Permanent Cranial Nerve Deficits Research Articles

Clinical characteristics and outcomes after trigeminal schwannoma resection: a multi-institutional experience.

Given their rarity, the clinical course of patients undergoing trigeminal schwannoma (TS) resection remains understudied. The objective of this study is to describe clinical characteristics and outcomes in patients undergoing surgical resection for TS in a multi-institutional cohort. This is a retrospective study of patients undergoing TS resection at two institutions between 2004 and 2022. Patient, radiographic, and clinical characteristics were reviewed and analyzed with standard statistical methods. Thirty patients were included. The median patient age was 43 (IQR: 35-52) years, and 14 (47%) patients were female. Median clinical and radiographic follow-ups were 43 (IQR: 20-81) and 47 (IQR: 27-97) months respectively. The most common presenting symptoms were trigeminal hypesthesia (57%) and headaches (30%), diplopia (30%), and ataxia/cerebellar signs (30%). The median maximum tumor diameter was 3.3 (IQR: 2.5-5.4) cm. Most tumors were Samii type C (50%) and mixed cystic-solid (63%). Surgical approaches included endoscopic endonasal (33%), supratentorial (30%), combined/staged (20%), infratentorial (10%), and anterior petrosal (7%) approaches. Gross-total resection was achieved in 16 (53%) patients. Radiographic tumor recurrence was noted in four patients at a median of 79 (range 5-152) months. Twenty-six (87%) patients reported improvements in at least one symptom by last follow-up. The most common perioperative complication was new cranial nerve deficit, with 17% of patients having a transient deficit and 10% having a permanent cranial nerve deficit. Surgical resection of TS showed good progression-free survival and symptom improvement, but was associated with cranial nerve deficits.

Giant Meningiomas Invading the Cavernous Sinus: The “Inevitable Ones”

Abstract Introduction Giant meningiomas invading the cavernous sinus (GMICSs) are a subgroup of challenging tumors due to their volume and the extent of neurological impairment. Preserving quality of life is one of the most relevant aspects of treating patients with GMICS. Methods A retrospective study was conducted for surgeries performed between 2012 and 2022, including 33 patients presenting meningiomas with the largest diameter of at least 5 cm invading the cavernous sinus. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgeries were reviewed. Results The group comprised 25 women and 8 men with a median age of 56 years. The mean follow-up period was 52 months. The tumors were in the sphenoid wing, anterior clinoid, spheno-orbital, spheno-petroclival, petroclival, and Meckel's cave. Simpson grade I, II, and III were obtained in 70% of cases. The meningiomas were classified as WHO grade 1 in 94%, grade 2 in 3%, and grade 3 in 3%. The overall mortality was 3%. Permanent cranial nerve deficits occurred in 21%, transient cranial nerve deficits in 42%, cerebrospinal fistula in 15%, and hemiparesis in 18%. The recurrence/regrowth rate was 6%. The Karnofsky Performance Status score of 100 and 90 was 82%. Conclusions The surgical treatment of GMICS is an effective treatment modality with acceptable morbimortality and good long-term control. Involvement of the internal carotid artery is essential to determine the extent of resection inside the cavernous sinus, and training in the microsurgical laboratory is mandatory for safe surgical treatment.

Microsurgical treatment of carotid body tumors using periadventitial dissection: Analysis of outcomes and prognostic factors in a neurological referral center.

Surgical resection for carotid body tumors (CBTs) is the gold standard of treatment and continues to be a challenging procedure, commonly associated with high vascular injury rates and neurological complications. It is a retrospective case series study between January 2002 and November 2020, with a mean follow-up of 29 months in a single nationwide referral center. Thirty-one patients diagnosed with a carotid body tumor and treated with microsurgical periadventitial resection were included in the study. Patients' demographics, comorbidities, clinical, radiological factors, and tumor grade, evaluated by the Shamblin scale, were obtained. Statistical analysis was performed on all collected data. In this study, we included 31 patients (32 tumors), 80% of the patients were female, and 20% were male, with a mean age of 53 years. One patient presented with bilateral lesions, while 17 tumors were located on the left side. The most frequent symptom was a painless, slow-growing neck mass in 74% of patients. Using the Shamblin classification, 13% of tumors were Grade I, 53% Grade II, and 34% Grade III. In the postoperative period, 3% of patients presented with permanent cranial nerve deficit, while none had vascular injuries or postoperative stroke. A tumor >5 cm increased the risk for nerve lesion by 11 times (OR 12.6, CI 95% 7.4-11.4, P < 0.001). Preoperative embolization followed by periadventitial resection by means of a microsurgical technique is a safe and effective approach to remove CBT, with 3% cranial nerve injury rate and no need for vascular sacrifice or reconstruction.

