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Our study aimed to evaluate the postoperative outcome of patients with unruptured giant middle cerebral artery (MCA) aneurysm revealed by intracranial hypertension associated to midline brain shift. From 2012 to 2022, among the 954 patients treated by a microsurgical procedure for an intracranial aneurysm, our study included 9 consecutive patients with giant MCA aneurysm associated to intracranial hypertension with a midline brain shift. Deep hypothermic circulatory flow reduction (DHCFR) with vascular reconstruction was performed in 4 patients and cerebral revascularization with aneurysm trapping was the therapeutic strategy in 5 patients. Early (< 7 days) and long term clinical and radiological monitoring was done. Good functional outcome was considered as mRS score ≤ 2 at 3 months. The mean age at treatment was 44 yo (ranged from 17 to 70 yo). The mean maximal diameter of the aneurysm was 49 mm (ranged from 33 to 70 mm). The mean midline brain shift was 8.6 mm (ranged from 5 to 13 mm). Distal MCA territory hypoperfusion was noted in 6 patients. Diffuse postoperative cerebral edema occurred in the 9 patients with a mean delay of 59 h and conducted to a postoperative neurological deterioration in 7 of them. Postoperative death was noted in 3 patients. Among the 6 survivors, early postoperative decompressive hemicraniotomy was required in 4 patients. Good functional outcome was noted in 4 patients. Complete aneurysm occlusion was noted in each patient at last follow-up. We suggest to discuss a systematic decompressive hemicraniotomy at the end of the surgical procedure and/or a partial temporal lobe resection at its beginning to reduce the consequences of the edema reaction and to improve the postoperative outcome of this specific subgroup of patients. A better intraoperative assessment of the blood flow might also reduce the occurrence of the reperfusion syndrome.
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Craniectomia Descompressiva , Aneurisma Intracraniano , Hipertensão Intracraniana , Humanos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/complicações , Adulto , Masculino , Feminino , Pessoa de Meia-Idade , Hipertensão Intracraniana/cirurgia , Hipertensão Intracraniana/etiologia , Adolescente , Craniectomia Descompressiva/métodos , Adulto Jovem , Idoso , Resultado do Tratamento , Artéria Cerebral Média/cirurgiaRESUMO
INTRODUCTION: The etiology of brain aneurysms remains poorly understood. Finnish research suggests that oral bacteria might contribute to the development and rupture of brain aneurysms. Previous studies by our team have not confirmed these findings, likely due to methodological differences. We aimed to replicate the Finnish study with a French population, using the same primers and comparing the results to internal controls. METHODS: We used RT-qPCR to retrospectively analyze the expression of oral bacterial genes in eight patients. During surgical procedures, four tissue types were consistently sampled from each patient: the aneurysmal wall, the superficial temporal artery (STA), the middle meningeal artery (MMA), and the dura mater (DM). Results were expressed as fold differences employing the 2-∆∆Ct method, and statistical analyses were performed accordingly. RESULTS: Our cohort included eight patients, evenly split into ruptured and unruptured groups. The sex distribution was balanced (4 females, 4 males). We observed DNA expression from oral bacteria in all sampled tissues; however, there were no significant differences between the ruptured and unruptured groups. CONCLUSION: We detected oral bacterial gene expression in the aneurysmal wall, STA, MMA, and DM in a sample of French patients. Although limited by the small sample size, our results suggest a potential role for bacterial involvement in vascular invasiveness related to bacteremia. These findings do not definitively link oral bacteria to the pathogenesis of aneurysm development and rupture.
