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

Helsinki Experiences on Surgical Approaches for Clivus Region Vertebrobasilar Artery Aneurysms

Objective Vertebrobasilar (VB) aneurysms remain considered as a significant challenge for both microneurosurgical and endovascular neurosurgeon/interventional neuroradiologists. The nature of the aneurysm formation and growth, as well as the tortuosity and geometry of the vessels in many cases, has reduced the efficacy of final clinical and radiological outcome of endovascular therapy. On the other hand, microsurgical treatment for VB aneurysms has also been reported to have a relatively high morbidity and mortality rate. The need to effectively treat the VB aneurysms was essentially based on the clinical fact that they have a higher rupture rate and worse prognosis than the anterior circulation group. Reducing the morbidity and mortality rate while increasing the aneurysm occlusion rate and its durability is the ultimate goal of aneurysm treatment. Our aim is to evaluate simple surgical techniques and their clinical and radiological results that have been used to treat VB aneurysms in department of neurosurgery of University of Helsinki and Helsinki University Hospital. Patients and Methods We analyzed surgical techniques that have been used in department of neurosurgery of University of Helsinki and Helsinki University Hospital during ten year period. The pre-operative clinical scale and final clinical and radiological outcomes were assessed to evaluate the efficacy of the surgical approaches. We used a defined subgroup of the surgical corridors into anterolateral, lateral, and posterolateral corridors to treat five levels of VB aneurysms. The five levels of VB aneurysms were divided based on their level to the clivus bone, which are above, upper, middle, lower, and lowermost. Results Above clivus level of VB aneurysm defined as more than 6 mm above the posterior clinoid process (PCP) was effectively treated by LSO approach, a simple modification of pterional approach which has anterolateral surgical corridors. Specifically for BB aneurysm, the wide P1 (first segment of PCA) angle was also a determined factor for the selection to use LSO. Upper clivus level defined as within 6 mm above and 8 mm below the PCP was simply treated with a subtemporal approach,at a lateral corridor to reach the lesion. This approach was a workhorse to treat theupper clivus level aneurysm because of shorter distance, more “straight to the point,”and better visibility of posterior basilar perforators. Middle clivus level aneurysms,defined as more than 8 mm below the PCP to the level of internal acoustic meatus (IAM) were commonly treated with a simplified presigmoid approach. This posterolateral corridor offered a wider and better exposure of VB artery and its surrounding neural structures. VB aneurysm which is located at lower clivus level, defined as more than 10 mm above the foramen magnum to the level of IAM, was effectively treated with simple lateral suboccipital approach or tic craniotomy. If the aneurysm is located very low or defined as less than 10 mm above the foramen magnum, a modification called “enough-lateral” approach was recommended. Conclusion These five simple surgical approaches (LSO, subtemporal, presigmoid, lateral suboccpital, and “enough-lateral”) were effective approaches to treat five different levels of VB aneurysm according to the clivus bone. The pre-operative clinical gradingscale and the large – giant size of aneurysm were the most consistent and determinant factors for unfavorable outcome in this study.Objective Vertebrobasilar (VB) aneurysms remain considered as a significant challenge for both microneurosurgical and endovascular neurosurgeon/interventional neuroradiologists. The nature of the aneurysm formation and growth, as well as the tortuosity and geometry of the vessels in many cases, has reduced the efficacy of final clinical and radiological outcome of endovascular therapy. On the other hand, microsurgical treatment for VB aneurysms has also been reported to have a relatively high morbidity and mortality rate. The need to effectively treat the VB aneurysms was essentially based on the clinical fact that they have a higher rupture rate and worse prognosis than the anterior circulation group. Reducing the morbidity and mortality rate while increasing the aneurysm occlusion rate and its durability is the ultimate goal of aneurysm treatment. Our aim is to evaluate simple surgical techniques and their clinical and radiological results that have been used to treat VB aneurysms in department of neurosurgery of University of Helsinki and Helsinki University Hospital. Patients and Methods We analyzed surgical techniques that have been used in department of neurosurgery of University of Helsinki and Helsinki University Hospital during ten year period. The pre-operative clinical scale and final clinical and radiological outcomes were assessed to evaluate the efficacy of the surgical approaches. We used a defined subgroup of the surgical corridors into anterolateral, lateral, and posterolateral corridors to treat five levels of VB aneurysms. The five levels of VB aneurysms were divided based on their level to the clivus bone, which are above, upper, middle, lower, and lowermost. Results Above clivus level of VB aneurysm defined as more than 6 mm above the posterior clinoid process (PCP) was effectively treated by LSO approach, a simple modification of pterional approach which has anterolateral surgical corridors. Specifically for BB aneurysm, the wide P1 (first segment of PCA) angle was also a determined factor for the selection to use LSO. Upper clivus level defined as within 6 mm above and 8 mm below the PCP was simply treated with a subtemporal approach,at a lateral corridor to reach the lesion. This approach was a workhorse to treat theupper clivus level aneurysm because of shorter distance, more “straight to the point,”and better visibility of posterior basilar perforators. Middle clivus level aneurysms,defined as more than 8 mm below the PCP to the level of internal acoustic meatus (IAM) were commonly treated with a simplified presigmoid approach. This posterolateral corridor offered a wider and better exposure of VB artery and its surrounding neural structures. VB aneurysm which is located at lower clivus level, defined as more than 10 mm above the foramen magnum to the level of IAM, was effectively treated with simple lateral suboccipital approach or tic craniotomy. If the aneurysm is located very low or defined as less than 10 mm above the foramen magnum, a modification called “enough-lateral” approach was recommended. Conclusion These five simple surgical approaches (LSO, subtemporal, presigmoid, lateral suboccpital, and “enough-lateral”) were effective approaches to treat five different levels of VB aneurysm according to the clivus bone. The pre-operative clinical gradingscale and the large – giant size of aneurysm were the most consistent and determinant factors for unfavorable outcome in this study