Sphenoid Wing Meningiomas with Secondary Cavernous Sinus Invasion: Surgical Results and Algorithm for Treatment at a Single Brazilian Center

Sphenoid wing meningiomas with cavernous sinus invasion (SWMCSI) are challenging tumors. The preservation of quality of life and cranial nerve function is one of the most relevant aspects of treating patients with SWMCSI. A retrospective study was conducted for surgery performed between 2008 and 2021, including 36 patients presenting with SWMCSI. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgery was reviewed. We examined the medical records, operative reports, radiologic examinations, and follow-up information. The group comprised 29 women and 7 men with an average age of 61 years (range, 31-87 years). The mean follow-up period was 75 months (range, 1-170 months). Simpson grade I and II resections were obtained in 80% of cases. The meningiomas were World Health Organization (WHO) grade 1 in 94% of cases, WHO grade 2 in 3%, and WHO grade 3 in 3%. The overall mortality was 5.5%. Permanent cranial nerve deficits occurred in 8% of cases, transient cranial nerve deficits in 22%, cerebrospinal fistula in 16.5%, and hemiparesis in 2.7%. The recurrence/regrowth rate was 14% during the follow-up period. The Karnofsky Performance Status 100 and 90 was 92%. The surgical treatment of symptomatic SWMCSI is an effective treatment modality with low morbimortality and good long-term control of the disease. Visual impairment is the most common abnormality, affecting preoperative and postoperative quality of life of patients with SWMCSI. Training in the microsurgical laboratory is essential for safe surgical approaches in this area.

Proposed modification to the Shamblin's classification of carotid body tumors: A single-center retrospective experience of 116 tumors

ObjectivesCarotid body tumors (CBTs) are rare head and neck neoplasms, we aimed to propose a modification to the Shamblin's classification of CBTs. Materials and methodsThis retrospective study included 105 patients (116 CBTs) operated at our institution from March 2013 to July 2020. CBTs were divided by a modified Shamblin's classification into five subtypes (type I–V) based on the radiographic features. Correlations between modified classification and intraoperative bleeding, internal carotid artery (ICA) bypass and postoperative neural complications, as main outcomes, as well as other outcomes were analyzed. ResultsSurgeries for type V and type I CBTs had the most (median: 700 ml, IQR: 375–1575 ml) and least (median: 20 ml, IQR: 20–50 ml) bleeding, respectively. Intraoperatively, ICA bypass was needed in 41.7% (10/24) type V, 18.2% (8/44) type IV and 5.9% (1/17) type III lesions, but not in other subtypes (p = .001). Postoperatively, overall cranial nerve deficits (CND) were found most frequently in type V tumors (17/24, 70.8%) (p = .016). Permanent CND were found in 33.3% (8/24) type V and 4.5% (2/44) type IV lesions, but not in other subtypes (p = .001). Other outcomes including external carotid artery ligation, operation time, blood transfusion, postoperative intensive unit care and postoperative hospitalization also showed significant difference among different subtypes. Patients recovered uneventfully during a follow-up of 23.5 ± 16.2 months except for one ipsilateral recurrence at 42 months after surgery. ConclusionsThe modified classification was correlated with surgical outcomes of CBTs and will be helpful for making surgical plans.

