Permanent Hemiparesis Research Articles

Extended pterional approach with orbital flattening for suprasellar and parasellar lesions

Background and aim The aim of this study was to investigate the advantages of the extended pterional approach and compare it with more invasive and less-invasive similar approaches. Patients and method s This study is an observational retrospective case-series study and descriptive statistics was used. Twelve patients with suprasellar and parasellar lesions were managed in the period between January 2016 and January 2019. Preoperative and postoperative clinical and radiological assessment were done for each patient. Results Twelve cases were done via this approach. There were nine females and three males. Age ranges from 2 to 55 years with a mean of 31.7 years. Regarding pathology, eight (67%) cases were meningiomas, three (25%) cases were craniopharyngiomas, while one (8.3%) case was pituitary adenoma. Most of the cases (91.7%) were presented with visual affection. The lesion was excised totally (gross total resection) in seven (58.3%) out of the 12 cases. Visual affection improved in seven (63.6%) out of 11 cases. Regarding complications, one case experienced permanent hemiparesis. One patient had deep-vein thrombosis that had been treated. One case had seizures. Approach-related complications: two cases had periorbital edema that disappeared within 1 week. One case had a rim of subdural hematoma. Frontalis nerve injury occurred in two cases, one of them improved within 6 months. We do not have a permanent cosmetic deformity with this approach. Conclusion The extended pterional approach has less functional and cosmetic complications and it can be done in lesser time than frontotemporal–orbitozygomatic approach. The exposure is much larger than conventional pterional approach.

Precise MEP monitoring with a reduced interval is safe and useful for detecting permissive duration for temporary clipping

Although temporary clipping of the parent artery is an indispensable technique in clipping surgery for intracranial aneurysms, the permissive duration of temporary clipping is still not well known. The aim of this study is to confirm the safety of precise motor evoked potential (MEP) monitoring and to estimate the permissive duration of temporary clipping for middle cerebral artery (MCA) aneurysm based on precise MEP monitoring results. Under precise MEP monitoring via direct cortical stimulation every 30 seconds to 1 minute, surgeons released a temporary clip and waited for MEP amplitude to recover following severe (>50%) reduction of MEP amplitude during temporary clipping. Precise MEP monitoring was safely performed. Twenty-eight instances of temporary clipping were performed in 42 MCA aneurysm clipping surgeries. Because precise MEP monitoring could be used to determine when to release a temporary clip even with a severe reduction in MEP amplitude due to lengthy temporary clipping, no patients experienced permanent postoperative hemiparesis. Based on logistic regression analysis, if a temporary clip is applied for 312 seconds or more, there is a higher probability of a severe reduction in MEP amplitude. We should therefore release temporary clips after 5 minutes in order to avoid permanent postoperative hemiparesis.

Predictors of Class I epilepsy surgery outcome in tumour-related chronic temporal lobe epilepsy in adults.

Temporal lobe tumours, especially low-grade gliomas and glioneuronal tumours, are common causes of seizures in patients referred for epilepsy surgery. We here present our experience of surgical treatment of patients with intractable chronic epilepsy associated with temporal lobe tumours, focusing on the long-term surgical outcomes and the features associated with better seizure control. In this study, we retrospectively analysed 44 consecutive patients from a total of 182 with refractory temporal lobe epilepsy presenting with long-term intractable epilepsy due to a temporal lobe tumour who were surgically treated at our institution between 2005 and 2015 with post-surgical follow-up of at least two years. All patients underwent a standard pre-surgical evaluation that included: history and physical examination with a description of the seizure semiology, serial scalp EEG recording, brain MR imaging, and a detailed neuropsychological evaluation. Our surgical strategy comprised tumour resection, and combined mesial temporal and neocortical resection in most cases. No patient died during surgery or the postoperative course. Seven patients had postoperative complications, of whom two had permanent hemiparesis due to ischaemic stroke. At the final follow-up, a favourable seizure outcome (Engel Class I) was found in 37 patients (84%), including 31 (70.5%) in Engel Class IA (excellent result). Two (4.5%) patients presented with an Engel Class II outcome (unfavourable outcome). Five patients (11.5%) were in Engel Classes III or IV (surgical failure). We found that complete resection of the hippocampus along with tumour and temporal pole removal was strongly associated with seizure freedom (p = 0.015). Pathological diagnosis was also a significant prognostic indicator of tumour-related seizure freedom. Patients with a diagnosis of a glioneuronal tumour benefited from more seizure freedom after resection compared to those who had a low-grade glioma (p = 0.024). The most appropriate management of tumour-related chronic temporal lobe epilepsy in adults appears to be tai-lored temporal lobe resection including tumour and hippocampal complex removal. Surgical treatment of tumoural temporal lobe epilepsy demonstrates excellent results in terms of seizure improvement, especially in patients with glioneuronal tumours.

