Jean G. de Oliveira

Assessment of flow in perforating arteries during intracranial aneurysm surgery using intraoperative near-infrared indocyanine green videoangiography

OBJECTIVE Perforating arteries are commonly involved during the surgical dissection and clipping of intracranial aneurysms. Occlusion of perforating arteries is responsible for ischemic infarction and poor outcome. The goal of this study is to describe the usefulness of near-infrared indocyanine green videoangiography (ICGA) for the intraoperative assessment of blood flow in perforating arteries that are visible in the surgical field during clipping of intracranial aneurysms. In addition, we analyzed the incidence of perforating vessels involved during the aneurysm surgery and the incidence of ischemic infarct caused by compromised small arteries. METHODS Sixty patients with 64 aneurysms were surgically treated and prospectively included in this study. Intraoperative ICGA was performed using a surgical microscope (Carl Zeiss Co., Oberkochen, Germany) with integrated ICGA technology. The presence and involvement of perforating arteries were analyzed in the microsurgical field during surgical dissection and clip application. Assessment of vascular patency after clipping was also investigated. Only those small arteries that were not visible on preoperative digital subtraction angiography were considered for analysis. RESULTS The ICGA was able to visualize flow in all patients in whom perforating vessels were found in the microscope field. Among 36 patients whose perforating vessels were visible on ICGA, 11 (30%) presented a close relation between the aneurysm and perforating arteries. In one (9%) of these 11 patients, ICGA showed occlusion of a P1 perforating artery after clip application, which led to immediate correction of the clip confirmed by immediate reestablishment of flow visible with ICGA without clinical consequences. Four patients (6.7%) presented with postoperative perforating artery infarct, three of whom had perforating arteries that were not visible or distant from the aneurysm. CONCLUSION The involvement of perforating arteries during clip application for aneurysm occlusion is a usual finding. Intraoperative ICGA may provide visual information with regard to the patency of these small vessels.

Advances in the treatment and outcome of brainstem cavernous malformation surgery: a single-center case series of 300 surgically treated patients.

BACKGROUND: Brainstem cavernous malformations (BSCMs) are relatively uncommon, low-flow vascular lesions. Because of their relative rarity, relatively little data on their natural history and on the efficacy and durability of their treatment. OBJECTIVE: To evaluate the long-term durability of surgical treatment of BSCMs and to document patient outcomes and clinical complications. METHODS: The charts of all patients undergoing surgical treatment of BSCM between 1985 and 2009 were reviewed retrospectively. The study population consisted of 300 patients who had surgery for BSCM. Forty patients were under 19 years of age at surgery; pediatric BSCMs have been reported separately. Patient demographics, lesion characteristics, surgical approaches, and patient outcomes were examined. RESULTS: The study population consisted of 260 adult patients with a female-to-male ratio of 1.5 and mean age of 41.8 years. Of the 260 patients, 252 presented with a clinical or radiographic history of hemorrhage. The mean follow-up in 240 patients was 51 months. The mean Glasgow Outcome Scale on admission, at discharge, and at last follow-up was 4.4, 4.2, and 4.6. Postoperatively, 137 patients (53%) developed new or worsening neurological symptoms. Permanent new deficits remained in 93 patients 3(36%). There were perioperative complications in 74 patients (28%); tracheostomy, feeding tube placement, and cerebrospinal fluid leakage were most common. Eighteen patients (6.9%) experienced 20 rehemorrhages. Twelve patients required reoperation for residual/recurrent BSCM. The overall annual risk of postoperative rehemorrhage was 2%/patient. CONCLUSION: Although BSCM surgery has significant associated risks, including perioperative complications, new neurological deficits, and death, most patients have favorable outcomes. Overall, surgery markedly improved the risk of rehemorrhage and related symptoms and should be considered in patients with accessible lesions.

Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: a single-institution series and meta-analysis.

OBJECTIVETo compare the risk of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by clipping versus coiling. METHODSWe analyzed 596 patients prospectively added to our database from July of 1999 to November of 2005 concerning the risk of shunt dependency after clipping versus coiling. Factors analyzed included age; sex; Hunt and Hess grade; Fisher grade; acute hydrocephalus; intraventricular hemorrhage; angiographic vasospasm; and number, size, and location of aneurysms. In addition, a meta-analysis of available data from the literature was performed identifying four studies with quantitative data on the frequency of clip, coil, and shunt dependency. RESULTSThe institutional series revealed Hunt and Hess grade, Fisher grade, acute hydrocephalus, intraventricular hemorrhage, and angiographic vasospasm as significant (P < 0.05) risk factors for shunt dependency after a univariate analysis. In a multivariate logistic regression analysis, we isolated intraventricular hemorrhage, acute hydrocephalus, and angiographic vasospasm as independent, significant risk factors for shunt dependency. The meta-analysis, including the current data, revealed a significantly higher risk for shunt dependency after coiling than after clipping (P = 0.01). CONCLUSIONClipping of a ruptured aneurysm may be associated with a lower risk for developing shunt dependency, possibly by clot removal. This might influence long-term outcome and surgical decision making.

