Thomas A. Kopitnik

Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage.

OBJECTIVEThe purpose of this study was to identify factors predictive of shunt-dependent hydrocephalus among patients with aneurysmal subarachnoid hemorrhage. The data can be used to predict which patients in this group have a high probability of requiring permanent cerebrospinal fluid diversion. METHODSSeven hundred eighteen patients with aneurysmal subarachnoid hemorrhage who were treated between 1990 and 1999 were retrospectively studied, to identify factors contributing to shunt-dependent hydrocephalus. With these data, a stepwise logistic regression procedure was used to determine the effect of each variable on the development of hydrocephalus and to create a scoring system. RESULTSOverall, 152 of the 718 patients (21.2%) underwent shunting procedures for treatment of hydrocephalus. Four hundred seventy-nine of the patients (66.7%) were female. Of the factors investigated, the following were associated with shunt-dependent hydrocephalus, as determined with a variety of statistical methods: 1) increasing age (P < 0.001), 2) female sex (P = 0.015), 3) poor admission Hunt and Hess grade (P < 0.001), 4) thick subarachnoid hemorrhage on admission computed tomographic scans (P < 0.001), 5) intraventricular hemorrhage (P < 0.001), 6) radiological hydrocephalus at the time of admission (P < 0.001), 7) distal posterior circulation location of the ruptured aneurysm (P = 0.046), 8) clinical vasospasm (P < 0.001), and 9) endovascular treatment (P = 0.013). The presence of intracerebral hematomas, giant aneurysms, or multiple aneurysms did not influence the development of shunt-dependent hydrocephalus. CONCLUSIONThe results of this study can help identify patients with a high risk of developing shunt-dependent hydrocephalus. This may help neurosurgeons expedite treatment, may decrease the cost and length of hospital stays, and may result in improved outcomes.

Evolution of the management of tentorial dural arteriovenous malformations

OBJECTIVETentorial dural arteriovenous malformations (DAVMs) are uncommon lesions associated with an aggressive natural history. Controversy exists regarding their optimal treatment. We present a single-institution series of tentorial DAVMs treated during a 12-year period, address the current controversies, and present the rationale for our current therapeutic strategy. METHODSTwenty-two patients with tentorial DAVMs were treated between 1988 and 2000. Treatment consisted of transarterial or transvenous embolization, surgical resection, disconnection of venous drainage, or a combination of these therapies. The clinical presentations, radiological features, treatment strategies, and results were studied. RESULTSEighteen patients (82%) presented with intracranial hemorrhage or progressive neurological deficits. Retrograde leptomeningeal venous drainage was documented in 22 cases (100%), classifying the lesions as Borden Type III. Angiographic follow-up monitoring was performed for 0 to 120 months and clinical follow-up monitoring for 1 to 120 months. Posttreatment angiography demonstrated obliteration in 22 cases (100%). Two patients experienced neurological decline after endovascular treatment and died. All of the 20 surviving patients exhibited clinical improvement; there were no episodes of rehemorrhage or new neurological deficits. Outcomes were excellent in 17 cases (77%), good in 2 cases (9%), and fair in 1 case (5%), and there were 2 deaths (9%). CONCLUSIONTentorial DAVMs are aggressive lesions that require prompt total angiographic obliteration. Disconnection of the venous drainage from the fistula may be accomplished with transarterial embolization to the venous side, transvenous embolization, or surgical disconnection of the fistula. We think that extensive nidal resections carry more risk and are unnecessary. We do not think there is a role for stereotactic radiosurgery in the treatment of these lesions.

Current results of the surgical management of aneurysms of the basilar apex.

OBJECTIVE To provide current information regarding the expected clinical outcomes and sources of morbidity and mortality in the modern surgical management of basilar apex aneurysms. METHOD A retrospective review was conducted of 303 cases of such aneurysms that were treated surgically during 18 years at one institution. Postoperative angiography was performed in 81% of the cases. Clinical grading using the Glasgow Outcome Scale was conducted at the time of hospital discharge and for 91% of the surviving patients at 6 months after surgery. The preoperative parameters that were linked statistically to poor clinical outcome were identified through the use of single and multivariate analyses. RESULTS More than 80% of the patients were operated on using some modification of the trans-sylvian exposure, and temporary arterial occlusion was used routinely. Good outcomes (Glasgow Outcome Scale scores of 4 or 5) were achieved in 76% of the patients at the time of discharge and in 81% of the patients at 6 months after surgery. There was no incidence of postoperative subarachnoid hemorrhage. Residual aneurysm was revealed by postoperative angiography in 6% of the cases. Factors found to be statistically linked to poor outcome included poor admission grade (Hunt and Hess Grades IV and V), patient age older than 65 years, computed tomographic demonstration of thick basal cistern clot, aneurysm size greater than 20 mm, and symptoms attributable to brain stem compression. CONCLUSION Direct microsurgical repair of basilar apex aneurysms should result in good clinical outcomes in 80 to 85% of cases, with reliable prevention of subarachnoid bleeding and routine elimination/reduction of symptoms secondary to mass effect. Those patients who are at high risk for poor outcomes can be identified by the presence of certain clinical, radiographic, and demographic features before undergoing surgery and can be considered for alternative or adjunctive modes of therapy if long-term efficacy of such treatment is demonstrated.