Transient episodes of hemiparesis in Sturge Weber Syndrome - Causes, incidence and recovery.

Sturge Weber Syndrome (SWS) arises from a sporadic condition secondary to a post zygotic mutation in the GNAQ gene, manifested in the majority of cases by capillary malformation of the skin. Children present with seizures, acquired hemiparesis, transient hemiparesis and intellectual disabilities. This project aimed to establish incidence of transient episodes, their recovery time if full recovery was achieved, and events associated with the transient episode. This was a retrospective cohort study, approved for clinical audit (Institution number 2182). Children with a diagnosis of SWS seen in a tertiary multidisciplinary clinic from September 2013 to September 2016 were included in the analysis. Data was collated from clinical notes. SPSS 21 was used for analysis. A total of 102 patients had a diagnosed of SWS, the mean age was 10.86 years (range 2-22years). 47/102 participants with SWS had permanent hemiparesis. 32/102 presented with transient episodes. All children with transient hemiparesis had epilepsy. Median recovery time to previous function, following a transient episode was 24h (range 1 minute-4392h). All participants fully recovered from the transient episode within a 6 months' time frame. The factors associated with transient episodes were seizures, or a blow to the head. To our knowledge this is the largest cohort of children with SWS analysed to describe occurrence, association and recovery time of transient hemiparesis. The findings informed service development including change in method to record details of transient episodes. Further information provided to other health professionals will be reviewed.

Perisylvian, including insular, childhood epilepsy: Presurgical workup and surgical outcome.

To report the presurgical workup, surgical procedures, and outcomes in a series of pediatric patients with drug-resistant epilepsy involving the perisylvian/insular regions. We retrospectively assessed 16 pediatric patients affected by drug-resistant focal epilepsy involving perisylvian/insular regions, who consecutively underwent tailored resective surgery. All patients underwent a detailed presurgical workup, which included the analysis of the anatomoelectroclinical correlations with scalp electroencephalography (EEG) and/or with stereo-electroencephalography (SEEG), brain magnetic resonance imaging (MRI), and comprehensive cognitive and neuropsychological evaluations. After surgery, all patients underwent serial clinical and laboratory evaluations. Focal motor seizures restricted to perioral area, associated with symptoms related to the surrounding areas (as auditory hallucinations, unpleasant paresthesia, fear, and epigastric sensation), characterized the ictal semiology in 75% of patients. In 50%, autonomic manifestations were present and in 56% subjective manifestations were reported. The 50% of the patients underwent SEEG with insular sampling to better define the epileptogenic zone. In all patients, the insular cortex was always part of the epileptogenic zone, and tailored resections also involved, with variable degree, the frontal, parietal, and temporal opercula. Preoperatively, the neuropsychological assessment revealed impairments in specific cognitive functions and mild or moderate cognitive compromise in 88% of the patients. Postoperatively, one patient had permanent slight hemiparesis. At the most recent follow-up (median 39 months), seizure outcome was satisfactory in 69% of patients: seven patients were completely seizure-free (Engel class Ia), two were free of disabling seizure (class Ic), and two had rare disabling seizures (class II). The cognitive functioning remained unchanged in 62%, and improved in 38%. The assessment of perisylvian/insular epilepsy in children is particularly challenging. However, tailored resections based on a careful presurgical evaluation, including SEEG recording, may lead to a good seizure control and to a better overall outcome.