Intraventricular neuroepithelial tumors: surgical outcome, technical considerations and review of literature

BackgroundIntraventricular neuroepithelial tumors (IVT) are rare lesions and comprise different pathological entities such as ependymomas, subependymomas and central neurocytomas. The treatment of choice is neurosurgical resection, which can be challenging due to their intraventricular location. Different surgical approaches to the ventricles are described. Here we report a large series of IVTs, its postoperative outcome at a single tertiary center and discuss suitable surgical approaches.MethodsWe performed a retrospective chart review at a single tertiary neurosurgical center between 03/2009–05/2019. We included patients that underwent resection of an IVT emphasizing on surgical approach, extent of resection, clinical outcome and postoperative complications.ResultsForty five IVTs were resected from 03/2009 to 05/2019, 13 ependymomas, 21 subependymomas, 10 central neurocytomas and one glioependymal cyst. Median age was 52,5 years with 55.6% (25) male and 44.4% (20) female patients. Gross total resection was achieved in 93.3% (42/45). 84.6% (11/13) of ependymomas, 100% (12/21) of subependymomas, 90% (9/10) of central neurocytomas and one glioependymal cyst were completely removed. Postoperative rate of new neurological deficits was 26.6% (12/45). Postoperative new permanent cranial nerve deficits occurred in one case with 4th ventricle subependymoma and one in 4th ventricle ependymoma. Postoperative KPSS was 90% (IR 80–100). 31.1% of the patients improved in KPSS, 48.9% remained unchanged and 20% declined. Postoperative adverse events rate was 20.0%. Surgery-related mortality was 2.2%. The rate of shunt/cisternostomy-dependent hydrocephalus was 13.3% (6/45). 15.4% of resected ependymomas underwent adjuvant radiotherapy. Mean follow-up was 26,9 (±30.1) months.ConclusionOur surgical findings emphasize satisfactory complete resection throughout all entities. Surgical treatment can remain feasible, if institutional experience is given. Satisfying long-term survival and cure is possible by complete removal. Gross total resection should always be performed under function-remaining aspects due to mostly benign or slow growing nature of IVTs. Further data is needed to evaluate standard of care and alternative therapy options in rare cases of tumor recurrence or in case of patient collective not suitable for operative resection.

Analysis and surgical treatment of 72 cases of parapharyngeal space tumors

Objective:To summarize and analyze the clinical features, diagnosis methods, surgical approaches and treatment outcomes of patients with parapharygeal space tumors.Method:A retrospective review of 72 cases with parapharygeal space tumors treated from March 1994 to June 2017 was performed. The data on presentation, surgical approach, histological diagnosis and postoperative complications were reviewed.Result:The postoperative pathological diagnosis included 62 benign tumors and 10 malignant tumors. The most frequent symptom was a cervical mass or an intraoral swelling. All patients underwent preoperative enhanced CT scan or MRI,which would be helpful to evaluate the tumor sizes,locations and possible sources,and to make operation scheme. The postoperative pathology included 24 salivary gland lesions and 30 neurogenic lesions. The postoperative complications happened in 13 patients. The surgical approaches included trans-cervical approach in 55 cases, cervical-parotid approach in 9 cases,trans-oral approach in 6 cases , and trans skull base approach in 2 case.Conclusion:A parapharygeal space tumor is an uncommon tumor and requires careful preoperative assessment. Surgery is the first choice for parapharygeal space tumors. These patients should be counseled appropriately about the potential for permanent cranial nerve deficits.

Microvascular decompression for hemifacial spasm: Outcome on spasm and complications. A review

Over the last decades microvascular decompression (MVD) has been established as the curative treatment of the primary Hemifacial Spasm (HFS), proven to be linked in almost all cases to a neurovascular compression of the facial nerve. Because the disease is not life-threatening and MVD not totally innocuous, efficacy and safety have to be weighted before decision taken of indicating surgery. The authors have been charged by the French Speaking Society of Neurosurgery to conduct a detailed evaluation of the probability of relief of the spasm that MVD is able to obtain, together with its potential complications. For the review, the authors have gone through the reports available from the Pubmed system. Eighty-two publications have been read and analysed, totalizing more than 10,000 operated cases. In most series, the percentage of patients with total relief ranged between 85% and 90%. Relief was obtained after a certain delay in as many as in 33%±8% of the patients in many series. For those, delay lasted around one year in 12% of them. When effect of MVD was considered achieved, relief remained permanent in all but 1%–2% of the long-term followed patients. As regards to complications, risk of permanent cranial nerve deficit was evaluated at 1%–2% for facial palsy, 2%–3% for non-functional hearing loss, 0.5%–1% for lower cranial nerve dysfunction. Risk of stroke was at 0.1% and mortality at 0.1%. CSF leakage and related complications could be reduced at less than 2% in most series provided careful closing techniques be applied. Complications were at a higher rate in repeated MVD. MVD is an effective curative method for almost all the patients affected with primary HFS. Because MVD for HFS is functional surgery, scrupulous consideration of its potential risks, together with the ways to avoid complications are of paramount importance. When MVD is estimated to have failed, it is wise to wait one year before considering to repeat surgery, as number of patients may benefit from delayed effect. This is the more so as important as repeated surgery entails a higher rate of complications.

