Andrea Saladino

Surgical treatment of spinal dural arteriovenous fistulae: a consecutive series of 154 patients.

BACKGROUND:Embolization of spinal dural arteriovenous fistulae (SDVAFs) has emerged as an alternative to surgery. However, surgical disconnection is a simple and effective procedure. OBJECTIVE:To review results and complications of surgical treatment of 154 consecutive SDAVFs. METHODS:The records of 154 consecutive patients with SDAVFs were retrospectively reviewed. RESULTS:There were 120 males and 34 females (male/female ratio 3.5:1, mean age 63.6 years). The SDAVFs were located at the thoracic level in 92 patients and at the lumbar and sacral spine levels in 45 and 15 patients, respectively. The most common presenting symptoms were motor dysfunction (65 patients), sensory loss (31 patients), and paresthesias without sensory loss (13 patients). The mean interval from symptom onset to definitive diagnosis was 24.7 months (median 12 months). Surgery resulted in complete exclusion of the fistula at first attempt in 146 patients (95%). There were no deaths or major neurological complications related to the surgery. Six percent of patients experienced subjective or objective worsening of preoperative symptoms and signs by the time of discharge that persisted at follow-up. Other surgical complications consisted of wound infection in 2 patients and deep venous thrombosis in 3. Eight patients were lost to follow-up; 141 patients (96.6%) experienced improvement (120 patients, 82.2%) or stability (21 patients, 14.4%) of motor function at last follow-up compared with their preoperative status. Other symptoms such as numbness, sphincter dysfunction, and dysesthesias/neuropathic pain improved in 51.5%, 45%, and 32.6%, respectively. CONCLUSION:Surgical obliteration of SDAVFs is safe and very effective. Prognosis of motor function is favorable after surgical treatment.

Intraoperative contrast-enhanced ultrasound for brain tumor surgery.

BACKGROUND Contrast-enhanced ultrasound (CEUS) is a dynamic and continuous modality that offers a real-time, direct view of vascularization patterns and tissue resistance for many organs. Thanks to newer ultrasound contrast agents, CEUS has become a well-established, live-imaging technique in many contexts, but it has never been used extensively for brain imaging. The use of intraoperative CEUS (iCEUS) imaging in neurosurgery is limited. OBJECTIVE To provide the first dynamic and continuous iCEUS evaluation of a variety of brain lesions. METHODS We evaluated 71 patients undergoing iCEUS imaging in an off-label setting while being operated on for different brain lesions; iCEUS imaging was obtained before resecting each lesion, after intravenous injection of ultrasound contrast agent. A semiquantitative, offline interobserver analysis was performed to visualize each brain lesion and to characterize its perfusion features, correlated with histopathology. RESULTS In all cases, the brain lesion was visualized intraoperatively with iCEUS. The afferent and efferent blood vessels were identified, allowing evaluation of the time and features of the arterial and venous phases and facilitating the surgical strategy. iCEUS also proved to be useful in highlighting the lesion compared with standard B-mode imaging and showing its perfusion patterns. No adverse effects were observed. CONCLUSION Our study is the first large-scale implementation of iCEUS in neurosurgery as a dynamic and continuous real-time imaging tool for brain surgery and provides the first iCEUS characterization of different brain neoplasms. The ability of CEUS to highlight and characterize brain tumor will possibly provide the neurosurgeon with important information anytime during a surgical procedure.

