Primary treatment of ruptured blood blister-like aneurysms with stent-assisted coil embolization: report of two cases.

Blood blister-like aneurysms (BBAs) are among the most hazardous cerebrovascular aneurysms to treat; microsurgical treatment of these small, wide-necked, and exceptionally fragile aneurysms place patients at significant risk of morbidity or mortality. We report two cases of ruptured BBAs attempted to be treated for the first time with stent-assisted coil embolization solely and review the current literature on treatment options. Our patients underwent stent-assisted coil embolization of the aneurysms in the acute stage of subarachnoid hemorrhage (SAH). One patient was successfully treated without procedure-related complications. The other patient died after surgical internal carotid artery (ICA) occlusion, carried out after intraoperative rerupture of the aneurysm during the endovascular treatment. In the successful case, 8-month and 19-month follow-up angiograms demonstrated incomplete (>90%) occlusion with residual filling of the aneurysm neck, which did not need additional coil embolization. Even though stent-assisted coil embolization of ruptured BBAs in the acute stage appears to be a technically feasible treatment option, the present stent-related endovascular technology has potentially hazardous drawbacks.

Herpes simplex virus encephalitis: new diagnostic and clinical features and results of therapy.

Six patients with herpes simplex virus (HSV) encephalitis underwent diagnostic and clinical evaluation. The HSV or its antigenic material was found in three brain biopsy specimens. In the remaining three cases, the diagnosis was supported by detection of HSV antibodies in the CSF. Cell count and total protein concentration in the CSF reached a maximum level at three weeks and two months, respectively. The IgG index and HSV antibody level in the CSF often remained constant after reaching maximal values. In three patients, a transient low serum sodium level was observed. Characteristic EEG changes were present five to 11 days after the onset of symptoms. Computerized tomographic scanning revealed a temporal low-density lesion. Three patients became deeply comatose and had respiratory failure. The patient without vidarabine therapy and one of the five patients treated with vidarabine died.

MR of intracranial tumors: combined use of gadolinium and magnetization transfer.

PURPOSE: To study the potential combined application of gadolinium and magnetization transfer in the MR imaging of intracranial tumors. METHODS: Twenty-two patients were imaged at low field strength (0.1 T). Corresponding gradient-echo partial saturation images without and with magnetization transfer pulse were produced. Images with intermediate repetition times were obtained in 18 cases; five different sequences were produced in 4 cases. Gadopentetate dimeglumine was used at a dose of 0.1 mmol/kg. RESULTS: Magnetization transfer effect increased the contrast between enhancing lesion and normal brain and the contrast between edema and normal brain; the contrast between enhancing lesion and edema was not significantly changed. On intermediate-repetition-time magnetization transfer images the contrast between enhancing tumor and normal brain and the contrast between edema and normal brain were superior to short-repetition-time magnetization transfer images, but the differentiation between enhancing tumor and edema was poorer. CONCLUSION: Magnetization transfer can be used to improve contrast in Gd-enhanced MR imaging. Combining magnetization transfer with an intermediate-repetition-time image provides the possibility for displaying both enhancing and nonenhancing lesions on a single MR image.

Interstitial chemotherapy with carmustine-loaded polymers for high-grade gliomas: a randomized double-blind study.

OBJECTIVE: To find out the effect of carmustine (bischloroethyl-nitrosourea) combined with a biodegradable polymer in the treatment of malignant (Grades III and IV) gliomas, applied locally, at the time of the primary operation. METHODS: Prospective, randomized double-blind study of an active treatment group versus a placebo group. Conducted at the Departments of Neurosurgery of the University Hospitals of Helsinki, Tampere, and Turku in Finland and Trondheim in Norway. The study consisted of 32 patients (16 in each treatment group) enrolled between March 23, 1992, and March 19, 1993. The study was planned to include 100 patients but had to be terminated prematurely, because the drug that was being used had become unobtainable. The main outcome measures included the survival times of patients after the operations and the application of an active drug or placebo. RESULTS: The median time from surgery to death was 58.1 weeks for the active treatment group versus 39.9 weeks for the placebo group (P = 0.012). For 27 patients with Grade IV tumors, the corresponding times were 39.9 weeks for the placebo group and 53.3 weeks for the active treatment group (P = 0.008). At the end of the study, six patients were still alive, five of whom belonged to the active treatment group. CONCLUSION: Carmustine applied locally in a biodegradable polymer at the time of primary operation, seems to have a favorable effect on the life span of patients with high-grade gliomas.