Anaesthetic management in the excision of large carotid body tumours: Surgeons perspectives

Objective(s): Carotid body tumours (CBT) are considered rare. Surgical excision is the treatment of choice and poses many anaesthetic challenges especially in large tumours. In this paper we present our experience of anaesthetic management of CBT which is one of the largest series on management of large (Shamblin II, III) tumours in the world. Design: Retrospective cohort, Instituitional Review Board (IRB) Approved. Setting: Single-Centre Tertiary care institute in South India. Participants: Patients undergoing operative intervention for carotid body tumours. Interventions: nil, observational. Results: 66 tumours were excised in 62 patients (27 female, 39 male). The average age was 37.5. All tumours presented with a slow growing neck mass.7 patients complained of pain,as the presenting symptom. 2 were malignant, all were non-functional. 4 presented with preoperative neurological dysfunction- 2 with cranial nerve palsy following excision of contralateral CBT and 2 with resolved stroke following preoperative embolization. Nasotracheal intubation with mandibular subluxation was performed in 5. The average operating time was 2.5 hours. Average blood loss was 900 ml (200- 5000ml). Perioperative blood or product requirement varied from no transfusion to one patient with a very large (20cm tumour) requiring transfusion of a total of 20 products. Clamping of the carotid was necessary in 22 patients. 3 patients received heparin prior to clamp. There were 4 perioperative strokes, none of whom had any precipitous intraoperative hypotension. Transient postoperative cranial nerve palsy/paresis occurred in 50% with permanent cranial nerve deficits in 5%. There was no perioperative mortality. Tracheostomy was required in one patient for bilateral vocal cord palsy. Conclusions: Several preoperative ,intraoperative and postoperative management points (airway, intraoperative blood loss, stroke, cranial nerve dysfunction ,blood pressure control), are specific to the management of carotid body F tumours.Increased awareness of these specific scenarios and appropriate management ensures minimal perioperative morbidity and mortality.

Jugulotympanic paragangliomas in southern Finland: a 40-year experience suggests individualized surgical management.

Treatment of jugulotympanic paragangliomas (JTPGLs) remains challenging with no clear guidelines for management or follow-up. The aim of this retrospective case-note study was to assess long-term results of operatively and conservatively managed JTPGLs between years 1974-2013. A total of 36 patients with JTPGLs were identified. Clinical characteristics and management outcomes of patients were reviewed. Data were extracted on demographics, symptoms, timing of diagnosis, tumor location and size, embolization, and management, including pre- and post-operative imaging, analysis of operative techniques, and follow-up. Pulsatile tinnitus and hearing loss were the most common presenting symptoms. Thirty-four (94%) patients were treated with primary surgical therapy and two (6%) with radiotherapy. The surgical approaches included endaural approach for Fisch Class A tumors and a variety of approaches for Fisch Class B-D tumors with an increasing predilection for function-preserving surgery. Eight (24%) patients received subtotal resection. Five (15%) patients had a local recurrence within 10years after primary surgery. Two (6%) patients suffered a permanent cranial nerve (CN) deficit after primary surgery. We advocate radical surgery when tumor resection is possible without compromising CNs. Function-preserving surgery with at least a 10-year follow-up for Fisch Class B-D tumors should be considered if CNs are in danger.

