Showing papers in "British Journal of Neurosurgery in 2013"
TL;DR: A small but significant number of patients appear to improve clinically following cranioplasty, and the so-called syndrome of the trephined may be more common than had been previously appreciated.
Abstract: Objectives. To assess changes in neurological function after cranioplasty. Methods. Functional and neurocognitive assessments including activities of daily living assessment, functional independence measure (FIM) and the Cognitive assessment report (COGNISTAT) were conducted on all patients within 72 h before and 7 days after cranioplasty. A change in the total FIM score of 2 points was taken to be clinically significant. Results. Assessments were performed on 25 patients. The functional status was unchanged in eighteen patients (72%), four patients (16%) demonstrated a significant improvement and three patients (12%) deteriorated significantly. Those with deterioration after cranioplasty had some forms of complications including pneumocephalus or seizure. After excluding the three patients who had immediate medical or surgical complications after surgery, there was a mild overall improvement in the mean FIM score (2.1, 95% confidence interval 0.1–4.3, p = 0.049), mainly due to an improvement in t...
99 citations
TL;DR: Implant extrusions were found to be associated with infection of the implant, and they should therefore be treated early as patients with neurological deficits were susceptible to seizures and infection.
Abstract: Introduction. Cranial reconstruction with a cranioplasty is performed to repair skull defects after decompressive craniectomies. Aims. To retrospectively review all cranioplasties performed in our institution over 10 years and analyse the complications and the factors that cause complications. Patient and methods. Two hundred and forty-three cranioplasties were performed from 2000 to 2010, with a follow-up of at least 1 year. Age, sex, comorbidities, material, site of skull defect, time between decompression and cranioplasty, and rate of complications were collected from our database. Fischer's T-test and direct logistical regression were performed to identify factors that contributed to the rate of complications. p < 0.05 was considered significant. Results. Post-cranioplasty seizures (14.81%), infection and exposed implant (9.05%), haemorrhage (1.65%) and others (0.82%) were identified complications. Total percentage of complications was 25.92%. Previous trauma (p = 0.034) and intracranial haemo...
90 citations
TL;DR: The results suggest that Cerebrolysin improves the cognitive function of the MTBI in patients at 3rd month after injury, especially for long-term memory and drawing function.
Abstract: In adults, mild traumatic brain injury (MTBI) frequently results in impairments of cognitive functions which would lead to psychological consequences in the future. Cerebrolysin is a nootropic drug, and can significantly improve cognitive function in patients with Alzheimer's disease and stroke. The purpose of this study was to investigate how Cerebrolysin therapy enhances cognitive recovery for mild traumatic brain injury patients using a double-blinded, placebo-controlled, randomized phase II pilot study. Patients having head injury within 24 h sent to our hospital were screened and recruited if patients were alert and conscious, and had intracranial contusion haemorrhage. From July 2009 to June 2010, totally, thirty-two patients were recruited in the double-blinded, placebo-controlled, and randomized study. Patients were randomized to receive Cerebrolysin (Group A, once daily intravenous infusion of 30 mL Cerebrolysin over a 60-min period for 5 days) or placebo (Group B, same dosage and administration of normal saline as Group A). The primary outcome measures were differences of cognitive function including Mini-Mental Status Examination (MMSE), and Cognitive Abilities Screening Instrument (CASI) scores between baseline and week 1, between baseline and week 4, and between baseline and week 12. Thirty-two patients completed the trial. For Group A, the CASI score difference between baseline and week 12 was 21.0 ± 20.4, a significantly greater change than that of Group B (7.6 ± 12.1) (p = 0.0461). Besides, drawing function (one of the domains of CASI; p = 0.0066) on week 4 and both drawing function (p = 0.0472) and long-term memory (one of the domains of CASI; p = 0.0256) on week 12 were also found to be significantly improved in the patients receiving Cerebrolysin treatment. Our results suggest that Cerebrolysin improves the cognitive function of the MTBI in patients at 3rd month after injury, especially for long-term memory and drawing function.
68 citations
TL;DR: The first Australian study to evaluate a single surgeon's experience by comparing their results with other series and attempting to identify a learning curve was presented in this article, where a retrospective analysis was carried out on 79 consecutively treated patients by fully endoscopic transsphenoidal surgery by a single neurosurgeon over a period spanning from July 1998 to September 2010 at St George Public and Private hospitals.
