Sean M. Barber

Middle cerebral artery aneurysms: A single-center series comparing endovascular and surgical treatment

OBJECTIVE The optimal treatment for middle cerebral artery (MCA) aneurysms is controversial. MCA aneurysms have been considered more conducive to surgical treatment. Recent technology has led to successful endovascular treatment of MCA aneurysms. The objective of this study was to analyze the outcomes of endovascular and surgical treatment of MCA aneurysms as experienced by a single tertiary center. METHODS We retrospectively reviewed 90 MCA aneurysms in 84 patients treated from 2005 to 2010. They were separated into 2 groups: endovascular coiling, with 50 (59.5%) patients, and surgical clipping, with 34 (40.5%) patients. Outcome was based on complications, procedural morbidity and mortality, clinical and angiographic outcomes, and retreatment rates. Patients were further separated into ruptured and unruptured aneurysm groups. RESULTS Ruptured aneurysms were 10 of 50 (20%) and 9 of 34 (26.5%) patients in the endovascular and surgical groups, respectively. Procedure-related complications were 16% and 0% for the endovascular and surgical groups (P = .01), respectively. Overall rate of complete or near-complete occlusion at angiographic follow-up was 86% and 95% for the endovascular and surgical groups (P = .16), respectively. Proportion of patients with modified Rankin scale of 3 to 6 at 6 months follow-up was 10% and 5.9% for the endovascular and surgical groups (P = .5), respectively. The mean angiographic follow-up was 9.02 months (range 0 to 5.2 years). Retreatment rates were 14% and 0% for the endovascular and surgical groups, respectively (P = .01). CONCLUSIONS In this nonrandomized sample of 90 MCA aneurysms treated with endovascular coiling or neurosurgical clipping, we observed a similar clinical outcome based on the modified Rankin scale and angiographic occlusion. Complication and retreatment rates were higher but not significant for the endovascular group. Both treatment modalities are good alternatives and should be individualized based on aneurysm angioarchitecture and the patients general conditions.

The Role of Endoscopic Third Ventriculostomy in the Treatment of Communicating Hydrocephalus

OBJECTIVE To elucidate the role of endoscopic third ventriculostomy (ETV) in patients with secondary and idiopathic communicating hydrocephalus (HCP). METHODS A series of 36 patients with communicating HCP (21 men and 15 women) were treated by ETV between November 2007 and February 2010. The patients age ranged from 19 to 81 years old (mean 52 years), and had a follow-up of 6 to 36 months (mean 9.2 months). The patients were divided into a group of 29 patients with secondary communicating HCP and a group of 7 patients with normal pressure HCP. Sixteen (44.4%) of the patients had a previous ventriculoperitoneal shunt placement that presented with shunt malfunction. RESULTS The etiology of secondary HCP was subarachnoid hemorrhage, meningitis, trauma, neoplasm, and others. Etiology was not possible to determine in some patients. The outcome of ETV was considered successful in 27/36 patients (75%). A Kaplan-Meier analysis revealed that the successful proportion of ETVs in secondary communicating HCP at 0.5, 1, and 3 months of follow-up was 0.83, 0.8, and 0.77, respectively; in the idiopathic normal pressure HCP group it was 0.83 initially and became stable at 0.66 after the first month. Overall, the successful proportion of ETV in communicating HCP was at 0, 0.5, 1, and 3 months of follow-up was 0.97, 0.83, 0.78, and 0.75. CONCLUSIONS ETV is a good option in the management of secondary communicating HCP, normal pressure HCP, and replacing malfunctioning ventriculoperitoneal shunts. The indications of ETV as a first-line treatment in communicating HCP needs further study; however, results are promising.

Neuroendoscopic Resection of Intraventricular Tumors: A Systematic Outcomes Analysis

Introduction. Though traditional microsurgical techniques are the gold standard for intraventricular tumor resection, the morbidity and invasiveness of microsurgical approaches to the ventricular system have galvanized interest in neuroendoscopic resection. We present a systematic review of the literature to provide a better understanding of the virtues and limitations of endoscopic tumor resection. Materials and Methods. 40 articles describing 668 endoscopic tumor resections were selected from the Pubmed database and reviewed. Results. Complete or near-complete resection was achieved in 75.0% of the patients. 9.9% of resected tumors recurred during the follow-up period, and procedure-related complications occurred in 20.8% of the procedures. Tumor size ≤ 2cm (P = 0.00146), the presence of a cystic tumor component (P < 0.0001), and the use of navigation or stereotactic tools during the procedure (P = 0.0003) were each independently associated with a greater likelihood of complete or near-complete tumor resection. Additionally, the complication rate was significantly higher for noncystic masses than for cystic ones (P < 0.0001). Discussion. Neuroendoscopic outcomes for intraventricular tumor resection are significantly better when performed on small, cystic tumors and when neural navigation or stereotaxy is used. Conclusion. Neuroendoscopic resection appears to be a safe and reliable treatment option for patients with intraventricular tumors of a particular morphology.

