Brain and Spinal Cavernomas : Helsinki Experience

Cavernomas are rare neurovascular lesions, encountered in up to 10% of patients harboring vascular abnormalities of the CNS. Cavernomas consist of dilated thin-walled sinusoids or caverns covered by a single layer of endothelium. Due to advancements in neuroradiology, the number of cavernoma patients coming to be evaluated in neurosurgical practice is increasing. In the present work, we summarized our results on the treatment of cavernomas. Particular attention was paid to uncommon locations or insufficiently investigated cavernomas, including 1. Intraventricular cavernomas; 2. Multiple cavernomas; 3. Spinal cavernomas; and 4. Temporal lobe cavernomas. After analyzing the patient series with these lesions, we concluded that: 1. IVCs are characterized by a high tendency to cause repetitive hemorrhages in a short period of time after the first event. In most patients, hemorrhages were not life-threatening. Surgery is indicated when re-bleedings are frequent and the mass-effect causes progressive neurological deterioration. Modern microsurgical techniques allow safe removal of the IVC, but surgery on fourth ventricle cavernomas carries increased risk of postoperative cranial nerve deficits. 2. In MC cases, when the cavernoma bleeds or generates drug-resistant epilepsy, microsurgical removal of the symptomatic lesion is beneficial to patients. In our series, surgical removal of the most active cavernoma usually the biggest lesion with signs of recent hemorrhage - was safe and prevented further bleedings. Epilepsy outcome showed the effectiveness of active treatment of MCs. However, due to the remaining cavernomas, epileptogenic activity can persist postoperatively, frequently necessitating long-term use of antiepileptic drugs. 3. Spinal cavernomas can cause severe neurological deterioration due to low tolerance of the spinal cord to mass-effect with progressive myelopathy. When aggravated by extralesional massive hemorrhage, neurological decline is usually acute and requires immediate treatment. Microsurgical removal of a cavernoma is effective and safe, improving neurological deficits. Sensorimotor deficits and pain improved postoperatively at a high rate, whereas bladder dysfunction remained essentially unchanged, causing social discomfort to patients. 4. Microsurgical removal of temporal lobe cavernomas is beneficial for patents suffering from drug-resistant epilepsy. In our series, 69% of patients with this condition became seizure-free postoperatively. Duration of epilepsy did not correlate with seizure prognosis. The most frequent disabling symptom at follow-up was memory disorder, considered to be the result of a complex interplay between chronic epilepsy and possible damage to the temporal lobe during surgery.Kavernoomien osuuden kaikista aivosuonten epämuodostumista arvioidaan olevan 5-10%. Pään magneettitutkimuksen tultua kliiniseen käyttöön on diagnosoitujen kavernoomien lukumäärä jatkuvasti lisääntynyt. Noin puolessa tapauksista kavernoomia pidetään synnynnäisinä. Kavernoomien histologiset piirteet on perusteellisesti tutkittu. Tavalliset taudin oireet ovat epilepsia tai neuroloogiset puutokset, mutta se voi aiheuttaa aivojensisäistä verenvuotoa, joka äärimmillään johtaa kuolemaan. Vuotuisen vuotoriskin arvioidaan olevan 0,3 5 % sijainnista riippuen. Ainoana radikaalina kavernoomien hoitomuotona pidetään nykyään mikrokirurgista poistoa. Muista neurokirurgiassa käytettävistä hoitomenetelmistä ei ole varmistettu selvää tulosta. Tähän tutkimukseen rekisteröity kaikki kavernomatapaukset Töölön sairaalasta ja Meilahden sairaalasta ajalta 1.01.1980 31.12.2009. Suurin osa Töölössä hoidetuista potilaista on saanut leikkaushoitoa. Tässä tutkimuksessa erityistä huomiota kiinnitettiin harvinaisiin kavernoomiin: 1. Aivokammioiden sisällä sijaitsevat kavernoomat ; 2. Multippeli kavernoomat ; 3. Selkäkanavan kavernoomat; 4. Ohimolohkon kavernoomat . Tutkittuaan potilaiden sarjoja voimme päätellä, että: 1. Aivokammioiden sisällä sijaitsevilla kavernoomilla on suuri taipumus aiheuttaa toistuvia aivoverenvuotoja, vaikka useimmiten nämä vuodot eivät ole hengenuhkaavia. Kavernooman poisto on aiheellinen silloin, kun aivoverenvuodot toistuu useasti tai itse kavernooma johtaa neuroloogisiin puutoksiin. Nykyisellä mikroneurokirurgisella hoidolla aivokammion kavernoomia saadaan turvallisesti poistettua. 2. Verenvuodot ja vaikea-hoitoinen epilepsia liittyy tyypillisesti multippeli kavernoomiin. Meidän sarjassa, isoimman ja vuotaneen kavernooman mikrokirurginen poisto oli tehokas sekä verenvuodon ehkäisemisessä että epilepsian hoitamisessa. Kuitenkin jäljellä olevat kavernoomat kantavat mahdollisen riskin aiheuttaa epileptisiä kohtauksia, minkä takia epilepsialääkityksen pitkäkestoinen käyttö on suosi-teltu. 3. Selkäkanavan kavernoomat voivat johtaa vakaviin neuroloogisin puutoksiin. Äkillinen halvaus tai kipu raajoissa voi olla merkki kavernoomavuodosta, jolloin leikkaus on suoritettava päivystyksenä. Selkäkanavan kavernoomien mikrokirurginen poisto on tehokas ja turvallinen. Leikkauksen jälkeen, halvaus ja kipu paranevat hyvin, mutta virtsarakon toimintahäiriö pysyy pääosin ennallaan. 4. Ohimolohkon kavernoomilla on taipumusta aiheuttaa vaikea-hoitoista epilepsiaa. Niiden mikrokirurginen poisto parantaa potilaita kohtauksettomiksi noin 70 prosentissa. Yleisin leikkauksen jälkiseuraus oli muistivaikeuksia, minkä syy voi olla pitkäkestoinen epilepsia tai toimenpiteen aiheuttama vaurio

