Brainstem Compression Research Articles

Efficacy and Safety of Duraplasty in Chiari Malformation Type-I Patients Associated With Syringomyelia

Background Data: Chiari malformation type-I (CM-I) is a challenging subject to wrap our hands around table. Chiari symptoms often range from, unexplained, and/or occipital Valsalva type headache, chronic fatigue syndrome, tolower cranial nerve abnormalities, or brain stem compression, till severe neurological insult which augmented by syringomyelia, or syringobulbia. Exact diagnostic and prognostic tools carry a great controversy which ranged from simple MRI study to MR imaging–based CSF velocity measurements, morphological, dynamic craniocervical junction assessments, subarachnoid pressure recordings, and compliance calculations were compared before and after surgical treatment.Purpose: This study aimed to estimate the efficacy and safely of duraplasty in CM-I patients associated with yringomyelia. Study Design: A retrospective descriptive clinical case study. Patients and Methods: The study was conducted on 23 consecutive adults patients with CM-I associated with syringomyelia. They underwent surgicaltreatments at Sohag University Hospital from February 2012 to May 2015. Results: The current study was applied to 23 patients; 10 males (43.5%) and 13 females (56.5%), aged 18-64 with a mean age of 41 years. The durationof symptoms before presentation varied from 1 month to 20 years. Clinical outcome was classified according to Glasgow outcome scale, 21 patients (91.3%) were graded V, 2 patients (8.7%) were grade IV, and no patient gradedI. Radiologically MRI craniocervical junction suggested that decompression of the posterior fossa was achieved in all patients. Post-operative reports showed that no deterioration occurred in any of our patients. Improvement occurred and increased gradually on post-operative period. Conclusion: Craniocervical decompression with duraplasty is effective in treating patients with Chiari Malformation type-I with syringomyelia. Both clinical and radiologic improvement was documented on the follow up period. (2015ESJ099)

Early Decompression of Acute Subdural Hematoma for Postoperative Neurological Improvement: A Single Center Retrospective Review of 10 Years.

ObjectiveThis study was conducted to investigate survival related factors, as well as to evaluate the effects of early decompression on acute subdural hematoma (ASDH).MethodsWe retrospectively reviewed cases of decompressive craniectomy (DC) for decade. In total, 198 cases of DC involved ASDH were available for review, and 65 cases were excluded due to missing data on onset time and a delayed operation after closed observation with medical care. Finally, 133 cases of DC with ASDH were included in this study, and various factors including the time interval between trauma onset and operation were evaluated.ResultsIn the present study, survival rate after DC in patients with ASDH was shown to be related to patient age (50 years old, p=0.012), brain compression ratio (p=0.042) and brain stem compression (p=0.020). Sex, preoperative mental status, and time interval between trauma onset and operation were not related with survival rate. Among those that survived (n=78), improvements in Glasgow Coma Scale (GCS) score of more than three points, compared to preoperative measurement, were more frequently observed among the early (less than 3 hours between trauma onset and operation) decompressed cases (p=0.013). However, improvements of more than 4 or 5 points on the GCS were not affected by early decompression.ConclusionEarly decompression of ASDH was not correlated with survival rate, but was related with neurological improvement (more than three points on the GCS). Accordingly, early decompression in ASDH, if indicated, may be of particular benefit.

Single-Stage Posterior Decompression and Occipitocervical Fusion Using a Screw-Rod-Plate System for Basilar Invagination with Anterior Spinal Cord Compression and Craniocervical Instability

Purpose: To review our experience with surgical management of basilar invagination causing foramen magnum compression, focusing on selection of the surgical approach. Methods: Twelve consecutive patients underwent posterior foramen magnum decompression with occipitocervical fixation and fusion for treatment of basilar invagination causing brain stem compression and instability. Gentle traction and reduction during positioning of the patients also were performed. Ventral decompression (odontoid resection) was performed in none of the patients. Pre- and postoperative neurologic status was graded according to JOA and Nurick scales. Results: All patients had anterior spinal cord compression due to cranial settling of the cervical spinal column as well as instability at the craniocervical junction. The average follow-up period was 31 months (range, 24–42 months). All patients’ JOA and Nurick scores improved after surgery, but postoperative neurologic improvement and odontoid reduction were better in patients with atlas assimilation compared with patients with other pathologies. Conclusion: Odontoid reduction using an occipitocervical fixation system and decompression of the foramen magnum through a single-stage posterior approach is an effective treatment for basilar invagination, particularly in patients with atlas assimilation. Since odontoid reduction and foramen magnum decompression can be achieved through a single-stage posterior approach in most patients, odontoid resection should remain as a secondary procedure when these decompression efforts are insufficient.