Abstract: Endoscopic transsphenoidal surgery for pituitary adenomas has been introduced as an alternative to transsphenoidal microsurgery. This is the first Australian study to evaluate a single surgeon's experience by comparing our results with other series and attempting to identify a learning curve. Retrospective analysis was carried out on 79 consecutively treated patients by fully endoscopic transsphenoidal surgery by a single neurosurgeon over a period spanning from July 1998 to September 2010 at St George Public and Private hospitals. The mean age at time of surgery was 56.7 years (SD ± 16.3, range 26–85) and the mean follow-up period was 38.2 months (SD ± 33, range 1–136). Gross total resection (GTR) was noted in 63% of patients, endocrinological cure was achieved in 53% and visual field improvements were noted in 86% of patients. Intra-operative CSF leaks occurred in 19% of procedures, while the rates of post-operative CSF rhinorrhea was 3% and post-operative diabetes insipidus was 13%. There was o...
56 citations
TL;DR: This meta-analysis showed a slight increased risk of death in patients with blunt head trauma who were taking pre-injury antiplatelet agents although the results did not reach statistical significance.
Abstract: Introduction. Anticoagulation abnormalities have been recognized for several decades as potential risk factors for increasing the risk of traumatic intracranial haemorrhage in patients with blunt head trauma. The potential increased risk of death as a consequence has not been fully evaluated. The aim of the study was to perform a meta-analysis in order to evaluate based upon the current level of evidence whether the use of pre-injury aspirin or clopidogrel increases the risk of mortality in patients with blunt head trauma. Methods. The databases Medline and EMBASE were searched via the Ovid interface. The Medline database was also searched using the PubMed interface. Case control studies or nested case control studies were identified comparing mortality rates on patients with blunt head trauma in patients on aspirin or clopidogrel against patients not on antiplatelet agents. Results. Five studies in total were identified as suitable for the meta-analysis. Four of these studies were suitable for th...
54 citations
TL;DR: Surgical treatment of spheno-orbital en plaque meningiomas is safe and effective: a low morbidity rate was recorded and visual function improved in about two-thirds of patients, allowing to minimise surgical morbidity and to achieve tumour control.
Abstract: Objective. The clinical results of combined surgical–radiosurgical treatment of the spheno-orbital en plaque meningiomas in a consecutive series of 40 patients are presented. The clinical outcome is evaluated in terms of surgical morbidity, tumour control, visual function and cosmetic result. Methods. Forty patients harbouring spheno-orbital en plaque meningiomas were treated. Forty-two surgical procedures were performed through a fronto-temporal craniotomy. The reconstruction of the orbital walls was performed using a titanium mesh. In case of sub-total resection, the patients underwent Gamma-Knife radiosurgery on residual tumour. Visual function was evaluated considering visual acuity tested with a Snellen chart, funduscopy and Goldmann perimetry for visual field defects. Proptosis was quantified on CT scans. Results. Total or gross-total tumour resection was achieved in 56.1% of cases. Permanent morbidity was recorded in three patients after surgery. Visual acuity and visual field defect both i...
51 citations
TL;DR: High-resolution ultrasound, QST and NCV testing is suitable for early diagnosis of DPN, and abnormal QST is an indication of lower extremity nerve decompression for DPN.
Abstract: Objective. To evaluate the value of high-resolution ultrasonography and neural electrophysiology in early diagnosis, operative opportunity selection, and clinical effect assessment of DPN. Methods. Five hundred and sixty patients with diabetic peripheral neuropathy (DPN) were treated with DELLON surgical nerve decompression in our hospital in the past 5 years. Before and after 18 months surgery, the tests of the Toronto clinical scoring system, high-resolution ultrasonography, QST, and Nerve Conduction Velocity (NCV) were evaluated in all cases. The control group included 40 diabetic patients in the same age range but without DPN. Results. Ultrasonographic images revealed an apparently normal proximal common peroneal nerve, tibial nerve marked swelling, enlarged, and hypoechogeneity with loss fascicular pattern. The cross-sectional-area, anteroposterior and transverse diameter were measured preoperative and prooperative, and the differences had statistical significance（P < 0.01）. NCV-positive case...
47 citations
TL;DR: There was benefit of simvastatin in terms of reduction in clinical vasospasm, mortality or improved functional outcome, however, this was not statistically significant.