Radiotherapy for head and neck paragangliomas

Treatment options for benign paragangliomas include surgery, radiotherapy (RT), stereotactic radiosurgery (SRS), and observation. Patients who are elderly, infirm, and have a limited life expectancy may be followed. This is also a reasonable option for younger, healthier patients who have no evidence of progression on serial computed tomography or magnetic resonance imaging. Patients who require intervention are treated with either RT (45 Gy/25 fractions) or SRS (12.5-15 Gy) if resection would result in significant morbidity such as permanent cranial nerve deficits. The probability of tumor stabilization or regression after RT or SRS exceeds 95% and the probability of a significant complication is remote.

Giant intracranial epidermoids: is total removal feasible?

Epidermoid tumors arise from misplaced squamous epithelium and enlarge through the accumulation of desquamated cell debris. Optimal treatment consists of total removal of the capsule; therefore, giant and multicompartmental tumors are particularly challenging. A conservative attitude in handling the tumor capsule is common given concerns about capsule adherence to neurovascular structures, and thus the possibility of recurrence is accepted with the intent of minimizing complications. This study focuses on the outcome of surgery in patients with giant epidermoid tumors for which total capsule removal was the aim. The authors conducted a retrospective analysis of all patients with giant epidermoid tumors treated by the senior author (O.A.), who pursued total removal of the capsule through skull base approaches. Patients were divided into 2 groups: one including patients with de novo tumors and the other consisting of patients who presented with recurrent tumors. Thirty-four patients had undergone 46 operations, and the senior author performed 38 of these operations in the study period. The average tumor dimensions were 55 × 36 mm, and 25 tumors had multicompartmental extensions. Total removal of the tumor and capsule was achieved with the aid of the microscope in 73% of the 26 de novo cases but in only 17% of the 12 recurrent tumor cases. The average follow-up among all patients was 111 months (range 10-480 months), and the average postsurgical follow-up was 56.8 months (range 6-137 months). There were 4 recurrences in the de novo group, and every case had had a small piece of tumor capsule left behind. One patient died after delayed rupture of a pseudoaneurysm. In the de novo group, the average preoperative Karnofsky Performance Scale (KPS) score was 71.42%, which improved to 87.14% on long-term follow-up. In the group with recurrences, the KPS score also improved on long-term follow-up, from 64.54% to 84.54%. In the de novo group, 3 cases (11.5%) had permanent cranial nerve deficits, and 4 cases (15.4%) had a CSF leak. In the recurrence group, 3 cases (25%) had new, permanent cranial nerve deficits, and 1 (8.3%) had a CSF leak. Two patients in this group developed hydrocephalus and required a shunt. Total removal of the capsule of giant epidermoid tumors was achieved in 73% of patients with de novo tumors and was associated with improved function, low morbidity and mortality, and a lower risk of recurrence. Surgery in patients with recurrent tumors was associated with higher morbidity and persistence of the disease.

Surgical treatment of jugular foramen meningiomas

ObjectWe present our experience with surgery of jugular foramen meningiomas with special consideration of clinical presentation, surgical technique, complications, and outcomes. MethodsThis retrospective study includes three patients with jugular foramen meningiomas treated by the senior author between January 2005 and December 2010. The initial symptom for which they sought medical help was decreased hearing. In all of the patients there had been no other neurological symptoms before surgery. The transcondylar approach with sigmoid sinus ligation at jugular bulb was suitable in each case. ResultsNo death occurred in this series. All of the patients deteriorated after surgery mainly due to the new lower cranial nerves palsy occurred. The lower cranial nerve dysfunction had improved considerably at the last follow-up examination but no patient fully recovered. Two of three patients with preoperatively impaired yet functional hearing deteriorated after surgery with no subsequent cranial nerve VIII function improvement. In one case postoperative stereotactic radiosurgery was performed due to non-radical tumour resection (Simpson Grade IV) and tumour remnant proved stable in the 4-year follow-up. None of the patients have shown signs of tumour recurrence in the mean follow-up period of 56 months. ConclusionsJugular foramen meningiomas represent one of the rarest subgroups of meningiomas and their surgical treatment is associated with significant risk of permanent cranial nerve deficits.

