Özgür Celik

Lateral supraorbital approach applied to olfactory groove meningiomas: experience with 66 consecutive patients.

OBJECTIVEThe lateral supraorbital approach for safely and completely removing olfactory groove meningiomas was assessed. METHODSBetween September 1997 and June 2008, a total of 656 meningiomas were operated on by the senior author (JH) at the Department of Neurosurgery, Helsinki University Central Hospital; 66 were olfactory meningiomas. We retrospectively analyze the clinical data, radiological findings, surgical treatment, histology, and outcome of all the olfactory groove meningioma patients and discuss the operative techniques used. RESULTSSixty-six patients were operated on by the lateral supraorbital approach. The median preoperative Karnofsky Performance Scale score was 80 (range, 40–100). Three patients were redo cases in which the primary operation had been performed elsewhere. Seemingly complete tumor removal was achieved in 60 patients (91%); there was no surgical mortality. Postoperatively, 6 patients (9%) had cerebrospinal fluid leakage, 5 (8%) had new visual deficits, 4 (6%) had wound infections, 4 (6%) had cotton granulomas, and 1 (2%) had a postoperative hematoma. The median Karnofsky score at discharge was 80 (range, 40–100). Six patients had recurrent tumors; 3 underwent reoperations after an average of 21 months (range, 1–41 months); 1 was treated with radiosurgery, and 2 were only followed. During the median follow-up time of 45 months (range, 2–128 months), there were 4 recurrences (6%) diagnosed on average 32 months (range, 17–59 months) after surgery. CONCLUSIONThe lateral supraorbital approach can be used safely for olfactory groove meningiomas of all sizes with no mortality and relatively low morbidity. Surgical results and tumor recurrence with this fast and simple approach are similar to those obtained with more extensive, complex, and time-consuming approaches.

Application of microscope integrated indocyanine green video-angiography during microneurosurgical treatment of intracranial aneurysms: a review.

Indocyanine Green Video Angiography (ICG-VA) is recently introduced to the practice of cerebrovascular neurosurgery. This technique is safe and noninvasive and provides reliable real-time information on the patency of blood vessels of any size, as well as residual filling of aneurysms. In this article, a review of the literature and our experience with ICG-VA during microneurosurgery of intracranial aneurysms is presented.

Microneurosurgical management of internal carotid artery bifurcation aneurysms

BACKGROUND Internal carotid artery bifurcation aneurysms form 2% to 9% of all IAs. They are more frequent in younger patients than other IAs. In this article, we review the practical microsurgical anatomy, the preoperative imaging, surgical planning, and the microneurosurgical steps in the dissection and the clipping of ICAbifAs. METHODS This review and the whole series on IAs are mainly based on the personal microneurosurgical experience of the senior author (JH) in 2 Finnish centers (Helsinki and Kuopio), which serve, without patient selection, the catchment area in Southern and Eastern Finland. RESULTS These 2 centers have treated more than 11 000 patients with IAs since 1951. In the Kuopio Cerebral Aneurysm Database of 3005 patients with 4253 IAs, 831 (28%) patients had altogether 980 ICA aneurysms, of whom 137 patients had 149 (4%) ICAbifAs. Ruptured ICAbifAs, found in 78 (52%) patients, with median size of 8 mm (range, 2-60 mm), were associated with ICH in 15 (19%) patients. Ten (7%) ICAbifAs were giant (> or = 25 mm). Multiple aneurysms were seen in 59 (43%) patients. The ICAbifAs represented 18% of all IAs ruptured before the age of 30 years. CONCLUSIONS The main difficulty in microneurosurgical management of ICAbifAs is to preserve flow in all the perforators surrounding or adherent to the aneurysm dome. This necessitates perfect surgical strategy based on preoperative knowledge of 3D angioarchitecture and proper orientation during the microsurgical dissection.

Ectopic recurrence of craniopharyngioma along the surgical route: case report and literature review

We present a 22-year-old woman with an ectopic recurrence of a craniopharyngioma. The patient presented first with a visual field deficit, and a craniopharyngioma was removed via an interhemispheric transcallosal approach. Magnetic resonance imaging (MRI) performed at 1 month, and then at 1 year after surgery showed complete removal of the lesion. However, at 4 years, MRI showed the presence of a small tumor in the right medial frontal lobe attached to the falx and along the previous surgical route. We present possible explanations for the ectopic recurrence and literature review.