Abstract: Background. Vasospasm plays a major role in the morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The preliminary studies suggest that statins protect against cerebral vasospasm. Objective. The aim of the study was to determine the role of simvastatin in preventing clinical vasospasm and improving functional outcome in patients with aSAH. Methods. All patients with aSAH admitted within 96 h of ictus were randomized to receive either Simvastatin or placebo – 80 mg/day for 14 days. Thirty eight patients were recruited in the study- 19 received Simvastatin and 19 placebo. All the patients underwent surgical clipping of the aneurysm. The primary outcome of the study was the development of clinical cerebral vasospasm. The secondary outcomes included Glasgow Outcome Score (GOS), Modified Rankin Scale (MRS) and Barthel Index Score (MBI) at follow-up at 1, 3 and 6 months. Results. 16% of the patients in the simvastatin group had high Middle Cerebral Artery velocities (> 160 cm/sec) ...
47 citations
TL;DR: Digital rectal examination has no significant value in the acute diagnosis of cauda equina syndrome and there is no discreet clinical protocol applicable with which to confidently confirm or rule out this diagnosis.
Abstract: Purpose. This study aims to quantify the value of digital rectal examination (DRE) in the clinical diagnosis of cauda equina syndrome. Methods. A retrospective case note review was performed on all patients referred to a University Teaching Hospital over a one-year period with documented suspicion of cauda equina syndrome. All Patients underwent MRI scanning to either confirm or rule out the diagnosis. Results. Fifty-seven such patients were identified, 13 (23%) of whom had confirmation of cauda equina syndrome on MRI scanning. The DRE did not significantly discriminate for the outcome of MRI (p = 0.897, test accuracy 51%, diagnostic odds ratio 1.42). There was no correlation between the cumulative number of positive clinical findings in an individual patient and the likelihood of MRI diagnosis and no significant link between any individual clinical feature and the MRI result. Conclusions. Digital rectal examination has no significant value in the acute diagnosis of cauda equina syndrome. This stu...
45 citations
TL;DR: There is significant uncertainty as to the optimal surgical technique for primary evacuation of ASDH, and the majority of the respondents are willing to become collaborators in the planned RESCUE-ASDH trial, highlighting the relevance of this important subject to the neurosurgical community in the UK and Ireland.
Abstract: Introduction. Uncertainty remains as to the role of decompressive craniectomy (DC) for primary evacuation of acute subdural haematomas (ASDH). In 2011, a collaborative group was formed in the UK with the aim of answering the following question: “What is the clinical- and cost-effectiveness of decompressive craniectomy, in comparison with craniotomy for adult patients undergoing primary evacuation of an ASDH?” The proposed RESCUE-ASDH trial (Randomised Evaluation of Surgery with Craniectomy for patients Undergoing Evacuation of Acute Subdural Haematoma) is a multicentre, pragmatic, parallel group randomised trial of DC versus craniotomy for adult head-injured patients with an ASDH. In this study, we used an online questionnaire to assess the current practice patterns in the management of ASDH in the UK and the Republic of Ireland, and to gauge neurosurgical opinion regarding the proposed RESCUE-ASDH trial. Materials and methods. A questionnaire survey of full members of the Society of British Neuro...
45 citations
TL;DR: Early results suggest that endoscopic trans-sphenoidal surgery provides favourable results in both tumour resection and control of secreting tumours in comparison with microscopic surgery.
Abstract: Introduction Pituitary surgery has seen a recent shift from a microscopic to an endoscopic trans-sphenoidal approach We present our early experience with endoscopic surgery and compare the outcome with our recent microscopic experience Methods From January 2008 until present time, 80 consecutive patients underwent trans-sphenoidal pituitary surgery in our institution Until September 2009, all patients had a microscopic trans-septal approach After this time, the patients underwent endoscopic trans-sphenoidal surgery All patients underwent pre- and post-operative MRI and full endocrinological evaluation Data was collected prospectively including tumour volume, endocrine function, visual function, length of stay and complications Results There were 40 patients in each group In the microscopic group, there were 26 non-functioning tumours and 14 functioning tumours In the endoscopic group, there were 24 non-functioning and 16 functioning tumours There were significantly better results in t
TL;DR: Hematoma volume, preoperative GCS score, and ICH score are of predictive value for surgical outcome of large basal ganglia hemorrhage, and DC can be used for patients with low preoperativeGCS score and effectively reduces ICP and 30-day mortality.