The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment.

In a prospective study, 52 patients with a spontaneous supratentorial intracerebral hematoma (ICH) were randomly assigned to receive emergency surgery or conservative treatment within 48 hours after the bleed. Patients with a decreased level of consciousness and/or a severe neurological deficit were admitted to the study. The overall mortality rate at 6 months was 42%: 10 (38%) of the 26 patients in the conservative group and 12 (46%) of the 26 in the surgical group. Six (20%) of the 30 survivors at 6 months were able to conduct their activities of daily living independently: five (31%) of the 16 patients in the conservative group and one (7%) of the 14 in the operative group. These differences are not statistically significant. The mortality rate of semicomatose or stuporous patients (Glasgow Coma Scale score 7 to 10) was statistically significantly lower in the surgical group (none of the four patients) than in the conservative group (four of five patients) (p less than 0.05); however, all surviving patients in this subgroup were severely disabled. The study suggests that surgical treatment of this category of patients with ICH does not offer any definite advantage over conservative treatment. In semicomatose or stuporous patients, surgery may improve the length of survival, but the quality of life remains poor.

MR classification of brain gliomas: value of magnetization transfer and conventional imaging.

We compared quantitative analysis of conventional MR and magnetization transfer (MT) images with visual morphologic assessment of standard images in the classification of gliomas. Thirty-two patients with gliomas were imaged preoperatively. Relative signal intensities on T2- and T1-weighted images, Gd-enhancement, signal heterogeneity on T2-weighted and Gd-enhanced T1-weighted images and MT ratios were measured. In 16 astrocytomas, the MT ratios were correlated with the volume fraction of tumor cell nuclei in histological sections. Among the conventional sequences T2-weighted images were most accurate for quantitative classification; signal heterogeneity was more accurate than relative signal intensity. MT ratios were superior to quantitative analysis of conventional images and equal to visual morphologic evaluation in discriminating between low-grade and high-grade gliomas and correlated with the volume fraction of nuclei in the tumor tissue (r = 0.71, p < .01). The results indicate that quantitative analysis is generally of minor value in the grading of gliomas. In spite of sensitivity to tissue changes associated with malignancy MT imaging cannot significantly improve MR classification of gliomas.

Magnetic resonance image changes and clinical outcome after microdiscectomy or nucleotomy for ruptured disc.

Preoperative and postoperative magnetic resonance imaging (MRI) of the lumbar spine was performed on 41 patients treated either microsurgically or with percutaneous nucleotomy for lumbar disc herniation. On the first postoperative day, MRI revealed an edematous mass effect at the level of surgery in 25 (61%) patients. The mass effect caused compression of the anterior dural sac mimicking preoperative disc herniation. After the follow-up of 6 months, the mass effect had disappeared in all patients, and the MRI finding in the operated disc space was that of a prolapse in six (15%) patients and that of a protrusion in 16 (39%) patients. Postoperative scarring was detected in 23 (56%) patients. The amount of the epidural scar tissue was significantly (p = 0.0002) associated with the extent of the early postoperative hemorrhagic changes detected in these patients with MRI. No association was observed between these MRI findings (mass effect, disc herniation, epidural scarring) and the clinical outcome of the patients.

Postoperative hematomas after successful lumbar microdiscectomy or percutaneous nucleotomy: a magnetic resonance imaging study.

We evaluated the incidence of postoperative extradural hematomas by means of magnetic resonance imaging (MRI) technique in 44 patients who underwent successful surgery for a virgin lumbar disc herniation. Of these patients, 28 were treated with microdiscectomy and 16 with percutaneous nucleotomy. Postoperative hematoma proved to be a universal MRI finding in the microsurgically treated patients: hematomas were found in all patients in the microdiscectomy group. In 12 (43%) patients the hematoma extended into the dural sack. The incidence of hematomas was significantly (p = 0.001) lower in the patients treated with percutaneous nucleotomy: hematomas were detected in only 10 (63%) of the 16 patients in the nucleotomy group. The hematomas in these patients were also smaller in size and none of them connected with the dural sac. Correlation between the hematomas and clinical findings showed that the presence of a hematoma had no obvious effect on the immediate postoperative recovery of a patient.