Successful combination treatment of a bifocal secretory germinoma with brain stem compression in a 17-year-old girl

A 17-year-old girl, evaluated since 2007 for endocrinological disorders due to secondary amenorrhea and weight loss, was referred to the neurosurgery department in May 2011 due to symptoms of rapidly increasing intracranial pressure. Computed tomography revealed a bifocal, irregular, non-homogeneous tumour localised in pineal and suprasellar regions (Figures 1 A, B). Immediate septostomy, ventriculo-peritoneal valve implantation and suprasellar tumour biopsy were performed. Histopathological examination confirmed the tumour to be a secretory type germinoma (β-HCG = 0.696 mIU/ml; AFP = 79.89 µg/ml in serum). After surgical biopsy (Figure 1 C) the chemotherapy was introduced according to the GCT SIOP96 protocol – which is the standard protocol for children in Poland with this diagnosis. The control magnetic resonance imaging (MRI) confirmed total regression of the suprasellar tumour and a residual pineal mass (Figure 1 D). At the end of July 2011 the patient was transferred to the Radiotherapy Department for treatment planning. Radiation therapy was initiated using both static and dynamic fields, including 3 target volumes (Figure 1 E): brain ventricles (blue) irradiated up to 30.6 Gy, PTV2 (cyan) – both tumour loci – up to 45.0 Gy with dose escalation on the pineal tumour residue up to 52.2 Gy (turquoise). Currently the patient is in 3.5-year follow-up (Figure 1 F) in a good clinical condition, presenting only minor left-sided convergent strabismus, slight deafness for high frequency sounds and requires hormonal supplementation. The last MRI revealed only a residual mass in the pineal region 10 × 7 × 12 mm and a “flat” pituitary gland as deviations from the normal condition. Figure 1 A, B – Transverse and sagittal computed tomography scans before initiation of treatment of pineal (38 × 30 × 30 mm) and suprasellar regions (25 × 20 × 20 mm), C – MRI scan after the surgical procedure, ... Intracranial germ cell tumours (GCTs) account for 1–2% of all primary paediatric central nervous system (CNS) tumours and have a peak incidence at between 10 and 14 years with a male-female ratio of 2 : 1 [1]. Although multiple loci at presentation are associated with poorer prognosis [2], in this relatively unusual case, despite dramatic onset of symptoms, the treatment has proven successful thus far. Up to 20% of intracranial GCTs are multifocal, and they usually involve the suprasellar and pineal gland region. This is typically observed in adolescent males rather than females. Pineal GCTs induce acute symptoms of intracranial pressure which may be manifested by the classic triad of chronic symptoms: diabetes insipidus, visual deficits and precocious or delayed sexual maturity [3]. Evaluation must include MRI of the brain and serum marker levels (AFP, β-HCG) should be obtained. Biopsy sampling is recommended in all cases nowadays. Surgical treatment of intracranial GCTs remains controversial. Limited volume radiation therapy (whole ventricle followed by boost for residual tumour) is an important part of treatment preceded by chemotherapy according to currently used protocols. Endocrinopathies are a common complication of treating brain GCTs [4]. If pituitary gland insufficiency persists, it may however be easily corrected by hormonal treatment. The potential late sequelae due to chemotherapy and radiotherapy do not generally impair future mental and social development in adolescents, which gives a chance for a good quality of life in the future for these patients [5]. However, in younger patients, persistent neurological deficiencies resulting from surgical and radiotherapeutic complications may be a serious issue [4, 5].

Audiovestibular Function Deficits in Vestibular Schwannoma.