True petroclival meningiomas: results of surgical management

The relentless natural progression of petroclival meningiomas mandates their treatment. The management of these tumors, however, is challenging. Among the issues debated are goals of treatment, outcomes, and quality of life, appropriate extent of surgical removal, the role of skull base approaches, and the efficacy of combined decompressive surgery and radiosurgery. The authors report on the outcome in a series of patients treated with the goal of total removal. The authors conducted a retrospective analysis of 64 cases of petroclival meningiomas operated on by the senior author (O.A.) from 1988 to 2012, strictly defined as those originating medial to the fifth cranial nerve on the upper two-thirds of the clivus. The patients' average age was 49 years; the average tumor size (maximum diameter) was 35.48 ± 10.09 mm (with 59 tumors > 20 mm), and cavernous sinus extension was present in 39 patients. The mean duration of follow-up was 71.57 months (range 4-276 months). In 42 patients, the operative reports allowed the grading of resection. Grade I resection (tumor, dura, and bone) was achieved in 17 patients (40.4%); there was no recurrence in this group (p = 0.0045). Grade II (tumor, dura) was achieved in 15 patients (36%). There was a statistically significant difference in the rate of recurrence with respect to resection grade (Grades I and II vs other grades, p = 0.0052). In all patients, tumor removal was classified based on postoperative contrast-enhanced MRI, and gross-total resection (GTR) was considered to be achieved if there was no enhancement present; on this basis, GTR was achieved in 41 (64%) of 64 patients, with a significantly lower recurrence rate in these patients than in the group with residual enhancement (p = 0.00348). One patient died from pulmonary embolism after discharge. The mean Karnofsky Performance Status (KPS) score was 85.31 preoperatively (median 90) and improved on follow-up to 88, with 30 patients (47%) having an improved KPS score on follow-up. Three patients suffered a permanent deficit that significantly affected their KPS. Cerebrospinal fluid leak occurred in 8 patients (12.5%), with 2 of them requiring exploration. Eighty-nine percent of the patients had cranial nerve deficits on presentation; of the 54 patients with more than 2 months of follow-up, 21 (32.8%) had persisting cranial nerve deficits. The overall odds of permanent cranial nerve deficit of treated petroclival meningioma was 6.2%. There was no difference with respect to immediate postoperative cranial nerve deficit in patients who had GTR compared with those who had subtotal resection. Total removal (Grade I or II resection) of petroclival meningiomas is achievable in 76.4% of cases and is facilitated by the use of skull base approaches, with good outcome and functional status. In cases in which circumstances prevent total removal, residual tumors can be followed until progression is evident, at which point further intervention can be planned.

Intérêt du monitoring électrophysiologique dans la chirurgie éveillée des gliomes de bas grade en zone fonctionnelle

Over the last decades microvascular decompression (MVD) has been established as the curative treatment of the primary Hemifacial Spasm (HFS), proven to be linked in almost all cases to a neurovascular compression of the facial nerve. Because the disease is not life-threatening and MVD not totally innocuous, efficacy and safety have to be weighted before decision taken of indicating surgery. The authors have been charged by the French Speaking Society of Neurosurgery to conduct a detailed evaluation of the probability of relief of the spasm that MVD is able to obtain, together with its potential complications. For the review, the authors have gone through the reports available from the Pubmed system. Eighty-two publications have been read and analysed, totalizing more than 10,000 operated cases. In most series, the percentage of patients with total relief ranged between 85% and 90%. Relief was obtained after a certain delay in as many as in 33% ± 8% of the patients in many series. For those, delay lasted around one year in 12% of them. When effect of MVD was considered achieved, relief remained permanent in all but 1%–2% of the long-term followed patients. As regards to complications, risk of permanent cranial nerve deficit was evaluated at 1%–2% for facial palsy, 2%–3% for non-functional hearing loss, 0.5%–1% for lower cranial nerve dysfunction. Risk of stroke was at 0.1% and mortality at 0.1%. CSF leakage and related complications could be reduced at less than 2% in most series provided careful closing techniques be applied. Complications were at a higher rate in repeated MVD. MVD is an effective curative method for almost all the patients affected with primary HFS. Because MVD for HFS is functional surgery, scrupulous consideration of its potential risks, together with the ways to avoid complications are of paramount importance. When MVD is estimated to have failed, it is wise to wait one year before considering to repeat surgery, as number of patients may benefit from delayed effect. This is the more so as important as repeated surgery entails a higher rate of complications.

