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

Brainstem intraparenchymal schwannoma : A case report and literature review

Publisher Copyright: ©2021 Published by Scientific Scholar on behalf of Surgical Neurology InternationalBackground: Intracranial intraparenchymal schwannomas (IS) are rare tumors that have mainly been described in case reports. Here, we report on a case of a brainstem IS and included a comprehensive literature review. Case Description: A 74-year-old man presented with progressive gait disturbances. CT- and MRI-imaging revealed a contrast-enhancing mass accompanied by a cyst in the dorsolateral pons. Hemangioblastoma was suspected and surgery was advised. During surgery, gross total resection of a non-invasive tumor was performed. Postoperative recovery was uneventful. Based on histopathological examination, the intraparenchymal brainstem tumor was diagnosed as schwannoma. Conclusion: Our extensive review illustrates that ISs are benign tumors that most often present in relatively young patients. Malignant cases have been described but form an extremely rare entity. Preoperative diagnosis based on radiological features is difficult but should be considered when peritumoral edema, calcifications, and cysts are noted. In benign cases, gross total resection of the lesion is curative. To adequately select this treatment and adjust the surgical strategy accordingly, it is important to include IS in the preoperative differential diagnosis when the abovementioned radiological features are present.Peer reviewe

Posttraumatic subarachnoid hemorrhage related to concomitant carotid artery dissection and ruptured basilar trunk aneurysm : A case report and literature review

Publisher Copyright: © 2021 Published by Scientific Scholar on behalf of Surgical Neurology International.Background: Carotid artery dissections (CADs) are a relatively rare disorder, whereas intracranial aneurysms (IAs) form a common cerebrovascular pathology. Since both vascular entities share similar risk factors and associations with connective tissue and vascular disorders, a common pathogenesis has been suggested. Here, we present a case of the concomitant occurrence of a CAD and a ruptured basilar trunk aneurysm (BTA). In the discussion, we elaborate on both vascular entities and have reviewed the literature on their concomitant incidence and potential shared pathogenesis. Case Description: We present a case of a 40-year-old female patient who was admitted to our hospital because of subarachnoid hemorrhage following a minor head trauma. Imaging revealed a BTA and unilateral extracranial dissection of the internal carotid artery. Despite coiling of the aneurysm, stenting of the dissection, and antithrombotic therapy, the patient died due to extensive cerebral ischemia sequelae. Conclusion: CAD and BTAs have both been associated with a vascular vulnerability but their concomitant occurrence has not been described previously. The previous studies have suggested an increased incidence of IAs in patients with a CAD and vice versa. However, the number of studies and reports on this mutual increased incidence is limited. Therefore, a shared pathogenesis seems rather speculative. In our case, we suggest that a posttraumatic CAD-induced hemodynamic alterations resulting in rupture of the saccular BTA.Peer reviewe

Fast Transition from Open Surgery to Endovascular Treatment of Unruptured Anterior Communicating Artery Aneurysmse-A Retrospective Analysis of 128 Patients

OBJECTIVE: Anterior communicating artery aneurysms (ACoAAs) are challenging to treat both surgically and endovascularly. In this study, we evaluate the treatment-related morbidity and clinical outcome of microsurgical clipping and endovascular treatment for a consecutive series of unruptured ACoAAs while the treatment paradigm was in transition from surgical to endovascular first.METHODS: We retrospectively reviewed clinical and radiologic data of adult patients who underwent microsurgical clipping or endovascular treatment of an unruptured ACoAA at a high-volume academic neurovascular center (Helsinki University Hospital) during 2012-2019. During this period, a transition from microsurgical clipping to endovascular treatment took place. Regarding outcome, we focused on treatment-related complications, dischargeto-home rates, functional performance (modified Rankin Scale score), and obliteration rates.RESULTS: Of 128 treated ACoAAs, 81 (64%) were treated surgically and 47 (36%) endovascularly. There was no difference in major complications, intracranial hemorrhagic complications or ischemic complications, discharge-to-home rates, or functional performance between the surgically and endovascularly treated patients. With time, a decrease in major complications was observed in the surgical cases (from 29% to 17%), whereas the major complication rate increased in the endovascularly patients (from 0% to 25%). Cerebral ischemia was the most frequent complication in both groups. The risk for permanent neurologic deficit remained low in both groups (9% for endovascular and 5% for surgery).CONCLUSIONS: We did not find any major differences regarding complications and outcomes after the treatment paradigm shift from clipping to endovascular of unruptured ACoAAs. Prospective studies evaluating durability of treatments are needed to compare overall effectiveness.Peer reviewe