Abstract: Objectives. Spontaneous intracerebral hemorrhage (ICH) is a challenge to both neurologists and neurosurgeons. We aim to summarize the surgical treatment of ICH based on retrospective analysis of our patients. Methods. Two hundred and fifty-three patients with spontaneous ICH from August 2008 to August 2011 were retrospectively analyzed. Clinical data, including preoperative ICH score, pre- and postoperative GCS score, hematoma volume, postoperative brain infarction, 30-day mortality, and GOS 3 months postictus, were collected. One hundred and fifty patients had their intracranial pressure (ICP) monitored, and data were recorded and analyzed. All patients underwent craniotomy and clot removal under general anesthesia. Outcome analysis was stratified using hematoma volume, ICH score, preoperative GCS score, and decompressive craniectomy (DC). Results. The mean hematoma volume was 70.8 mL, and 68 patients (26.9%) underwent DC. The mean postoperative ICP was 28.8 ± 6.7 mmHg for patients without DC, an...
TL;DR: Treatment of cystic craniopharyngioma by drainage through an ORS is very effective and the majority of patients do not need any further treatment and those who develop re-accumulated cystic fluid are easily treated by simple aspiration of the fluid through the reservoir.
Abstract: Background Surgical removal (gross total or partial removal), radiotherapy and cyst evacuation have all been used individually or in combination to treat cystic craniopharyngioma, although it is unclear which is the best method Objective To report the results of treating cystic craniopharyngioma by insertion of an Ommaya reservoir system (ORS) and aspiration of the cyst Patients and methods As from 1990, patients admitted to the neurosurgical department at Assiut University Hospital, Egypt, with grossly cystic craniopharyngioma and who had a single cyst and did not have previous surgery were treated by insertion of an ORS and drainage of the cyst By 2010, 52 patients had received this treatment with the cystic fluid aspirated completely on the day of surgery The main presenting symptoms were raised intracranial pressure and visual changes with hormonal changes observed in some patients The minimal follow-up period was 7 years Results To our surprise, 38 (73%) patients did not develop any
TL;DR: A longer period of mandatory bed rest does not decrease the rate of complications, and patients should be mobilised as soon as they can to reduce the length of hospital stay and the cost of aftercare.
Abstract: Introduction. An accidental durotomy is a recognised and not infrequent complication of lumbar spine surgery, and may lead to postoperative low-pressure headaches, pseudomeningocele and CSF leak. Conventional postoperative management involves a period of flat bed rest. There is no agreement as to the need for and duration of postoperative bed rest. This study aims to determine whether the duration of flat bed rest alters the rate of these complications. Materials and methods. This is a retrospective study. All patients who underwent surgery for degenerative spinal disease between May 2010 and May 2011 were reviewed. All patients who incurred an accidental durotomy and who were repaired using fibrin glue were included in this study. Their notes were reviewed for evidence of complications for a minimum of 12 months after surgery. The following complications were identified: postural headache, pseudomeningocele, CSF leak wound infection, subdural haematoma. Results. Eight hundred and eighty-nine pati...
TL;DR: A comprehensive review of the literature on CHS after revascularization in MMD patients is presented, focusing on the pathogenesis, clinical features, imaging techniques, treatment, and prognosis of CHS.
Abstract: Moyamoya disease (MMD) is a progressive occlusive disease of the distal internal carotid artery that is primarily treated by superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Despite its effectiveness, several postoperative complications have been reported with STA-MCA bypass. Cerebral hyperperfusion syndrome (CHS) after STA-MCA has attracted considerable attention as a hemodynamics-related complication because more cases of CHS after STA-MCA bypass are reported in MMD than in non-MMD patients. The mechanisms underlying CHS after revascularization in MMD patients are poorly understood. This report presents a comprehensive review of the literature on CHS after revascularization in MMD patients, focusing on the pathogenesis, clinical features, imaging techniques, treatment, and prognosis of CHS. Impaired cerebrovascular autoregulation has been implicated in the pathogenesis of CHS, which is characterized by unilateral headache, face and eye pain, seizures, and focal neurological deficits secondary to cerebral edema, and intracranial hemorrhage. Imaging techniques, such as single photon emission computed tomography (SPECT), 3-T magnetic resonance imaging/angiography, and selective arterial spin-labeling magnetic resonance imaging, are valuable for identifying patients at risk for CHS. Treatment strategies include strict blood pressure control, intracranial hemorrhage prevention, and free oxygen radical scavenger administration. Most patients can achieve a satisfying prognosis after effective treatment.