Muscle Insertion Line as a Simple Landmark To Identify the Transverse Sinus When Neuronavigation Is Unavailable

OBJECTIVE: Skull opening in occipital and suboccipital regions might be associated with risk of damage to the transverse venous sinus and the confluence of sinuses. We analyze the value of magnetic resonance (MR) imaging in localizing the venous sinuses in relation to the superior muscle insertion line (MIL) on the occipital bone. METHODS: We retrospectively analyzed head MR images of 100 consecutive patients imaged for any reason from 1 January 2013. All MR images were interpreted by a radiologist (R.K.). The superior MIL was identified at the midline and on both midpupillar lines, which represent the most frequent sites of skin incision and craniotomy (median and lateral suboccipital craniotomy, respectively). RESULTS: Patients comprised 56women (56%) and 44 men (44%). Their mean age was 54 (range 18-84) years. The muscles of the posterior skull were readily visible and clearly identified in both T1 and T2 images of all patients. Identification of the insertion zone and its relation to the venous structures was most readily made in the sagittal plane. CONCLUSION: We found that the upper muscle insertion line on occipital bone corresponds to the underlying venous sinus and can be used as a reliable anatomic landmark. We identified it in 100% of preoperative MR images of heads with an intact occiput.Peer reviewe

Brainstem Cavernous Malformations Management : Microsurgery vs. Radiosurgery, a Meta-Analysis

