Bernard George

Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials

BACKGROUND Malignant infarction of the middle cerebral artery (MCA) is associated with an 80% mortality rate. Non-randomised studies have suggested that decompressive surgery reduces this mortality without increasing the number of severely disabled survivors. To obtain sufficient data as soon as possible to reliably estimate the effects of decompressive surgery, results from three European randomised controlled trials (DECIMAL, DESTINY, HAMLET) were pooled. The trials were ongoing when the pooled analysis was planned. METHODS Individual data for patients aged between 18 years and 60 years, with space-occupying MCA infarction, included in one of the three trials, and treated within 48 h after stroke onset were pooled for analysis. The protocol was designed prospectively when the trials were still recruiting patients and outcomes were defined without knowledge of the results of the individual trials. The primary outcome measure was the score on the modified Rankin scale (mRS) at 1 year dichotomised between favourable (0-4) and unfavourable (5 and death) outcome. Secondary outcome measures included case fatality rate at 1 year and a dichotomisation of the mRS between 0-3 and 4 to death. Data analysis was done by an independent data monitoring committee. FINDINGS 93 patients were included in the pooled analysis. More patients in the decompressive-surgery group than in the control group had an mRS<or=4 (75%vs 24%; pooled absolute risk reduction 51% [95% CI 34-69]), an mRS<or=3 (43%vs 21%; 23% [5-41]), and survived (78%vs 29%; 50% [33-67]), indicating numbers needed to treat of two for survival with mRS<or=4, four for survival with mRS<or=3, and two for survival irrespective of functional outcome. The effect of surgery was highly consistent across the three trials. INTERPRETATION In patients with malignant MCA infarction, decompressive surgery undertaken within 48 h of stroke onset reduces mortality and increases the number of patients with a favourable functional outcome. The decision to perform decompressive surgery should, however, be made on an individual basis in every patient.

Sequential-Design, Multicenter, Randomized, Controlled Trial of Early Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarction (DECIMAL Trial)

Background and Purpose— There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction. The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. Methods— We conducted in France a multicenter, randomized trial involving patients between 18 and 55 years of age with malignant MCA infarction to compare functional outcomes with or without decompressive craniectomy. A sequential, single-blind, triangular design was used to compare the rate of development of moderate disability (modified Rankin scale score ≤3) at 6 months’ follow-up (primary outcome) between the 2 treatment groups. Results— After randomization of 38 patients, the data safety monitoring committee recommended stopping the trial because of slow recruitment and organizing a pooled analysis of individual data from this trial and the 2 other ongoing European trials of decompressive craniectomy in malignant MCA infarction. Among the 38 patients randomized, the proportion of patients with a modified Rankin scale score ≤3 at the 6-month and 1-year follow-up was 25% and 50%, respectively, in the surgery group compared with 5.6% and 22.2%, respectively, in the no-surgery group (P=0.18 and P=0.10, respectively). There was a 52.8% absolute reduction of death after craniectomy compared with medical therapy only (P<0.0001). Conclusions— In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.

Lateral approach to the anterior portion of the foramen magnum: Application to surgical removal of 14 benign tumors: Technical note

In surgery, better access to the anterior part of the foramen magnum with less risk to the lower brainstem can be obtained by lateral enlargement of the usual posterior opening. This requires exposure and control of the vertebral artery (VA) and the sigmoid sinus (SS) and, for further enlargement, medial transposition of the VA and section of the SS with inferior petrosal resection. This technique has been applied fully or partially in 14 cases of anteriorly located tumors of the foramen magnum. It widens exposure on the anterior aspect of the neural axis and allows work in a nearly frontal plane.

Intradural Perimedullary Arteriovenous Fistulae: Results of Surgical and Endovascular Treatment in a Series of 35 Cases

A series of 35 patients treated for an intradural perimedullary arteriovenous fistula (AVF) between 1970 and 1990 is reported. Angiography was performed on all of the patients, leading to the diagnosis. The patients were classified into Type I (4 patients), Type II (9 patients), and Type III (22 patients). One Type I patient was not treated, two others underwent surgery, and the last one was embolized. All of the Type II AVFs were treated, two by embolization, four by direct surgery, and three by surgery after incomplete embolization. All of the Type III AVFs were treated by endovascular detachable silicone balloon. Complete occlusion of the AVF was achieved in all treated cases of Types I and II AVF and in 15 cases of Type III AVF; for the 6 other cases of Type III AVF, incomplete occlusion was achieved. In the Types I and II AVFs, partial improvement was clinically observed in only half of the patients; the others remained unchanged. The 15 patients whose Type III AVF was completely embolized recovered completely, and four patients with Type III AVF who were incompletely embolized remained unchanged; 2 other patients with Type III AVF worsened after incomplete occlusion, and 1 additional patient died a few hours after an attempt of endovascular occlusion of a cervical Type III AVF. The place of the perimedullary AVFs among the other vascular malformations involving the spinal cord is discussed according to this classification into three types. Their specific diagnostic and therapeutic difficulties are discussed, resulting in a simplified classification including two types of perimedullary AVF.