Intracranial hemangiopericytoma: radiology, surgery, radiotherapy, and outcome in 21 patients.

At operation, 21 meningeal intracranial hemangiopericytomas resembled meningiomas, but differed histologically. They were frequently attached to sinuses, occipitally located, bled profusely at operation, and had a higher risk of recurrence and metastasis. Specific preoperative diagnosis is possible: computed tomography scan showed a meningiomalike tumor, which on the angiogram looked malignant and highly vascular. Two tumors showed a malignant growth pattern on computed tomography scan, "mushrooming." After a radical removal, three patients have lived for more than 10 years without recurrence; two of them were irradiated postoperatively. Three recurrent tumors were treated with radiotherapy only; one responded favorably.

The growth rate of intracranial meningiomas and its relation to histology. An analysis of 43 patients.

The growth rate of intracranial meningiomas was studied in 43 patients against a histologic grading based on the degree of anaplasia. The mean time for doubling of the tumor volume was 415 days (138-1045) in grade I (benign), 178 days (34-551) in grade II (atypical), and 205 days (30-472) in grade III (anaplastic). The difference between grade I and the combined grades II-III was highly significant. Both the mitotic index and the absence of calcification on the computed tomography scan correlated strongly with the doubling time. The growth rate should be carefully considered in planning therapy and timing computed tomography studies for patients with meningioma.

Arterial oxygen tension and high intracranial pressure.

Arterial oxygen and carbon dioxide tension was measured in spontaneously breathing rabbits whose intracranial pressure was raised by a freeze lesion, oil embolism, or hydrostatic pressure. Reports elsewhere had stated that high intracranial pressure led to hypoxaemia. In this series of experiments, arterial oxygen tension appeared to rise and carbon dioxide tension appeared to drop. Both changes were slight and not significant statistically. There was no evidence to suggest that arterial hypoxaemia is caused by high intracranial pressure.

Respiration and acid-base balance of blood after diffuse experimental brain injury.

Diffuse brain injury in rabbits was caused by injecting olive oil and saline into one internal carotid artery. In this report, the fourth of a series, the effects of this experimental brain injury on respiration and acid-base balance of blood are analyzed. The animals that withstood the injury best were those that had a lower pre-traumatic pCO2; the animals that suffered a rise in intracranial pressure and succumbed to the injury quickly did so in spite of pronounced hyperventilation after the injury. Arterial pCO2 immediately before the injury was the only significant prognostic factor in this analysis. Respiratory rate only dropped immediately before respiratory arrest and death. The findings concerning pCO2 tally with results after experimental ligation of a cerebral artery, but less so with results after other types of experimental brain injury. This emphasizes again that conclusions drawn from one type of brain injury must not be extrapolated to other types.

Percutaneous nucleotomy in the treatment of lumbar disc herniation results after a mean follow-up of 2 years.

We have evaluated the clinical outcome of 45 consecutive patients who underwent percutaneous nucleotomy for a single-level disc herniation. Included were 28 (62%) woman and 17 (38%) men, with a mean age of 46 years. The mean postoperative follow-up time was 2 years. Intra-operatively, disc herniation was graded as a protrusion in 23 (51%) patients and as a prolapse in 22 (49%) patients. During the follow-up, sciatic pain completely recovered or markedly diminished in 38 (84%) patients and 35 (78%) patients returned to work. The occupational outcome of the patients operated on for a protrusion was inferior to that of the patients operated on for a prolapse: only 22% of the patients who underwent surgery for a protrusion reported to manage their work well, while as many as 41% of those with a prolapse managed well (p = 0.04). Pre-operatively, clinical examination revealed segmental instability of the lumbar spine in 11 (24%) patients. There was a significant association between instability and unsatisfactory long-term outcome: of the patients with pre-operative instability, 45% were postoperatively retired or on sick leave because of the back, as compared to 15% of the 34 patients without instability (p = 0.03). Furthermore, patients with instability suffered from sciatica and low back pain significantly (p = 0.02) more often than those without instability. Surgical complications were infrequent. There were no nerve root lesions and no vascular injuries. Postoperative discitis developed in 2 (4%) patients. Of all patients, only 1 (2%) has been re-operated on for a recurrent disc.