Flow Diversion for the Treatment of MCA Bifurcation Aneurysms—A Single Centre Experience

Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms. We retrospectively reviewed our prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, we recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up. Our search identified 13 patients (7 males) with an average age of 61.7 years (47-74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5-10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic. In our series, 91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible.

クリッピング困難な脳動脈瘤治療における術中運動誘発電位（MEP）の有用性

The utility of motor evoked potentials (MEPs) for intraoperative neurophysiological monitoring for unclippable complex aneurysms has not been established.The aim of this study was to evaluate and validate the usefulness of intraoperative MEP monitoring in the treatment of complex aneurysms with and without extracranial-intracranial (EC-IC) bypass.From among a group of patients who underwent intraoperative MEP monitoring during surgery for aneurysm, between 2007 and 2014, we retrospectively enrolled 17 consecutive patients with complex aneurysms.Aneurysms were located in the cavernous portion of the internal carotid artery (ICA) in 6, the intracranial portion of the ICA in 6, the anterior cerebral artery in 1, and the vertebral artery in 4 patients. They included 4 large, 7 thrombosed, and 6 dissecting aneurysms. All were treated with parent artery occlusion with or without EC-IC bypass, which included 7 high-flow bypass procedures with radial artery grafting, and 7 low-flow bypass procedures. Of the 17 patients, 6 showed transient or permanent MEP changes. Four of 6 patients showed MEP changes due to temporary occlusion of the recipient artery during bypass construction. However, these changes were reversed by substitution of the recipient artery, intentional hypertension, and shortening of occlusion time. Two patients demonstrated MEP changes when the parent artery was occluded. In one of those two patients, MEP completely disappeared after parent artery trapping, and this remained unchanged until the completion of the surgery without any modification in obliteration of the parent artery. This patient experienced permanent postoperative hemiparesis. The second patient showed significant changes in MEP during temporary ICA occlusion, which however improved after changing the site of occlusion to the common carotid artery (CCA).In conclusion, intraoperative MEP monitoring has a useful role in the treatment of complex aneurysms—in the selection of the safest and most appropriate recipient artery for EC-IC bypass, and choosing the most appropriate point for occlusion of the parent artery.

Contemporary management of carotid blowout syndrome utilizing endovascular techniques

To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS). Retrospective chart review. Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied. Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable. The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist. 4. Laryngoscope, 2016 127:383-390, 2017.

P2Y12 hyporesponse (PRU>200) is not associated with increased thromboembolic complications in anterior circulation Pipeline

IntroductionRecent reports suggest that thromboembolic complications are associated with Pipeline embolization device (PED) placement cluster in P2Y12 hyporesponders.ObjectiveTo evaluate the role of P2Y12 hyporesponse in PED placement by retrospectively reviewing...

Recurrent Stroke-Like Episodes in FBXL4-Associated Early-Onset Mitochondrial Encephalomyopathy

Mutations in the FBXL4 gene have been recently identified as the cause of early-onset mitochondrial encephalomyopathy (EOMEM, OMIM #615471).1,2 Progressive supratentorial and cerebellar atrophy are known manifestations (Figure A); strokelike episodes, although well described in mitochondrial encephalopathy, lactic acidosis, and strokelike episodes (MELAS), however, have not yet been reported with this entity. We document two strokelike episodes in a 13-year-old girl with genetically confirmed FBXL4 (p.[Gln106*]; [Gly568Ala])-associated EOMEM. At age 10 years, she suffered a large right-hemispheric stroke crossing vascular territories and resulting in significant damage with permanent left-sided hemiparesis (Figure B-C). A contralateral left-

Complications of spinal fluid drainage in thoracic and thoracoabdominal aortic aneurysm surgery in 724 patients treated from 1987 to 2013.