TL;DR: By combining anatomical (DTI-FT) and functional (subcortical DES) studies for intraoperative localization of the PT, the authors achieved a good volumetric resection of tumours located in eloquent motor areas, with low morbidity.
Abstract: Introduction. For gliomas, the goal of surgery is maximal tumour removal with the preservation of neurological function. We evaluated the contribution of the combination of diffusion tensor imaging-based fibre tracking (DTI-FT) of the pyramidal tract (PT) integrated to the navigation and subcortical direct electrical stimulations (DESs) to surgical outcomes. Method. Ten patients underwent surgery for gliomas located in close relationship with the subcortical course of the PT. Preoperative DTI was performed with a three-Tesla magnetic resonance scanner applying an echo-planar sequence with 20 diffusion directions. DTI-FT data were systematically loaded into the navigation for intraoperative guidance. When the resection closely approached the PT as illustrated on navigation images, subcortical DESs were used to confirm the proximity of the PT by observing motor responses. The location of all subcortically stimulated points with positive motor response was correlated with the illustrated PT. Motor de...
TL;DR: A retrospective long-term study confirms the relatively favourable prognosis associated with PXA, with young patients with a low-grade tumour who underwent GTR carry the longest OS and PFS.
Abstract: Background. Pleomorphic Xanthoastrocytoma (PXA) is a rare brain tumour, most commonly affecting children and young adults. To date, only few data regarding the long-term follow-up of these patients after surgery are available. The aim of this study is to describe our single-institution experience in the surgical management of this particular glioma over a period of over 18 years. Methods. We performed a retrospective review of all cases of PXA (40 patients) operated upon at the Department of Neurosurgery of Verona, Italy, between 1990 and 2008. The impact of clinical, radiological, surgical and histological factors on overall survival (OS) and progression-free survival (PFS) was analysed by means of univariate and multivariate models. Findings. We achieved a gross total resection (GTR) in 65% of patients. Histological diagnosis was of grade II in 80%; anaplastic features were present in the remaining 20%. Adjuvant treatment, radiotherapy or chemo-radiotherapy, was administered in 40% of the cases....
TL;DR: Robot-guided depth electrodes implantation for stereotactic electroencephalography is a less invasive technique that allows accurate implantation of multiple deep brain electrodes along predefined trajectories, and has not been associated with any major surgical complications in the initial experience.
Abstract: We describe the operative technique and our preliminary experience with use of the Renishaw neuromate(®) stereotactic robot to implant depth electrodes for investigation of focal epilepsy in the UK. Conventional electrocorticography involving a craniotomy and implantation of grids of electrodes directly onto the brain surface is invasive and carries a high risk of major complications such as acute subdural haematoma and infection. Robot-guided depth electrodes implantation for stereotactic electroencephalography is a less invasive technique that allows accurate implantation of multiple deep brain electrodes along predefined trajectories, and has not been associated with any major surgical complications in our initial experience.
TL;DR: Following pituitary surgery, patients with large tumours, in particular those of young age, are at higher risk for losing control of their plasma sodium level, and postoperative follow-up of patients with sellar tumours should include careful monitoring of plasma sodium levels within the first two postoperative weeks.
Abstract: Objective. Surgical manipulation of the pituitary stalk, neurohypophysis or the hypothalamus may disturb control of the plasma sodium level. The factors that might predict the risk of postoperative sodium imbalance are not clear, and were investigated in this study. Methods. A retrospective survey of 129 surgical records for the occurrence of plasma sodium levels outside the normal range, following transsphenoidal procedures. Median patient age was 49 (range 20–78) years, 65 female. 73 of the operated lesions were non-functioning pituitary adenomas. Patients were considered to have impaired plasma sodium balance if the range of 135–145 mmol/L was not maintained. Results. Of all 129 surgical cases, 68 (53%) experienced an imbalance in sodium levels. Severe sodium imbalance (≥ 149 or ≤ 131 mmol/L) was observed in 28 patients (22%). 13 showed hypernatraemia (median day 1), and 15 hyponatraemia (median day 6). Tumour size was associated with an increased incidence of sodium imbalance, particularly in ...
TL;DR: Recovery to ‘normal’, or ‘incomplete SCI”, is possible with surgical decompression if performed within 12 h, even if the patient is paraplegic pre-operatively, even in patients who were paraplegics pre- operatively.
