A Giant Tumefactive Virchow-Robin Space: A Rare Cause of a Homonymous Quadrantanopia.

A 53-year-old woman was found to have a left inferior homonymous quadrantanopia. Brain MRI disclosed a giant Virchow-Robin space compressing the right optic tract. After fenestration of this cystic lesion, most of the visual field loss resolved. Giant Virchow-Robin spaces may cause homonymous field defects which, with appropriate management, may improve.

Age, Neurological Status MRC Scale, and Postoperative Morbidity are Prognostic Factors in Patients with Glioblastoma Treated by Chemoradiotherapy.

INTRODUCTION: Temozolomide and concomitant radiotherapy followed by temozolomide has been used as a standard therapy for the treatment of newly diagnosed glioblastoma multiform since 2005. A search for prognostic factors was conducted in patients with glioblastoma routinely treated by this strategy in our institution. METHODS: This retrospective study included all patients with histologically proven glioblastoma diagnosed between June 1, 2005, and January 1, 2012, in the Franche-Comté region and treated by radiotherapy (daily fractions of 2 Gy for a total of 60 Gy) combined with temozolomide at a dose of 75 mg/m(2) per day, followed by six cycles of maintenance temozolomide (150-200 mg/m(2), five consecutive days per month). The primary aim was to identify prognostic factors associated with overall survival (OS) in this cohort of patients. RESULTS: One hundred three patients were included in this study. The median age was 64 years. The median OS was 13.7 months (95% confidence interval, 12.5-15.9 months). In multivariate analysis, age over 65 years (hazard ratio [HR] = 1.88; P = 0.01), Medical Research Council (MRC) scale 3-4 (HR = 1.62; P = 0.038), and occurrence of postoperative complications (HR = 2.15; P = 0.028) were associated with unfavorable OS. CONCLUSIONS: This study identified three prognostic factors in patients with glioblastoma eligible to the standard chemotherapy and radiotherapy treatment. Age over 65 years, MRC scale 3-4, and occurrence of postoperative complications were associated with unfavorable OS. A simple clinical evaluation including these three factors enables to estimate the patient prognosis. MRC neurological scale could be a useful, quick, and simple measure to assess neurological status in glioblastoma patients.

Distal posterior inferior cerebellar artery aneurysms: clinical features and outcome of 80 patients.

OBJECTIVE: Aneurysms of the posterior inferior cerebellar artery (PICA) distal to its origin are rare. Beside their rarity, their treatment is challenged by a high proportion of fusiform aneurysms, torturous course of PICA, and often severe bleeding. Our aim is to represent the characteristics of these aneurysms and their treatment, as well as to analyze outcome. METHODS: We reviewed retrospectively 80 patients with PICA aneurysms who were treated at the Department of Neurosurgery, Helsinki, Finland. RESULTS: The 80 patients had altogether 91 distal PICA aneurysms. Subarachnoid hemorrhage occurred in 74 (93%), and the distal PICA aneurysm was ruptured in 68 (85%). Compared with aneurysms at other locations, distal PICA aneurysms were smaller, more often fusiform, and more often caused an intraventricular hemorrhage as well as rebleeding. Modified surgical techniques (trapping, wrapping, proximal occlusion, resection, coagulation) were used in 10 (32%) fusiform and in 3 (6%) saccular aneurysms. Revascularization was needed in 3 (4%) cases. One aneurysm was primarily embolized. Within a year after aneurysm diagnosis, 18 patients had died. Among survivors, most returned to independent or previous state of living: 52 (91%); only 1 patient was unable to return home. CONCLUSIONS: Microsurgery is a feasible treatment for distal PICA aneurysms. Despite the challenge of often severe hemorrhage, wide-necked aneurysms, and some risk for laryngeal palsy, most patients surviving the initial stage return to normal life. Because of the greater number of rebleedings than for aneurysms at other locations, immediate treatment is crucial.

Anatomic risk factors for middle cerebral artery aneurysm rupture: computed tomography angiography study of 1009 consecutive patients.

