Serra Sencer

Surgical results in pediatric Spetzler–Martin grades I–III intracranial arteriovenous malformations

ObjectsThe goal of cerebral arteriovenous malformation (AVM) therapy in pediatric patients should be complete resection or obliteration of the AVM to eliminate subsequent hemorrhage, because of high mortality and morbidity rates related to hemorrhage in addition to the longer life expectation. Despite advances in Gamma knife radiosurgery and in endovascular embolization, surgical resection is still the gold standard for treating cerebral AVMs.MethodsBetween 1986 and 2003, 20 children were surgically treated for cerebral AVMs. The AVMs were graded I, II, and III using the Spetzler–Martin (S–M) Grading Scale. Good recovery was achieved in 18 out of 20 patients (90%) and only 1 patient was moderately disabled (5%). There was one mortality (5%) related to the preoperative deep comatose state of the patient. The total obliteration rate was 89% (17 out of 19).ConclusionFor S–M grade I–III AVMs, surgical resection is the treatment of choice, considering its high cure rate and low morbidity and mortality rates.

Vertebral sarcoidosis: imaging findings

Abstract. Sarcoidosis is a multisystemic disease of unknown aetiology characterised by noncaseating granulomatous inflammation with varying presentation and prognosis. Osseous disease reported in 1–13 % of cases commonly involves hands and feet; however, vertebral sarcoidosis is rare. This report describes the radiologic, CT, MRI and radionuclide imaging findings of vertebral involvement of a case with sarcoidosis.

Treatment of ruptured blood blister-like aneurysms with flow diverter SILK stents

Introduction Blood blister-like aneurysms (BBAs) are fragile and difficult to treat. Routine surgical and endovascular treatment methods, such as clipping, clip wrapping, primary coiling, or stent assisted coiling, have relatively high morbidity and mortality rates. In this study, we report clinical and angiographic results for treatment of ruptured BBAs using flow diverter stents. Methods We retrospectively reviewed patients who presented with subarachnoid hemorrhages caused by rupture of BBAs and who were treated using flow diverter stents at three neurointervention centers between January 2009 and January 2013. Clinical and angiographic findings, together with the procedural data and follow-up results, are reported. Results 11 patients were identified in this study. BBAs were located on the supraclinoid internal carotid artery (nine patients) and basilar arteries (two patients). Eight patients were treated by implantation of a single flow diverter stent. Two flow diverter stents were telescopically deployed in each of three patients. The procedures were successful in all cases. No acute complications developed in any case. One patient who had an initial Hess–Hunt grade 4 died of septicemia 2 weeks after the procedure (9%). Another patient developed a minor stroke caused by parent artery thrombosis (9%). Control angiographies performed 3 and 6 months post stenting revealed complete occlusion of the aneurysms in all of the remaining nine patients (82%). 10 of the 11 patients (92%) had good clinical outcomes (modified Rankin Scale score ≤2). Conclusions Implantation of flow diverter stents seems to be a safe and feasible alternative for treatment of ruptured BBAs.

LOCALIZATION OF CEREBROSPINAL FLUID LEAKS BY GADOLINIUM-ENHANCED MAGNETIC RESONANCE CISTERNOGRAPHYA 5-YEAR SINGLE-CENTER EXPERIENCE

OBJECTIVEIntrathecal gadolinium (Gd)-enhanced magnetic resonance (MR) cisternography is a newly introduced imaging method. Two main objectives of this study were to investigate the sensitivity of Gd-enhanced MR cisternography for presurgical localization of cerebrospinal fluid (CSF) leaks in patients with CSF rhinorrhea and to study the potential long-term adverse effects of intrathecal Gd application. METHODSFifty-one patients (19 women; mean age, 36.2 yr) with CSF rhinorrhea were included in the study. A total of 0.5 ml of Gd was injected into the lumbar subarachnoid space. T1-weighted MR cisternographic images were obtained to detect CSF leakage. The patients neurological states and vital signs were recorded for the first 24 hours after the procedure. Neurological evaluations were repeated 1, 3, and 12 months after the procedure. The patients were followed for at least 3 years with annual neurological examinations. RESULTSGd-enhanced MR cisternography demonstrated CSF leaks in 43 of the 51 patients. The sensitivity of Gd-enhanced MR cisternography for localization of CSF leaks was 84%. Forty-four patients underwent surgery to repair dural tears. Surgical findings confirmed the results of Gd-enhanced cisternography in 43 of the 44 patients who underwent surgery (98%). Eight patients with negative Gd-enhanced MR cisternography had no active rhinorrhea at the time of procedure, and seven of them did not need surgery. None of the patients developed an acute adverse reaction that could be attributed to the procedure. None of the patients developed any neurological symptoms or signs caused by intrathecal Gd injection during a mean follow-up period of 4.12 years. CONCLUSIONGd-enhanced MR cisternography is a sensitive and safe imaging method for detection of CSF leaks in patients with rhinorrhea.