Comparison of Operating Microscope and Exoscope in a Highly Challenging Experimental Setting

BACKGROUND: The use of a digital three-dimensional (3D) exoscope system in neurosurgery is increasing as an alternative to the operative microscope. The objective of this study was to compare a digital 3D exoscope system with a standard operating microscope as a neurosurgical visualization tool in a highly challenging experimental setting. METHODS: End-to-side bypass procedures, each at a depth of 9 cm, were performed in a simulation setting. The quality of the task and the depth effect, visualization, magnification, illumination, and ergonomics were evaluated. RESULTS: No major differences were noted between the microscope and the 3D exoscope in terms of the quality of the work. Working with the 3D exoscope was more time-consuming than working with the microscope. Changing the depth and focus was faster using the operative microscope. The 3D exoscope enabled higher magnification and offered better ergonomic features. CONCLUSIONS: In a highly challenging experimental setting, comparable procedural quality was found for the microscope and the 3D exoscope. Each visualization tool had advantages and disadvantages. Over time and with technologic advances, the digital 3D exoscope may become the main operative visualization system in microneurosurgery.Peer reviewe

The Role of the Glycocalyx in the Pathophysiology of Subarachnoid Hemorrhage-Induced Delayed Cerebral Ischemia

The glycocalyx is an important constituent of blood vessels located between the bloodstream and the endothelium. It plays a pivotal role in intercellular interactions in neuroinflammation, reduction of vascular oxidative stress, and provides a barrier regulating vascular permeability. In the brain, the glycocalyx is closely related to functions of the blood-brain barrier and neurovascular unit, both responsible for adequate neurovascular responses to potential threats to cerebral homeostasis. An aneurysmal subarachnoid hemorrhage (aSAH) occurs following rupture of an intracranial aneurysm and leads to immediate brain damage (early brain injury). In some cases, this can result in secondary brain damage, also known as delayed cerebral ischemia (DCI). DCI is a life-threatening condition that affects up to 30% of all aSAH patients. As such, it is associated with substantial societal and healthcare-related costs. Causes of DCI are multifactorial and thought to involve neuroinflammation, oxidative stress, neuroinflammation, thrombosis, and neurovascular uncoupling. To date, prediction of DCI is limited, and preventive and effective treatment strategies of DCI are scarce. There is increasing evidence that the glycocalyx is disrupted following an aSAH, and that glycocalyx disruption could precipitate or aggravate DCI. This review explores the potential role of the glycocalyx in the pathophysiological mechanisms contributing to DCI following aSAH. Understanding the role of the glycocalyx in DCI could advance the development of improved methods to predict DCI or identify patients at risk for DCI. This knowledge may also alter the methods and timing of preventive and treatment strategies of DCI. To this end, we review the potential and limitations of methods currently used to evaluate the glycocalyx, and strategies to restore or prevent glycocalyx shedding.Peer reviewe

Visualization and Maneuverability Features of a Robotic Arm Three-Dimensional Exoscope and Operating Microscope for Clipping an Unruptured Intracranial Aneurysm: Video Comparison and Technical Evaluation