The clinical and radiological presentation of spinal dural arteriovenous fistula

Study Design. Retrospective consecutive case series. Objective. To assess the symptoms, neurologic signs, and radiologic findings in a large series of patients with myelopathy due to spinal dural arteriovenous fistula (SDAVF). Summary of Background. The clinical diagnosis of SDAVF is difficult because presenting symptoms and signs can be similar to those seen with spinal canal stenosis or peripheral nerve or root disorders. Methods. We reviewed 153 consecutive patients with SDAVF treated surgically at our institution between 1985 and 2008. Before surgery, all patients had detailed neurologic examination, 147 patients had spinal magnetic resonance imaging (MRI) and all but one, had spinal angiography. We evaluated associations between symptoms, physical signs, spinal cord T2 signal abnormality on MRI, and fistula level on angiogram. Results. Mean age was 63.5 years and 119 (77.8%) were men. Weakness and sensory changes are usually symmetric and ascend from the lower extremities. Presenting symptoms included leg weakness (74 patients, 48.4%), leg sensory disturbances (41 patients, 26.8%), pain involving back or legs (31 patients, 20.3%), and sphincter disturbances (6 patients, 3.9%). Worsening weakness with exertion was present in 66 (43.1%) patients and correlated with thoracic fistula location (P=0.04). Pinprick level was identified in 57 (37.3%) patients; L1 level (22.8%) was the most common, followed by T10 (19.3%). Fistula level (±2 levels) corresponded to pinprick level in only 40% of these patients. T2 signal abnormality involved the conus in 95% of our patients. Highest cord level of T2 signal hyperintensity (±2 levels) corresponded to pinprick level in 25% of cases. Conclusion. Leg weakness exacerbated by exercise, likely due to worsening hypertension in the arterialized draining vein, is a common manifestation of thoracic SDAVF. Although a sensory level is often found, it cannot reliably guide the level of imaging. Thus, the entire spine should be examined with MRI when an SDAVF is suspected.

Magnetic resonance imaging findings in treated spinal dural arteriovenous fistulas: Lack of correlation with clinical outcomes: Clinical article

OBJECT Little information is available on follow-up MR imaging after treatment of spinal dural arteriovenous fistulas (DAVFs). The authors studied MR imaging findings in treated spinal DAVFs in relation to clinical outcomes. METHODS A retrospective review of patients with spinal DAVFs who had undergone both pre- and postoperative spinal MR imaging was conducted. Postoperative MR images were obtained as routine follow-up studies or because of subjective or objective clinical deterioration. Several pre- and posttreatment MR imaging characteristics were evaluated by 2 neuroradiologists blinded to the clinical outcome. Clinical outcomes of motor, sensory, and urinary function (in relation to the patients preoperative status) at the time of the postoperative MR imaging were obtained from the clinical record. The chi-square, Fisher exact, and rank-sum tests were performed to correlate imaging findings and changes with clinical outcomes. RESULTS Thirty-four patients met inclusion criteria. Treatment was surgical in 33 patients and endovascular in 1 patient. Follow-up MR imaging was performed at a mean 168 ± 107 days after treatment. Twenty-seven patients (79.4%) were either clinically stable or improved, and 7 (20.6%) experienced worsening in one or more clinical outcomes. Most patients were found to have improvement of MR imaging changes. However, some degree of persistent spinal cord signal abnormality, enhancement, and swelling was observed in 31 (91.2%), 29 (85.3%), and 18 (52.3%) patients, respectively. Changes in these MR imaging characteristics compared with preoperative MR imaging did not correlate with clinical outcomes (p > 0.05), with the one exception of a significant correlation between change in urinary function and extent of spinal cord contrast enhancement (p = 0.026), a correlation of uncertain importance. Ten of the 34 patients underwent posttreatment digital subtraction angiography, and 3 of these patients had recurrent/residual DAVFs. Worsening of motor function significantly correlated with recurrent/residual DAVF (p = 0.053). CONCLUSIONS Spinal cord abnormalities persist on postoperative MR imaging studies in patients with treated spinal DAVFs, and although they tend to mildly improve with time, these changes may not correlate with clinical outcomes. However, regardless of imaging findings, worsening motor function may correlate with a recurrent or residual DAVF.

