Techniques of intracranial aneurysm wall biopsy

Current treatment modalities for the treatment of intracranial aneurysms including surgical clipping and endovascular coiling are invasive and have some treatment risks. Since not all aneurysms rupture, it is critical to detect rupture prone aneurysms. Molecular and cellular analysis of aneurysm tissue may provide understanding about pathobiology of aneurysm rupture and to develop imaging techniques to detect rupture prone aneurysms. For more than 15-years we have collected samples to identify pathological processes in the aneurysm wall itself predisposing to rupture. This has opened a new field of research leading to novel findings and multiple scientific publications. Surgical techniques of sampling the aneurysm dome have never been demonstrated so therefore many neurosurgeons are reluctant to take biopsies for research. Now we demonstrate with an intraoperative video the techniques of sampling the aneurysm dome after clipping an incidental right-sided 5-mm unruptured MCA aneurysm in a 58-year-old hypertensive male with past long history of smoking through lateral supraorbital approach. A focused opening of the Sylvian fissure was performed and the aneurysm was clipped using standard techniques. After placement of a titanium clip, ICG and Doppler were performed to ensure patency of both M2 vessels and the aneurysm was punctured. The aneurysm dome was then held in place with the suction and cut with microscissors for research purposes. Another titanium clip was placed (Video 1). The clinical course was uneventful. This technical note will help young neurosurgeons to contribute actively in aneurysm research also potentially to find non-invasive methods to prevent aneurysms from rupture.Peer reviewe

Optic canal decompression in patients with vision reduction due to tumour growth in optic canal: A technical note

Improvement of the vision is one of the main goals in skull base meningiomas compressing the optic nerve (ON) in optic canal (OC). Extracranial drilling of anterior clinoid process with extradural optic canal decompression has been demonstrated in anterior clinoid meningioma surgery. Extensive drilling of anterior clinoid has however some morbidity. Here we demonstrate the technical aspects of intradural opening of optic canal using Kerrison rongeur. This technique is effective and has no additional morbidity.Peer reviewe

Recovery Potential of Spinal Meningioma Patients With Preoperative Loss of Walking Ability Following Surgery - A Retrospective Single-Center Study

Objective: Spinal meningiomas are neurosurgical rarities that manifest with progressive paraor tetraparesis. The effect of timing of surgery on the recovery after the loss of walking ability is poorly known. We studied the effect of timing of surgery on restoring walking ability in surgically-treated spinal meningioma patients. Methods: Using electronic health records, we retrospectively identified >= 18-year-old patients operated on during 2010-2020. The patients were followed until 30th September 2020, death or emigration. Results: We identified 108 patients (81% women) with operated spinal meningiomas. The mean age of the patients was 64 years (range, 18-94 years). A gross total resection was achieved in 101 (94%), and 21 patients (19%) suffered from perioperative complications. Of the 108 patients operated on, 49 (45%) could not walk without assistance prior to surgery. At the time of first postoperative visit (mean, 3.1 months; range, 1.3-13.1 months), 14 out of 24 patients (58%) operated on within 29 days and 8 out of 20 patients (40%) operated on later than 29 days since the loss of walking ability without assistance, were able to walk without assistance. Also, 3 out of 5 paraplegic patients who underwent surgery later than 29 days after they lost the walking ability, were able to at least walk with assistance at first postoperative visit. Conclusion: Early surgical treatment following the loss of walking ability restores walking ability in a substantial number of patients. However, even late surgery may restore walking ability.Peer reviewe

Coagulopathy and its effect on treatment and mortality in patients with traumatic intracranial hemorrhage

Background The role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality. Methods An observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count 1.2, or thromboplastin time <60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality. Results Of our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p <0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy. Conclusions Coagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.Peer reviewe

Effect of Surgeon Experience on Surgical Outcome of 80-Year-Old or Older Intracranial Meningioma Patients

OBJECTIVE: Previous reports suggest that more experienced surgeons have better postoperative outcomes in neurosurgery. We studied whether this association is found in a fragile cohort of >= 80-year-old intracranial meningioma (IM) patients. METHODS: We identified 83 very old IM patients who were operated on by 12 different surgeons between 2010 and 2018. Besides general patient-and tumor-related characteristics, we collected information about the surgeons' case volume and length of surgical career (LSC). We classified neurosurgeons into 3 different categories: 1) low-volume (8 surgeons; 1-4 operations per surgeon); 2) moderate-volume (3 surgeons; 8e12 operations per surgeon); and 3) high-volume (1 reference surgeon; 37 operations). We calculated odds ratios (ORs) with 95% confidence intervals for 1-year mortality and 3-month independency (capability to live at home) by surgeon volume categories and per 5-year increase of LSC. RESULTS: We found no significant differences in any preoperative characteristics between the surgeon volume categories. IM patients operated on by low-volume surgeons had the lowest risk of first-year mortality (OR, 0.15 [0.01-2.05]) and the highest likelihood of living at home 3 months after surgery (OR, 12.61 [1.21-131.03]). Increasing LSC was associated with 1-year mortality (OR, 1.34 [1.03-1.73]) and with lower likelihood to live at home 3 months after surgery (OR, 0.83 [0.69-1.00]), but these associations were slightly nonsignificant after adjusting for IM patients' age, sex, and preoperative independency. CONCLUSIONS: In a high-volume academic hospital, less experienced neurosurgeons seem to achieve similar results as the more experienced neurosurgeons, even when operating on selected highly fragile meningioma patients.Peer reviewe

