Gustavo Luzardo

Extraventricular cerebral anaplastic ependymomas

BACKGROUND Anaplastic ependymomas are considered to be uncommon cerebral tumors by most authors. We have had the opportunity to study 34 cases of such lesions in 13 years. METHODS 34 cases of anaplastic ependymoma operated in different hospitals of Maracaibo, Venezuela, during the period of 1983-1995 were analyzed. Cases of ependymoblastoma were excluded. RESULTS Adult patients made up most of the present series. All patients harbored supratentorial growths in locations distant from the ventricular system. The microscopic pattern was of limited value to establish prognosis, for there was no constant correlation between the histologic features and tumor relapse; only in sporadic cases in which high cell density and conspicuous mitotic activity were maximally expressed, did tumor relapse occur shortly after removal of the lesion. CONCLUSION This type of paradoxical behavior being the rule makes all attempts at predicting prognosis in these entities a disappointing task.

Transarterial balloon assisted Onyx embolization of pericallosal arteriovenous malformations

Summary Preliminary experience using a balloon assisted technique (BAT) for embolization of arteriovenous malformations (AVM) is reported. Two patients with large pericallosal AVMs were successfully embolized with Onyx under Scepter C balloon catheter flow arrest. Clinical presentation One patient presented with a large intraventricular hemorrhage and hydrocephalus. The second patient presented with a long history of seizures and a small intracerebral hemorrhage. Both patients demonstrated extensive interhemispheric AVMs with multiple arterial feeders, predominantly from the pericallosal arteries. Intervention A Marathon microcatheter was navigated into the target arterial feeders and a Scepter C occlusion balloon catheter was inflated immediately proximal. Under flow arrest, Onyx was injected via the microcatheter with excellent nidal penetration. In both cases, there was complete angiographic obliteration of the treated component of the AVM. Conclusions Onyx embolization under balloon catheter flow arrest allows for greater nidal penetration of embolic material and improved reflux control. The technique is limited by the current deliverability of balloon catheters and the potential risk for earlier embolization of dangerous anastomosis.

What causes a prolactinoma to be aggressive or to become a pituitary carcinoma

INTRODUCTIONMalignant prolactinoma is an exceedingly rare endocrine tumor and cannot be diagnosed on histological grounds alone. Similarly to other neuroendocrine tumors such as pheochromocytoma, the mitoses index, Ki-67, p53, and others are utilized in helping understand whether a tumor is benign or malignant or to better predict tumor behavior. We here present the unusual case of an unfortunate young man with an aggressive prolactinoma, the complications of which led to his premature death.CASE REPORTA 25-year-old white man developed severe headaches, low energy, and decreased libido. A brain magnetic resonance imaging (MRI) showed a 4 × 3 × 2 cm pituitary tumor invading the left cavernous sinus. Laboratory findings revealed elevated prolactin (470 ng/mL) and adrenocorticotropic hormone (ACTH, 82 pg/ml) and decreased total testosterone (176 ng/dl). Visual fields showed superior quadrantanopia in the left eye. Transsphenoidal pituitary resection was undertaken. Pathology revealed a prolactinoma with atypical cells, diffuse p53 nuclear labeling, and a Ki-67 index of 23% (high). Postoperatively, prolactin remained elevated (725–891 ng/ml) and cabergoline was increased to 1 mg three times weekly, with serum prolactin further increasing to 3507 ng/ml five months postoperatively. Repeat MRI revealed extension of the tumor with optic chiasm compression and left orbit invasion. Because of acute left vision loss with ophthalmoplegia, an urgent left frontotemporal craniotomy and tumor resection were conducted. The Ki-67 index of the tumor was 24.8%, the mitotic figure immunostain phosphohistone-H3 positive. Sixty percent (60%) of tumor cells were positive for p53. Cabergoline was increased to 1 mg daily but prolactin remained elevated (770 ng/ml). The patient then underwent proton beam radiation to the area of concern involving the sella. Prolactin thereafter improved to 44 ng/ml. He then developed acute vision loss of the right eye with an MRI showing tumor in the right cavernous sinus. A 15 mm dural-based right temporal mass believed to be a metastasis was also noted. Following this scan, he was considered too high risk for debulking surgery and instead underwent gamma knife irradiation to the sella area. This shrank the right cavernous sinus tumor mass, while the right temporal mass increased in size. The patient developed blindness and left-sided weakness and required enteral feeding and tracheostomy after prolonged intubation. A trial of chemotherapy with temozolomide (350 mg daily for 5 days) near the end of his life was unsuccessful. He died on home hospice 31 months after his first surgery.CONCLUSIONHeadaches, vision changes, and symptoms of androgen deficiency syndrome can be manifestations of an aggressive prolactinoma that might require surgery and additional medical therapy including cabergoline and temozolomide with an unpredictable time of survival.