Real-time magnetic resonance-guided laser thermal therapy for focal metastatic brain tumors.

OBJECTIVE We report the initial results of a pilot clinical trial exploring the safety and feasibility of the first real-time magnetic resonance-guided laser-induced thermal therapy of treatment-resistant focal metastatic intracranial tumors. METHODS Patients with resistant metastatic intracranial tumors who had previously undergone chemotherapy, whole-brain radiation therapy, and radiosurgery and who were recused from surgery were eligible for this trial. Under local anesthesia, a Leksell stereotactic head frame was used to insert a water-cooled interstitial fiberoptic laser applicator inside the cranium. In the bore of a magnetic resonance imaging (MRI) scanner, laser energy was delivered to heat the tumor while continuous MRI was performed. A computer workstation extracted temperature-sensitive information to display images of laser heating and computed estimates of the thermal damage zone. Posttreatment MRI scans were used to confirm the zone of thermal necrosis, and follow-up was performed at 7, 15, 30, and 90 days after treatment. RESULTS In all cases, the procedure was well tolerated without secondary effect, and patients were discharged to home within 14 hours after the procedure. Follow-up imaging showed an acute increase in apparent lesion volume followed by a gradual and steady decrease. No tumor recurrence within thermal ablation zones was noted. CONCLUSION In this ongoing trial, a total of four patients have had six metastatic tumors treated with laser thermal ablations. Magnetic resonance-guided laser-induced thermal therapy appears to provide a new, efficient treatment for recurrent focal metastatic brain disease. This therapy is a prelude to the future development of closed-head interventional MRI techniques in neurosurgery.

Cervical Neuromas with Extradural Components: Surgical Management in a Series of 57 Patients

OBJECTIVE Cervical neuromas with extradural components (intraextradural or strictly extradural forms) are rare. Their resection raises the problems of nerve root preservation, vertebral artery (VA) control, and spinal stability. METHODS A series of 57 patients with neuromas (29 neurofibromas, 23 schwannomas, 4 neurofibrosarcomas, and 1 plexiform neurofibroma) was treated during the period of 1980 to 1995, using one of the lateral approaches (antero- or posterolateral approach). The VA was always controlled before resection of the tumor. In cases of intraextradural forms, the intradural component was removed by a complementary laminectomy (three patients) in the early period and then by an oblique corpectomy through the same lateral approach (five patients) in the late period. A laminectomy had been performed in 15 other patients (11 patients with intraextradural neuromas) before they were referred to us. These patients included seven with recurrent neuromas, occurring after an average period of 4.1 years (1-9 yr). RESULTS Complete resection was achieved in all except two patients, in whom the nerve root reacted positively to intraoperative stimulation and could not be separated from the tumor. One of the patients was subsequently operated on after 2 years. Another recurrence was observed in another patient at 1 year. The four patients with sarcomas died from recurrence within 2 years. The rate of root preservation included an average of 28%, including 43.5% for schwannomas, 18% for neurofibromas, 44% for lower cervical neuromas (C4-C8), and 4.5% for upper cervical neuromas (C1-C3). Worsening of preoperative neurological deficits was observed in only two patients. The VA was always preserved, except in one patient with a sarcoma that was preoperatively occluded. No instability was observed in any of the patients. CONCLUSION Complete resection with good neurological results can be achieved in most patients harboring cervical neuromas each with an extradural component by using a lateral approach and VA control. If the root cannot be separated from the tumor, especially in patients with neurofibromas, intraoperative stimulation can help decide whether the root may be divided without incurring postoperative deficit. The lateral approach permits the resection of the extradural as well as the intradural component by a complementary oblique corpectomy. There was no morbidity in relation to VA control as well as no postoperative instability.

The vertebral artery

Our common interest in surgery of the vertebral artery was born in 1976, when as residents in the same hospital, we attended an attempt by two senior surgeons to treat an aneurysm of the vertebral artery at the C 3 level. Long discussions had preceded this unsuccessful trial, to decide if surgery was indicated and to choose the surgical route. Finally a direct lateral approach was performed, but access was difficult and correct treatment was impossible, resulting in only partial reduction of the aneurysmal pouch. Following this experience, we decided to seek a regular and well defined approach for exposition of the vertebral artery. Review of the literature indicated some surgical attempts, but the descriptions did not give the impression of safety and reproducibility. No landmark on the described surgical route appeared sufficiently reliable. Henrys anatomical work (1917) gave the only accurate description on vertebral artery anatomy, and it became the basis for our work. When the same patient was referred again one year later, after a new stroke in the vertebro-basilar system, we had behind us repetitive experience on cadavers of an original approach to the distal vertebral artery.