Covered Carotid Stents

To the Editor: McDougall et al1 described in a recent article the use of a covered stent as an adjunct in the resection of the carotid body tumors (CBTs). Excision is indicated for most tumors, but the surgery is not risk free and the best results are achieved by specialist team. According to the Shamblin classification, the bigger the CBT is, the higher the risk of cranial nerve and vascular injury is. The transient ischemic attack/stroke rate after CBT excision varies from 0% to 8% in international studies. The incidence of cranial nerve deficit after CBT surgery varies from 11% to 49%, but the incidence of permanent cranial nerve deficit has been quoted as < 1% in international literature. The internal and external carotid artery injury rates vary from 2% to 13% and from 0% to 32%, respectively.2 The intraoperative blood loss is higher for type III (Shamblin classification) CBTs or with diameter > 4 cm, and in these cases, preoperative embolization is indicated. The use of a covered stent during the carotid paraganglioma excision is described in isolated cases. In addition, the use of this additional procedure is possible to increase the rate of early (carotid artery dissection) and late (restenosis) complications and does not modify substantially the risk of intraoperative bleeding (700 mL of blood loss in case 1) because of the need for dual antiplatelet therapy and incomplete CBT devascularization. Conversely, it may be useful for previously treating a carotid stenosis to avoid intraoperative embolization during CBT manipulation. Disclosure The authors have no personal financial or institutional interest in drugs, materials, or devices described in this manuscript.

Treatment policy for petroclival meningioma based on tumor size: aiming radical removal in small tumors for obtaining cure without morbidity

Aggressive tumor removal is not always the best treatment for petroclival meningioma (PCM). However, radical removal actually provides the cure with minimal morbidity. We evaluated the relation of surgical results and tumor size in the PCM removal to clarify the treatment policy for PCM. This study comprised 32 consecutive patients with newly-diagnosed PCM who underwent tumor removal; tumor size was small (< 3 cm) in 12 patients and large (≥3 cm) in 20. Tumor removal was classified into radical (Simpson's grade I/II) and non-radical (Simpson's grade III/IV). Removal of small PCM was 11 radical and one non-radical; no surgical morbidity/mortality occurred and postoperative regular follow-up using magnetic resonance imaging showed no recurrence in the period of 66±45 months. Removal of large PCM was eight radical and 12 non-radical; despite no mortality, the incidence of permanent cranial nerve deficits and major neurological deficits newly developed postoperatively was 35% and 25%, respectively. Radical removal was significantly more frequent in small PCMs than in large PCMs. Permanent cranial nerve deficits newly developed postoperatively and poor outcome (Karnofsky score ≤80) were significantly more frequent in large PCMs than in small PCMs. Radical removal of small PCM is achieved with minimal morbidity and results in the cure. Notwithstanding high morbidity, aggressive removal of large PCM does not achieve a high rate of radical removal. To find and remove PCM radically while it is small is the only way to cure the disease with minimal morbidity.

Microvascular decompression for elderly patients with trigeminal neuralgia: a prospective study and systematic review with meta-analysis

Because the incidence of trigeminal neuralgia (TN) increases with age, neurosurgeons frequently encounter elderly patients with this disorder. Although microvascular decompression (MVD) is the only etiological therapy for TN with the highest initial efficacy and durability of all treatments, it is nonetheless associated with special risks (cerebellar hematoma, cranial nerve injury, stroke, and death) not seen with the commonly performed ablative procedures. Thus, the safety of MVD in the elderly remains a concern. This prospective study and systematic review with meta-analysis was conducted to determine whether MVD is a safe and effective treatment in elderly patients with TN. In this prospectively conducted analysis, 36 elderly patients (mean age 73.0 ± 5.9 years) and 53 nonelderly patients (mean age 52.9 ± 8.8 years) underwent MVD over the study period. Outcome and complication data were recorded. The authors also conducted a systematic review of the English literature published before December 2009 and providing outcomes and complications of MVD in patients with TN above the age of 60 years. Pooled complication rates of stroke, death, cerebellar hematoma, and permanent cranial nerve deficits were analyzed. Thirty-one elderly patients (86.1%) reported an excellent outcome after MVD (mean follow-up 20.0 ± 7.0 months). Twenty-five elderly patients with Type 1 TN were compared with 26 nonelderly patients with Type 1 TN, and no significant difference in outcomes was found (p = 0.046). Three elderly patients with Type 2a TN were compared with 12 nonelderly patients with Type 2a TN, and no significant difference in outcomes was noted (p = 1.0). Eight elderly patients with Type 2b TN were compared with 15 nonelderly patients with Type 2b TN, and no significant difference in outcomes was noted (p = 0.086). The median length of stay between cohorts was compared, and no significant difference was noted (2 days for each cohort, p = 0.33). There were no CSF leaks, no cerebellar hematomas, no strokes, and no deaths. Eight studies (1334 patients) met the inclusion criteria for the meta-analysis. For none of the complications was the incidence significantly more frequent in elderly patients than in the nonelderly. Although patient selection remains important, the authors' experience and the results of this systematic review with meta-analysis suggest that the majority of elderly patients with TN can safely undergo MVD.

