Guolu Meng

Less-aggressive surgical management and long-term outcomes of jugular foramen paragangliomas: a neurosurgical perspective.

OBJECTIVE The aim of this study was to analyze the neurological functional outcome and recurrent risks in surgically treated jugular foramen paragangliomas (JFPs) and to propose an individualized therapeutic strategy. METHODS Clinical charts and radiological information were reviewed retrospectively in 51 consecutive cases of JFPs. Less-aggressive surgical interventions were adopted with the goal of preserving neurovascular structures. Scheduled follow-up was performed. RESULTS The mean age of the patients in the cases reviewed was 41.6 years, and the group included 27 females (52.9%). The mean preoperative Karnofsky Performance Scale (KPS) score was 78.4. The mean lesion size was 3.8 cm. Forty-three cases (84.3%) were Fisch Type D, including 37 cases (72.5%) of Type Di1 and Di2. Thirty-seven cases (72.5%) were Glasscock-Jackson Type III-IV. Gross-total resection and subtotal resection were achieved in 26 (51.0%) and 22 (43.1%) cases, respectively. Surgical morbidities occurred in 23 patients (45.1%), without surgery-related mortality after the first operation. The mean postoperative KPS scores at discharge, 3 months, 1 year, and most recent evaluation were 71.8, 77.2, 83.2, and 79.6, respectively. The mean follow-up duration was 85.7 months. The tumor recurrence/regrowth (R/R) rate was 11.8%. Compared with preoperative status, swallowing function improved or stabilized in 96.1% and facial function improved or stabilized in 94.1% of patients. A House-Brackmann scale Grade I/II was achieved in 43 patients (84.3%). Overall neurological status improved or stabilized in 90.0% of patients. Pathological mitosis (HR 10.640, p = 0.009) was the most significant risk for tumor R/R. A 1-year increase in age (OR 1.115, p = 0.037) and preoperative KPS score < 80 (OR 11.071, p = 0.018) indicated a risk for recent poor neurological function (KPS < 80). Overall R/R-free survival, symptom progression-free survival, and overall survival at 15 years were 78.9%, 86.8%, and 80.6%, respectively. CONCLUSIONS Surgical outcomes for JFPs were acceptable using a less-aggressive surgical strategy. Most patients could adapt to surgical morbidities and carry out normal life activities. Preserving neurological function was a priority, and maximal decompression with or without radiotherapy was desirable to preserve a patients quality of life when radical resection was not warranted. Early surgery plus preoperative devascularization was proposed, and radiotherapy was mandatory for lesions with pathological mitosis.

Two-bone flap craniotomy for the transpetrosal-presigmoid approach to avoid a bony defect in the periauricular area after surgery on petroclival lesions: technical note

The authors describe a two-bone-flap craniotomy technique to avoid the bone defect caused by the transpetrosal–presigmoid approach. Briefly, this technique includes three steps. The first step is to elevate a temporoparietal bone flap located superiorly to the transverse and sigmoid sinuses. The second step is to dissect the transverse and sigmoid sinuses away from the bone by inserting a gelatin sponge. This maneuver provides hemostasis and protects the sinuses from injury. The third step is to cut a second bone flap including part of the temporal bone and the outer table of the mastoid bone with a high-speed drill system. After the operation, the two bone flaps are fixed in place with titanium osteosynthesis fixation material. This approach provides a simple, easy, and safe technique for the transpetrosal–presigmoid approach. The technique has been performed in 83 patients treated for petroclival neoplasms with excellent cosmetic results.

Foramen magnum meningiomas: surgical results and risks predicting poor outcomes based on a modified classification.

