Anirban Deep Banerjee

An update on unilateral sporadic small vestibular schwannoma

Advances in neuroimaging have increased the detection rate of small vestibular schwannomas (VSs, maximum diameter < 25 mm). Current management modalities include observation with serial imaging, stereotactic radiosurgery, and microsurgical resection. Selecting one approach over another invites speculation, and no standard management consensus has been established. Moreover, there is a distinct clinical heterogeneity among patients harboring small VSs, making standardization of management difficult. The aim of this article is to guide treating physicians toward the most plausible therapeutic option based on etiopathogenesis and the highest level of existing evidence specific to the different cohorts of hypothetical case scenarios. Hypothetical cases were created to represent 5 commonly encountered scenarios involving patients with sporadic unilateral small VSs, and the literature was reviewed with a focus on small VS. The authors extrapolated from the data to the hypothetical case scenarios, and based on the level of evidence, they discuss the most suitable patient-specific treatment strategies. They conclude that observation and imaging, stereotactic radiosurgery, and microsurgery are all important components of the management strategy. Each has unique advantages and disadvantages best suited to certain clinical scenarios. The treatment of small VS should always be tailored to the clinical, personal, and social requirements of an individual patient, and a rigid treatment protocol is not practical.

Microsurgical Management of Basilar Artery Apex Aneurysms: A Single Surgeon's Experience from Louisiana State University, Shreveport

OBJECTIVE Basilar artery apex aneurysms continue to generate technical challenges and management controversy. Endovascular intervention is becoming the mainstay in the management of these formidable aneurysms, but it has limitations, especially with large/giant or wide neck basilar apex aneurysms. There is paucity of data in the available literature pertaining to the successful management of large/giant, wide neck, and calcified/thrombosed basilar apex aneurysms. We present our experience with consecutively operated complex basilar apex aneurysms so as to present the role of microneurosurgery as a viable management option for these aneurysms. METHODS Ours is a retrospective analysis of case-records for operated cases of basilar artery aneurysms spanning 18 years. Basilar apex aneurysms >10 cm, calcified or thrombosed, neck ≥4 mm posterior direction, and retro/subsellar were considered as complex anatomy aneurysms. Basilar apex aneurysms with favorable anatomy were included in the study as a reference group for statistical analysis. Patient demographics, complex features of aneurysms, clinical grade, and outcomes were analyzed. RESULTS A total of 33 (53.2%) patients had complex anatomy: large (>10 mm) in eight (24.2%); giant aneurysms (>25 mm) in seven (21.2%); wide-neck in 22 (66.7%); and calcified/thrombosed morphology in five (15.1%). The mean age was 48.5 years, and 22 (66.67%) were women. All aneurysms were clipped by the use of various skull base approaches. A total of 71.9% of patients harboring complex aneurysm had good outcomes. If only unruptured and good grade complex aneurysms also are considered, then 86.9% (n = 20) patients had good outcomes. Statistically there was no significant difference in the outcomes of complex and noncomplex aneurysm. CONCLUSIONS Although concerning, the management of large/giant, wide neck, and calcified/thrombosed aneurysms with microneurosurgery is still a competitive alternative to endovascular therapy. After careful selection of appropriate skull base approaches based on the complexity of the basilar apex aneurysm, microneurosurgery can achieve acceptable results.

Microsurgical Management of Giant Intracranial Aneurysms: A Single Surgeon Experience from Louisiana State University, Shreveport

BACKGROUND Surgical management of giant aneurysms is challenging because of multiple factors: aneurysm size, wide neck, thrombosis, and calcification. The risk of ischemic complications is higher when compared with smaller aneurysms. We present our surgical experience of clipping these difficult aneurysms. METHODS A total of 59 giant intracranial aneurysms underwent surgical clipping by a single surgeon over the last 2 decades. The case records of these patients were retrospectively reviewed to evaluate the operative outcome. The study was approved by the Institutional Review Board of the Louisiana State University Health Sciences Center, Shreveport, in compliance with Health Insurance Portability and Accountability Act regulations. RESULTS The mean age in our series was 50.57 years (range 19 to 77 years). There was a female preponderance (female-male ratio 2.47:1). Headache was the most common form of presentation (62.7%, n = 37), followed by cranial nerve deficits (32.2%, n = 19) and seizures (13.5%, n = 8). Subarachnoid hemorrhage was seen in 38.9% (n = 23). Eleven patients had posterior circulation aneurysm. At admission, 47.8% (n = 11) of the patients were in good grade (grade I and II). Multiple aneurysms were noted in 18.64% (n = 11) of cases, but none of the patients harbored more than 1 giant aneurysm. Mortality rate was 10.1% (n = 6). The majority of patients (71.9%) experienced a good outcome (Glasgow Outcome Scale score [GOS] 4 and 5) at the last follow-up. Binary logistic regression analysis was performed to find predictors of poor outcome. Poor clinical grade, ruptured aneurysm, and posterior location predicted independently for poor outcome. CONCLUSIONS Giant aneurysms impose a relatively higher risk of mortality and morbidity to patients. With proper case selection and appropriate surgical strategy, it is possible to achieve a favorable outcome in most cases.

Focal intradural brain infections in children: an analysis of management and outcome.

Introduction: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. Materials and Methods: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. Results: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. Conclusions: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

Do Concomitant Cranium and Axis Injuries Predict Worse Outcome? A Trauma Database Quantitative Analysis

We performed a trauma database analysis to identify the effect of concomitant cranial injuries on outcome in patients with fractures of the axis. We identified patients with axis fractures over a 14-year period. A binary outcome measure was used. Univariate and multiple logistic regression analysis were performed. There were 259 cases with axis fractures. Closed head injury was noted in 57% and skull base trauma in 14%. Death occurred in 17 cases (6%). Seventy-two percent had good outcome. Presence of abnormal computed tomography head findings, skull base fractures, and visceral injury was significantly associated with poor outcome. Skull base injury in association with fractures of the axis is a significant independent predictor of worse outcomes, irrespective of the severity of the head injury. We propose that presence of concomitant cranial and upper vertebral injuries require careful evaluation in view of the associated poor prognosis.