Surgical Treatment of Carotid Body Paragangliomas: Outcomes and Complications According to the Shamblin Classification

ObjectivesThe objective of this study was to review our experience in the surgical management of carotid body paragangliomas and evaluate the outcomes and complications according to the Shamblin classification.MethodsThirteen patients who had been diagnosed and surgically treated for carotid body tumors (CBTs) were enrolled in this study. We reviewed patient demographics, radiographic findings, and surgical outcomes collected from medical records.ResultsFifteen CBTs were found in 13 patients and 13 tumors were resected. Selective preoperative tumor embolization was performed on six patients. The median blood loss, operation time, and hospital stay for these patients were not significantly reduced compared to those without embolization. The median tumor size was 2.3 cm in Shamblin I and II and 4 cm in Shamblin III. The median intraoperative blood loss was 280 mL and 700 mL, respectively (P<0.05). Internal carotid artery ligation with reconstruction was accomplished on three patients (23%), and they all belonged to Shamblin III (38%). One Shamblin III patient (8%) developed transient cerebral ischemia, and postoperative stroke with death occurred in another Shamblin III patient. Postoperative permanent cranial nerve deficit occurred in three patients (23%) who were all in Shamblin III (P=0.03). There were no recurrences or delayed complications at the median follow up of 29 months.ConclusionShamblin III had a high risk of postoperative neurovascular complications. Therefore, early detection and prompt surgical resection of CBTs will decrease surgical morbidity.

Expérience préliminaire du traitement par radiochirurgie Gamma Knife® Perfexion™ au Maroc. Étude des 100 premiers cas

Over the last decades microvascular decompression (MVD) has been established as the curative treatment of the primary Hemifacial Spasm (HFS), proven to be linked in almost all cases to a neurovascular compression of the facial nerve. Because the disease is not life-threatening and MVD not totally innocuous, efficacy and safety have to be weighted before decision taken of indicating surgery. The authors have been charged by the French Speaking Society of Neurosurgery to conduct a detailed evaluation of the probability of relief of the spasm that MVD is able to obtain, together with its potential complications. For the review, the authors have gone through the reports available from the Pubmed system. Eighty-two publications have been read and analysed, totalizing more than 10,000 operated cases. In most series, the percentage of patients with total relief ranged between 85% and 90%. Relief was obtained after a certain delay in as many as in 33% ± 8% of the patients in many series. For those, delay lasted around one year in 12% of them. When effect of MVD was considered achieved, relief remained permanent in all but 1%–2% of the long-term followed patients. As regards to complications, risk of permanent cranial nerve deficit was evaluated at 1%–2% for facial palsy, 2%–3% for non-functional hearing loss, 0.5%–1% for lower cranial nerve dysfunction. Risk of stroke was at 0.1% and mortality at 0.1%. CSF leakage and related complications could be reduced at less than 2% in most series provided careful closing techniques be applied. Complications were at a higher rate in repeated MVD. MVD is an effective curative method for almost all the patients affected with primary HFS. Because MVD for HFS is functional surgery, scrupulous consideration of its potential risks, together with the ways to avoid complications are of paramount importance. When MVD is estimated to have failed, it is wise to wait one year before considering to repeat surgery, as number of patients may benefit from delayed effect. This is the more so as important as repeated surgery entails a higher rate of complications.