OBJECTIVE This study aimed to evaluate neurological function and progression/recurrence (P/R) outcome of foramen magnum meningioma (FMM) based on a modified classification. METHODS This study included 185 consecutive patients harboring FMMs (mean age 49.4 years; 124 females). The authors classified the FMMs into 4 types according to the previous classification of Bruneau and George as follows: Type A (n = 49, 26.5%), the dural attachment of the lesion grows below the vertebral artery (VA); Type B (n = 39, 21.1%), the dural attachment of the lesion grows above the VA; Type C1 (n = 84, 45.4%), the VA courses across the lesion with or without VA encasement or large lesions grow both above and below the bilateral VA; and Type C2 (n = 13, 7.0%), Type C1 plus partial/total encasement of the VA and extradural growth. RESULTS The median preoperative Karnofsky Performance Scale (KPS) score was 80. Gross-total resection (GTR) was achieved in 154 patients (83.2%). Lower cranial nerve morbidity was lowest in Type A lesions (16.3%). Type C2 lesions were inherently larger (p = 0.001), had a greater percentage of ventrolateral location (p = 0.009) and VA encasement (p < 0.001), lower GTR rate (p < 0.001), longer surgical duration (p = 0.015), higher morbidity (38.5%), higher P/R rate (30.8%, p = 0.009), and poorer recent KPS score compared with other types. After a mean follow-up duration of 110.3 months, the most recent follow-up data were obtained in 163 patients (88.1%). P/R was observed in 13 patients (7.2%). The median follow-up KPS score was 90. Compared with preoperative status, recent neurological status was improved in 91 (49.2%), stabilized in 76 (41.1%), and worsened in 18 (9.7%) patients. The multivariate Cox proportional hazard regression model demonstrated Type C2 (HR 3.94, 95% CI 1.04-15.0, p = 0.044), nontotal resection (HR 6.30, 95% CI 1.91-20.8, p = 0.003), and pathological mitosis (HR 7.11, 95% CI 1.96-25.8, p = 0.003) as independent adverse predictors for tumor P/R. Multivariate logistic regression analysis identified nontotal resection (OR 4.06, 95% CI 1.16-14.2, p = 0.029) and pathological mitosis (OR 6.29, 95% CI 1.47-27.0, p = 0.013) as independent risks for poor outcome (KPS score < 80). CONCLUSIONS The modified classification helped to predict surgical outcome and P/R in addition to the position of the lower cranial nerves. Preoperative imaging studies and neurological function should be reviewed carefully to establish an individualized management strategy to improve long-term outcome.

Long-Term Functional and Recurrence Outcomes of Surgically Treated Jugular Foramen Schwannomas: A 20-Year Experience

OBJECTIVE To investigate the outcomes of jugular foramen schwannomas (JFSs) and to evaluate the risk factors for tumor recurrence and poor final outcomes. METHODS Between 1993 and 2013, 133 patients (68 female patients) with JFSs were surgically treated. Clinical charts were reviewed, and scheduled follow-up examinations were performed. RESULTS The average preoperative Karnofsky Performance Scale (KPS) score was 79.6. The JFSs were classified as follows: 65 cases, type A; 15 cases, type B; 5 cases, type C; and 48 cases, type D. Gross total resection was achieved in 107 (80.5%) patients. Transient and permanent morbidities affecting cranial nerves IX and X were 19.8% and 11.5%, respectively. After a mean follow-up duration of 108.0 months, 13 (9.9%) patients experienced recurrence. The most recent KPS scores averaged 83.7. Compared with the preoperative KPS score, the most recent KPS score was improved in 87 (65.4%) patients and stabilized in 29 (21.8%) patients. The presence of a solid tumor (hazard ratio [HR] = 5.815, P = 0.010), nontotal resection (HR = 4.613, P = 0.007), and pathologic mitoses (HR = 11.018, P < 0.001) were independent risk factors for tumor recurrence. Decreased preoperative KPS score (per 10 points) (odds ratio [OR] = 2.483, P = 0.027), a less soft tumor consistency (OR = 2.257, P = 0.039), and a solid tumor (OR = 3.755, P = 0.041) were risk factors for poor long-term outcomes. CONCLUSIONS Quality of life and preservation of neurologic function are the goals of surgical treatment of JFSs. Favorable long-term surgical outcomes for JFSs can be achieved. Morbidity of cranial nerves IX and X is significant, and patients with nontotal resection or pathologic mitosis should be followed closely.