Introduction. Vestibular schwannomas (VS) are benign tumours of the vestibular nerve and can lead to hearing loss, tinnitus, vertigo, facial palsy, and brainstem compression. Audiovestibular diagnostic tests are essential for detection and treatment planning. Methods. Medline was used to perform a systematic literature review with regard to how audiovestibular test parameters correlate with symptoms, tumour size, and tumour location. Results. The auditory brainstem response can be used to diagnose retrocochlear lesions caused by VS. Since hearing loss correlates poorly with tumour size, a retrocochlear lesion is probably not the only cause for hearing loss. Also cochlear mechanisms seem to play a role. This can be revealed by abnormal otoacoustic emissions, despite normal ABR and new MRI techniques which have demonstrated endolymphatic hydrops of the inner ear. Caloric and head impulse tests show frequency specific dynamics and vestibular evoked myogenic potentials may help to identify the location of the tumour regarding the involved nerve parts. Conclusion. In order to preserve audiovestibular function in VS, it is important to stop the growth of the tumour and to avoid degenerative changes in the inner ear. A detailed neurotological workup helps to diagnose VS of all sizes and can also provide useful prognostic information.

An unusual cause of trochlear nerve palsy and brainstem compression

Schwannoma originates from the Schwann cells at the Obersteiner-Redlich zone, which marks the junction of central and peripheral myelin of the cranial nerves. Most frequently affected are the vestibular, trigeminal, and facial nerves followed by the lower cranial nerves. Trochlear schwannoma in the absence of neurofibromatosis is a rare entity. The purpose of this report is to serve as a reminder to consider trochlear nerve schwannoma in the list of differential diagnosis of such tumors as the outcome is far better than the intraaxial tumor in that location.

Resection of Deep Brain Stem Lesions: Evolution of Modern Surgical Techniques

Deep brain stem lesions have previously been considered unresectable. With the development of tailored skull base approaches, detailed knowledge of topographical anatomy, utilization of intra-operative mapping, identification of safe entry zones, extensive arachnoid dissection, cautious handling of neurovascular structures, modern surgical techniques with minimal compression of brain stem and retractor-less surgery, the resection of these previously unresectable lesions, has become possible. Herewithin, an overall review is provided and illustrative cases are presented with detailed discussion of the technical perspective of each approach and resection.

Hemangiopericytoma of the Cerebellopontine Angle: A Wolf in Sheep's Clothing.

Primary meningeal hemangiopericytoma (HPC) is a rare, aggressive dura based tumor that remarkably mimics a meningioma clinically and radiologically. Its occurrence within the cerebellopontine angle (CPA) is exceptional, and establishing the exact diagnosis is of the utmost importance since total resection remains the cornerstone of treatment. A 42-year-old man presented with a three-month history of progressively worsening vertigo and difficulty in walking. On admission, his neurological examination revealed a right peripheral facial palsy, right abducens palsy and left hemiparesis, suggesting the diagnosis of Millard-Gubler syndrome. Computed tomography and magnetic resonance imaging demonstrated a homogeneously enhancing dura based lesion of the right CPA causing major brain stem compression. There was no widening of the ipsilateral internal auditory canal. A standard retrosigmoid craniotomy was performed to access the right CPA. Exposure of the lesion revealed a well-encapsulated, gray, fibrous lesion, which appeared to originate from the tentorium. Gross total resection was achieved and confirmed radiologically. The microscopic features and the immunohistochemical profile confirmed the diagnosis of a HPC, and adjuvant radiation therapy was administered. Ten years later, the patient presented with a severe neurological deficit due to a local recurrence, but at that time refused any second intervention. He died three months later. HPC can locate within the CPA and present as a Millard-Gubler syndrome. The diagnosis should be kept in mind in case of a CPA dura based tumor. Radical surgery plus radiation therapy can maximize the recurrence-free survival and close follow-up remains mandatory to spot recurrences early.

Results of deconstructive endovascular surgery in treatment of large and giant intracranial aneurysms

To clarify the indications for deconstructive endovascular surgery in patients with large and giant intracranial aneurysms and to evaluate short-term and long-term postoperative outcomes. The study was based on a retrospective analysis of the treatment results in 50 patients with large (15-25 mm) and giant (more than 25 mm) intracranial aneurysms, aged from 18 to 75 years, who were treated at the Burdenko Neurosurgical Institute in 2002-2014. The patients underwent a balloon occlusion test (BOT) in various modifications before stationary occlusion of the carrier artery. For vascular occlusion, we used detachable latex balloon catheters (33 cases) and microcoils (17 cases). The condition of patients in the pre- and postoperative period was assessed by using the modified Rankin Scale. There were no deaths due to occlusion of the internal carotid artery (37 patients). Postoperative complications occurred in 5 patients. On the basis of BOT, revascularization surgery involving placement of an extra-intracranial microanastomosis (EICMA) was performed in 6 cases. In more 4 cases, EICMA was placed in the early postoperative period due to developing signs of ischemia. Two of 7 patients underwent occlusion of both vertebral arteries (VAs) in the vertebrobasilar basin, which led to fatal outcomes. One more patient died of aggravation of brainstem compression after VA occlusion. There was no worsening of neurological symptoms among survivors. There were no deaths and persistent neurological disorders upon occlusion of branches of the main cerebral arteries, starting with the first order arteries (6patients). Thirty one patients (66%) were followed-up in the period from 1 to 104 months. There were no deaths associated with artery occlusion. Two patients experienced delayed ischemic disorders. Occlusion of the carrier artery should be performed in a carefully selected group of BOT-negative patients. This surgery can be indicated for aneurysms with a complicated configuration, the topographic and anatomical features of which exclude reconstructive surgery.