Posteroinferior cerebellar artery aneurysms: Surgical results for 38 patients

OBJECTIVE Posteroinferior cerebellar artery aneurysms have an incidence of approximately 0.49%. Reports in the literature are sparse concerning outcomes in this patient population. We report our results for 38 consecutive patients who were treated during the last 6.5 years. METHODS All patients (n = 38) with posteroinferior cerebellar artery aneurysms that were surgically treated at Zale-Lipshy University Hospital between January 1990 and May 1997 were retrospectively reviewed. Data were collected and analyzed relating to demographics, condition at presentation, lesion characteristics, associated medical problems, postsurgical complications, and outcome. RESULTS Sixty-six percent of the patients (n = 25) experienced neurological sequelae, which included symptomatic vasospasm, hydrocephalus, dysarthria, paresis, diplopia, ataxia, and facial paralysis. Many, however, showed significant improvement during their hospitalization and during the course of the ensuing year. Seventy-four percent of the patients had a Glasgow Outcome Scale score of 1 or 2 at the time of discharge, 91% at 6 months after surgery, and 89% at 1 year after surgery. CONCLUSION This review summarizes the presentations and outcomes of 38 consecutive surgical cases during a 6.5-year period and concludes that posteroinferior cerebellar artery aneurysms are not benign entities. The study does, however, also demonstrate that patients have significant recuperative potential after the treatment of these lesions.

Surgical risks associated with the management of Grade I and II brain arteriovenous malformations.

OBJECTIVE Grade I and II arteriovenous malformations (AVMs) have been considered safe to resect. However, unoperated low-grade AVMs have not been considered in previously reported series. The aim of this study was to examine all cases, both operated and unoperated, to identify any characteristics of low-grade AVMs that comprise a subgroup that might pose a relatively higher risk. METHODS A prospectively enrolled AVM database included 237 patients in Spetzler-Martin Grade I or II. These patients were analyzed on the basis of demographic characteristics, angiographic and magnetic resonance imaging features, clinical presentation, method of treatment, and outcome. RESULTS Surgery was performed in 220 patients in Spetzler-Martin Grade I or II. Seventeen patients did not undergo treatment because of poor neurological condition (six patients), patient refusal (nine patients), and perceived surgical difficulty (AVM size approaching 3 cm adjacent to Brocas area) (two patients). The overall surgical morbidity rate was 0.9%, and the mortality rate was 0.5%. Adverse outcomes occurred in 1 (0.6%) of 180 patients with AVMs located away from eloquent cortex and in 2 (5%) of 40 patients with AVMs adjacent to eloquent cortex. None of 28 surgical patients with deep venous drainage had an adverse outcome. All 219 patients who survived surgery underwent postoperative angiography that confirmed cure. No postoperative hemorrhage has occurred in 1143 patient-years of follow-up (mean follow-up, 5.3 yr). CONCLUSION When considering adverse outcome in the surgical series of Grade I and II AVMs alone, no statistical difference between non-eloquently located AVMs (0.6%) and eloquently located AVMs (5% adverse outcome) can be detected. However, consideration of all Grade I and II AVMs, both surgical and nonsurgical, may prove that a difference in outcome exists between these two groups masked by case selection. Generalization of the chances of adverse outcomes to all Grade I and II AVMs (both operated and unoperated) suggests that the risk of performing surgery on noneloquent brain in our series was 0.6% and that in eloquent brain could have been as high as 9.5%, had all such patients undergone surgery.