Given the rareness of available data, we performed a systematic review and meta-analysis on therapeutic strategy microsurgical resection and stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs) and assessed mortality, permanent neurological deficits (PNDs), rebleeding rate, and patients who require reintervention to elucidate the benefits of each treatment modality. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for protocol development and manuscript preparation. After applying all inclusion and exclusion criteria, six remaining articles were included in the final manuscript pool. In total, this meta-analysis included 396 patients, among them 168 patients underwent microsurgical treatment and 228 underwent SRS. Findings of the present meta-analysis suggest that regarding the total group of patients, in terms of mortality, late rebleeding rate, and PNDs, there was no superiority of the one method over the other. Applying the leave-one-out method to our study suggests that with low robust of the results for the bleeding rate and patients who require reintervention outcome factor, there was no statistical difference among the surgical and SRS treatment. Microsurgical treatment of BSCMs immediately eliminates the risk of rehemorrhage; however, it requires complete excision of the lesion and it is associated with a similar rate of PNDs compared with SRS management. Apparently, SRS of BSCMs causes a marked reduction in the risk of rebleeding 2 years after treatment, but when compared with the surgical treatment, there was not any remarkable difference.Peer reviewe

Rates and age trends in lumbar fusions in 2002 – 2017 – a descriptive analysis of 3,000 patients

ObjectiveThe objective of this study was to describe the change in rates and age averages among patients undergoing lumbar fusion during the last 20 years in a university hospital district located in Finland.MethodsThe data on 3,066 fusion surgeries were obtained from an electronic register between 2002 – 2017. The t-test, chi square, and regression analyses were used.ResultsIn 2002 – 2017, 3,066 patients underwent lumbar fusion. The annual fusion rates grew in 16 years by 500%. The regression coefficient for annual rates of lumbar fusion procedures was 17.4 (95% CI 14.8 to 20.0, p-value p-value ConclusionsIn the studied cohort, the annual rates of lumbar fusions grew explosively during the last 16 years by 500% and the patients were 10 years older in 2017 than back in 2002. It seems, that if the trend observed here will continue then fusion patients may on average be even 20 years older in 2030 than they were in 2002. Surgeons and policy makers should take this probability under consideration when planning future techniques, rehabilitation, and allocation of funding.</p

Aivokavernooma - pitääkö olla huolissaan?

Aivokavernooma on laskimoepämuodostumasairaus, jonka nykyisiä hoitovaihtoehtoja ovat seuranta, leikkaus ja sädehoito. Aivokavernoomasta tunnetaan sporadinen ja familiaalinen muoto. Magneettikuvausten saatavuuden lisäännyttyä aivokavernoomia diagnosoidaan entistä enemmän, joten moni kliinikko saattaa törmätä tähän tautiin. Sen luonnollinen kulku on yleensä hyvälaatuinen. Pelätyin tapahtuma, aivokavernooman vuoto, on harvinainen. Uusimpia tautiin liittyviä tutkimushavaintoja on tehty vuodon ennustamisesta sekä mikrobiomin osuudesta taudin synnyssä ja kulussa. Tutkimustiedon lisääntymisen myötä uusia hoito- ja seurantamahdollisuuksia tulee kliiniseen käyttöön merkittävästi todennäköisesti jo lähivuosina. Aivokavernoomasta ei pidä olla huolissaan, mutta taudin erityispiirteiden vuoksi sen seurannasta ja hoidosta tulisi konsultoida yliopistosairaaloiden moniammatillista neurovaskulaarihoitotyöryhmää

Physical exertion as a risk factor for perimesencephalic nonaneurysmal subarachnoid hemorrhage