Posterior Fossa Extradural Haematomas: Operate or Conserve?

Background: Posterior fossa extradural haematomas (PFEDHs) are an uncommon entity, accounting for only 4 to 12.9% of all extradural haematomas encountered in clinical practice (EDHs). They have a characteristic clinical presentation, which if detected early, can be life saving. Most PFEDHs are operated owing to the imminent propensity of brainstem compression and death. However, a growing number of neurosurgeons, now consider conservative therapy for smaller bleeds. Clear and reliable criteria do not exist, to assist this critical decision-making process. Hence, here with our clinical experience, we attempt to formulate a clinico-radiologic criteria for the management of PFEDHs. When to operate and when to conserve –the jury is still out on this matter. Methods: The clinical and radiological data of patients with PFEDHs admitted to Kasturba Medical College hospital, Manipal between the period of January 2012 and September 2014 were considered to test the efficacy of the criteria proposed. We carried out a retrospective analysis of 12 patients with PFEDH who were admitted during the above said period. A transverse diameter of 4 cms (of the extradural haematoma) was taken as a cut-off for the decision-making process. Results: Of the 12 cases reviewed only 4 were operated with a single mortality. All the operated cases had bleeds of a transverse diameter of >4 cms or had a GCS of less than 13. 46% of bleeds occurred due to occipital bone fracture resulting in a diploic venous ooze or a sinus bleed. Conclusion: PFEDHs are relatively less often encountered in clinical practice. The PF is an unfavorable location for a hematoma. Good GCS scores, at the time of presentation, have a favorable prognosis. Our proposed criteria, for the management of PFEDHs, concluded that all bleeds greater than 4 cms in transverse diameter are to be treated surgically while those with less than 4 cms in diameter are to be managed on the basis of GCS.

Clinical significance of changes in pB-C2 distance in patients with Chiari Type I malformations following posterior fossa decompression: a single-institution experience.

OBJECT The coexistence of Chiari malformation Type I (CM-I) and ventral brainstem compression (VBSC) has been well documented, but the change in VBSC after posterior fossa decompression (PFD) has undergone little investigation. In this study the authors evaluated VBSC in patients with CM-I and determined the change in VBSC after PFD, correlating changes in VBSC with clinical status and the need for further intervention. METHODS Patients who underwent PFD for CM-I by the senior author from November 2005 to January 2013 with complete radiological records were included in the analysis. The following data were obtained: objective measure of VBSC (pB-C2 distance); relationship of odontoid to Chamberlain's, McGregor's, McRae's, and Wackenheim's lines; clival length; foramen magnum diameter; and basal angle. Statistical analyses were performed using paired t-tests and a mixed-effects ANOVA model. RESULTS Thirty-one patients were included in the analysis. The mean age of the cohort was 10.0 years. There was a small but statistically significant increase in pB-C2 postoperatively (0.5 mm, p < 0.0001, mixed-effects ANOVA). Eleven patients had postoperative pB-C2 values greater than 9 mm. The mean distance from the odontoid tip to Wackenheim's line did not change after PFD, signifying postoperative occipitocervical stability. No patients underwent transoral odontoidectomy or occipitocervical fusion. No patients experienced clinical deterioration after PFD. CONCLUSIONS The increase in pB-C2 in patients undergoing PFD may occur as a result of releasing the posterior vector on the ventral dura, allowing it to relax posteriorly. This increase appears to be well-tolerated, and a postoperative pB-C2 measurement of more than 9 mm in light of stable craniocervical metrics and a nonworsened clinical examination does not warrant further intervention.