Corrigendum: Quadrigeminal plate arachnoid cyst presenting with eye movement related migraine: a rare case report

[This corrects the article DOI: 10.13181/mji.cr.236858

Atlas operasi ilmu bedah saraf: perdarahan epidural dan fraktur kompresi tengkorak

vii, 119 hlm. : ilus. ; 21 cm

Memahami gambaran mikroanatomi pada operasi bedah saraf

vii, 92 hlm. : ilus. ; tab. ; 21 cm

Memahami gambaran mikroanatomi pada operasi bedah saraf

vii, 92 hal; 21 c

Simple Lateral Suboccipital Approach and Modification for Vertebral Artery Aneurysms : A Study of 52 Cases Over 10 Years

INTRODUCTION: Complex skull base approaches are frequently used to treat intracranial vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) aneurysms. These complex procedures are associated with higher risk of neurovascular injury. Hence, a less-invasive surgical approach is needed to improve the efficacy and safety of treatment. METHODS: A retrospective analysis was conducted on clinical and radiologic data from surgeries in which simple lateral suboccipital and "lateral-enough" approaches were used to clip VA aneurysms in the Department of Neurosurgery at Helsinki University Central Hospital from 2000 to 2009. RESULTS: Fifty-two VA or PICA aneurysms were treated using the simple lateral suboccipital approach. Sixteen patients (31%) presented with an unruptured aneurysm, 21 patients (40%) with World Federation of Neurosurgical Societies (WFNS) grade 1-3, and 15 patients (29%) with World Federation of Neurosurgical Societies grade 4-5. The aneurysms were saccular in 48 cases (92%), dissecting in 3 cases (6%), and fusiform in 1 case (2%). The most common aneurysm location was the VA-PICA junction (81%). The mean final modified Rankin Scale score was 2, and in unruptured cases, all patients had favorable clinical outcomes. The main causes of unfavorable outcome were poor preoperative clinical grade (P = 0.002), preoperative intraventricular hemorrhage (P = 0.008), postoperative hydrocephalus (P = 0.003), brain infarction (P = 0.005), and postoperative pneumonia (P <0.001). CONCLUSIONS: We describe a 10-year experience using a simple lateral suboccipital approach and its modification by the senior author (J.H.) to treat VA and proximal PICA aneurysms. Unfavorable outcome was related to the poor preoperative clinical grade, preoperative intraventricular hemorrhage, and postoperative pneumonia.Peer reviewe

Presigmoid Approach to Vertebrobasilar Artery Aneurysms : A Series of 31 Patients and Review of the Literature

Peer reviewe

Factors Determining Surgical Approaches to Basilar Bifurcation Aneurysms and Its Surgical Outcomes

ABSTRACT BACKGROUND: The basilar bifurcation aneurysm (BBA) is still considered to be one of the most challenging aneurysms for micro- and endovascular surgery. Classic surgical approaches, such as subtemporal, lateral supraorbital (LSO), and modified presigmoid, are still reliable and effective. OBJECTIVE: To analyze the clinical and radiological factors that affect the selection of these classic surgical approaches and their outcomes. METHODS: A retrospective analysis was conducted on the clinical and radiological data from computed tomographic angiography of BBA that have been clipped in the Department of Neurosurgery of Helsinki University Central Hospital between 2004 and 2014. Statistical analyses were performed using parametric and nonparametric tests where values were considered significant below P = .05. RESULTS: One hundred four patients with BBA underwent surgical clipping in our department between 2004 and 2014. Eight patients were excluded from the study because of incomplete preoperative radiological evaluations, leaving 96 patients for further analysis. Multiple aneurysm clipping, mean basilar bifurcation angle, and aneurysm neck distance from posterior clinoid process were shown to be factors that determine the surgical approach. Unfavorable outcome is strongly associated with poor Hunt-Hess grade on admission, distance from aneurysm neck (the posterior clinoid process), thrombosis, and dome size. CONCLUSION: Microsurgery for BBA clipping can be performed safely with simple surgical approaches: subtemporal and LSO. There are several factors determining the approach selected. Poor patient outcome in BBA was highly associated with poor preoperative clinical grade and large size of aneurysm dome