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Aneurisma Intracraniano , Humanos , Feminino , Masculino , Aneurisma Intracraniano/microbiologia , Pessoa de Meia-Idade , França , Idoso , Estudos Retrospectivos , Boca/microbiologia , Adulto , Aneurisma Roto/microbiologia , Artérias Temporais , Dura-Máter , Bactérias/genética , Bactérias/isolamento & purificação , Artérias MeníngeasRESUMO
Accounting for 70% of all spinal vascular malformations, spinal dural arteriovenous fistulas (SDAVF) are the most common type of malformation. Interruption of the fistulous arterialized vein point is the goal of surgical treatment. The aim of the study was to compare open surgery (laminectomy) versus minimal invasive surgery (MIS) in SDAVF treatment. Between March 2013 and March 2020, we retrospectively collected 21 consecutive adult patients with SDAVF. Since March 2017, MIS has been routinely used for surgical treatment. Pre- and post-operative clinical evaluations used Aminoff-Logue score (ALS). Complication rate was noted. Post-operative occlusion of the malformation was confirmed by digital subtraction angiography (DSA) in all patients. MIS was compared to open surgery in terms of efficacy and complications with statistical evaluation. Standard laminectomy was performed in 12 patients and MIS technique in 9 patients. No difference was noted on pre-operative parameters. ALS and MRI signs of myelopathy were improved in all cases except for 1 patient in each group. All SDAVFs were excluded based on post-operative DSA. Significant differences were noted between the 2 groups in terms of perioperative blood loss (p<0.001), post-operative pain visual analog scale values (p<0.001), and first time out of bed (p<0.001). Wrong level surgery occurred in one patient in each group; patients were re-operated using the same technique. No infection or cerebrospinal fluid (CSF) leak was noted. In our experience, MIS is a safe alternative to open laminectomy for SDAVF treatment. MIS contributes to patient comfort and minimizes blood loss without increasing complication rate.
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Malformações Vasculares do Sistema Nervoso Central , Doenças da Medula Espinal , Adulto , Humanos , Vazamento de Líquido Cefalorraquidiano , Laminectomia , Estudos RetrospectivosRESUMO
WHO grade II progestin-related meningiomas have been reported in recent series but we found no previous study describing their long-term outcome. Our study aimed to evaluate patients operated on for high-grade intracranial meningioma and who underwent long-term exposure to high dose of cyproterone acetate, nomegestrol acetate, and chlormadinone acetate. Our study retrospectively included 9 patients with high-grade progestin-related intracranial meningioma between December 2006 and September 2021. In each patient, clinico-radiological follow-up was performed every 6 months after diagnosis and treatment withdrawal recommendation. The mean progestative exposure was 11.4 years. Edema existence or absence of cleft sign on MRI were the key factors for surgical indication. All patients underwent surgery. Adjuvant radiotherapy was indicated in 1 patient, and Gamma Knife radiosurgery was proposed in 2 other patients for a second location of meningioma. Six patients harbored a grade II chordoid meningioma subtype with 100% PR expression and 3 patients a grade II atypical meningioma subtype with lower PR expression. The mean follow-up was 8.1 years and none of the 9 patients presented with a recurrence. Patients with grade II progestin-related meningiomas have less tumor recurrence after surgery than patients with sporadic grade II meningiomas, especially after progestin withdrawal. The presence/appearance of peri-meningioma edema and the absence of cleft sign before volumetric change should suggest the existence of an underlying WHO grade II meningiomas. In these cases, surgical resection may immediately be considered and adjuvant radiotherapy should be reserved for proven recurrence cases.
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Neoplasias Meníngeas , Meningioma , Criança , Humanos , Neoplasias Meníngeas/patologia , Meningioma/diagnóstico , Progestinas/uso terapêutico , Estudos Retrospectivos , Organização Mundial da SaúdeRESUMO
PURPOSE: Our study aimed to evaluate potential risk factors for the development of FDICA after suprasellar tumor resection. MATERIALS AND METHOD: After reviewing all cases of pediatric patients who benefited from a suprasellar lesion resection in our two medical institutions, we found 6 patients with a FDICA. Surgical approach strategy (pterional or subfrontal approaches) was noted. Postoperative cranial MRI was performed in each patient 3 months after surgery and every year. When a FDICA occurred, MRI was performed 6 months after the diagnosis and 1 year later to detect any progression. RESULTS: There were 6 males with a mean age at treatment of 11 years (6 to 15). Pterional approach was performed in these 6 patients. At the 2 institutions, we have done at least 50 pterional craniotomies for suprasellar lesion resection. No FDICA was reported after subfrontal approach in 27 consecutive pediatric patients operated on from a craniopharyngioma. The delay between the surgery and the diagnosis of the FDICA was 9 months (3 to 17 months). No symptoms related to the FDICA were recorded. The mean maximal diameter of the aneurysm was 14 mm (10 to 21). ICA bifurcation was involved in 2 cases. Asymptomatic FDICA progression was noted in 2 cases but no treatment was proposed. CONCLUSION: The pathogenesis of FDICA is unclear, and might involve arterial wall necrosis caused by postoperative arachnoid fibrosis which might be worsened by the pterional approach.