Background: Perimesencephalic and nonperimesencephalic nonaneurysmal subarachnoid hemorrhage (PM-naSAH and NPM-naSAH) have a different bleeding pattern and clinical course. The etiology and risk factors for PM-naSAH and NPM-naSAH are unclear. The objective of this study was to compare risk factors and triggering events between PM-naSAH and NPM-naSAH.Methods: We reviewed retrospectively all patients (n = 3475) who had undergone cerebral digital subtraction angiography between 2003 and 2020 at our tertiary hospital. Of these, 119 patients had 6-vessel angiography negative subarachnoid hemorrhage (47 (39%) PM-naSAH and 72 (61%) NPM-naSAH) and accurate information about the triggering event was available in 42 (89%) PM-NASAH and 64 (89%) NPM-naSAH patients.Results: PM-naSAH were younger compared to NPM-naSAH (mean age [SD]; 55.3 [11.1] years vs. 59.6 [12.2] years, p = .045. PM-naSAH was triggered during the physical exertion in 79% of patients and 16% of patients with NPM-naSAH (relative risk 5.4; 95% CI, 2.9-10.1, p .05.Conclusion: Physical exertion was a triggering factor in most of the PM-naSAH cases and the risk was five times greater than in NMP-naSAH. More studies are needed to confirm our results and to study pathophysiology of PM-naSAH and NPM-naSAH.</p

Outcome of decompressive craniectomy in comparison to nonsurgical treatment in patients with malignant MCA infarction

Background: Malignant cerebral infarction is a well-recognized disease, comprising 10-15% of all cases with cerebral infarction and causing herniation and death in 80% of cases. In this study, we compare the effects of decompressive craniectomy versus conventional medical treatment on mortality rate and functional and neurological outcome in patients with malignant MCA infarction. Methods: We performed a prospective case-control study on 60 patients younger than 80years of age suffering malignant MCA cerebral infarction. The case group underwent decompressive craniectomy in addition to routine aggressive medical care; while the control group received routine medical treatment. Patient outcome was assessed using Glasgow outcome scale and modified Rankin scale within three months of follow-up. The data were analyzed by SPSS version 16.0 software using Chi Square, One-way ANOVA and Mann-Whitney tests. Results: There were 27 male and 33 female patients with a mean age of 60.6 years (SD = 12.3). Glasgow outcome scale score averaged 2.93 in the surgical versus 1.53 in the medical group; this difference was significant (p = 0.001). Outcome in modified Rankin scale was also significantly lower in the surgical (3.27) versus medical (5.27) group (p <0.001). Surgery could decrease the mortality rate about 47%. Conclusion: In this study, decompressive craniectomy could decrease mortality rate, and improve neurological and functional outcome, and decrease long-term disability in patients with malignant MCA infarction.Peer reviewe

Intracranial aneurysm is predicted by abdominal aortic calcification index: A retrospective case-control study

Background and aimsPatients with intracranial aneurysms (IA) have excess mortality for cardiovascular diseases, but little is known on whether atherosclerotic manifestations and IA coexist. We investigated abdominal aortic calcification index (ACI) association with unruptured and ruptured IAs.MethodsThis retrospective case-control study reviews all tertiary centers patients (n = 24,660) who had undergone head computed tomography angiography (CTA), magnetic resonance angiography (MRA) or digital subtraction angiography (DSA) for any reason between January 2003 and May 2018. Patients (n = 2020) with unruptured or ruptured IAs were identified, and patients with available abdominal CT were included. IA patients were matched by sex and age to controls (available abdomen CT, no IAs) in ratio of 1:3. ACI was measured from abdomen CT scans and patient records were reviewed.Results1720 patients (216 ruptured IA (rIA), 246 unruptured IA (UIA) and 1258 control) were included. Mean age was 62.9 ± 11.9 years and 58.2% were female. ACI (OR 1.02 per increment, 95%CI 1.01–1.03) and ACI>3 (OR 5.77, 95%CI 3.29–10.11) increased risk for rIA compared to matched controls. UIA patients' ACI was significantly higher but ACI did not increase odds for UIA compared to matched controls. History of coronary artery disease was less frequent in rIA patients. There was no calcification in aorta in 8.8% rIA and 13.6% UIA patients (matched controls 25.7% and 22.6% respectively, p ConclusionsAortic calcification is greater in rIA and UIA patients than matched controls. ACI increases risk for rIAs.</p

The orbitozygomatic stich: A technical modification of the lateral supraorbital approach

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