From Grey Scale B-Mode to Elastosonography: Multimodal Ultrasound Imaging in Meningioma Surgery—Pictorial Essay and Literature Review

The main goal in meningioma surgery is to achieve complete tumor removal, when possible, while improving or preserving patient neurological functions. Intraoperative imaging guidance is one fundamental tool for such achievement. In this regard, intra-operative ultrasound (ioUS) is a reliable solution to obtain real-time information during surgery and it has been applied in many different aspect of neurosurgery. In the last years, different ioUS modalities have been described: B-mode, Fusion Imaging with pre-operative acquired MRI, Doppler, contrast enhanced ultrasound (CEUS), and elastosonography. In this paper, we present our US based multimodal approach in meningioma surgery. We describe all the most relevant ioUS modalities and their intraoperative application to obtain precise and specific information regarding the lesion for a tailored approach in meningioma surgery. For each modality, we perform a review of the literature accompanied by a pictorial essay based on our routinely use of ioUS for meningioma resection.

Safety of early ambulation after diagnostic and therapeutic neuroendovascular procedures without use of closure devices.

OBJECTIVETo evaluate the safety of manual compression and early ambulation after diagnostic and therapeutic neuroendovascular procedures. METHODSData were prospectively collected and retrospectively analyzed for consecutive patients undergoing diagnostic or therapeutic neuroendovascular procedures. Manual compression at the femoral access site was applied. The target for early ambulation was 2 hours after compression. RESULTSThree hundred forty-three patients were enrolled, of whom 295 were eligible for early ambulation. Diagnostic procedures totaled 214 (72.5%); therapeutic procedures, 81 (27.5%). Ambulation occurred at 2 hours for 82 patients who underwent a diagnostic and 11 patients who underwent a therapeutic procedure. Overall, 142 patients (66.4%) after a diagnostic and 21 patients (25.9%) after a therapeutic procedure ambulated within 3 hours; 94% of outpatients ambulated within 2 to 3 hours and were dismissed shortly thereafter. Delayed ambulation was related to nursing staff delays, recovery from general anesthesia, or patient preference. Fourteen patients (4.7%)—9 (4.2%) who had a diagnostic and 5 (6.2%) who had a therapeutic procedure—required delayed ambulation because of local oozing (8 patients), a hematoma of less than 5 cm (3 patients), a pseudoaneurysm (2 patients), or a large hematoma requiring surgical evacuation (1 patient). CONCLUSIONEarly ambulation is feasible and safe after diagnostic and therapeutic procedures and manual compression. A longer period of bed rest or the routine use of closure devices is often not required; thereby avoiding the costs associated with bed rest and the complications associated with closure devices.

Intraoperative Navigated Angiosonography for Skull Base Tumor Surgery.

BACKGROUND One of the main challenges during skull base tumor surgery is identifying the relationships between the lesion and the principal intracranial vessels. To this end, neuronavigation systems based on preoperative imaging lack accuracy because of brain shift and brain deformation. Intraoperative navigated B-mode ultrasonography is useful in defining the extent of brain tumor. Doppler imaging adds information regarding flow entity in neighboring vessels. Second-generation ultrasound contrast agents improve the signal-to-noise ratio of B-mode imaging and permit the study of the vessels course, blood flow, and perfusion characteristics of focal lesions. We report our experience using intraoperative navigated contrast-enhanced ultrasound to perform a navigated angiosonography (N-ASG) for the visualization of vessels in a series of 18 skull base tumors. METHODS We performed N-ASG in a series of 18 skull base tumors (10 meningiomas, 3 craniopharyngiomas, 2 giant pituitary adenomas, 1 posterior fossa epidermoid, 2 dermoid cysts). N-ASG was obtained after craniotomy before resecting each lesion and during tumor removal, after intravenous injection of ultrasound contrast agent. RESULTS In all 18 cases, major vessels and their branches were simultaneously identified (both high and low flow) using N-ASG, which allowed to visualize the whole length of each vessels. N-ASG was also useful in highlighting the lesion, compared with standard B-mode imaging, and showing its perfusion patterns. CONCLUSIONS N-ASG can be applied to skull base tumor surgery, providing helpful information about the relationship between principal intracranial vessels and tumors. This technique could be of assistance in approaching the tumor and avoiding vascular damages.