A case report; mumps acute cerebellitis presented as hydrocephalus and brainstem compression

A case report; mumps acute cerebellitis presented as hydrocephalus and brainstem compression

Internal carotid artery-to-posterior cerebral artery bypass for revascularization of the brainstem

We describe a novel bypass technique used to revascularize the brainstem by anastomosing the internal carotid artery (ICA) to the posterior cerebral artery (PCA) using a radial artery graft, effectively creating a functional alternative to the posterior communicating artery. A 72-year-old male patient presented with rapidly progressive neurological symptoms attributable to brainstem compression; imaging showed a giant, fusiform, partially thrombosed, vertebrobasilar artery aneurysm. An Alcock’s test revealed no significant collateral circulation from the posterior communicating arteries. To revascularize the top of the basilar artery, we performed an ICA-to-PCA bypass using a radial artery interposition graft. Specifically, we used the radial artery graft to connect the supraclinoid ICA to the P2 segment of the PCA. The basilar artery was subsequently occluded during the same operation by placing a clip below the superior cerebellar arteries. Although the bypass remained patent, the patient suffered an acute thrombosis of the aneurysm, resulting in fatal pontine infarction.

Neuroimaging-evident lesional pathology associated with REM sleep behavior disorder

Background/RationaleRapid eye movement (REM) sleep behavior disorder (RBD) is a potentially injurious parasomnia characterized by dream enactment behavior and polysomnographic REM sleep without atonia (RSWA). Recently, RBD not only has been shown to be strongly associated with synucleinopathy neurodegeneration but has also been rarely reported to be associated with structural lesions involving the brainstem or limbic system. The aim of this study was to describe the clinical, neuroimaging, and outcome characteristics in a case series of patients with lesional RBD. MethodsThis is a retrospective case series from a tertiary care referral center. ResultsA total of 10 patients with lesional RBD were identified. Seven (70%) were men, with an average age of sleep symptom onset of 53.7 ± 17.0 years. Structural pathology evident on neuroimaging included four extraaxial (three meningiomas and one basilar fusiform aneurysm with brainstem compression) and six intraaxial (encephalomalacia, multiple sclerosis, vasculitis, autoimmune limbic encephalitis, and leukodystrophy) lesions. No patient developed parkinsonian features or cognitive impairment suggestive of synucleinopathy over an average of 45.4 ± 35.2 months of follow-up. ConclusionsRBD is rarely associated with non-synuclein structural lesions affecting the pons, medulla, or limbic system. The spectrum of lesional RBD comprises tumors, aneurysms, leukodystrophy, and autoimmune/inflammatory/demyelinating brain lesions.

Outcome of surgery for operable supratentorial mass lesions in patients presenting with decerebration following severe head injury: A retrospective analysis of factors affecting outcome.

Aim:Abnormal motor response in the form of decerebration signifies either injury or compression of brain stem. The presence of decerebrate rigidity following head injury is a grave prognostic sign. Mortality may increase up to 70% in patients showing signs of decerebration. Although many studies have identified the prognostic factors in severe head injuries, few studies have focused on the operated patients with decerebration in predicting the long-term outcome. This study was planned to determine the outcome in this group of patients for prognostication and to help plan further line of management.Materials and Methods:All the patients admitted with severe head injury with decerebration (M2 motor response) admitted in neurosurgery department from September 2009 to January 2011 were included in the study. All the patients had operable supratentorial mass lesions with no direct evidence of brain stem damage. Patients with penetrating injury and diffuse injury with no operative mass lesions were excluded from the study. Clinical and computerized tomography (CT) data were correlated with outcome retrospectively. Glasgow outcome scale (GOS) was used as a measure of functional outcome.Results:The patients admitted with decerebration (M2 motor response) comprised 8% of the total head injury related operative procedures performed at our institute during the period. Of the 72 patients, 14 (19%) patients were more than 60 years old and 21% (15) were females. The surgical mass lesions comprised extradural hematoma in 27 (38%), cerebral contusions in 19 (26%), acute Subdural Hematoma alone in 7 (10%), and acute Subdural Hematoma (SDH) with cerebral contusion in 19 (26%) of the patients. Of the 72 patients, 36(50%) were operated within 24 hours of injury Follow-up of all, but 2 (3%) was obtained. Favorable outcome (GOS 4 and 5) was obtained in 14% (n = 10) of the patients with 83% (n = 60) mortality rate. The favorable outcome rate among the patients operated for Extradural Hematoma was 26% and for cerebral contusions was 11%. Only 5% of the patients operated for acute SDH survived.Conclusion:Radiological diagnosis (type of lesion), followed by duration of decerebration and age of the patient are the most important prognostic factors determining the outcome of surgery in decerebrating patients. Our results confirm that despite the poor prognosis in decerebrate patients, a significant number of patients may still survive and have a good outcome.