Abstract: Objective. Spinal epidural haematoma (SEH) causing spinal cord compression is potentially a cause of long-term neurological disability. We reviewed the relevant literature with the intention of establishing the factors that influence long-term outcome and the timeframe within which operative intervention must be undertaken for optimal results. Methods. A total of 1177 papers were identified using PubMed among which 31 papers were selected and analysed. The grades of neurological deficit, pre- and post-operatively, were classified according to the Frankel grade. The timing of surgery was from the onset of first symptoms of incomplete cord lesions and the onset of paraplegia with complete lesions. Results. The two main factors that determine long-term outcome were the degree of neurological deficit at the time of treatment and the timing of surgical intervention. Fifty-six per cent of patients who had ‘incomplete SCI’ made a full neurological recovery as compared to 27% when the initial injury was ‘...
TL;DR: This study demonstrates the long-term efficacy in seizure reduction with the use of VNS, indicating that VNS is a safe and effective treatment for seizure reduction in intractable epilepsy.
Abstract: Data for 100 vagal nerve stimulation (VNS) patients were collected and analysed retrospectively. The mean seizure reduction was 17.86% (n = 67) at 6 months, 26.21% (n = 63) at 1 year, 30.43% (n = 53) at 2 years, 48.10% (n = 40) at 3 years, 49.44% (n = 32) at 4 years, 50.52% (n = 35) at 5 years, 45.85% (n = 31) at 6 years, 62.68% (n = 25) at 8 years, 76.41% (n = 9) at 10 years, 82.90% (n = 4) at 12 years. Evidence of statistical significance for mean seizure reduction over time was strong with all p values less than 0.05 except at 12 years (p = 0.125) where the sample size was small (n = 4). Mean seizure reduction was 49.04% and 51 (51%) patients were considered responders, defined as a 50% or more reduction in seizure frequency. Twenty-one (21%) patients suffered surgical complications. Of these 15 patients were self-limiting and 6 patients were irreversible or required a device revision. Fifty patients (50%) suffered from side-effects, while vagal stimulation cycled on (VNS on) post-operatively. ...
TL;DR: It is possible to identify three invasive phenotypes in Glioblastomas multiformes using Diffusion tensor imaging, and these three phenotypes have different progression free survival.
Abstract: Introduction. Glioblastomas multiformes (GBM) remain incurable in most cases. Their invasion into normal brain makes current therapies ineffective. Post-mortem studies suggest about a 25% of GBMs invade less than 1 cm from the tumour bulk and 20% invade more than 3 cm. Aim of study. The study aims to use DTI to assess tumour extension and determine how previously reported patterns relate to the progression-free survival (PFS). Materials and methods. Twenty-five patients with GBM treated according to the EORTC/NCIC protocol were retrospectively analysed. Patients were imaged post-operatively at 1.5 T. The sequences were composed of standard anatomical and a standard DTI sequence. As described earlier p and q maps were constructed. For each of the p and q maps, regions of interest were drawn around the visible abnormality. Patients were assigned a diffuse, localised or minimally invasive pattern. Progression was defined according to the RANO criteria and PFS determined in days. Kaplan–Meier plots of...
TL;DR: The age of the patient, the volume and the histology of the brain lesion had an impact on the diagnostic yield of needle biopsy, and none of the other factors significantly influenced the diagnostic rate.
Abstract: Introduction. We analyse the factors that are associated with the diagnostic yield of needle brain biopsy. Material and methods. We present a retrospective series of 124 consecutive biopsies in a 30-month period. Patients’ demographics (age, gender), lesion topography (side, location, depth), lesion characteristics (histology, volume, radiological enhancement), type of biopsy procedure (freehand, ultrasound guided, frameless and frame-based stereotactic) and the use of intraoperative histologic examination were correlated with the diagnostic rate. Descriptive statistics and a nominal logistic regression model were used to evaluate the factors influencing diagnostic yield. Results. 63 men and 61 women were included in the study with mean age 59.2 (range: 16–86). 55 were frame-based stereotactic biopsies, 33 were frameless stereotactic biopsies, 29 biopsies were performed under ultrasound guidance and 7 freehand. The diagnostic yield in our series is 93.5%. The gender, lesion topography, biopsy meth...
TL;DR: The increasing number of reports in the literature shows how PGNT forms a good example of a newly diagnosed tumour category in evolution, which will hopefully lead to a narrower diagnostic, prognostic and therapeutic profile.