The semisitting position: Analysis of the risks and surgical outcomes in a contemporary series of 425 adult patients undergoing cranial surgery

OBJECTIVE The objective of this study was to analyze the incidence of the primary complications related to positioning or surgery and their impact on neurological outcome in a consecutive series of patients undergoing elective surgery in the semisitting position. METHODS The authors prospectively collected and retrospectively analyzed data from adult patients undergoing elective surgery in the semisitting position for a cranial disease. Patients were managed perioperatively according to a standard institutional protocol, a standardized stepwise positioning, and surgical maneuvers to decrease the risk of venous air embolism (VAE) and other complications. Intraoperative and postoperative complications were recorded. Neurointensive care unit (NICU) length of stay (LOS) and hospital LOS were the intermediate endpoints. Neurological outcome was the primary endpoint as determined by the modified Rankin scale (mRS) score at 6 months after surgery. RESULTS Four hundred twenty-five patients were included in the analysis. VAE occurred in 90 cases (21%) and it made no significant statistical difference in NICU LOS, hospital LOS, and neurological outcome. No complication was directly related to the semisitting position, although 46 patients (11%) experienced at least 1 surgery-related complication and NICU LOS and hospital LOS were significantly prolonged in this group. Neurological outcome was significantly worse for patients with complications (p < 0.0001). CONCLUSIONS Even in the presence of intraoperative VAE, the semisitting position was not related to an increased risk of postoperative deficits and can represent a safe additional option for the benefit of specific surgical and patient needs.

P16.27DIFFERENTIATING BRAIN RADIONECROSIS FROM TUMOR RECURRENCE: A ROLE FOR CONTRAST ENHANCED ULTRASOUND (CEUS)? CASE REPORT

BACKGROUND: Differentiating radionecrosis from local tumor recurrence is a major concern in the management of patients harbouring a cerebral tumor and treated with radiotherapy. In these cases, contrast-enhanced MRI usually shows ambiguous enhancement, while advanced imaging techniques (MRI spectroscopy, DWI, DTI, perfusion and PET) are still far from being validated as a reliable alternative to biopsy and histological assessment. CASE REPORT: We report the case of a patient who underwent cyberknife radiosurgery (21Gy) for a left rolandic brain metastasis from a lung carcinoma. Four months after radiotherapy, she started experiencing a progressive worsening of her upper right limbs strenght, with a neuroradiological evidence at serial MRIs of a progressive enhancing rolandic lesion. The patient underwent surgical removal of the lesion at our Neurosurgical Division: neurophysiological monitoring, standard B-mode UltraSonography and Contrast-Enhanced UltraSonography (CEUS) were performed intraoperatively to assist in tumor resection. Very interestingly, CEUS did not show any enhancement of the pathologic tissue, differently from what is expected for brain metastases, as reported in previous studies. Histopathological examination showed nervous tissue with post-treatment radiation effects (radionecrosis) with a few metastatic cells. DISCUSSION: Contrast-Enhanced UltraSound is progressively becoming a widespread tool in neurosurgery. Previous studies have described the contrastographic pattern of different cerebral lesions, including metastases. Surprisingly, despite a strong uptake of contrast agent at MRI, we observed that radionecrotic tissue did not show any enhancement at CEUS. For the first time we report the appearance of radionecrosis at CEUS; the lack of contrast enhancement could represent an important hallmark in differential diagnosis with neoplastic tissue. Moreover, in this report, the use of CEUS was confined to the intraoperative stage; however, new approaches to transcranial ultrasonography could extend the value of this technique to the bedside decision-making process. CONCLUSION: Of course, further investigation is required beyond this case report; nonetheless the findings here reported suggest that CEUS could become a promising tool in helping differentiating radionecrosis from tumor recurrence.