Marie-Agnès Docquier

Intraoperative magnetic resonance imaging at 3-T using a dual independent operating room-magnetic resonance imaging suite: development, feasibility, safety, and preliminary experience.

OBJECTIVEA twin neurosurgical magnetic resonance imaging (MRI) suite with 3-T intraoperative MRI (iMRI) was developed to be available to neurosurgeons for iMRI and for independent use by radiologists. METHODSThe suite was designed with one area dedicated to neurosurgery and the other to performing MRI under surgical conditions (sterility and anesthesia). The operating table is motorized, enabling transfer of the patient into the MRI system. These two areas can function independently, allowing the MRI area to be used for nonsurgical cases. We report the findings from the first 21 patients to undergo scheduled neurosurgery with iMRI in this suite (average age, 51 ± 24 yr; intracranial tumor, 18 patients; epilepsy surgery, 3 patients). RESULTSTwenty-six iMRI examinations were performed, 3 immediately before surgical incision, 9 during surgery (operative field partially closed), and 14 immediately postsurgery (operative field fully closed but patient still anesthetized and draped). Minor technical dysfunctions prolonged 10 iMRI procedures; however, no serious iMRI-related incidents occurred. Twenty-three iMRI examinations took an average of 78 ± 20 minutes to perform. In three patients, iMRI led to further tumor resection because removable residual tumor was identified. Complete tumor resection was achieved in 15 of the 18 cases. CONCLUSIONThe layout of the new complex allows open access to the 3-T iMRI system except when it is in use under surgical conditions. Three patients benefited from the iMRI examination to achieve total resection. No permanent complications were observed. Therefore, the 3-T iMRI is feasible and appears to be a safe tool for intraoperative surgical planning and assessment.

Microsurgical results with large vestibular schwannomas with preservation of facial and cochlear nerve function as the primary aim

SummaryObjective. To evaluate our microsurgical results in dealing with vestibular schwannomas (VS) greater than or equal to 30 mm when preservation of cranial nerve function was considered more important than total tumour removal.Methods. Sixteen consecutive cases were operated on by the same neurosurgeon according to a prospective protocol using intraoperative neuro-monitoring (IONM) based on electromyographic and brain stem auditory evoked potential recordings. Facial nerve function was evaluated on the House-Brackmann Scale and cochlear nerve function on the Gardner-Robertson Scale. Someone not involved in the clinical management of our patients collected all data.Results. Fifteen patients showed facial nerve (FN) function of House-Brackmann grade (HBG) I or II at one year postoperatively and one kept the HBG IV she had preoperatively. Two patients of four maintained a cochlear nerve function of Gardner-Robertson grade (GRG) II. The tumour excision rates were: total, 68.7%; near total, 6.3%; subtotal, 18.7%, and partial, 6.3%. The average follow-up was 55 months (1–106). Three patients underwent radiotherapy later with growth stabilisation and no additional morbidity.Conclusion. When dealing with VS greater than or equal to 30 mm, microsurgery guided by IONM, with a rate of total or near-total tumour excision of about 75%, can retain socially acceptable facial nerve function (HBG I or II) in all cases and serviceable hearing (GRG I or II) in two cases out of four. Maintaining serviceable cranial nerve function should take precedence over total tumour excision.

Patients with refractory epilepsy treated using a modified multiple subpial transection technique