Carotid cavernous fistulae occurring after the use of the Fogarty catheter in carotid surgery: a review.

The Fogarty catheter represents a major advancement for the effective removal of distal thrombi during vascular surgery, including carotid endarterectomy (CEA). One complication related to its use is injury to the cavernous carotid artery with development of a carotid cavernous fistula (CCF). Including a recent case at our institution, 21 patients with a Fogarty-related CCF have been reported since 1967. We performed a detailed review of all Fogarty-related CCFs during the treatment of carotid occlusive disease. We suggest a management algorithm for post-CEA acute carotid occlusion.

The maxillary artery and its variants: an anatomical study with neurosurgical applications

BackgroundThe maxillary artery (MA) has gained attention in neurosurgery particularly in cerebral revascularization techniques, intracranial endonasal approaches and endovascular procedures.ObjectivesTo describe and illustrate the anatomy of the MA and its neurosurgical importance in a detailed manner.MethodsSix cadaveric heads (12 MAs) were injected with latex. The arteries and surrounding structures were dissected and studied using microsurgical techniques. The dimensions, course and branching patterns of the MA were recollected. In addition, 20 three-dimensional reconstruction CT head and neck angiograms (3D CTAs) of actual patients were correlated with the cadaveric findings.ResultsThe MA can be divided in three segments: mandibular, pterygoid and pterygopalatine. Medial and lateral trunk variants regarding its course around the lateral pterygoid muscle can be found. The different branching patterns of the MA have a direct correlation with the course of its main trunk at the base of the skull. Branching and trunk variants on one side do not predict the findings on the contralateral side.ConclusionIn this study the highly variable course, branching patterns and relations of the MA are illustrated and described in human cadaveric heads and 3D CTAs. MA 3D CTA with bone reconstruction can be useful preoperatively for the identification of the medial or lateral course variants of this artery, particularly its pterygoid segment, which should be taken into account when considering the MA as a donor vessel for an EC-IC bypass.

Advanced Imaging Assessment of Posterior Circulation Stroke Before and After Endovascular Intervention

BackgroundPerfusion-computed tomography (CTP) is a relatively new technique that allows rapid semiquantitative noninvasive evaluation of cerebral perfusion aiding in the diagnosis of cerebral ischemia and infarction. There is a paucity of data on its application within the posterior circulation, especially, the brainstem. We describe a case of basilar artery thrombosis with cerebellar and brainstem CTP mismatch and discuss possible future applications of CTP for acute posterior fossa circulation and infarction.MethodsCase report.ResultsSuccessful use of CTP to aid in decision to proceed with neurointervention in acute basilar artery occlusion and confirm its resolution after mechanical clot retrieval.ConclusionPerfusion-computed tomography can successfully be used to define cerebral ischemia and infarction within the posterior fossa and aid in decisions to proceed with neurointervention.

P-022 Endovascular revascularization of carotid artery using a flow reversal device

Introduction Surgical carotid revascularization has been described with various degrees of technical and clinical success. Currently, carotid revascularization is not recommended, based on the high potential for embolic stroke during the procedure. The data is however limited to only surgical cases. One series of endovascular revascularization for occluded carotids of unknown length of time has already been communicated. The authors present a similar series using a flow reversal device. Method During the period of February 2009 to November 2011 a total of 13 patients underwent endovascular revascularization of either single or both occluded carotid arteries. The procedure was done in all cases using a flow reversal system (the Gore flow reversal) In three cases the procedure had to be aborted due to the fact that the occluded segment included part of the supraclinoid carotid. In the rest of cases the procedure was technically feasible succesfully. After revascularization all patients underwent stenting of their extracranial carotids. Two patients had either bilateral occlusions or presented with a non-disabling stroke due to a severe stenosis on one side and a chronic occlusion on the other. In these cases the revascularizations have been performed in stages with a 2–3 month interval in between interventions. Results There were no neurologic complications related to the procedure either in the successful or in the aborted cases. Two patients developed large inguinal hematomas and had to be transfused. Conclusion The endovascular revascularization of carotid artery occlusion of unknown duration is feasible using a flow reversal device. Addditional information regarding clinical and imaging indications for the procedure is necessary in order to proper select patients that might benefit. Long term follow-up will also be necessary in order to assess the viability of re-opened carotids as well as risks for stroke in patients after this procedure. Competing interests None.