Abstract: We report two cases of papillary glioneuronal tumour (PGNT). One was located in the supratentorial parenchyma and the other was intraventricular. Both patients underwent gross total resection of their tumour and have returned to normal lifestyle. Papillary glioneuronal tumor is a recently described rare cerebral neoplasm. Recently classified by the World Health Organization in 2007 as a Grade I neuronal-glial tumour, these tumours are infrequent lesions that can be challenging to the practising pathologist. Patients commonly present with headaches or seizures, but may be asymptomatic with the mass discovered incidentally. The characteristic radiological, histological and immunohistochemical features are discussed. Surgical excision has been curative in most of the cases with only a handful of cases of recurrence reported. The increasing number of reports in the literature shows how PGNT forms a good example of a newly diagnosed tumour category in evolution. New classifications and re-classifications of broad categories of brain tumours will hopefully lead to a narrower diagnostic, prognostic and therapeutic profile. The even rarer presence of atypia calls for longer follow-up to help elucidate further its biological behaviour.
TL;DR: In this paper, the prognostic role of O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation in glioblastoma patients treated with carmustine wafer implantation is unclear.
Abstract: The prognostic role of O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation in glioblastoma patients treated with carmustine (BCNU) wafer implantation is unclear. Here, we report on a retrospective study of 47 patients with either newly diagnosed (30 patients) or recurrent (17 patients) glioblastoma (WHO grade IV) treated with BCNU (bis-chloroethylnitrosourea) wafers. Thirteen of the newly diagnosed patients received local BCNU and irradiation only (first-line BCNU), while 17 patients additionally received concomitant and adjuvant temozolomide (TMZ) radiochemotherapy (first-line BCNU + TMZ). Of the 17 patients treated for recurrent glioblastoma (second-line BCNU), 16 had received radiotherapy with concomitant and adjuvant TMZ as an initial treatment. Median overall survival (OS) did not significantly differ between 19 patients with MGMT promoter methylated tumors when compared to 28 patients with unmethylated tumors (18.9 vs 15.0 months; p = 0.1054). In the first-line BCNU + TMZ group, MGMT promoter methylation was associated with longer OS (21.0 vs 11.1 months, p = 0.0127), while no significant survival differences were detected in the other two subgroups. Progression-free survival did not significantly differ between patients with and without MGMT promoter methylated tumors in the entire patient cohort or any of the three subgroups. The first-line BCNU + TMZ group showed no significant difference in OS when compared to the first-line BCNU group (18.9 vs 14.7 months), but tended to have more therapy-related adverse effects (53% vs 24%, p = 0.105). In summary, MGMT promoter methylation showed a non-significant trend toward longer survival in our patient cohort. The combination of TMZ radiochemotherapy with local delivery of BCNU did not provide a significant survival benefit compared to local BCNU alone, but was associated with a higher rate of adverse effects. Owing to the small number of patients investigated, however, these findings would need to be corroborated in larger patient cohorts.
TL;DR: The management of patients with NF2 presents the clinician with a formidable challenge with many patients still presenting themselves late with the neurological compromise and a large tumour load, and the translabyrinthine approach provides a very satisfactory means of reducing the overall tumour volume.
Abstract: Objectives. To analyse the long-term outcome of translabyrinthine surgery for vestibular schwannoma (VS) in neurofibromatosis type 2 (NF2). Research type. Retrospective cohort study. Setting. Two tertiary referral NF2 units. Patients. One hundred and forty eight translabyrinthine operations for patients with VS were performed. Preoperative stereotactic radiotherapy had been performed on 12(9.4%) patients. Results. Mean tumour size was 3.1 cm. Total tumour excision was achieved in 66% of cases, capsular remnants were left in 24% of cases, and subtotal excision was achieved in 5% and partial removal was achieved in 5%. The radiological residual/recurrence rate was 13.9%. The perioperative mortality was 1.6%. At 2 years postoperatively, facial function was expressed in terms of House–Brackmann score (HB): HB 1 in 53.4%, HB 1/2 in 61.3%, HB 1–3 in 83.2% and HB 4–6 in 16.8%. All nine patients who underwent surgery following failed stereotactic radiotherapy had HB 3 function or better. Among 9.5% of the...
TL;DR: Although there were complications and failures, syringopleural shunting produced satisfactory results at long-term follow-up and 88.6% showed significant clinical improvement.