Incidence, Etiology and Outcomes of Hyponatremia after Transsphenoidal Surgery: Experience with 344 Consecutive Patients at a Single Tertiary Center

Hyponatremia is often seen after transsphenoidal surgery and is a source of considerable economic burden and patient-related morbidity and mortality. We performed a retrospective review of 344 patients who underwent transsphenoidal surgery at our institution between 2006 and 2012. Postoperative hyponatremia was seen in 18.0% of patients at a mean of 3.9 days postoperatively. Hyponatremia was most commonly mild (51.6%) and clinically asymptomatic (93.8%). SIADH was the primary cause of hyponatremia in the majority of cases (n = 44, 71.0%), followed by cerebral salt wasting (n = 15, 24.2%) and desmopressin over-administration (n = 3, 4.8%). The incidence of postoperative hyponatremia was significantly higher in patients with cardiac, renal and/or thyroid disease (p = 0.0034, Objective Risk (OR) = 2.60) and in female patients (p = 0.011, OR = 2.18) or patients undergoing post-operative cerebrospinal fluid drainage (p = 0.0006). Treatment with hypertonic saline (OR = −2.4, p = 0.10) and sodium chloride tablets (OR = −1.57, p = 0.45) was associated with a non-significant trend toward faster resolution of hyponatremia. The use of fluid restriction and diuretics should be de-emphasized in the treatment of post-transsphenoidal hyponatremia, as they have not been shown to significantly alter the time-course to the restoration of sodium balance.

Neurosurgery Certification in Member Societies of the WFNS: Global Overview

OBJECTIVE To determine the complexity and diversity of the neurosurgery certification and recertification process in member societies of the World Federation of Neurosurgical Societies. MATERIAL AND METHODS A 13-item survey was sent to 88 national and regional societies that are members of the World Federation of Neurosurgical Societies. Variables included in the survey covered a wide range of aspects pertaining to the certification process achieved by cognitive and oral examinations. The data received from 40 responding societies (response rate 45%) were tabulated, and an individual and comparative (global) analysis was performed for all categories, including eligibility and requirements for certification, examination components, use of computer-assisted technology and imaging, performance, validation of foreign degrees, recertification, and maintenance of certification. RESULTS We present here the global analysis, which is comparative of all participating societies. Although there is high variability in the structure of certification programs worldwide, performance in knowledge-based examinations is similar. Recertification and maintenance of certification are still under development in many societies. CONCLUSION With the onset of globalization, we anticipate that efforts will be made in the future to obtain homogeneity in the structure of certification, recertification, and in criteria for international reciprocity of postgraduate neurosurgical training. Peer-Review Article.

Neurosurgery Certification in Member Societies of the WFNS: Europe

OBJECTIVE To objectively compare the complexity and diversity of the certification process in Neurological Surgery in European member societies of the World Federation of Neurosurgical Societies. MATERIALS AND METHODS The attention of this study centers on Europe. We provide here a subgroup analysis based on the responses provided to a 13-item survey. The data received were analyzed and three regional complexity scores (RCS) were designed. To compare national board experience as well as eligibility requirements to access the certification process and obligatory nature of the examinations, a RCS Organizational score was created (RCS-O, 20 points maximum). To analyze the complexity of the examination a RCS Components score was designed (RCS-C, 20 points maximum). The sum of both is presented in a Global RCS score (RCS-G). In addition, a descriptive summary of the certification process per responding society is also provided. RESULTS AND CONCLUSIONS Based on the data provided by our RCS system, the highest RCS-G was obtained by the United Kingdom (19/40 points) followed by European Association of Neurosurgical Societies, Poland, and Sweden (16/40 points each), Portugal (15/40 points), and Switzerland (14/40 points). The experience from these leading countries should be of value to all countries of the European Union.