Obsessive–compulsive disorder after epilepsy surgery

It is a well-known fact that after epilepsy surgery (ES) preexisting psychopathology may deteriorate or de novo psychopathological syndromes, mainly of a depressive and psychotic nature, may appear. Previously, recovery of obsessive-compulsive disorder (OCD) after ES has been reported in patients who had comorbid OCD preoperatively; however, there have been no reports on the appearance of de novo OCD interfering with daily living activities post-ES. This is the first report of OCD after ES in patients with mesial temporal lobe epilepsy (MTLE). Five patients with MTLE were identified with obsessive personality traits before surgery. Within the first 2 months after ES, two of these MTLE patients fulfilled OCD diagnostic criteria. These OCD patients were not any different from the other three patients with respect to age, age of onset of epilepsy, seizure types, and seizure frequency. All patients stopped having seizures postoperatively, but the OCD patients had worse quality of life postoperatively than preoperatively. Our findings show that those patients with obsessive traits preoperatively should be carefully monitored after ES.

Do unilateral ablative lesions of the subthalamic nucleu in parkinsonian patients lead to hemiballism

We report the safety results in nine patients with advanced idiopathic Parkinsons disease (PD) who underwent ablative surgery of unilateral subthalamic nucleus (STN). In eight patients, surgical objectives were attained without induction of abnormal involuntary movements or other adverse effects. One patient developed transient hemiballistic movements which improved within 2 weeks after surgery. Assessment at 2 weeks to 20 months postoperatively revealed no long‐term adverse effects. We conclude that hemiballism following unilateral ablation of STN in patients with PD is a rare phenomenon, and unilateral ablative lesions of STN can be performed safely.

Stereotactic surgery in the management of brain abscess

BACKGROUND Bacterial brain abscesses can be diagnosed and treated with stereotactic aspiration. METHODS From 1991 to 1997 we have used computed tomography-guided stereotactic aspiration to diagnose and treat 21 patients with a total of 58 bacterial brain abscesses. The ages of the patients ranged from 4 to 72 years (median 25 years); 11 of these 21 patients had multiple abscesses. The number of abscesses per patient with multiple abscesses ranged from 2 to 9, all located deep in subcortical white matter. RESULTS All patients underwent stereotactic surgical drainage and an 8-week intravenous antibiotic medical treatment. Of the 58 abscesses, 23 were aspirated. Of these 23 abscesses, 19 were radiologically stage III or IV and four were stage I or II. Pathological examination confirmed radiological staging in 19 patients (83%). Except for the three patients who have mild residual hemiparesis and one patient recovering from ataxia, all patients had complete neurological recovery. CONCLUSIONS Computed tomography-guided stereotaxy achieved all the objectives of management; namely, ascertaining the diagnosis, draining the content of the mass, and obtaining pus for accurate bacteriological diagnosis without morbidity. Stereotactic aspiration combined with an 8-week intravenous antibiotic regimen has yielded an effective therapeutic result in all of our abscesses, small or large, solitary or multiple, superficial or deep-seated. A high radiological-pathological correlation was also deduced from this study.