Using a modified far-lateral approach to remove hypoglossal neurilemmomas: notes on technique

OBJECT In this paper the authors describe a modified far-lateral transcondylar approach to remove hypoglossal neurilemmomas (HGNs). METHODS Between September 2008 and June 2011, 11 consecutive patients with HGNs underwent tumor removal via a modified far-lateral transcondylar approach. The average age at presentation, tumor characteristics, cranial nerve (CN) deficits, and outcomes were assessed. The modified far-lateral transcondylar approach comprises several important steps. The first step is to remove the limited posterior aspect of the condylar facet to open the hypoglossal canal. The second step is to expose the posterior arch and the transverse process of C-1. A fat layer covers the venous plexus of the vertebral artery, and careful dissection along this surface of the fat layer is important to protect the vertebral artery from damage. The neck muscles are dissected caudally to expose the extracranial component of the tumor, which is located in front of the transverse process of C-1. RESULTS Eleven cases of HGNs were treated during the study period. The mean patient age was 47.4 ± 8.9 years (range 31-59 years); there were 3 men and 8 women. The mean follow-up period was 14.1 ± 9 months. All patients presented with hypoglossal nerve deficits; other commonly observed deficits included glossopharyngeal and vestibular/cochlear nerve deficits. Gross-total resection of the tumor was achieved in 10 patients. A subtotal resection of the tumor was achieved in the remaining patient. Two patients had transient postoperative facial nerve palsies, 1 patient developed a new CN XI palsy postoperatively, and 5 patients experienced transient hoarseness and difficulty swallowing. Two patients required a tracheotomy because they demonstrated dysfunction of the caudal CNs and subsequently developed postoperative pneumonia. Postoperatively, 5 patients required the temporary placement of a nasogastric feeding tube. There were no surgery-related deaths in this series. CONCLUSIONS The modified far-lateral transcondylar approach is an effective treatment for HGNs, yielding a high total tumor removal rate with an acceptable rate of morbidity.

The Differentially Expressed Genes of Human Sporadic Cerebral Cavernous Malformations

OBJECTIVES To understand the development of sporadic cerebral cavernous malformations (SCCM) comprehensively, we analyzed gene expression profiles in SCCMs by gene microarray. METHODS The total number of the specimens collected in our study was 14, 7 of which were SCCMs, and the others were controls that were obtained from normal brain vessels. The total RNA was extracted and hybridized with oligonucleotide array containing 21522 genes. The analysis of Gene Ontology (GO) items and molecular pathways was performed based on the GO and Kyoto Encyclopedia of Genes and Genomes databases. The gene coexpression networks were constructed to identify the core genes regulating the progression of SCCMs. RESULTS A total of 785 probes, showing differentially expressed genes (DEGs) between the 2 groups, were found by the gene chips. According to the analysis based on GO and Kyoto Encyclopedia of Genes and Genomes, 286 GO terms and 53 pathways were identified to be significantly relevant with the DEGs. All differential gene interactions were analyzed and the core genes were selected in the coexpression networks. CONCLUSIONS The gene expression profiles obtained from SCCMs were significantly distinct from those of control brain vascular specimens. These DEGs are related to multiple molecular signal pathways, such as the mitogen-activated protein kinase pathway, cytokine-cytokine receptor interaction, focal adhesion, and inflammatory response. According to the analysis of the core genes selected in the gene coexpression networks, we postulated that CSF1R, XCL1, KCNMB1, RHOG, and TJP1 might exert enormous functions in the pathogenesis of SCCMs. However, further studies are required to aid in the clinical diagnosis and prevention of SCCMs.

Human brain arteriovenous malformation: an analysis of differential expressed genes

BackgroundMuch still remains unknown about the pathogenesis of brain arteriovenous malformations (AVMs). Previous studies have revealed the abnormal expression of various angiogenesis-related genes in AVMs. To further understand this disease, we sought to identify genes differently expressed in AVMs by means of the gene microarray technique.MethodsNine AVMs specimen and nine samples of normal vessels are collected. Total RNA isolated from these specimen is hybridized with Oligonucleotide array and gene analysis was conducted. Analyzing data with the help of significance analysis of microarrays (SAM) and a free web-based molecular annotation system 3.0 (MAS 3.0).ResultsThe SAM method identify 37 gene significantly up-regulated and 10 genes down-regulated in AVMs.ConclusionsAmong those genes, VACN, SPARK and ARHGAP18 seem to play a facilitating role during the genesis of AVMs. Multiple pathways, as MAPK pathway, may also be involved.