Hydrocephalus in Wegener’s Granulomatosis: Neuroendoscopic Findings and Management

To the Editor: Wegener’s granulomatosis (WG) is a systemic disease characterized by inflammatory changes of small and medium-size blood vessels. The clinical features in correlation with histopathology were initially described by Wegener in 19361. The disease is associated with granuloma formation and necrosis of the upper airway, lungs, and kidneys2, although other organs can also be affected. The nervous system is involved in up to 33% of cases, with the peripheral nervous system most commonly affected. Involvement of the central nervous system (CNS) is highly unusual3. Similarly, hydrocephalus is very uncommon, occurring in only 4 previously documented cases4,5,6,7. We describe an unusual case of WG with pachymeningitis and aqueductal stenosis resulting in hydrocephalus in a patient who underwent neuroendoscopic exploration of the ventricular system. We believe this is the first report of WG-associated hydrocephalus secondary to aqueductal stenosis effectively managed with cerebral endoscopy. A 33-year-old right-handed white man with WG presented to the emergency department with symptoms of subacute onset of headache, neck and retroorbital pain, diplopia, … Address correspondence to Dr. Rangel-Castilla; E-mail: LRcastilla{at}tmhs.org

Neurosurgery Certification in Member Societies of the World Federation of Neurosurgical Societies (WFNS). The Americas

INTRODUCTION This article aims to objectively compare the complexity and diversity of the certification process in neurologic surgery in member societies of the World Federation of Neurosurgical Societies. METHODS This study centers on the certification processes in the geographic regions of North, South, and Central America. It presents a subgroup analysis based on the responses provided to a 13-item survey. The data received were analyzed and three Regional Complexity Scores (RCSs) were designed. To compare national board experience, eligibility requirements to access the certification process, and the degree to which exams were obligatory, an RCS-Organizational score was created (RCS-O, 20 points maximum). To analyze the complexity of the examination, an RCS-Components score was designed (RCS-C, 20 points maximum). The sum of both is presented as the Global RCS (RCS-G) score. In addition, a descriptive summary of the certification process for each responding society is also provided. RESULTS On the basis of the data provided by the RCS system, the United States and Brazil seem to have the most developed certification processes in the American continent (20 points each), followed by Canada (18 points) and Mexico (17 points). CONCLUSION The experience from these leading countries should be of value and reference to other countries, allowing future improvement within the region. Peer-Review Article.

Calcifying pseudoneoplasm of the neuraxis (CAPNON): a case illustrating natural history over 17 years of radiological surveillance

BACKGROUND Calcifying pseudoneoplasm of the neuraxis (CAPNON) is a rare central nervous system lesion that can occur in both the brain and the spine. Although this entity is poorly understood, radiologic and histological features have been identified. CASE DESCRIPTION We report a unique case of a 31-year-old patient who was managed with antiepileptic medication for 17 years before requiring neurosurgical intervention for tumor progression. T2-weighted magnetic resonance imaging revealed hyperintensity within the tumor with extensive associated vasogenic edema, which is not normally associated with CAPNON. Resection was successful with no complications. CONCLUSIONS The present case illustrates the long-term natural history of CAPNON before resection and highlights the variations in radiologic appearance that may be associated with this poorly understood entity.

Delayed Hydrocephalus and Perianeurysmal Cyst Formation After Stent-Assisted Coil Embolization of a Large, Unruptured Basilar Apex Aneurysm: A Case Report and Literature Review.

PurposeEndovascular aneurysm embolization possesses a unique set of infrequently seen complications distinct from those associated with microsurgical clipping, which may arise after an otherwise uncomplicated coil embolization procedure, including postembolization, hydrocephalus, and perianeurysmal cyst formation. DesignThe authors report an illustrative case of 2 rarely seen complications of aneurysm embolization with literature review. MethodsWe present a case of a basilar apex aneurysm that was treated with endovascular coil embolization with multiple Cerecyte (Micrus Endovascular, San Jose, Calif) coils and 2 Enterprise (Codman & Shurtleff, Inc, Raynham, Mass) stents. ResultsPostembolization angiography demonstrated complete aneurysm obliteration without distal branch occlusion or other complication. Twenty-two months after the embolization, however, the patient presented with progressively worsening headaches. Repeat magnetic resonance imaging revealed hydrocephalus and a perianeurysmal cyst measuring 1 × 2 cm adjacent to the previously coiled basilar apex aneurysm. After endoscopic third ventriculostomy, the patient experienced significant relief of her headaches and was discharged to rehabilitation. ConclusionsClinicians should be aware that worsening or new neuro-ophthalmic findings may be the presenting sign of postembolization hydrocephalus or perianeurysmal cyst formation.