To study complications from spinal fluid drainage in open thoracic/thoracoabdominal and thoracic endovascular aortic aneurysm repairs to define risks of spinal fluid drainage. Retrospective, prospectively maintained, institutionally approved database. Single institution university center. 724 patients treated from 1987 to 2013 INTERVENTIONS: The authors drained spinal fluid to a pressure≤6 mmHg during thoracic aortic occlusion/reperfusion in open and ≤8 mmHg after stent deployment in endovascular procedures. Low pressure was maintained until leg strength was documented. If bloody fluid appeared, drainage was stopped. Head computed tomography (CT) and, if indicated, spine CT and magnetic resonance imaging (MRI) were performed for bloody spinal fluid or neurologic deficit. Spinal fluid drainage was studied for bloody fluid, CT/MRI-identified intracranial and spinal bleeding, neurologic deficit, and death. Seventy-three patients (10.1%) had bloody fluid; 38 (5.2%) had intracranial blood on CT. One patient had spinal epidural hematoma. Higher volume of fluid drained and higher central venous pressure during proximal clamping were associated with intracranial blood. Most patients with intracranial blood were asymptomatic. Six patients had neurologic deficits: of the 6, 3 died (0.4%), 1 (0.1%) had permanent hemiparesis, and 2 recovered. Three of the six deficits were delayed, associated with heparin anticoagulation. 10% of patients had bloody spinal fluid; half of these had intracranial bleeding, which was almost always asymptomatic. In these patients, immediately stopping drainage and correcting coagulopathy may decrease the risk of serious complications. Neurologic deficit from spinal fluid drainage is uncommon (0.8%), but has high morbidity and mortality.

SUTURELESS AORTIC VALVE REPLACEMENT USING THE PERCEVAL S PROSTHESIS: SHOULD BICUSPID DISEASE BE A CONTRAINDICATION?

Sutureless aortic valve replacement (AVR) is a relatively new technique for the treatment of aortic stenosis. Bicuspid aortic valve is generally considered a contraindication to sutureless AVR. The aim of this study was to evaluate the feasibility and perioperative outcomes of this technique in patients with bicuspid aortic disease. Between June 2011 and January 2014, 25 patients with aortic bicuspid disease underwent sutureless AVR. Data were collected from preoperative and postoperative transthoracic echocardiography reports (maximum 28 days post-op) and from intensive care unit charts. Surgical approach consisted in a median sternotomy in 13 patients (52%), partial sternotomy in 5 (20%) and minithoracotomy in 7 (28%). Due to advanced age and presence of comorbidities, these patients were selected for AVR. Sutureless AVR was successfully performed in all patients (n=25, 100%). The study population included 17 (68%) male and 8 (32%) female, with a median age of 77.8 ± 5.4 years old. Eleven (44%) of these patients had a preoperative New York Heart Association functional class of III-IV/IV. The mean Euroscore II was 3.4 ± 2.6 %. Concomitant procedures included CABG in 8 patients (32%), ascending aortic replacement in 2 (8%), mitral valve repair in 1 (4%), septal myomectomy in 1 (4%) and atrial septal defect closure in 1 (4%). Mean aortic cross-clamp time was 46 ± 14 minutes in patients who had sutureless AVR alone and 56 ± 14 minutes in those who had concomitant procedures. Mean trans-aortic valve gradient decreased from an average of 49.4 ± 15.7 mmHg preoperatively to 14.5 ± 5.4 mmHg postoperatively. Mean aortic valve area increased from 0.78 ± 0.18 cm2 preoperatively to 1.75 ± 0.43 cm2 postoperatively. Five patients suffered from atrio-ventricular block requiring permanent pacemaker implantation. Two patients suffered from stroke, one of which resulted in permanent hemiparesis. There was no paravalvular leak at the pre-discharge TTE. No postoperative valve migration or embolization was reported. In-hospital mortality occurred in one patient (4%). Mean ICU length of stay was 3 ± 2 days postoperatively. This study demonstrates that Perceval S sutureless valve can be deployed in patients with bicuspid aortic disease without increasing the risk of paravalvular leak, allowing short cross-clamp times, satisfactory postoperative mean trans-aortic gradients and good perioperative mortality and morbidity, considering the high baseline risk status of this population. Bicuspid aortic valve disease should not be considered a contraindication to sutureless AVR.

