the availability of collateral flow have not been uniformly accurate. A new test that significantly increases the safety of surgical removal of the ICA is described. One hundred thirty-six patients were studied with temporary balloon occlusion (TBO) of the ICA and determination of stable xenon-enhanced computed tomography cerebral blood flow (Xe/CT CBF) measurements. Eleven patients failed TBO and were determined to be at very high risk of stroke with loss of the ICA. Ninety-six of the patients were predicted to be at minimal risk with permanent loss of the ICA by Xe/CT CBF studies. Twenty-one patients in this group had either permanent balloon occlusion (PBO) or surgical resection of the ICA with no permanent neurologic sequelae. Our studies show that the combination of preoperative TBO and Xe/CT CBF studies significantly increases the safety of ICA resection.
Assuntos
Artéria Carótida Interna/cirurgia , Cateterismo , Infarto Cerebral/prevenção & controle , Circulação Cerebrovascular , Neoplasias de Cabeça e Pescoço/cirurgia , Cuidados Pré-Operatórios , Adolescente , Adulto , Idoso , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Artéria Carótida Interna/diagnóstico por imagem , Cateterismo/normas , Criança , Pré-Escolar , Circulação Colateral , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Lactente , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Risco , Fatores de Risco , Tomografia Computadorizada por Raios X , XenônioRESUMO
Teratoma is the most common nasopharyngeal tumor in neonates. The tumor is usually limited to the oropharynx and is manifest by stridor and respiratory distress. Complete excision affects a cure. An unusual case of nasopharyngeal teratoma extending into the temporal bone, causing facial paralysis and conductive hearing loss, in addition to stridor, is presented. Stridor was relieved by transoral partial excision shortly after birth. Complete removal of the tumor by way of a subtemporal and infratemporal fossa approach was performed at 14 months of age. The defect was filled with a rectus abdominis muscle graft with microvascular anastomoses. The facial nerve was reconstructed secondarily with a sural nerve graft. The patient has no recurrence tumor and has good facial function at 30 months. This case demonstrates the first known case of facial paralysis due to nasopharyngeal teratoma. The surgical approach for tumor removal: lateral infratemporal fossa dissection, and the method of reconstruction: free rectus abdominis muscle flap with microvascular anastomoses, had so far not been described in a patient this young.
Assuntos
Neoplasias Nasofaríngeas/patologia , Neoplasias Cranianas/patologia , Osso Temporal/patologia , Teratoma/patologia , Humanos , Lactente , Masculino , Invasividade NeoplásicaRESUMO
Curability of skull base tumors is related to the ability to achieve a complete resection. Resection of the internal carotid artery with the tumor puts the patient at risk for catastrophic cerebral injury. Autogenous vein grafting is not always technically or physiologically possible. We present eight patients with tumors eroding the cranial base who underwent safe resection or occlusion of the internal carotid artery as predicted by three tests: 1. carotid arteriography, 2. temporary balloon occlusion of the internal carotid artery, and 3. xenon computerized tomography cerebral blood flow mapping. No patient suffered permanent central nervous system injury.
Assuntos
Artéria Carótida Interna/cirurgia , Neoplasias de Cabeça e Pescoço/irrigação sanguínea , Adulto , Idoso , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/patologia , Circulação Coronária , Feminino , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Tomografia Computadorizada por Raios X , XenônioRESUMO
A specially designed computerized acoustic aneurysm detection system has been developed and used for recording the acoustic signal produced by aneurysms in dogs. Two transducer types, a modified horn-coupled microphone and a microvascular intra-operative Doppler flowmeter have been used. The results show that the aneurysm signal is time-varying and that a stronger vibration signal can be obtained if a proximal stenosis presents. With direct contact recording, the acoustic signals from aneurysms and parent arteries show different characteristics that can be easily distinguished. The aneurysm signals are processed by spectrograms, and a smoothing technique for suppressing noise is introduced.