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Aneurisma Intracraniano , Neoplasias Hipofisárias , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Criança , Craniotomia , Dilatação , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Neoplasias Hipofisárias/cirurgia , Resultado do TratamentoRESUMO
Our study aimed to evaluate the outcome of patients with ruptured blood-blister like aneurysm (BBLA) in our institution by comparing microsurgical selective treatment to endovascular treatment using flow-diverter stent (FD). Our study included 18 consecutive patients treated for BBLA between 2004 and 2020. Until 2014, microsurgery was preferred in all patients with BBLA (n = 10). Significant postoperative morbi-mortality was recorded at this time and led us to change therapeutic strategy and to favor FD as first-line treatment in all patients (n = 8). Postprocedural complications and BBLA occlusion were recorded. High WFNS score (> 2) was noted in 6 patients of microsurgical group and in 2 of endovascular group. In microsurgical group, ischemic lesions were noted in 6 patients and led to death in 3 patients. Immediate BBLA occlusion was obtained in all patients. Favorable outcome after 3 months (mRS < 3) was recorded in 4 of the 7 survivors. In endovascular group, ischemic lesions were noted in 4 patients. One patient died from early postprocedural BBLA rebleeding. Scarpa hematoma was noted in 3 patients with surgical evacuation in 1. Persistent BBLA at 3 months was recorded in 4 patients without rebleeding, but further FD was required in 1 with growing BBLA. Favorable outcome was noted in 6 of the 7 survivors. Although, rate of morbi-mortality appear lower in patients treated with FD, neurological presentation was better and BBLA diagnosis remains questionable in this group. Moreover, persistent BBLA imaging with potential risk of rebleeding after FD deserves to be discussed.
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Aneurisma Roto , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Hemorragia Subaracnóidea , Aneurisma Roto/cirurgia , Humanos , Aneurisma Intracraniano/cirurgia , Estudos Retrospectivos , Hemorragia Subaracnóidea/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: High-flow extracranial-intracranial bypass is associated with a significant risk of ischemic stroke. The goal of this study is to evaluate the effectiveness of STA-MCA bypass preceding a high-flow bypass as a means of protecting the brain from ischemia during the high-flow bypass anastomosis in patients with otherwise untreatable aneurysms. MATERIALS AND METHOD: This prospective study included 10 consecutive patients treated for complex/giant aneurysm using a previous combined STA-MCA bypass and high-flow EC-IC bypass between June 2016 and January 2018 when classical endovascular or microsurgical exclusion was estimated too risky. Early cranial Doppler, MRI, CT scan, and conventional angiography were performed in each patient to confirm patency of bypasses, measure flow in the anastomoses, detect any ischemic lesions, and evaluate exclusion of the aneurysm. RESULTS: The mean age at treatment was 55 years (range 34 to 67). The mean time of microsurgical procedure was 11 h (range 9 to 12). In all patients, the high-flow bypass was patent intraoperatively and complete occlusion of aneurysm was obtained. No ischemic lesions were noted on early MRI. One patient died from a large hemispheric infarction related to a common carotid artery dissection 10 days after the microsurgical procedure and immediate postoperative epidural hematoma was noted in one other patient. CONCLUSION: In this study, we described the use of a protective STA-MCA bypass, performed prior to the high-flow bypass, in order to reduce the risk of perioperative ischemic lesions without increasing the morbidity of the surgical procedure. This treatment paradigm was feasible in all ten patients without complications related to the STA-MCA anastomosis.
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Anastomose Cirúrgica/métodos , Aneurisma/cirurgia , Isquemia Encefálica/prevenção & controle , Revascularização Cerebral/métodos , Microcirurgia/métodos , Complicações Pós-Operatórias/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Adulto , Idoso , Anastomose Cirúrgica/efeitos adversos , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Doenças das Artérias Carótidas/cirurgia , Revascularização Cerebral/efeitos adversos , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Microcirurgia/efeitos adversos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Ultrassonografia DopplerRESUMO
BACKGROUND/AIMS: Our study aimed to evaluate the efficiency and morbidity of Gamma Knife radiosurgery (GKS) in the treatment of hemorrhagic brainstem cavernous malformations (CMs). METHODS: We included in this study all patients who underwent GKS for the treatment of a hemorrhagic brainstem CM(s) in our institution between January 2007 and December 2012. The GKS was privileged when the surgical procedure was evaluated as very risky. The mean dose of radiation was 14.8 Gy, and the mean target volume was 0.282 cm3. All patients participated in a scheduled clinical follow-up. The posttreatment MRI was performed after 6 months and after 1 year, and then all patients had an annual MRI follow-up. RESULTS: There were 19 patients with a mean age of 36.7 years. The mean follow-up period was 51.2 months. The annual hemorrhage rate (AHR) was 27.31% before GKS, 2.46% during the first 2 years following the GKS, and 2.46% after the first 2 years following the GKS. The decrease in AHR after GKS was significant (p < 0.001). CONCLUSION: GKS should be suggested when the surgical procedure harbors a high risk of neurological morbidity in patients with brainstem CM. Compared to prior literature results, a lower dose than applied in this study could be discussed.
