Application of indocyanine green videoangiography in surgery for spinal vascular malformations.

We present our recent experience with indocyanine green videoangiography (ICGVA) in intra-operative evaluation of two patients with dorsal spinal dural arteriovenous fistula (SDAVF) and one patient with conus medullaris arteriovenous malformation (AVM). To our knowledge, the latter is the first report of this in the literature. Intra-operative ICGVA was used to identify an early filling vessel and to obliterate the site of fistulous connection. This was confirmed by a repeat ICGVA study and correlated with post-operative digital subtraction angiography (DSA). The abnormal fistulous site was identified in all three patients and disconnected. Complete obliteration was confirmed in all patients using ICGVA and with post-operative imaging. There was no untoward reaction to the dye injection. We conclude that ICGVA is a useful adjunct in surgical treatment of spinal vascular malformations since it is a real-time, non-invasive, radiation-free technique with good image resolution, and is repeatable and easily reproducible. Technical disadvantages can be minimized by proper exposure of the operative field.

Thoracic nerve root hemangioblastoma: a rare cause of posterior mediastinal mass.

BACKGROUND: Hemangioblastomas are benign tumors that occur sporadically or as part of von Hippel-Lindau disease. Occasionally, they have an extramedullary location along the nerve roots and, rarely, are purely extradural. CASE DESCRIPTION: We report a rare case of a completely extradural large hemangioblastoma in a 32-year-old man presenting with radiculopathy and a posterior mediastinal mass. Screening revealed a similar tumor in the right cerebellar hemisphere. The patient underwent a right paramedian suboccipital craniotomy and total excision of the cerebellar tumor, followed by a left lateral thoracotomy and complete excision of the mediastinal lesion. The patient had an uneventful recovery. CONCLUSIONS: Hemangioblastomas should be considered in the diagnosis of posterior mediastinal tumors in the presence of typical imaging features or with associated intra-axial tumors, so as to plan preoperative angiography and embolization.

Carotid endarterectomy: results and long-term follow-up of a single institution.

OBJECTIVES: To document our experiences, technical procedure and outcomes of carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis. MATERIAL AND METHODS: A total of 49 consecutive patients underwent 53 CEAs (three bilateral, one redo) for severe carotid artery stenosis. There were 39 males and 10 females, with mean age of 63 years. All patients underwent neck Doppler, computed tomography/magnetic resonance angiography/digital substraction angiography and a detailed cardiological evaluation. Antiplatelet drugs were continued perioperatively. Surgery was performed under general anesthesia with propofol cerebral protection, mild hypothermia and continuous electroencephalogram monitoring. The procedure was done under microscope and closure was done using 6-0 prolene. Clinical and radiological follow-up was done. RESULTS: Our mean follow-up was 4.69 years. All patients underwent primary suturing except one redo CEA done with venous patch graft. Three patients required intraoperative shunting. One patient died secondary to myocardial infarction peroperatively prior to carotid manipulation. One patient had stroke within 6 h, secondary to operative site intraluminal thrombus and was re-explored. Two patients had transient postoperative hemiparesis and aphasia while two patients had altered sensorium, all self-limiting, with normal imaging. One patient developed temporary twelfth-nerve paresis. One patient had persistent transient ischemic attack on the follow-up. Thus, the perioperative mortality rate was 1.89% and stroke rate was 1.89%. CONCLUSIONS: CEA for severe carotid stenosis is a safe procedure with good protection from ischemic events. Detailed preoperative cardiac evaluation and appropriate patient selection is essential.

Current treatment strategy in the management of vestibular schwannoma.

BACKGROUND: The changing trends in the management of vestibular schwannoma (VS) in our practice over the last two decades as well as the current status are presented here. MATERIALS AND METHODS: The observations are based on the experience of 559 consecutive cases of VS operated by the first author between 1987 and 2008, 438 of which were operated by microsurgery and 139 by gamma knife radiosurgery (GKR) (18 of which were previously operated by the authors). A detailed analysis of microsurgically managed patients in two different periods (100 consecutive patients each before 1993 and 2008) were compared to see the changing trend and document current results. RESULTS AND DISCUSSION: In the initial experience (1990s), the emphasis in microsurgery was preserving life, total excision of tumor and preservation of function in that order. In the 21 st century, the emphasis in microsurgery has been all about functional preservation. In 100 consecutive cases of VS (excluding neurofibromatosis-2) that were treated microsurgically between 2005-08, there were four small tumors (<2 cm), 14 medium-sized tumors (2-3 cm) and 82 large tumors (>or=3 cm). The total excision rate was 83%. The facial nerve anatomical preservation rate was 96% and function was Grade III House-Brackmann (HB) or better in 87%. Both the total excision rate and facial function of Grade II HB or better were 100% in cases with tumor size less than three cm. Functional hearing preservation was achieved in ten cases. There was no operative mortality. CONCLUSION: Total excision of VS, though aimed at, is no more pursued at the cost of facial function. Moreover, microsurgery, radiosurgery and observation are all valid options in the management of VS and choosing the correct modality helps in achieving optimal outcome.