Short term effect of multiple stents parallel placement and reconstruction technique for the treatment of giant fusiform vertebrobasilar dissecting aneurysms

To investigate the feasibility,safety and follow-up results of multiple stents parallel placement and reconstruction technique for treating giant vertebrobasilar dissecting aneurysms. Five consecutive patients with giant fusiform vertebrobasilar dissecting aneurysms in Department of Neurology,Chinese People's Liberation Army General Hospital were retrospectively reviewed from April 2011 to October 2013. All patients were diagnosed vertebrobasilar dissecting aneurysms by MRI and digital subtraction angiography (DSA), the aneurysm size ranged 8.2-15.0 mm. All patients were treated by multiple stents parallel placement and reconstruction technique under general anesthesia. In the endovascular treatment process, 2-3 Solitaire or Neuroform self-expandable stents were parallel implanted in the maximum extension segment of the aneurysms to reconstruct the cavity of the aneurysm and solved the problem that the diameter of the intracranial stent is less than the diameter of the aneurysms. Multiple stents parallel placement can keep the stents stable in the cavity. The parallel stent can close the dissection as well as strengthen the aneurysm walls to alleviate the vessel pulsative compression of the brain stem. Furthermore, one of the parallel stents was selected for the main blood flow channel. Based on the main channel, telescope technique was used to completely covering the dissection. It can not only prevent the progress of dissection to normal regions, but also be helpful for blood flow channel reconstruction to reduce the hemodynamic disorders. All Patients received routine antiplatelet therapy before and after endovascular treatment. The operative procedures were succeeded in all patients. Five patients were implanted 18 stents (3 stents in 3 patients; 4 stents in 1 patient; 5 stents in 1 patient; parallel 3 stents in 2 patients; parallel 2 stents in 3 patients). The signs and symptoms of brain stem and posterior group of cranial nerves improved significantly. All patients lived and worked normally and had no recurrent symptoms on follow-up of 6-24 months. All patients performed DSA reexamination at 6-12 months postoperation. The aneurysm size lessened in 2 patients and had no change in 3 patients. Multiple stents parallel placement and reconstruction technique for treating giant fusiform vertebrobasilar dissecting aneurysms is feasible and have good operation safety. It may control the dilatation of the aneurysm and reduce the probability of thrombosis or hemorrhage. It can improve the patients' clinical symptoms and quality of life in short term follow-up. The long term result need for further follow-up.

The Predictor of Mortality within Six-Months in Patients with Spontaneous Cerebellar Hemorrhage: A Retrospective Study.

Background and PurposeThe mortality rate of cerebellar hemorrhage (CH) is generally higher than other types of intracranial hemorrhage. Recently, the increased survey rate of CH has come from improved clinical imaging and earlier surgical intervention. Hence, the predictors of intermittent- (1 to 6 months) and long-term (> 6months) mortality are clinically practical use for educational and therapeutic decisions. Unfortunately, the factors predictive mortality within six-month had not yet been systematically investigated.MethodsSeventy-two patients with acute spontaneous CH were retrospectively analyzed. The patients were divided into the six-month mortality group (n = 21, died within 6 months after CH onset) and survival group (n = 51, survived beyond 6 months). The independent predictors of six-month mortality were investigated by multivariate Cox proportional hazards regression.ResultsThe radiological brainstem compression (hazard ratios = 23.5; p < 0.001) was independent predictor of mortality within six-month after CH onset. The median onset time of six-month mortality was 5 days in patients with brainstem compression (p < 0.001) and the hazard ratios for the onset time was 13.1 compared with those without brainstem compression (95% CI, 4.7 to 36.3, p < 0.001).ConclusionsWe report the first study that radiological brainstem compression predicted the mortality within six-month after onset of CH. Patients with radiological brainstem compression were about 23 times more likely to die within 6 months after CH than those without radiological brainstem compression.