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Tronco Encefálico/cirurgia , Hemorragia Cerebral/cirurgia , Hemangioma Cavernoso do Sistema Nervoso Central/cirurgia , Radiocirurgia/métodos , Adulto , Tronco Encefálico/diagnóstico por imagem , Hemorragia Cerebral/complicações , Hemorragia Cerebral/diagnóstico por imagem , Feminino , Seguimentos , Hemangioma Cavernoso do Sistema Nervoso Central/complicações , Hemangioma Cavernoso do Sistema Nervoso Central/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
OBJECTIVE: This study aims to describe the clinical and molecular presentation of pediatric neurofibromatosis type 2 (NF2) and the subsequent management of vestibular schwannomas (VS) and hearing rehabilitation. METHODS: This is a single-center retrospective study of neurofibromatosis type 2 diagnosed before the age of 18 years old from 1997. Natural history of vestibular schwannomas and surgical outcomes were evaluated using volumetric MRI, hearing, and facial nerve assessment. Patients included in chemotherapy protocols were excluded. RESULTS: From a database of 80 patients followed up for NF2 on a regular basis, 25 patients were eligible (11 sporadic cases, 14 inherited in five families). The mean age at diagnosis was 11.6 years old. The average clinical follow-up was 6.5 years. NF2 mutation was identified in 81 % of the probands. The average growth rate based on the maximum linear diameter (DGR) was 1.68 mm/year (n = 33, average follow-up 4.22 years) and 545 mm3/year in volumetric assessment (VGR) for VS larger than 1 cm (n = 21, average follow-up 3.4 years). In unoperated ears, hearing was stable in about 50 % of ears. The mean change in dB HL was 9.5 dB/year for pure-tone average and 3.5 for speech-recognition threshold (n = 34, 5.5 years 1-12). Eight children required removal through a translabyrinthine approach (mean follow-up was 4.5 years), six patients were operated on for hearing preservation (mean postoperative follow-up 4.3 years). Six patients were eligible for hearing rehabilitation with cochlear implantation (I), and five received placement of an auditory brainstem implant. CONCLUSION: Early diagnosis and treatment of small growing VS should be carefully discussed considering familial history and possible rehabilitation with a CI.
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Correção de Deficiência Auditiva/métodos , Neurofibromatose 2/complicações , Neuroma Acústico/diagnóstico , Neuroma Acústico/etiologia , Neuroma Acústico/terapia , Adolescente , Criança , Pré-Escolar , Feminino , Testes Auditivos , Humanos , Masculino , Estudos RetrospectivosRESUMO
Ventricular access devices (VAD) offer several advantages compared to intralumbar injections for the administration of intra-CSF agents in the treatment of leptomeningeal metastases (LM). However, there are few prospective studies reporting on complications with the use of VADs. All complications were prospectively collected that pertained to the implantation and use of a VAD in consecutive patients with solid tumor-related LM from June 2006 to December 2013. Clinical follow-up was every 2 weeks during the initial 2 months of treatment and then once monthly. Complete neuraxis MRI was performed at baseline and then every 2-3 months. A total of 112 patients (88 women) with a mean age of 51.1 years (range 26-73) were included. Primary cancers included breast (79 patients), lung (12) and melanoma (6). All patients were treated with intra-CSF liposomal cytarabine. 72 % of the patients received concomitant systemic and intra-CSF chemotherapy. The placement of the VAD was performed under local anesthesia in all cases. The mean operative time was 15 min and no perioperative complications were reported. The mean number of intraventricular injections per patient was 9.34 (range 1-47). A total of 11 complications in 11 patients were seen including 7 infections, 1 intracranial hemorrhage, 2 instances of symptomatic leukoencephalopathy and 1 catheter malpositioning. 8 complications required an operation and 1 complication was fatal. The use of a VAD is safe and may improve patients' comfort and compliance with LM-directed therapy.