Recurrence of endovascularly and microsurgically treated intracranial aneurysmsreview of the putative role of aneurysm wall biology

Although endovascular therapy has been proven safe and has become in many centers the primary method of treatment for intracranial aneurysms, the long-term durability of endovascular embolization remains a concern; at least for some aneurysms despite initial good result. While healing after clipping relies on mechanical occlusion, restoration after endovascular occlusion mainly requires the induction of a biological response. Healing after embolization depends on the growth of new tissue over the thrombus formed by the embolization material, or alternatively, on the organization of thrombus into fibrous tissue. This review highlights the fundamental importance of aneurysm wall biology on the healing process and long-term occlusion after intracranial aneurysm (IA) treatment. It seems likely that the effect of luminal thrombus on the IA wall, as well as the IA wall condition at the time of thrombosis, determine if thrombus organizes into scar tissue (neointima formation by infiltration of cells originating from the IA wall) or if the wall undergoes continuous remodeling, which is primarily destructive (loss of mural cells). In the latter, intraluminal thrombus organization fails and the impaired healing increases the chance of recurrence. Mechanisms underlying IA reopening, the influence of intraluminal thrombosis on the IA wall, and clinical implications of the IA wall condition are discussed in detail, along with how knowledge of IA wall biology can offer new solutions for IA treatment and affect the patient selection for and follow-up after endovascular treatment.Peer reviewe

Mortality of surgically treated 80-year-old or older intracranial meningioma patients in comparison to matched general population

Population aging is likely increasing the number of surgically treated very old (>= 80-year-old) intracranial meningioma (IM) patients. Since there is little data on mortality in this patient group, we studied whether survival of surgically treated very old IM patients differs from survival of a matched general population. We retrospectively identified 83 consecutive very old IM patients (median age 83 years; 69% women) operated between 2010 and 2018. During the first postoperative year, operated IM patients suffered 2.5 times higher mortality as compared to age- and sex-matched general population but no annual survival difference occurred thereafter. Regarding cumulative estimates, no excess mortality was detected after the second postoperative year. Of the patient who were and who were not able to live at home preoperatively, 78% and 42% lived at home within 3 months, respectively. Preoperative loss of capability to live at home associated with a less frequent return to home [odds ratio (95% confidence interval) 0.21 (0.06-0.67)]. Operated very old IM patients had short-term excess mortality but similar cumulative survival as the matched general population. Moreover, most patients returned home soon after surgery.Peer reviewe

Bypass Surgery for Complex Internal Carotid Artery Aneurysms : 39 Consecutive Patients

OBJECTIVE: Bypass surgery is a special technique used to treat complex internal carotid artery (ICA) aneurysms. The aim of this retrospective study is to provide a comprehensive description of treatment and outcome of complex ICA aneurysms at different ICA segments (cavernous, supraclinoid, ICA bifurcation) treated with bypass procedures. METHODS: We identified 39 consecutive patients with 41 complex ICA aneurysms that were treated with 44 bypass procedures between 1998 and 2016. We divided the aneurysms into 3 anatomic subgroups to review our treatment strategy. All the imaging studies and medical records were reviewed for relevant information. RESULTS: The aneurysm occlusion (n = 34, 83%) or flow modification (n = 5, 12%) was achieved in 39 aneurysms (95%). The long-term bypass patency rate was 68% (n = 30). Minor postoperative ischemia or hemorrhage was commonly seen (n = 20, 51%), but large-scale strokes were rare (n = 1, 3%). Preoperative dysfunction of extraocular muscles (cranial nerves III, IV, and VI) showed low-to-moderate improvement rates (20%-50%). Preoperative vision disturbance (cranial nerve II) improved seldom (22%). At the latest follow-up (mean; 51 months) 29 patients (74%) were independent (modified Rankin Scale CONCLUSIONS: Bypass surgery for complex ICA aneurysms is a feasible treatment method with an acceptable risk profile. Patients should be informed of the uncertainty related to improvement of pretreatment cranial nerve dysfunctions.Peer reviewe