REPAIR OF AN ALARMING INTRAOPERATIVE INTRACAVERNOUS CAROTID ARTERY TEAR WITH ANASTOCLIPS: TECHNICAL CASE REPORT

OBJECTIVESurgical treatment of an intracavernous carotid aneurysm (ICCA) is difficult because of the close relationship to bone, dura, and neurovascular structures. Intraoperative rupture of an ICCA is challenging, especially if the site of rupture is at the base of the aneurysm. We present a case of intraoperative rupture of an ICCA caused by clinoidectomy. We repaired it by using a single-clamp applicator (AnastoClip Vessel Closure System, 1.4 mm; LeMaitre Vascular, Burlington, MA). CLINICAL PRESENTATIONIn April 2007, a 40-year-old woman underwent neurosurgical treatment at another institution for a ruptured basilar bifurcation aneurysm, with good recovery. Digital subtraction angiography performed at this time showed the presence of left internal carotid artery aneurysms, 1 at the anterior wall of the paraclinoidal segment and 1 at the lateral wall of the intracavernous segment. In February 2008, the patient was referred from outside Finland to our department for microsurgical treatment of both aneurysms. TECHNIQUEA lateral supraorbital approach was used, and during extradural removal of the anterior clinoid with a rongeur, the ICCA ruptured. The base of the intracavernous aneurysm was involved in the rupture, and we used a single-clamp applicator to repair the internal carotid artery. Intraoperative digital subtraction angiography, indocyanine green video angiography, and Doppler ultrasonography showed a good flow in the artery. The paraclinoid aneurysm was uneventfully clipped during the same intervention. CONCLUSIONIntraoperative rupture of ICCA was repaired quickly and effectively by using a single-clamp applicator. Our case and experimental data from other microsurgical vascular experiences suggest that the future of intracranial vessel repair/anastomoses will be using microclips and other simpler devices more, allowing the neurosurgeon to perform fast and effective vessel repair.

Microsurgical principles for anterior circulation aneurysms.

Microneurosurgical techniques introduced by Prof. Yaşargil have been modified by the senior author (JH) when treating more than 4,000 patients with aneurysms at two of the Departments of Neurosurgery in Finland, Kuopio and Helsinki, with a total catchment area of close to three million people. This experience is reviewed, and the treatment of anterior circulation aneurysms by simple, fast, normal anatomy preserving strategy is presented.Most of the aneurysms of the anterior circulation are treated by using the lateral supraorbital approach, a less invasive, more frontally located modification of the pterional approach. To avoid extensive skull base surgery, a slack brain is needed and achieved by experienced neuroanesthesia and by surgical tricks for removal of CSF.Diagnosis of cerebral aneurysm before rupture improves treatment results more than any technical advances. Until this is realized, we continue to treat cerebral aneurysms by simple, fast, preserving normal anatomy-strategy, which has served our patients well.Patients with cerebral aneurysms should be treated at specialized neurovascular centers.

Inappropriate application of Yaşargil aneurysm clips: a new observation and technical remark.

OBJECTIVE Recurrences after complete surgical clipping of an aneurysm base are rare. We describe a potential reason for such recurrences: the inappropriate application of a popular aneurysm clip. CLINICAL PRESENTATION We present 3 cases in which intraoperative indocyanine green video angiography after clipping clearly demonstrates filling of the aneurysm. INTERVENTION During surgery, the necks of the aneurysms were clipped with Yaşargil aneurysm clips (Aesculap AG & Co., Tuttlingen, Germany) without any problems; however, indocyanine green video angiography after clipping showed filling of the aneurysms through the point located at the junction of the blade and spring portions of the clips. In the first patient, the aneurysm sac was further coagulated, and a second, smaller clip was applied to completely occlude the untreated part. In the second patient, the clip was replaced with a different clip that had longer blades. In the third patient, 2 additional clips were applied, and the aneurysm sac was also coagulated. The postoperative computed tomographic angiographic examinations showed total occlusion of the aneurysms and patency of the parent arteries. All patients achieved full recovery after the operations. CONCLUSION We present here, for the first time, evidence that the small orifice located at the junction of the blade and spring portions of Yaşargil aneurysm clips can lead to failure of initial surgery and/or recurrence. This can be avoided by using clips with slightly longer blades to keep the orifice away from the aneurysm or by applying a second clip to occlude the untreated part.

Management of Dural Arteriovenous Fistulas – Helsinki and Kuopio Experience

Dural arteriovenous fistulas (DAVFs) are complex disorders, some of them with aggressive clinical behaviour. During past decades their treatment strategy has changed due to increased knowledge of their pathophysiology and natural history, and advances in treatment modalities. In asymptomatic cases or cases with mild symptoms in the absence of cortical venous drainage (CVD) no treatment is necessarily required, whereas aggressive DAVFs should be treated promptly by endovascular or microsurgical means.In our series of 323 patients with 333 fistulas, treated in two neurosurgical units in Finland since 1944, there were 265 true DAVFs and 68 Barrow type A caroticocavernous fistulas. Among the DAVFs there was a slight female predominance, 140 women (55%) and 115 men (45%), and the majority of the cases were located in the area of transverse and sigmoid sinuses. Mode of treatment in the early series was proximal ligation of feeding artery, and later craniotomy, endovascular treatment and radiosurgery, or combination of these treatments, with total occlusion rate being 53%.