Clinical instability of the lumbar spine after microdiscectomy.

A total of 190 patients treated microsurgically for a virgin single level lumbar disc herniation were examined physically after a mean follow-up period of 3 years (range 21-68 months). Included were 99 (52%) men and 91 (48%) women with a mean age of 42 years. During the observation period, sciatica had completely recovered or markedly diminished in 172 (90%) patients, and 142 (75%) patients had returned to work. However, as many as 29% of the patients occasionally suffered from low back pain. Clinical examination revealed various signs and symptoms of segmental instability of the lumbar spine in 22% of the surgical patients. There was a significant association between postoperative instability and unsatisfactory long-term outcome: of the 42 patients with instability, 62% suffered from low back pain and 45% were on sick leave or retired because of the back, while the corresponding numbers for those patients without instability were 20% and 8%, respectively (p < 0.0001). Moreover, the mean value of the Oswestry index in instability patients was as high as 34% (SD 12), indicating moderate disability, whereas a significantly (p = 0.0001) lower Oswestry Index 16% (SD 13), indicating minimal disability, was detected in patients without instability.

Outcome of patients after transcranial operation for pituitary adenoma.

A retrospective study of 111 craniotomies for pituitary adenomas was analyzed. The follow-up time was 14-33 years. Thirteen patients died from complications of primary or secondary operations, 23 of causes otherwise related to the tumor and 20 of unrelated causes. 40% of patients surviving the primary operation had recurrence of their tumor. Radiotherapy did not prevent recurrences, but postponed their occurrence. Some tumors appeared very late, the last one 18 years after operation. 70% of the surviving patients need hormone substitution, but only 8 patients have severe impairment of vision.

Operative management of chromophobe pituitary tumour recurrences.

Twenty-three operations were performed for recurrences of previously treated chromophobe pituitary adenomas. Eleven operations were transcranial, and 12 were transsphenoidal. Twenty-two patients were operated on because of deteriorating eyesight; this improved in ten patients, deteriorated further in three, and did not significantly change in the remaining nine patients. There was one postoperative death. The patients generally had hypopituitarism already at the time of diagnosis, and it tended to increase during treatment. The results are certainly worse than after primary operations, but there is no alternative for handling a sizeable recurrence that has already affected the optic pathways.

Long-term outcome of patients who underwent percutaneous nucleotomy for lumbar disc herniation: results after a mean follow-up of 5 years.

A total of 41 patients who had undergone percutaneous nucleotomy for a single level lumbar disc herniation were clinically examined after a mean postoperative follow-up of 5 years (range 4 to 7 years). There were 14 (34%) male and 27 (66%) female patients with a mean age of 49 years. By intra-operative discography, the herniation had been graded as a protrusion in 21 (51%) patients and as a prolapse in 20 (49%) patients. At the time of the investigation, sciatica had completely recovered or markedly diminished in 32 (78%) patients, and 29 (71%) patients had returned to work. Evaluated by a 100 mm visual analog pain scale (VAS), the postoperative pain relief was statistically significant (p < 0.0001). Clinical signs and symptoms of segmental instability of the lumbar spine were detected in 10 (24%) patients. Instability was significantly associated with an unsatisfactory long-term outcome in the patients with the occurrence of sciatica (p = 0.003) and low back pain (p = 0.001) as well as the VAS score (p = 0.005) and Oswestry index (p < 0.0001). Clinical investigation revealed sensory deficits in the leg in 12 (29%) patients, weakness of the extensor hallucis longus muscle in 5 (12%) patients and a total peroneal paresis in one (2%). The patellar and achilles tendon reflexes were depressed in 2 (5%) and 5 (12%) patients, respectively. During the follow-up period, recurrent disc herniation was detected in 3 (7%) patients who were all re-operated on. In addition, 3 (7%) patients were re-operated on for other back problems. Corroborating earlier findings, the results of this study indicate that percutaneous nucleotomy is an effective and safe alternative to open surgery in the treatment of patients with a small prolapse or a protrusion.