BACKGROUND : Multiple subpial transection (MST) is a potential surgical treatment for patients with epileptogenic foci located in cortical areas with higher functions. As neurosurgical teams have become more experienced with MST, the original technique has adapted. OBJECTIVE : To report our 6-year experience with a modified MST technique. METHODS : The population included 62 consecutive patients with medically refractory epilepsy treated by MST, with a follow-up period ranging from 2 to 9 years. MST was performed on gyri under neuronavigation and guided by intraoperative electrocorticography. We performed radiating MST from a single cortical entry point. The MST technique was described according to the number of transections performed and the Brodmann areas (BAs) involved. Any MST-related complications were registered and followed up. Clinical outcome was described in terms of seizure suppression or reduction according to the Engel modified classification. RESULTS : Twelve patients underwent MST alone (MSTa), and 50 had MST with another procedure. The main MST sites were BA 4 (61%) and 3, 1, 2 (58%); in 22% of cases, MST was performed in BA 44, 22, 39, and 40. Permanent neurological deficits were observed in 4 (6.4%) patients; 2 minor deficits were MST related (3.2%). A reduction in the seizure rate of at least 50% was seen in 79% of patients (MSTa group, 75%), and 42% became seizure free (MSTa group, 33%). CONCLUSION : This study demonstrates the efficacy and low morbidity of radiating MST performed under neuronavigation and intraoperative electrocorticography. ABBREVIATIONS : BA, Brodmann areaEEG, electroencephalogramFDG, 18-fluorodeoxyglucoseioECoG, intraoperative electrocorticographyMRE, medically refractory epilepsyMST, multiple subpial transectionMSTa, multiple subpial transection aloneMST+, multiple subpial transection with other procedures.

Neurosurgical management of inadequately embolized intracranial aneurysms: a series of 17 consecutive cases.

SummaryObjective. Inadequately embolized aneurysms (IEA) are coiled aneurysms with a significant remnant (>5%), initially or after recanalisation, or with a coil extrusion deemed too thrombogenic or threatening the blood flow in the parent vessel. Our objective is to report our experience with the surgical clipping (SC) of a consecutive series of 17 IEA considered as not appropriate for an additional endovascular procedure. Methods. Between February 1996 and April 2006, we evaluated 523 ICA in 380 patients of whom 192 underwent coil embolisation (CE), 117 with complete occlusion (61%), 47 with near complete occlusion (≥95%), 9 with partial occlusion (<95%), and 19 without any coil delivery (attempted embolisation). Of the 173 ICA embolized one or two times, at their radiological follow-up 15 (8.6%) were considered as IEA and not appropriate for an additional CE. Two IEA treated endovascularly before February 1996 were added to this series. The female/male ratio was 0.47 with an average age of 54 years (range, 37–65). All cases were located on the anterior circulation except the last one. The 17 IEA were treated by SC either because of an aneurysm remnant deemed not accessible to a further CE and large enough for direct clipping or because the risks of a thromboembolic event related to extruded coils was too high. Results. SC was complete in all 17 cases, confirmed angiographically. Postoperatively, the clinical status of two patients deteriorated slightly but transiently. Our surgical experience with this series led us to classify IEA into five types, in three groups: group A (with one type: type A) was the most important group (n = 11) with IEA characterized by an aneurysm residue allowing direct SC, as assessed preoperatively; group B (n = 4) comprised aneurysms with a residue smaller than predicted and showing parent vessel stenosis when a clip was applied to the neck residue requiring the fundus full of coils to be removed followed by either clip application to the neck residue (type B1, n = 3) or suture if the remnant was too small (type B2, n = 1); and group C (n = 2) grouping cases requiring coil extraction through the parent vessel (type C2, n = 1) or through the fundus (type C2, n = 1). Conclusions. With this series of IEA, we observed that open surgery of type A and C aneurysms can be a straightforward procedure. Our experience with type B IEA encourages us to wait for a sufficient aneurysm residue before performing SC because of the potential difficulties that may be encountered by the surgeon, particularly in type B2. SC of IEA was very effective with complete occlusion and no permanent morbidity in all 17 cases.