Comparison between clipping and coiling on the incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Cerebral vasospasm is one of the most important complications of aneurysmal subarachnoid hemorrhage. The effect of aneurysm occlusion technique on incidence of vasospasm is not exactly known. The objective was to analyze surgical clipping versus endovascular coiling on the incidence of cerebral vasospasm and its consequences. Using the MEDLINE PubMed (1966–present) database, all English-language manuscripts comparing patients treated by surgical clipping with patients treated by endovascular coiling, regarding vasospasm incidence after aneurysmal subarachnoid hemorrhage, were analyzed. Data extracted from eligible studies included the following outcome measures: incidence of total vasospasm, symptomatic vasospasm, ischemic infarct vasospasm-induced and delayed ischemic neurological deficit (DIND). A pooled estimate of the effect size was computed and the test of heterogeneity between studies was carried out using The Cochrane Collaboration’s Review Manager software, RevMan 4.2. Nine manuscripts that fulfilled the eligibility criteria were included and analyzed. The studies differed substantially with respect to design and methodological quality. The overall results showed no significant difference between clipping and coiling regarding to outcome measures. According to the available data, there is no significant difference between the types of technique used for aneurysm occlusion (clipping or coiling) on the risk of cerebral vasospasm development and its consequences.

Supracerebellar infratentorial approach to cavernous malformations of the brainstem: surgical variants and clinical experience with 45 patients.

OBJECTIVEThe supracerebellar infratentorial (SCIT) approach can be performed at the midline (median variant), lateral to the midline (paramedian variant), or at the level of the angle formed by the transverse and sigmoid sinuses (extreme lateral variant). We analyzed our experience with SCIT approaches for the surgical treatment of cavernous malformations of the brainstem (CMBs). METHODSDemographic, clinical, radiologic, and surgical data from 45 patients (20 males and 25 females; mean age, 36.2 years) with CMBs surgically removed through SCIT approaches were reviewed retrospectively. Anatomic information was explored using cadaver head dissection. RESULTSTwenty-three lesions were in the midbrain, 3 were at the midbrain and extended to the thalamus, 9 were at the pontomesencephalic junction, and 10 were in the upper pons. All patients presented with hemorrhage. The median variant was used in 13 patients, the paramedian variant in 9, and the extreme lateral variant in 23. Intraoperatively, all CMBs were associated with a developmental venous anomaly. At last follow-up, 88% of the patients were the same or better. After a mean follow-up of 20 months, their mean Glasgow Outcome Scale score was 4.1. CONCLUSIONSCIT approaches provide excellent exposure to CMBs located at the posterior incisural space, not only in the midline but also in the posterolateral surface of the upper pons and midbrain. Careful preoperative planning and neuronavigational assistance are needed to determine the best angle of attack and trajectory for SCIT approaches. Refined microsurgical techniques are paramount to achieve safe surgical removal of CMBs with good outcomes.

Surgical management of glomus jugulare tumors: a proposal for approach selection based on tumor relationships with the facial nerve

OBJECT The goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed. METHODS Between December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41%; and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients. RESULTS Radical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%. CONCLUSIONS Radical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches, with or without closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients.

Intracranial aneurysms presenting with mass effect over the anterior optic pathways: neurosurgical management and outcomes

OBJECT Intracranial aneurysms may grow closer to anterior optic pathways, causing mass effect over these anatomical structures, including visual deficit. The authors retrospectively reviewed a series of aneurysms in patients presenting with visual field deficit caused by mass effect, to analyze the aneurysms characteristics, the neurosurgical management of these aneurysms, as well as their clinical, visual, and radiological outcomes. METHODS The authors reviewed the medical charts, neuroimaging examination results, and surgical videos of 15 patients presenting with visual symptoms caused by an aneurysms mass effect over the anterior optic pathways. These patients were treated at the Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, Brazil. Statistical analysis was performed to identify the variables related to partial or total recovery of the visual symptoms. RESULTS All patients underwent microsurgical clip placement and emptying of their aneurysms. After a mean follow-up of 38.5 months, the mean postoperative Glasgow Outcome Scale score was 4.33, and the visual outcomes were as follows: 1 patient (6.6%) unchanged, 7 (46.6%) improved, and 7 (46.6%) experienced complete recovery from visual deficits. The variables that influenced the visual outcomes were the size of the aneurysm (p = 0.039), duration of the visual symptoms (p = 0.002), aneurysm wall calcification (p = 0.010), and intraluminal thrombosis (p = 0.007). Postoperative examination using digital subtraction angiography showed complete aneurysm occlusion in 14 (93.3%) of the 15 patients. CONCLUSIONS Intracranial aneurysms causing mass effect over the anterior optic pathways usually present with complex features. The best treatment option must include not only the aneurysm occlusion but also relief of the mass effect. Microsurgical clip placement with reduction of aneurysmal mass effect achieved improvement in visual ability or recovery from visual impairment, as well as total aneurysm occlusion, in 93.3% of the study group. Therefore, this option is well supported as the first choice of treatment for intracranial aneurysms presenting with mass effect over the anterior visual pathways.