Meningioma of the foramen magnum: A series of 40 cases

BACKGROUND Surgical treatment of foramen magnum meningiomas (FM meningiomas) has been improved by the recently developed posterolateral and anterolateral approaches. The choice of these approaches and the extent of bone resection, however, need to be defined according to the tumor location. METHODS Over a short period (1980-1993), 40 cases of FM meningiomas were treated either by the posterolateral (N = 31), the anterolateral (N = 5), or the midline posterior approaches (N = 4). The choice of surgical technique (surgical approach, extent of bone drilling, and dural opening) was made according to the tumor location, which is defined by three parameters: the horizontal plane (anterior N = 18, lateral N = 21, and posterior N = 1); the vertebral artery (above N = 4, below N = 20, and on both sides N = 16); the dura mater (intradural N = 24, extradural N = 2, and intraextradural N = 4). RESULTS Intradural anterior and lateral FM meningiomas were operated by the posterolateral approach. The bone drilling was limited either to the occipital condyle or to the lateral mass of the atlas, depending on whether the tumor location is above or below the vertebral artery, respectively. Intradural posterior meningiomas were treated by the midline posterior approach. FM meningiomas with an extradural component were resected by the anterolateral approach alone or combined with a midline posterior approach. The rate of complete resection was 94% for intradural FM meningiomas and 50% for the extradural ones. FM meningiomas with an extradural component generally have aggressive features invading the adjacent bone and soft tissues; this explains the difficulty of performing a complete resection. The clinical condition improved in 90%, worsened in 7.5%, and did not change in 2.5%. The worsened group consisted of three deaths (one case of air embolism, one case of pulmonary embolism, and one case with preoperative coma and tetraplegia). Similar results were obtained in both anterior and lateral locations. CONCLUSION FM meningiomas can be completely and safely removed in most cases, using an appropriate surgical technique. The technique must be chosen after precise and correct analysis of the tumor location. The lateral approaches are very effective in the treatment of lateral and anterior FM meningiomas.

Multisegmental cervical spondylotic myelopathy and radiculopathy treated by multilevel oblique corpectomies without fusion.

OBJECTIVE The description of the technique of multilevel oblique corpectomy (MOC) without fusion in the treatment of spondylotic myelopathy and radiculopathy and the analysis of the results of this technique from a series of 101 cases are presented. METHODS MOC is performed using an anterolateral approach with control of the vertebral artery. The vertebral bodies are drilled obliquely from the lateral side toward the opposite posterolateral corner. More than half of the vertebral bodies are preserved, and no fusion procedure is required. The series of patients from 1992 through 1997 included 54 men and 47 women, with an average age of 57.9 years, who presented with myelopathy (n = 66) or radiculopathy (n = 35). MOC was realized on one to five levels from C2-C3 to C7-T1. Follow-up data were obtained by performing dynamic roentgenography, computed tomography, and magnetic resonance imaging 2 months, 1 year, and 3 years after surgery. RESULTS The results (Japanese Orthopedic Association score) were improvement in 82% of the patients, worsening in 8%, and stabilization in 10%. Better results were observed in younger patients (<50 yr). No relation between results and duration of symptoms or number of levels could be established. One death occurred as a result of multiorgan failure. No late deterioration was observed; however, three patients with particular features showed delayed instability requiring fusion. CONCLUSION MOC is a safe and efficient technique. It must be applied for patients with anterior compression and straight or kyphotic axis of the spine. No fusion is required regardless of the number of levels, providing there are no soft discs and there is no preoperative instability.

Foramen magnum meningiomas: detailed surgical approaches and technical aspects at Lariboisière Hospital and review of the literature

Foramen magnum meningiomas are challenging tumors, requiring special considerations because of the vicinity of the medulla oblongata, the lower cranial nerves, and the vertebral artery. After detailing the relevant anatomy of the foramen magnum area, we will explain our classification system based on the compartment of development, the dural insertion, and the relation to the vertebral artery. The compartment of development is most of the time intradural and less frequently extradural or both intraextradural. Intradurally, foramen magnum meningiomas are classified posterior, lateral, and anterior if their insertion is, respectively, posterior to the dentate ligament, anterior to the dentate ligament, and anterior to the dentate ligament with extension over the midline. This classification system helps to define the best surgical approach and the lateral extent of drilling needed and anticipate the relation with the lower cranial nerves. In our department, three basic surgical approaches were used: the posterior midline, the postero-lateral, and the antero-lateral approaches. We will explain in detail our surgical technique. Finally, a review of the literature is provided to allow comparison with the treatment options advocated by other skull base surgeons.