Glioblastoma surgery with and without intraoperative MRI at 3.0T

BACKGROUND Gross total or near total resection (GTR/NTR; resection ≥95%) of glioblastoma (GBM) seems correlated with a longer survival. Intraoperative MRI (ioMRI) is one method to evaluate the extent of resection (EOR) in order to improve it during the same anesthesia. We compared GBM resections using a 3.0T ioMRI and then without considering the EOR, safety, survival and discussed the indications for using this expensive modality. METHODS Between March 2006 and November 2011, 56 GBM resections were performed using an ioMRI, and 38 without (control group). The only criterion in order to have access to the ioMRI was its availability. We compared the variables EOR, Karnofsky Performance Scale scores and survival in both groups. RESULTS In the ioMRI group, 15 patients (26.8%) underwent an immediate second resection increasing the GTR rate of 10.7% and the GTR/NTR rate of 8.9%. There was a significant difference between the use of an ioMRI and the control group in reaching a larger EOR (P=0.049, Fishers exact test). The effect of using the ioMRI or not on the overall survival, with EOR as covariate, was not significant (P=0.147, Likelihood ratio test). However, the EOR alone had a significant effect on survival (P=0.049, Wald test), with a shorter survival for the patients with a partial resection (PR) than a GTR/NTR (Hazard ratio=1.6, 95% CI HR: 1.00-2.69), with a median overall survival of 15.26 months (95% CI: 12.34-19.08) for the GTR/NTR subgroup versus 10.26 months (95% CI: 6.64-15.82) for the PR subgroup. Multivariate regression analysis also identified age, sex and adjuvant chemotherapy as factors significantly associated with overall survival. CONCLUSIONS A 3.0T ioMRI improved the quality of resection by 17.8% and increased the GTR/NTR rate by 8.9% up to 73.2% without additional morbidity. A GTR/NTR improves survival duration by about 50%. Thus, it remains reasonable to increase the EOR to reach GTR/NTR using an intraoperative control. However, ioMRI should be limited to the cases for which a GTR/NTR seems preoperatively possible.

Intraoperative 3T MRI for pituitary macroadenoma resection: Initial experience in 73 consecutive patients

OBJECTIVE To report a single-center experience with a 3T intraoperative magnetic resonance imaging (iMRI) to assess transsphenoidal microsurgery on pituitary macroadenomas. METHODS In a dual, independent operating room (OR) magnetic resonance imaging (MRI) suite, the operating table with the anesthetized patient was moved on rail tracks once a supposed maximized resection was reached to the MRI room for intraoperative image acquisition and interpretation. After the assessment of the iMRI images, the neurosurgeon evaluated whether additional resection was still possible. The resection rates were assessed on iMRI and postoperative MRI at 3 months. RESULTS A total of 73 macroadenomas benefited from an iMRI from March 2006 to October 2011. The gross total resection (GTR) rate at the time of the first iMRI was 58.9% (n=43). Based on the iMRI, eight patients (10.9%) underwent a second surgical resection. In 3 cases, the intraoperative imaging results were suspicious for a minor residue but not convincing enough for further surgery. Fortunately, the 3 months postoperative MRI control did not disclose any residual tumor in these cases. Finally, the GTR rate at the 3-month postoperative MRI increased to 72.6% (n=53). CONCLUSIONS 3T intraoperative MRI offered excellent quality images. Its use during transsphenoidal microsurgery on pituitary macroadenomas led to an increase not only in the extent of tumor resection (in 8 patients) but also in the rate of radical resections (69% instead of 60%). No complications due to the iMRI procedure were observed.

Detection by NeuroSENSE(®) Cerebral Monitor of Two Major Neurologic Events During Cardiac Surgery

From the Departments of *Anesthesiology, †Cardiac Intensive Care Unit, ‡Neurology; and §Cardiac Surgery, Université Catholique de Louvain, Cliniques Universitaires Saint Luc, Brussels, Belgium. Address reprint requests to Mona Momeni, MD, PhD, Université Catholique de Louvain, Cliniques Universitaires Saint Luc, Department of Anesthesiology, Avenue Hippocrate 10/1821 1200, Brussels, Belgium. E-mail: mona.momeni@uclouvain.be

Feasibility of the Video-Assisted Thyroid Surgery Under Hypnosis Associated to local Anesthesia

Background: Video-assisted thyroidectomy (VAT) is feasible and safe compared to conventional surgery. Thyroidectomy under hypnosis associated to local anesthesia (HYLA) as an alternative to general anesthesia (GA) has been shown to be effective. However, its combination with VAT has not yet been reported. The aim of the study is to describe the feasibility of VAT under HYLA as a complete minimally invasive approach and evaluate its safety. Methods: Out of 130 consecutive patients referred for thyroidectomy and selected for VAT, 50 patients opted voluntarily for HYLA. Safety and feasibility were considered primary endpoints. Results: Twenty eight patients benefited from a total thyroidectomy (56%). The remaining patients underwent thyroid lobectomy. Median operating time was 102.5minutes (range 70-177) and 92.5minutes (range 51-143) for total thyroidectomy and lobectomy, respectively. Median time in operating room was 146.5minutes (range101-222) and 133minutes (range 96-178) for total thyroidectomy and lobectomy, respectively. Conversion from VAT to a conventional surgical approach occurred in 4 patients (8%). No conversion to GA was required. Hemodynamic parameter measurements were stable during surgery. No permanent hypocalcemia or vocal cord palsy were observed. Ninety eight percent of the patients required just one overnight stay in hospital. Conclusion: The current brief report demonstrates that the combination of VAT and HYLA is feasible without the risk of additional surgical morbidity.