Single-voxel proton MR spectroscopy in toluene abuse

Inhalation of toluene, which is an organic solvent, causes toxic encephalopathy characterized by cognitive impairment, cerebellar and extra-pyramidal symptoms. We studied cranial MR images and single-voxel MR spectroscopy of 22 toluene abusers and age-matched control subjects. The mean age of the abusers and mean duration of abuse were 18,1 years and 47 months, respectively. We got three MR spectra from the centrum semiovale, cerebellum and thalamus by using STEAM sequence with a TE value of 30 ms. N-acetyl aspartate (NAA)/Creatine (Cr), Choline (Cho)/Cr, myo-inositol (mI)/Cr peak integral ratios were calculated. NAA/Cr in the cerebellum and centrum semiovale of the abusers were significantly lower than those of the control subjects. mI/Cr in centrum semiovale and cerebellum were higher in toluene abusers. No significant difference was found in the metabolite ratios of the thalami. The association of NAA/Cr and mI/Cr ratios in cerebellum and centrum semiovale with the duration of abuse was significant. Normal level of NAA in thalamus, which was a neuron rich gray matter structure, might imply that toluene inhalation did not cause direct neuronal injury. Selective reduction of NAA and increased level of mI in white matter supported the theory of that axonopathy and gliosis were the main mechanisms of pathophysiology in chronic toluene encepholopathy. Insignificance of elevation of Cho/Cr ratios demonstrated that toluene inhalation did not cause active demyelination.

Dual Stenting Using Low-Profile LEO Baby Stents for the Endovascular Management of Challenging Intracranial Aneurysms

BACKGROUND AND PURPOSE: Endovascular treatment of wide-neck, complex, and distally located cerebral aneurysms is a challenging issue. This study evaluated the safety and efficacy of dual stent placement by using a low-profile stent system (LEO Baby) for the treatment of challenging distal intracranial aneurysms. MATERIALS AND METHODS: We retrospectively reviewed patients in whom at least 1 LEO Baby stent was used in the context of dual stent placement for the treatment of intracranial aneurysms. Patients who were treated with dual stent-assisted coil embolization and telescopic implantation of LEO Baby stents were included in the study. Clinical and angiographic findings, procedural data, and follow-up are reported. RESULTS: Twelve patients were included in this study. Three patients presented with subarachnoid hemorrhage in the subacute-chronic phase, and the remaining patients had unruptured aneurysms. Nine patients were treated by using the dual stent-assisted coiling method. X- (nonintersecting), Y- (intersecting and reversible), T-, and parallel-stent configurations were performed for the dual stent-assisted coiling procedures. Three patients were treated by using telescopic stent placement for a flow diverter–like effect. The procedures were successful in all cases. Technical complications without a significant clinical adverse event developed in 2 patients. The 3- and 6-month control MRAs and DSAs demonstrated complete occlusion of the aneurysms in all patients except 1. All patients had good clinical outcomes on follow-up (mRS ≤1). CONCLUSIONS: The results of this small study showed the feasibility of dual stent placement by using low-profile LEO Baby stents to treat distally located complex intracranial aneurysms.

Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms Using Low-Profile LEO Baby Stents: Initial and Midterm Results.

BACKGROUND AND PURPOSE: Low-profile self-expandable stents were recently introduced for the treatment of wide-neck intracranial aneurysms. This study investigated the initial and midterm clinical and angiographic results of LEO Baby stent–assisted coiling in the treatment of wide-neck intracranial aneurysms. MATERIALS AND METHODS: A retrospective review was performed to identify patients who were treated with LEO Baby stent–assisted coiling. Eighty patients with 80 wide-neck intracranial aneurysms were included in the study. Eleven patients (13.8%) presented with subarachnoid hemorrhage. All patients were treated with LEO Baby stent–assisted coiling. Technical success and immediate postprocedural clinical and angiographic outcomes were evaluated. Seventy-three patients attended angiographic and clinical follow-up for a mean duration of 7.2 ± 3.8 months. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed by using the modified Rankin Scale. RESULTS: The technical success rate of the procedure was 97.5%. The immediate postprocedural angiography revealed a complete occlusion of the aneurysm in 75% of the 80 patients. The last follow-up angiograms showed complete occlusion in 85.7% of the 77 patients with an angiographic follow-up. Of the 77 patients with a follow-up angiography, 6.5% showed an increase in the filling status of the aneurysm and 5.2% required retreatment. The overall procedure-related complication rate, including asymptomatic complications, was 11.3%. The permanent morbidity rate was 3.8%. There was no mortality in this study. CONCLUSIONS: This case series demonstrates the relative safety, efficacy, and midterm durability of the LEO Baby stent–assisted coiling procedure for the treatment of wide-neck intracranial aneurysms.