Impact of body mass index in spinal surgery for degenerative lumbar spine disease

BACKGROUND Obesity is a factor for degenerative lumbar spine disease (DLSD), with increasing prevalence worldwide. Consequently, patients who are overweight or obese have benefited from surgical treatment for DLSD, despite their anatomical and clinical differences. OBJECTIVES To analyse the effect of body mass index (BMI) in spinal surgery for degenerative lumbar spine disease (DLSD). PATIENTS AND METHODS A retrospective analysis of 100 patients who underwent surgery for DLSD was performed. The study time was 13 months (January 2013-January 2014). The patients were first evaluated with regard to their BMI and were subsequently divided into four groups of patients: BMI <25, BMI between 25 and 30, BMI between 30 and 35, and BMI above 35. The same patients were assessed for their results regarding the extent of surgery in four groups: patients undergoing surgery for treatment of one segment, two segments, three segments, and four or more segments of DLS. The aspects evaluated were surgical time, bleeding, surgical complications, surgical site infection (SSI), and re-operation due to failure of the first procedure. RESULTS A total of 118 surgeries were performed on 100 patients (52 male/48 female), mean age 52.77 years old (52.77 ± 14.45), range between 26 and 85 years old, and a mean BMI of 29.43 kg/m(2) (29.43 ± 5.54). The surgical time averaged 258.1 min (258.1 ± 82.79); the bleeding was 660 millilitres (ml) (660 ± 509.1); complications that were related to the surgical procedure occurred in 38% of cases; SSI occurred in 5% of cases, and re-operations or SSI due to complications occurred in 12% of cases. After analysis of all variables, it was observed that the groups were homogeneous without statistical variation when divided by the BMI; however, it was also observed that the extent of surgery was the factor responsible for the increased rate of SSI (p=0.05) and increased potential of re-operation due to complications (p=0.003). CONCLUSION BMI is not a complicating factor for the outcome of patients undergoing surgery for DLSD in terms of SSI, surgical complications, and re-operation rates. Furthermore, the extent of surgery was associated with increased postoperative SSI and the need for a second surgery due to the failure of the first procedure.

Cavernous sinus medial wall: dural or fibrous layer? Systematic review of the literature.

The cavernous sinus (CS) has one of the most complex anatomical networks of the skull base and because of the diversity of its contents is involved in many pathological processes. Nevertheless, anatomical literature concerning the CS is still controversial, so a systematic literature review was performed to find out the microanatomy of the medial wall of the CS and its clinical importance on sellar pathologies. Experimental studies from English-language literature between 1996 and 2010 were identified in MEDLINE, LILACS, and Cochrane databases. After analysis, two tables were prepared exhibiting the major points of each article. Fourteen experimental studies were included in the tables. Four studies concluded that the medial wall of the CS is composed of a loose, fibrous structure, and the remaining ten presumed that the medial wall is formed by a dural layer that constitutes the lateral wall of the sella. The lack of definition standards and of methodological criteria led to variation in the results among different studies. Thus, this hindered results comparison, possibly explaining the different observations.

Cervical epidural haematoma with clivus fracture: case report

Clivus fractures are rare and severe entities, usually associated with vascular or cranial nerve lesions and frequently diagnosed postmortem. Cervical epidural haematomas can be traumatic or spontaneous, manifested in acute or chronic form, and are treated surgically in the majority of cases, although the conservative treatment also can be indicated to patients with incomplete and non-progressive deficits. The authors report the case of a female patient, 8 years old, victim of trampling in public way by a high velocity motorized vehicle, admitted in Glasgow 7, anisocoric pupils (left pupil midriatic), whose radiological investigation showed a transverse fracture of the clivus, cervical epidural haematoma and diffuse axonal injury. The patient was submitted to intracranial pressure monitorization, sedation and conservative treatment with dexamethasone, with good outcome. The authors also present a literature review.