Lung Deposition of a Radiolabeled Aerosol With Two Ventilation Modalities During Invasive Mechanical Ventilation: A Randomized Comparative Study

Volume-controlled ventilation has been suggested during nebulization to optimize lung deposition although promoting spontaneous ventilation is targeted for ventilated patient management. Comparing topographic lung aerosol deposition during volume-controlled and spontaneous ventilation in pressure support has never been performed.

Abstract P2-18-03: Potential benefits of hypnosis sedation on different modalities of breast cancer treatment

Background: In oncology, hypnosis has been used for pain relief in metastatic patients but rarely for induction of anaesthesia. Material and methods: Between January 2010 and February 2014, 220 patients from our breast clinic (Cancer Center - Cliniques universitaires Saint-Luc - Universite catholique de Louvain) were included in an observational, non randomized study approved by our local ethics committee. 110 consecutive patients underwent breast surgery (lumpectomy or mastectomy +/- axillary lymph node dissection or sentinel lymph node biopsy) while on general anaesthesia (group I) and 110 consecutive patients underwent the same surgical procedures while on hypnosis sedation (group II). The stages and the tumor characteristics were well balanced between the two groups. After surgery, 28 patients received chemotherapy in group I and 27 patients in group II. Radiotherapy was administered to 96 patients of group I and 95 patients of group II. Currently, 83 patients of group I and 82 patients of group II are receiving endocrine therapy. Different parameters were studied for each treatment modality. Results: Duration of hospitalization was statistically significantly reduced in group II vs. group I (3.3 days vs. 4.4 days) (CI 95% range: -1.48 -0,72, p=0,0000000578) for all surgical procedures. The same results were observed for mastectomies alone (3.1 vs. 5.3 days) (CI 95 % range: -3,19 -1,31, p=0,0002 ) and for lumpectomies (3.1 vs. 4.3 days) (CI 95 % range: -1,024 -0,364, p=0,00065). The number of post-mastectomy lymph punctures was reduced in group II (1 to 3 (median value n=1.6) vs. group I (2 to 5 (median value n=3.1, p=0.01), as was the quantity of lymph removed (103 ml versus 462.7 ml) (p=0,0297) in the group of mastectomies. Concerning chemotherapy, the incidence of asthenia was statistically decreased (p=0.015) in group II. There was a statistically non significant trend towards a decrease in the incidence of nausea/vomiting and muscle pain in group II (respectively p=0.1 and p=0.2). The frequencey of severe radiodermitis (p=0.01) and post-radiotherapy asthenia (p=0.01) were significantly reduced in group II. Finally, compliance to endocrine therapy was improved in group II (p=0.05), while incidence of hot flashes (p=0,00029), joint or muscle pain (p=0,000139) and asthenia (p=0,00002) were statistically significantly decreased in group II. Discussion: Hypnosis sedation exerts beneficial effects on nearly all modalities of breast cancer treatment. The absence of a significant benefit for chemotherapy-induced nausea/vomiting and muscle pain observed is probably due to the small number of patients receiving chemotherapy in our study. Conclusion: Benefits of hypnosis sedation on breast cancer treatment are very encouraging and further promote the concept of integrative oncology. Citation Format: Martine Berliere, Sarah Lamerant, Philippe Piette, Aurore Lafosse, Laurence Delle Vigne, Fabienne Roelants, Christine Watremez, Marie-Agnes Docquier, Lafita Fellah, Isabelle Leconte, Francois Duhoux. Potential benefits of hypnosis sedation on different modalities of breast cancer treatment [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-18-03.