E-052 Initial Institutional Experience with the Sceptre XC Balloon for the Endovascular Treatment of Cerebral Aneurysms

Background and purposeThe Sceptre XC balloon is a novel extra-compliant dual-lumen balloon microcatheter designed for the endovascular treatment of cerebral aneurysms and arteriovenous malformations. This study aims to describe our...

4. Usefulness of new protocol for stable monitoring of transcranial MEP in aneurysm surgery

We examined the usefulness of a new protocol for stable monitoring of transcranial (TC) motor evoked potential (MEP) in aneurysm surgery. Data of TC stimulation MEP were compared with those of direct cortical (DC) stimulation MEP which had been considered the gold standard in aneurysm surgery. The study included 177 patients (ruptured 66, unruptured 111) who underwent aneurysmal clipping between September 2009 and April 2013. In all patients both TC and DC stimulations were used for MEP monitoring. After introduction of anaesthesia, TC MEP was recorded every 10 min. Stimulation strength of TC MEP was set + 20% of stimulation threshold, since stimulation thresholds fluctuated due to craniotomy and aspiration of cerebrospinal fluid. After dural opening, a strip electrode with 16 contacts was inserted subdurally. Stimulation strength of DC MEP was set + 2 mA of stimulation threshold. Thereafter both stimulations were used to record MEPs every ten minutes. In both stimulations, electromyograms of contralateral thenar muscle were recorded. TC MEP was recorded in all patients, while DC MEP could not be recorded in 18 patients (10%), mainly due to subdural resistance. The threshold of TC MEP was decreased after craniotomy and increased after CSF suction significantly. In 22 patients both MEPs disappeared after temporary occlusion or aneurysmal clipping. In 20 of these patients both MEPs recovered after release of temporary occlusion or clipping. In the remaining 2 patients MEPs did not recover. Consequently these two patients developed permanent hemiparesis (MMT 4/5). TC MEP was recorded in all cases and paralleled changes with DC MEP, suggesting TC MEP alone is enough to monitor MEP. Our new protocol of TC MEP is useful for stable monitoring in aneurysm surgery.

Controversies in the role of preoperative embolization in meningioma management

The role of preoperative embolization in meningioma management remains controversial, even though 4 decades have passed since it was first described. It has been shown to offer benefits such as decreased blood loss and "softening of the tumor" during subsequent resection. However, the actual benefits remain unclear, and the potential harm of an additional procedure along with the cost of embolization have limited its use to a small proportion of the meningiomas treated. In this article the authors retrospectively reviewed their experience with preoperative embolization of meningiomas over the previous 6 years (March 2007-March 2013). In addition, they performed a MEDLINE search using a combination of the terms "meningioma," "preoperative," and "embolization" to analyze the indications, embolizing agents, timing, and complications reported during preoperative embolization of meningiomas. In this retrospective review, 18 cases (female/male ratio 12:6) were identified in which endovascular embolization was used prior to resection of an intracranial meningioma. Craniotomy for tumor resection was performed within 4 days after endovascular embolization in all cases, with an average time to surgery of 1.9 days. The average duration of surgery was 4 hours and 18 minutes, and the average blood loss was 574 ml, with a range of 300-1000 ml. Complications following endovascular therapy were identified in 3 (16.7%) of 18 cases, including one each of transient hemiparesis, permanent hemiparesis, and tumor swelling. The literature review returned 15 articles consisting of a study population greater than 25 patients. No randomized controlled study was found. The use of small polyvinyl alcohol particles (45-150 μm) is more effective in preoperative devascularization than larger particles (150-250 μm), but is criticized due to the higher risk of complications such as cranial nerve palsies and postprocedural hemorrhage. Time to surgery after embolization is inconsistently reported across the articles, and conclusions on the appropriate timing of surgery could not be drawn. The overall complication rate reported after treatment with preoperative meningioma embolization ranges from as high as 21% in some of the older literature to approximately 6% in recent literature describing treatment with newer embolization techniques. The evidence in the literature supporting the use of preoperative meningioma embolization is mainly from case series, and represents Level III evidence. Due to the lack of randomized controlled clinical trials, it is difficult to draw any significant conclusions on the overall usefulness of preoperative embolization during the management of meningiomas to consider it a standard practice.