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Cateteres de Demora/efeitos adversos , Injeções Intraventriculares/efeitos adversos , Injeções Intraventriculares/instrumentação , Neoplasias Meníngeas/tratamento farmacológico , Neoplasias Meníngeas/secundário , Adulto , Idoso , Antimetabólitos Antineoplásicos/administração & dosagem , Antimetabólitos Antineoplásicos/efeitos adversos , Encéfalo/patologia , Neoplasias da Mama/patologia , Citarabina/administração & dosagem , Citarabina/efeitos adversos , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/patologia , Imageamento por Ressonância Magnética , Masculino , Melanoma/patologia , Neoplasias Meníngeas/patologia , Neoplasias Meníngeas/cirurgia , Pessoa de Meia-Idade , Estudos Prospectivos , Medula Espinal/patologiaRESUMO
OBJECT: The causes of mortality in neurofibromatosis type 2 (NF2) patients are poorly studied in the literature. Our study aimed to fit this gap by analyzing the main causes of death in this population. METHODS: This study is the retrospective review of prospectively collected data of 80 patients with NF2 disease followed in Lille University Hospital between 1987 and 2011. Demographical data, diagnosis criteria, and cause of death were recorded. RESULTS: There were 45 men and 35 women, with a mean age at diagnosis of 27.2 years (range: 6-73 years; SD: ± 15.4). Sixty-eight patients met Manchester criteria and the others had an identified mutation in the NF2 gene which confirmed the diagnosis. Of all patients, we noted 7 deaths. The mean age at diagnosis of dead patients was 26 years. The mean age of death was 38.9 years. The causes of death were suicide in 1 patient, hematoma after surgical removal of grade IV vestibular schwannoma in 1 patient, aspiration pneumonia after swallowing disturbances in 3 patients, intracranial hypertension related to growth of multiple meningiomas in 1 patient, and brachial plexus sarcoma grade 3 in the last patient. CONCLUSION: NF2 is a serious disease that can quickly be life-threatening. The presence of lower cranial nerves schwannomas is a poor prognostic factor, and radiosurgery should be considered for their treatment, as surgical removal often worsens the swallowing disturbances. A psychological support should also be provided.
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The authors report the case of a man who underwent cranial surgery for the removal of a craniopharyngioma using a right pterional approach. Three months later, he developed a right-sided temporal glioblastoma. The presentation is suggestive of a causal relationship between surgery and the development of a malignant glial tumor.
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Neoplasias Encefálicas/etiologia , Neoplasias Encefálicas/terapia , Craniofaringioma/complicações , Craniofaringioma/cirurgia , Glioblastoma/etiologia , Glioblastoma/terapia , Neoplasias Hipofisárias/complicações , Neoplasias Hipofisárias/cirurgia , Idoso , Antineoplásicos Alquilantes/uso terapêutico , Quimiorradioterapia , Protocolos Clínicos , Dacarbazina/análogos & derivados , Dacarbazina/uso terapêutico , Humanos , Imuno-Histoquímica , Imageamento por Ressonância Magnética , Masculino , Procedimentos Neurocirúrgicos , Temozolomida , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: This study was design to investigate the surgical and functional outcome based on the preaneurysmal M1 length for unruptured MCA aneurysm. METHODS: Among 250 consecutive patients with unruptured aneurysms operated in our institution between 2015 and 2017, 72 were MCA aneurysms. Risk factors for IR (i.e., intraoperative rupture) were investigated including age, sex, preaneurysmal M1 length, maximal MCA aneurysm diameter, neck size, aneurysm shape, sphenoid ridge proximation sign. Outcome was measured at discharge, 1 yr and last follow-up. Outcome was compared according to the preaneurysmal M1 length. RESULTS: Among 68 patients included, five patients (7.3%) suffered IR. Mean maximal diameter of MCA aneurysm (7.9 mm ± 3.4 vs. 4.5 ± 1.8; p = 0.01) was significantly associated with IR risk. Mean M1 length seemed to be shorter in the IR group although not statistically significant (16.2 mm ± 5.1 vs. 11.5 mm ± 4.8; p = 0.053). Mid-term outcome was favorable for all patients at last follow-up but was worsen in case of short preaneurysmal M1 segment (10.7 mm ± 4.8 vs. 16.4 mm ± 5.3, p = 0.02). Complete aneurysm occlusion was achieved for sixty-nine patients (95.5%) with 6.9% of early postoperative complications. CONCLUSIONS: The microsurgical treatment of unruptured MCA aneurysm was associated with favorable mid-term outcome in all patients and high rates of complete occlusion. Aneurysm size was significantly associated with the intraoperative rupture risk for unruptured MCA aneurysm and patients with a short preaneurysmal M1 segment seemed to have a greater risk of intraoperative rupture although not statistically significant. Short preaneurysmal M1 patients had worsen mid-term outcome.