CLINICAL ASSESSMENT A SEVERITY OF ACUTE DISLOCATION SYNDROME IN PATIENTS WITH SEVERE BRAIN INJURY

Acute progressive dislocation syndrome is an urgent condition in neurology and neurosurgery and is the main cause of death in patients with severe brain injury (BI). In patients with severe BI and dislocation syndrome regardless the amount, volume and localization of intracranial lesions, we see brain stem compression with typical symptoms of awareness decrease and appearance of secondary symptoms of stem dysfunction which can conceal the signs of focal or hemisphere damage. Frequent and precise functional evaluation of every part of brain stem (middle brain, Pons and medulla oblongata) plays an important role in choosing of surgical intervention and prognosis of treatment outcomes in patients with BI. Proposed by authors Dislocation Syndrome Severance Assessment Scale (DSSAS) is based on measurement / quantitative evaluation of awareness level and function of every part of brain stem. The significance of Dislocation syndrome severance Assessment Scale was assessed on 43 patients with severe BI. We revealed significant correlation between the stage of dislocation syndrome according the DSSAS and the state of basal cisterns, therapeutic approach and outcomes of surgery (p <0,05). Proposed scale can be recommended as additional diagnostic and prognostic tool on pre- and in-hospital treatment stages of patients with severe BI .

Clinical and Radiological Guidance in Managing Facial Nerve Schwannomas

To present a review of all patients diagnosed with a facial nerve schwannoma (FNS) managed in our center over almost two decades, and suggest guidelines for their classification and management. Retrospective case review Tertiary referral center Twenty-eight patients with a facial nerve schwannoma Conservative or surgical management depending on clinical and radiological features Patient demographics, site of tumor, and clinical symptoms, including facial nerve function (House-Brackmann score) at baseline and follow-up. In those managed surgically, operative approach and surgical outcomes were also recorded. Of 28 patients, 16 were male. Mean age at presentation was 46 years. The majority presented with either facial weakness or hearing loss. The internal auditory canal segment of the facial nerve was the most commonly affected (19/28, 68%). Multi-segmental lesions were found in almost half (46%) of patients. Facial weakness was most commonly associated with involvement of the labyrinthine segment (89%). Overall, 16 (57%) patients were managed surgically. FNS may be difficult to distinguish on both clinical and imaging grounds from other cerebellopontine pathologies on the basis of audiovestibular symptoms alone. The presence of facial weakness in combination with imaging findings suggestive of FNS is highly suggestive for FNS. In patients with brainstem compression, rapid tumor growth, or House-Brackmann greater than 4, we suggest a surgical approach based on preoperative audiovestibular status, helping optimize long-term facial function and minimize morbidity. Facial nerve reanimation at the time of primary surgery is preferred.

Bevacizumab decreases vestibular schwannomas growth rate in children and teenagers with neurofibromatosis type 2.

Vestibular schwannoma (VS) growth in neurofibromatosis type 2 (NF2) can be responsible for brainstem compression and hearing loss. Surgical removal remains the standard therapy despite potential morbidity. Previous studies suggested that the inhibition of the VEGF-pathway with bevacizumab could result in hearing improvement, reduction of the tumor volume or both in adults. We retrospectively describe the French experience of bevacizumab treatment delivered for progressive VS in pediatric NF2 patients. Patients received Bevacizumab 5 or 10mg/kg every 2weeks according to the physician's choice. Follow-up included clinical assessment, audiometry and volumetric MRI every 3-6months. Seven patients harboring 11 VS were included. The median age at inclusion was 15years (11.4-18.8), and the median treatment duration was 11.3months (3.2-55.6). At baseline, the median tumor volume was 1.2cm(3) (0.52-13.5) and the median word recognition score was 90% (0-100). We observed one major response, two minor responses and a decrease in the rate of tumor growth for the 4 other patients. The median annual growth rate before treatment was significantly higher than after 1year of treatment (138 vs. 36%, n=5, p=0.043). We noted one hearing improvement over the course of 1year under treatment (hearing response rate was 14%). Overall, the treatment was well tolerated. Our study supports that bevacizumab is an attractive therapeutic option for pediatric NF2 patients with growing VS. Thorough multidisciplinary evaluation is necessary to identify the best candidates prior to treatment. It is likely that a better functional outcome would be expected if targeted therapies were discussed early in the management of the disease.