BACKGROUND: In recent years, three-dimensional (3D) digital exoscope systems have been developed and reported to form an adequate alternative to the conventional operating microscope. OBJECTIVE: To illustrate essential and practical features in a surgical video comparing a robotic arm 3D digital exoscope and a conventional operating microscope to clip a middle cerebral artery aneurysm. METHODS: We used a mouth switch-controlled operating microscope (OPMI PENTERO 900; Carl Zeiss Meditec AG) and robotic arm-controlled 3D digital Aeos exoscope (Aesculap Inc). We assessed the following visualization and optical features: overall visualization quality, color and contrast quality, range and quality of magnification, and adjustment of focus. In addition, we assessed maneuverability for changing surgical site within and viewing angle of the surgical field. RESULTS: We found that both modalities are suitable for this surgery and offer distinct qualities. The microscope enables faster magnification adjustment and continuous mouth switch-controlled focus adjustments. The advantages of the exoscope include the adaptation of color and contrast settings, and the surgeon can keep both hands in the surgical field while the camera pivots around its working field. CONCLUSION: The exoscope and operating microscope offer a similar high-quality visualization of, and smooth maneuvering within, the surgical field. The method of visualization and maneuvering is, however, very distinct. Therefore, a surgeon's acquaintance and experience with the specific features and how to optimally use them in surgery are of utmost importance. Further analyses of both systems are needed to evolve these tools

Visualization and Maneuverability Features of a Robotic Arm Three-Dimensional Exoscope and Operating Microscope for Clipping an Unruptured Intracranial Aneurysm:Video Comparison and Technical Evaluation

BACKGROUND: In recent years, three-dimensional (3D) digital exoscope systems have been developed and reported to form an adequate alternative to the conventional operating microscope. OBJECTIVE: To illustrate essential and practical features in a surgical video comparing a robotic arm 3D digital exoscope and a conventional operating microscope to clip a middle cerebral artery aneurysm. METHODS: We used a mouth switch-controlled operating microscope (OPMI PENTERO 900; Carl Zeiss Meditec AG) and robotic arm-controlled 3D digital Aeos exoscope (Aesculap Inc). We assessed the following visualization and optical features: overall visualization quality, color and contrast quality, range and quality of magnification, and adjustment of focus. In addition, we assessed maneuverability for changing surgical site within and viewing angle of the surgical field. RESULTS: We found that both modalities are suitable for this surgery and offer distinct qualities. The microscope enables faster magnification adjustment and continuous mouth switch-controlled focus adjustments. The advantages of the exoscope include the adaptation of color and contrast settings, and the surgeon can keep both hands in the surgical field while the camera pivots around its working field. CONCLUSION: The exoscope and operating microscope offer a similar high-quality visualization of, and smooth maneuvering within, the surgical field. The method of visualization and maneuvering is, however, very distinct. Therefore, a surgeon's acquaintance and experience with the specific features and how to optimally use them in surgery are of utmost importance. Further analyses of both systems are needed to evolve these tools

Surgery on giant meningiomas in very old patients entails frequent postoperative intracranial hemorrhages and atypical histopathology

Purpose Surgical resection of intracranial meningiomas in patients that are 80 years old and older, i.e. very old patients, is increasingly considered. Meningiomas with a largest diameter of at least 5 cm-'giant meningiomas'-form a distinct entity, and their surgical resection is considered more difficult and prone to complications. Here, we evaluated functional outcome, morbidity and mortality, and the prognostic value of tumor size in very old patients who underwent resection of giant supratentorial meningiomas. Methods We retrospectively reviewed clinical and radiological data, functional performance (Karnofsky Performance Score), histopathological diagnosis and complications of very old patients who underwent surgery of a supratentorial meningioma at the Helsinki University Hospital between 2010 and 2018. Results We identified 76 very old patients, including 28 with a giant meningioma. Patients with a giant meningioma suffered from major complications more commonly than those with a non-giant meningioma (36% vs. 17%, p = 0.06), particularly from postoperative intracranial hemorrhages (ICH). At the 1-year follow-up, functional performance and mortality rate were comparable between patients with giant meningiomas and those with non-giant meningiomas. An exceptionally high rate of giant meningiomas were diagnosed as atypical meningiomas (WHO II) at an (11 out of 28 cases). Conclusions Giant meningioma surgery entails a high complication rate in frail, very old patients. The prevention of postoperative ICH in this specific patient group is of utmost importance. An atypical histopathology was notably frequent among very old patients with a giant meningioma, which should be taken into account when planning the surgical strategy.Peer reviewe