Intraoperative High Frequency Ultrasound in Intracerebral High-Grade Tumors

To demonstrate the utility of a new concept of intraoperative use of high frequency ultrasound (hfioUS) in maximizing the extent of resection (EOR) of intracerebral high-grade tumors. 22 Patients harboring an intracerebral high-grade tumor were retrospectively included in this study (14 primary tumors, 8 metastasis). 14 of them had a perilesional edema equal or greater to lesion volume, 3 had previously received radiotherapy. Following macroscopic tumor debulking, the small (11 × 31 mm) L15 - 7io (Philips, Bothell, USA) high-frequency probe (7 - 15 MHz) was introduced into the resection cavity and its walls were meticulously scanned to search for tumor remnants. Postoperative MR scan was evaluated by a board-certified independent neuroradiologist, who assessed the EOR. Gross total resection was achieved in 21 patients (95.5 %). One patient had a small tumor remnant (6 × 4 × 3 mm) of a very large (80 × 60 × 74 mm) anaplastic astrocytoma, detected in the postoperative MR scan. A permanent postoperative hemiparesis was diagnosed in one patient with a metastasis in the motor area, while the other patients recovered without permanent neurological deficits from the surgery. The hfioUS probe allowed in this study a precise detection of the tumor and a detailed discrimination between normal, pathological and edematous tissue in all 22 cases.

Vascular complications of stereotactic radiosurgery for arteriovenous malformations

ObjectiveAlthough vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience. MethodsOur review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies. ResultsAfter a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage. ConclusionWhile radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.

Surgical treatment of insular tumours with tractography, functional magnetic resonance imaging, transcranial electrical stimulation and direct subcortical stimulation support

Background and purposeSurgical treatment of insular tumours carries significant risks of limb paresis or speech disturbances due to their localization. The development of intraoperative neuromonitoring techniques that involve evoked motor potentials induced via both direct and transcranial cortical electrical stimulation as well as direct subcortical white matter stimulation, intraoperative application of preoperative tractography and functional magnetic resonanceimaging (fMRI) in conjunction with neuronavigation resulted in significant reduction of postoperative disabilities that enabled widening of indications for surgical treatment. The aim of this study was to present the authors’ own experience with surgical treatment of insular gliomas. Material and methodsOur cohort comprises 30 patients with insular gliomas treated at the Department of Neurosurgery in Sosnowiec. Clinical symptoms included sensorimotor partial seizures in 86.6%; generalized seizures in 23.3%; persistent headaches in 16.6% and hemiparesis in 6.6%. All the patients were operated on with intraoperative neuromonitoring that included transcranial cortical stimulation, direct subcortical white matter stimulation as well as tractography and fMRI concurrently with neuronavigation. The analysis included postoperative neurological evaluation along with the assessment of the radicalism of resection evaluated based on postoperative MRI. ResultsPostoperatively, four patients had permanent hemiparesis (13.3%); importantly, two out of those patients had preoperative deficits (6.6%). Persistent speech disturbances were present in four patients (13.3%). Partial sensorimotor seizures were noted in two patients (6.6%). Seizures in the other patients receded. Intraoperative transcranial electrical stimulation as well as direct subcortical white matter stimulation along with tractography (DTI) and fMRI facilitated gross total resection of insular gliomas in 53.5%, subtotal in 13.3% and partial resection in 33.1%. ConclusionsImplementation of TES, direct subcortical white master stimulation, DTI and fMRI into the management protocol of the surgical treatment of insular tumours resulted in total and subtotal resections in 66% of cases with permanent motor disability in 6.6% of patients. Poor prognosis for independent living after surgery mainly affects patients with WHO grade III or IV.