Aneurysm retreatment after Guglielmi detachable coil and nondetachable coil embolization: Report of nine cases and review of the literature

OBJECTIVE Guglielmi detachable coil embolization of cerebral aneurysms is becoming increasingly used to manage certain intracranial lesions based on aneurysm geometry, patient condition, and patient and surgeon preferences. Aneurysm recurrences or incomplete initial treatments are not uncommon, making repeat treatment necessary using either surgical or endovascular techniques. METHODS Between January 1993 and June 1998, 1025 cerebral aneurysms were managed by the authors at a single hospital. One hundred twenty-four of these lesions were treated using Guglielmi detachable coils, and one was managed with nondetachable coils. During the follow-up period, eight patients who underwent embolization at our institution and one who underwent embolization elsewhere received repeat treatment. Five were approached surgically, and four underwent re-embolization. All charts and films were reviewed retrospectively to determine patient outcome and clinical success. RESULTS No patient in the subgroup of this clinical study suffered a permanent complication from initial aneurysm coiling, no episodes of subsequent bleeding occurred, and no complications resulted from any subsequent therapies. The anatomic results were excellent, and all aneurysms were totally or near totally obliterated. CONCLUSION Subtotal initial coil embolization of aneurysms can be managed safely using a variety of surgical and endovascular techniques. Our approach to this predicament, lessons we have learned, and a review of the literature are herein discussed.

Multidisciplinary approach to traumatic intracranial aneurysms secondary to shotgun and handgun wounds

BACKGROUND Traumatic intracranial aneurysms (TICAs) may develop following gunshot injuries to the head. Management of these lesions often combines various aspects of microneurosurgical and endovascular techniques to safely repair or obliterate vessel defects. METHODS We reviewed our experience over the last 18 years and identified five cases of intracranial aneurysms following gunshot and handgun wounds that were treated surgically and/or endovascularly. RESULTS All patients had successful obliteration of their lesions using a variety of therapeutic modalities aimed at preserving neurologic function while at the same time eliminating the aneurysm from the circulation. CONCLUSION Both microneurosurgery and endovascular surgery have important roles to play in the management of TICAs. In some cases, both methods can be combined to eliminate lesions and maximize patient recovery in a safe, efficient, and effective fashion.

Orbital Infarction Syndrome after Surgery for Intracranial Aneurysms

Background: Global orbital infarction results from ischemia of the intraocular and intraorbital structures due to hypoperfusion of the ophthalmic artery and its branches. Patients: The authors describe six patients in whom acute proptosis, ophthalmoplegia, and blindness developed immediately after surgery for intracranial aneurysms. Results: All patients underwent standard frontotemporal craniotomies to clip their aneurysms. In all patients, proptosis, ophthalmoplegia, and blindness developed in the immediate postoperative period; fundus abnormalities included retinal edema, retinal arteriolar narrowing and other vascular abnormalities, and pale optic disc swelling. Some patients had facial and corneal anesthesia. Ophthalmoplegia and facial anesthesia improved in most patients, but none regained any vision in the affected eye. Conclusion: Orbital infarction syndrome is a rare complication of neurosurgical procedures. Increased orbital pressure probably reduced ophthalmic artery and collateral arterial perfusion, resulting in ischemia of the intraocular and intraorbital structures. There may be multiple factors that compound the risk for orbital infarction, and patients with subarachnoid hemorrhage, increased intracranial pressure, anomalous arterial or venous circulation, or impaired orbital venous outflow seem particularly vulnerable.

Ventriculopleural shunting used as a temporary diversion

SummaryDue to the limited absorptive capacity of the pleural cavity, infants and young children are not generally ideal candidates for ventriculopleural shunts. We report using chest cavities as alternate for temporary diversion of CSF in a young child. Venous access to the cervical region could not be utilized because of scarring from previous procedures, while peritoneal access was contraindicated due to repeated pseudocyst formation. Pleural effusions were removed by thoracentesis when necessary, and the shunt catheter was changed to the opposite side of the chest when the effusions reaccumulated within one week. Utilizing the ventriculopleural shunts allowed us to temporize her non-communicating hydrocephalus for a period of one year, until a definitve CSF procedure by direct intracardiac placement of the distal catheter could be performed.

Chronic extradural haematomas: Indications for surgery

Non-invasive neuro-imaging has led to the detection of minimally symptomatic or asymptomatic chronic extradural haematomas. Our experience and review of the literature suggests that, as in the case of chronic subdural haematomas, there is development of membranes and liquifaction of the clot which may permit drainage of such collections through twist drill or burrholes. The time from development and the neuro-imaging chanes on CT and MRI can suggest the age and nature of the clot and thus permit timing of surgery so that drainage may be accomplished with a minor procedure.