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Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Resultado do Tratamento , Idoso , Artéria Cerebral Média/cirurgia , Adulto , Aneurisma Roto/cirurgia , Fatores de Risco , Estudos Retrospectivos , Procedimentos Neurocirúrgicos/métodosRESUMO
OBJECTIVE: The aim of this study was to evaluate the morbidity associated with microsurgical treatment in patients with a recurrent aneurysm to improve their surgical management. METHODS: From 2012 to 2022, among the 3128 patients with ruptured or unruptured intracranial aneurysms managed at the authors' institution, 954 patients were treated by a microsurgical procedure. Of these 3128 patients, 60 consecutive patients (6.3%) who had a recurrent microsurgically treated aneurysm after previous endovascular treatment were included in this study. Additional microsurgical treatment was considered in case of progressive remnant growth or significant aneurysm recurrence. Intraoperative and postoperative complications were noted. Early (< 7 days) and long-term clinical and radiological monitoring were performed. Good functional outcome was considered as a modified Rankin Scale score < 3. RESULTS: The mean age at initial treatment was 45 years (range 26-65 years). The mean delay between the first treatment and microsurgical treatment of the recurrence was 64 months (range 2 days-296 months). The mean size of the fundus recurrence was 5 mm, and the mean size of the neck recurrence was 4.6 mm. Five patients (8.3%) presented with subarachnoid hemorrhage associated with rupture of the recurrent aneurysm. Three patients died (6%) of aneurysm rupture and/or intensive care complications. The total morbidity rate associated with the microsurgical procedure was 14.5% (8/55) in patients with unruptured recurrent aneurysms. Among these patients, postoperative definitive complications (ischemic lesions) directly related to the microsurgical procedure were present in 3 patients (5.5%). Intraoperative rupture was recorded in these 3 patients. In the 54 surviving patients with unruptured recurrent aneurysms, good functional outcome was noted in 49 (91%). Poor functional outcome was significantly associated with intraoperative rupture. CONCLUSIONS: Microsurgery remains an effective therapeutic option for recurrent intracranial aneurysms. However, in the authors' experience, postoperative morbidity is higher than in patients with nonrecurrent aneurysms. Therefore, a pretherapeutic multidisciplinary evaluation is mandatory to reduce the potential morbidity associated with the retreatment as much as possible. When endovascular occlusion of the aneurysm requires both stenting and coiling, alternative microsurgical treatment should be carefully evaluated, as microsurgical clipping will become much more challenging in cases of aneurysm recurrence.
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BACKGROUND: Difficult-to-treat aneurysms of the distal posterior cerebral artery (PCA) can often be treated by parent artery occlusion. A cerebrovascular bypass can complement PCA occlusion to curb the risk of ischemic complications. An in situ bypass may be considered when the occipital artery or superficial temporal artery cannot serve as a bypass donor. This article describes the use of a side-to-side bypass of superior cerebellar artery as a donor to the PCA via an extreme lateral supracerebellar infratentorial approach (ELSCIT). This bypass approach can be a useful surgical strategy for PCA revascularization. METHODS: A 40-year-old woman underwent a side-to-side PCA-superior cerebellar artery bypass via the ELSCIT approach for to treat a complex and previously coiled PCA aneurysm. The bypass was followed by endovascular aneurysm and parent artery occlusion. RESULTS: Postoperatively, the patient experienced transient, partial trochlear nerve palsy of the left eye without ischemic lesions on magnetic resonance imaging. The clinical condition was stable, and angiography showed a patent bypass and complete aneurysm occlusion 12 months after surgery. CONCLUSIONS: The ELSCIT approach offers access to the medial and distal PCA that is suitable for a side-to-side PCA-superior cerebellar artery bypass. This type of approach and bypass may be of value when revascularization of a P2-P3 portion of the PCA is needed, but a suitable occipital artery or superficial temporal artery is not available.