BACKGROUND: The middle cerebral artery (MCA) is the most frequent location for unruptured intracranial aneurysms. Controversy remains as to which unruptured MCA aneurysms should be treated prophylactically. OBJECTIVE: To identify independent topographical and morphological variables that could predict increased rupture risk of MCA aneurysms. METHODS: A retrospective analysis of computed tomography angiography data of 1009 consecutive patients with 1309 MCA aneurysms, referred between 2000 and 2009 to Helsinki University Hospital, was carried out. Morphological and topographical parameters examined for MCA aneurysms comprised aneurysm wall regularity, size, neck width, aspect ratio, bottleneck factor, height-width ratio, location along the MCA, side, distance from the internal carotid artery bifurcation, and dome projection in axial and coronal computed tomography angiography views. Univariate and multivariate logistic regression analyses were performed to determine independent risk factors for rupture. RESULTS: Of the 1309 MCA aneurysms, 69% were unruptured and 31% were ruptured. Most unruptured MCA aneurysms were smaller than 7 mm (78%), with a smooth wall (80%) and a height-width ratio of 1 (47%) and were located at the main bifurcation (57%). Ruptured MCA aneurysms, mostly 7 to 14 mm in size (55%), had an irregular wall (78%) and a height-width ratio greater than 1 (72%) and were located at the main bifurcation (77%). Thirty-eight percent of MCA bifurcation aneurysms, 74% of large aneurysms, 64% of aneurysms with an irregular wall, and 49% of aneurysms with a height-width ratio greater than 1 were ruptured. CONCLUSION: Location at the main MCA bifurcation, wall irregularity, and less spherical geometry were independently associated with rupture of MCA aneurysms with a correlation with aneurysm size. artery.

A new, more accurate classification of middle cerebral artery aneurysms: computed tomography angiographic study of 1,009 consecutive cases with 1,309 middle cerebral artery aneurysms.

BACKGROUND: Classification of middle cerebral artery (MCA) aneurysms is sometimes difficult because the identification of the main MCA bifurcation, the key for accurate classification of MCA aneurysms, is inconsistent and somewhat subjective. OBJECTIVE: To use the meeting point of the M1 and M2 trunks as an objective, generally accepted, and angiographically evident hallmark for identification of MCA bifurcation and more accurate classification of MCA aneurysms. METHODS: We reviewed the computed tomographic angiography data of 1009 consecutive patients with 1309 MCA aneurysms. The M2 trunks were followed proximally until their meeting with the M1 trunk at the main MCA bifurcation. The aneurysms were classified according to their relative location: proximal, at, or distal to the MCA bifurcation. The M1 aneurysms were further subgrouped into M1 early cortical branch aneurysms and M1 lenticulostriate artery aneurysms, extending the classic 3-group classification of MCA aneurysms into a 4-group classification. RESULTS: The main MCA bifurcation was the most common location for MCA aneurysms, harboring 829 aneurysms (63%). The 406 M1 aneurysms comprised 242 M1 early cortical branch aneurysms (60%) and 164 M1 lenticulostriate artery aneurysms (40%). We found 106 MCA aneurysms (8%) at the origin of large early frontal branches simulating M2 trunks liable to be misclassified as MCA bifurcation aneurysms. Even though 51% of the 407 ruptured MCA aneurysms were associated with an intracerebral hematoma, this did not affect the classification. CONCLUSION: Studying MCA angioarchitecture and applying the 4-group classification of MCA aneurysms is practical and facilitates the accurate classification of MCA aneurysms, helping to improve surgical outcome.

Early microsurgical treatment for spinal hemangioblastomas improves outcome in patients with von Hippel-Lindau disease.

BACKGROUND: Spinal hemangioblastomas (HB) are rare, histologically benign, highly vascularized tumors often associated with von Hippel-Lindau (VHL) disease. The aim of the current study is to demonstrate the benefit of early surgical resection of large spinal HBs in selected asymptomatic patients with VHL. METHODS: Seventeen patients underwent microsurgical resection of 20 spinal HBs at the Department of Neurosurgery at Helsinki University Central Hospital (HUCH). Thirteen tumors were in the cervical spine, five in thoracic and one patient had two lumbar lesions. MRI tumor showed an associated syrinx in 16 patients (94%). Tumor volume ranged from 27 to 2730 mm(3). Out of 17 patients, 11 (65%) tested positive for VHL in mutation analysis. Five of these patients with tumors ranging from 55 to 720 mm(3) were treated prophylactically. RESULTS: Complete tumor resection was performed in 16 patients (94%) who were followed up for a median of 57 months (range 2-165 months). No patient had neurological decline on long-term follow-up. Among the patients with VHL, five patients with preoperative sensorimotor deficits showed improvement of their symptoms but never regained full function. One patient who presented with tetraplegia remained the same. Otherwise, all five patients with prophylactic surgery remained neurologically intact. CONCLUSION: Although documented growth on serial MRIs and the need for pathological diagnosis have been suggested as indications for surgery in otherwise asymptomatic patients, our series showed that a potentially larger group of asymptomatic patients with spinal HB associated with VHL would benefit from microsurgical resection. Long-term results of the surgical management of spinal HB are generally favorable. Our results suggest staging and early treatment for spinal HB larger than 55 mm(3), especially in patients with VHL. Small spinal HBs may be followed up.