Abstract: Background. The use of drains in the treatment of syringomyelia has a simple and immediate appeal. Syringopleural shunting in syringomyelia has produced good short-term results, but limited information is available on long-term effects. We analyzed the complications and long-term outcomes after syringopleural shunting for syringomyelia. Clinical material and methods. Fourthy-four patients with large-sized syringomyelia underwent syringopleural shunting because of spinal cord compression between 1992 and 2010 in our clinic. Thirty-two patients had Chiari malformation type I (Group B), and 12 patients were associated with primary parenchymal cavitations (Group A). Their ages ranged from 14 to 71 years. Both craniovertebral decompression and syringopleural shunting were performed on 21 patients, whereas only syringopleural shunting was performed on another 21 patients. Results. The follow-up period ranged from 1 year to 17 years (mean: 9.1 years). There was no operative mortality. Early postoperative...
TL;DR: Surgical embolectomy for occlusion of large vessels in the anterior circulation resulted in a high complete recanalization rate with an acceptable safety profile and use of MRA–DWI mismatch as an indication for surgical em Bolectomy was associated with a reduced complication rate.
Abstract: Object. The aim of this study was to assess the technical details and the efficacy and safety of surgical embolectomy for occlusion of large vessels in the anterior circulation. Methods. Twenty-three consecutive patients with acute ischemic stroke attributed to embolic occlusion of large arteries of the anterior circulation who underwent treatment with surgical embolectomy were retrospectively reviewed. Twenty patients were treated based on data from magnetic resonance angiography (MRA)–diffusion weighted imaging (DWI) mismatch, while three other patients had contraindications to magnetic resonance imaging (MRI) and were treated based on computed tomography (CT) and digital subtraction angiography (DSA) findings. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin Scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month, were evaluated. Results. Among the 23 patients (median age, 80 years; median p...
TL;DR: The advent of the pedicled NSF conveys a significant advantage in preventing post-operative CSF leak, decreasing the morbidity associated with lumbar drain insertion and reduces the length of hospital stay.
Abstract: Introduction. Our aim was to evaluate the routine use of a pedicled nasoseptal flap (NSF) as a primary repair for intra-operative CSF leaks compared with fat/fascia lata graft and lumbar drain insertion by performing a retrospective review of elective patients undergoing primary trans-sphenoidal surgery from January 2008 to present. Materials and methods. A retrospective review of consecutive primary elective trans-sphenoidal cases for sellar pathology was undertaken. Prior to September 2009, microscopic trans-sphenoidal surgery (MTSS) was performed in 40 cases and since then endoscopic trans-sphenoidal surgery (ETSS) was performed in 100 cases. Results and analysis. In the MTSS group, intra-operative CSF leaks were repaired with fat graft, tisseal and lumbar drain insertion. Intra-operative leaks in the ETSS group were routinely repaired with a pedicled NSF. Post-operative CSF leak rates were 12.5% in the MTSS and 3% in the ETSS groups, respectively. Three patients in the ETSS group developed a p...
TL;DR: Encompassing all age-groups and locations, Pilomyxoid Astrocytomas constitute about 10% of all tumours previously diagnosed as Pilocytic AstrocyToma, and nearly two-thirds are hypothalamo-chiasmatic in location.
Abstract: Purpose . To know the occurrence and distribution of Pilomyxoid Astrocytomas amongst tumours previously diagnosed histologically as Pilocytic Astrocytoma and to assess the clinical impact of this new entity. Methods . Retrospective Diagnostic review of all cases histologically diagnosed as WHO Grade I Astrocytoma at a single Neurosurgical unit between 1990 and 2003. Results. Of a total of 91 cases identifi ed, 9 were found to have Pilomyxoid histology. Of these, 8 were children (mean age 3.33 years) and 1 adult. 6 tumours were hypothalamochiasmatic in location. The clinical course of Pilomyxoid tumours was aggressive marked by maturation, multiple recurrences and disease control was rarely achieved with single treatment modality as opposed to typical pilocytics. The overall survival of the pilomyxoid group was not statistically diff erent from the pilocytic tumours. Conclusions. Encompassing all age-groups and locations, Pilomyxoid Astrocytomas constitute about 10% of all tumours previously diagnosed as Pilocytic Astrocytoma. Nearly two-thirds are hypothalamo-chiasmatic in location. Knowledge of this entity is essential for appropriate aggressive treatment and follow-up.