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Cerebelo , Revascularização Cerebral , Aneurisma Intracraniano , Artéria Cerebral Posterior , Humanos , Feminino , Adulto , Revascularização Cerebral/métodos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Artéria Cerebral Posterior/cirurgia , Artéria Cerebral Posterior/diagnóstico por imagem , Cerebelo/irrigação sanguínea , Cerebelo/cirurgia , Procedimentos Neurocirúrgicos/métodosRESUMO
Background: The objective of this study was to describe the long-term hearing outcomes of gamma knife treatment for unilateral progressing vestibular schwannomas (VS) presenting with good initial hearing using audiologic data. Methods: A retrospective review was performed between 2010 and 2020 to select patients with progressing unilateral VS and good hearing (AAO-HNS class A) treated with stereotactic gamma knife surgery (GKS). Their audiograms were analyzed along with treatment metrics and patient data. Results: Hearing outcomes with a median follow-up of 5 years post-treatment showed statistically significant loss of serviceable hearing: 34.1% of patients maintained good hearing (AAO-HNS class A), and 56.1% maintained serviceable hearing (AAO-HNS class A and B). Non-hearing outcomes are favorable with excellent tumor control and low facial nerve morbidity. Conclusions: Hearing declines over time in intracanalicular VS treated with GKS, with a significant loss of serviceable hearing after 5 years. The mean cochlear dose and the presence of cochlear aperture obliteration by the tumor are the main statistically significant factors involved in the hearing outcomes.
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PURPOSE: Multiple endocrine neoplasia type 1 (MEN1) is thought to increase the risk of meningioma and ependymoma. Thus, we aimed to describe the frequency, incidence, and specific clinical and histological features of central nervous system (CNS) tumors in the MEN1 population (except pituitary tumors). EXPERIMENTAL DESIGN: The study population included patients harboring CNS tumors diagnosed with MEN1 syndrome after 1990 and followed up in the French MEN1 national cohort. The standardized incidence ratio (SIR) was calculated based on the French Gironde CNS Tumor Registry. Genomic analyses were performed on somatic DNA from seven CNS tumors, including meningiomas and ependymomas from patients with MEN1, and then on 50 sporadic meningiomas and ependymomas. RESULTS: A total of 29 CNS tumors were found among the 1,498 symptomatic patients (2%; incidence = 47.4/100,000 person-years; SIR = 4.5), including 12 meningiomas (0.8%; incidence = 16.2/100,000; SIR = 2.5), 8 ependymomas (0.5%; incidence = 10.8/100,000; SIR = 17.6), 5 astrocytomas (0.3%; incidence = 6.7/100,000; SIR = 5.8), and 4 schwannomas (0.3%; incidence = 5.4/100,000; SIR = 12.7). Meningiomas in patients with MEN1 were benign, mostly meningothelial, with 11 years earlier onset compared with the sporadic population and an F/M ratio of 1/1. Spinal and cranial ependymomas were mostly classified as World Health Organization grade 2. A biallelic MEN1 inactivation was observed in 4/5 ependymomas and 1/2 meningiomas from patients with MEN1, whereas MEN1 deletion in one allele was present in 3/41 and 0/9 sporadic meningiomas and ependymomas, respectively. CONCLUSIONS: The incidence of each CNS tumor was higher in the MEN1 population than in the French general population. Meningiomas and ependymomas should be considered part of the MEN1 syndrome, but somatic molecular data are missing to conclude for astrocytomas and schwannomas.
Assuntos
Neoplasias do Sistema Nervoso Central , Neoplasia Endócrina Múltipla Tipo 1 , Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Neoplasia Endócrina Múltipla Tipo 1/genética , Neoplasia Endócrina Múltipla Tipo 1/epidemiologia , Adolescente , Criança , Neoplasias do Sistema Nervoso Central/epidemiologia , Neoplasias do Sistema Nervoso Central/genética , Neoplasias do Sistema Nervoso Central/patologia , Incidência , Adulto Jovem , Estudos de Coortes , Pré-Escolar , Idoso , Meningioma/genética , Meningioma/epidemiologia , Meningioma/patologia , França/epidemiologia , Lactente , Ependimoma/genética , Ependimoma/epidemiologia , Ependimoma/patologia , Mutação , Sistema de RegistrosRESUMO
BACKGROUND: Grade 2 meningiomas are a real problem in therapeutic management because of their tendency to reoccur. The most effective treatment is surgery. The role of adjuvant radiotherapy in this disease is still disputed due to its uncertain effect on progression-free survival. OBJECTIVE: To show that early adjuvant radiotherapy is an effective treatment in patients with grade 2 meningiomas. MATERIALS AND METHODS: A retrospective study was performed on all patients operated on for grade 2 meningioma in our center between 1994 and 2011. For every patient, we recorded the age at diagnosis, sex, background of neurofibromatosis type 2 (NF2) or meningiomatosis, location of meningioma, quality of tumor resection and whether the patient received early postoperative radiotherapy. These prognosis factors were studied using statistical tests. RESULTS: We included 167 patients (94 women, 73 men, sex ratio = 1.28); the mean age at diagnosis was 53.8 years. Twenty-seven patients received early adjuvant radiotherapy after surgery. Patients who received early postoperative radiotherapy had a significantly longer progression-free survival (8.2 years) than patients without radiotherapy (5.7 years, p = 0.04). In multivariate analysis, quality of tumor resection and early postoperative radiotherapy decrease the risk of recurrence of meningioma (p < 0.05). CONCLUSION: Adjuvant radiotherapy is an important therapeutic tool in the treatment of patients with grade 2 meningioma. It delays tumor progression and reduces the need for further surgery. Adjuvant radiotherapy must be considered as a treatment option in oncological multidisciplinary meetings, regardless of the quality of surgical resection.