The place for surgical treatment for AVM involving the temporal lobe

The objective of this study was to analyze preoperative symptoms and late clinical outcomes in patients who underwent surgical treatment of arterio-venous malformations (AVMs) of the temporal lobe, including those involving the Sylvian fissure (SF) and the lateral wall of the inferior ventricular horns-with special respect to postoperative hemiparesis and visual field defects (VFD). Between 1990 and 2007, 44 patients (n = 22 women, n = 22 men) with a mean age of 41 (12-67) years were operated on an AVM of the temporal lobe. All data had been collected prospectively. Patients' charts, as well as surgical reports and outpatient files, were analyzed. Thirteen patients showed an involvement of the SF, and six were localized partially in the lateral wall of the temporal horn. Eight AVMs were located in the temporo-mesial region. Fourteen patients had an AVM located mainly within the visual pathway. In 24 cases, the AVM was located in the dominant hemisphere. The AVMs were classified by the Spetzler-Martin grading system (SM). Visual fields were assessed in all patients pre- and postoperatively by independent ophthalmological examiners. The initial symptoms leading to the diagnosis of the AVM were seizures in 20 cases (45%), headache without hemorrhage in six cases (14%), incidental finding in five cases (11%), and tinnitus in two cases (5%). Hemorrhage had occurred in 15 cases (34%). Based on SM, 7 AVMs were grade I, 17 grade II, 17 grade III, and 3 grade IV. Preoperatively, seven patients presented with a VFD and two with a hemiparesis. Postoperatively, 8 of 44 (18%) patients presented with a new hemiparesis, remaining permanent in 3 of 44 (7%). In two of these patients, the AVMs were localized temporo-mesially (n = 2/8, 25%). Seven patients (19%) showed a new significant postoperative VFD, and in addition, three patients had worsening of their preexisting VFD (3/7, 43%). Postoperative angiography verified complete AVM occlusion in 43 of 44 (98%) cases. One patient needed reoperation for residual AVM; hence, in all patients, complete occlusion before discharge was achieved. Treatment of temporal lobe AVMs is demanding due to their close spatio-anatomical relationship with important neurovascular structures and the optic radiation. In this surgically treated series, morbidity for a new permanent hemiparesis was 7% and preservation of the visual field could be achieved in almost 90% of all cases. This is a calculable risk for most patients that renders microsurgical resection a justifiable option, even in light of other treatment modalities. The risk for new permanent motor deficits is elevated in temporo-mesial AVMs, and these patients have to be advised accordingly for surgical treatment.

Utility and the Limit of Motor Evoked Potential Monitoring for Preventing Complications in Surgery for Cerebral Arteriovenous Malformation

To evaluate the usefulness of motor evoked potential (MEP) monitoring and mapping in arteriovenous malformation surgery. Intraoperative MEP monitoring was performed in 21 patients whose AVMs were located near the motor area or fed by arteries related to the corticospinal tract to detect blood flow insufficiency and/or direct injury to the corticospinal tract and/or to map the motor area. In 4 of 16 patients monitored for blood flow insufficiency, the MEP changed intraoperatively. In 2 patients, the changes were attributable to temporary occlusion of the feeding artery (anterior choroidal or lenticulostriate artery): 1 patient had a venous infarction around the internal capsule caused by thrombosis of the draining vein and the other bled intraoperatively from the nidus. In 17 patients, the MEP was monitored to rule out direct injury. In 1 patient, the MEP changed on coagulation of fragile vessels around the nidus in the precentral gyrus; it recovered after coagulation was discontinued. In 1 of 5 patients with MEP changes, the MEP did not recover; permanent hemiparesis developed in this patient because of venous infarction. In 1 of 11 patients subjected to MEP mapping of the motor area, we found translocation to the postcentral sulcus. In arteriovenous malformation surgery, MEP monitoring facilitates the detection of blood flow insufficiency and/or direct injury of the corticospinal tract and mapping of the motor area. It contributes to reducing the incidence of postoperative motor paresis.