Assuntos
Neoplasias Meníngeas/radioterapia , Meningioma/radioterapia , Adulto , Idoso , Terapia Combinada/métodos , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Neoplasias Meníngeas/mortalidade , Neoplasias Meníngeas/patologia , Neoplasias Meníngeas/cirurgia , Meningioma/mortalidade , Meningioma/patologia , Meningioma/cirurgia , Pessoa de Meia-Idade , Gradação de Tumores , Recidiva Local de Neoplasia/prevenção & controle , Período Pós-Operatório , Prognóstico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: In spite of the few clinical studies regarding the occurrence of intracranial meningiomas, their prognosis in neurofibromatosis type 2 (NF2) has not been accurately assessed and their management remains controversial. This study aims to compare NF2 patients with intracranial meningiomas to those without, and consequently to identify prognostic factors in attempt to improve the management of these tumors. METHODS: This retrospective study includes a total of 80 NF2 patients followed at Lille Hospital Center between 1987 and 2011. The diagnosis of NF2 was confirmed either because the patient met the Manchester criteria or by the presence of genetic mutation. Clinical, radiological and genetic data were retrospectively recorded and analyzed. Patients underwent annual cranial and spinal MRI. Both location and size of each tumor were reported. RESULTS: The mean follow-up period was 8.8 years (range 1-24 years; SD: ±0.8) and the mean age at diagnosis was 27.2 years (range 6-73 years; SD: ±1.7). Among all patients, 34 harbored intracranial meningiomas. Patients with intracranial meningiomas had a higher number of intracranial schwannomas, spinal tumors and cutaneous tumors (p < 0.05). They underwent more surgical procedures (p < 0.012). Twenty five intracranial meningiomas were surgically removed in 17 patients. The decision to perform surgery was taken in 10 cases for symptomatic tumors and in 15 cases for growing asymptomatic tumors determined by radiology. The histological analysis found a high rate of fibroblastic, transitional or grade 2 meningiomas preferentially located at the cerebri falx. CONCLUSION: Intracranial meningiomas are common in NF2. They are associated with poor prognosis factors. Clinical and radiological monitoring could lead to early treatment of these tumors both when clinical symptoms are present and in case of proven radiological evolution, and thus trying to maintain a favorable functional prognosis for as long as possible.
Assuntos
Genes da Neurofibromatose 2/fisiologia , Meningioma/genética , Neurofibromatose 2/genética , Neoplasias da Coluna Vertebral/genética , Adolescente , Adulto , Idoso , Criança , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Meningioma/diagnóstico , Meningioma/cirurgia , Pessoa de Meia-Idade , Mutação/genética , Neurofibromatose 2/diagnóstico , Neurofibromatose 2/cirurgia , Prognóstico , Estudos Retrospectivos , Neoplasias da Coluna Vertebral/patologia , Neoplasias da Coluna Vertebral/cirurgia , Adulto JovemRESUMO
PURPOSE: Neurofibromatosis type 2 (NF2) is a well-studied disease. Although spinal tumors are frequent, many issues concerning their prognosis and management still have to be clarified. The authors studied the clinical impact and radiological progression of spinal tumors in patients with NF2 to determine their prognostic value. METHODS: A total of 80 NF2 patients were followed in the Lille University Hospital between 1987 and 2011. Clinical, radiological and genetic data were retrospectively recorded and analyzed. Patients underwent annual cranial and spinal MRI. Both the location and size of each tumor were reported. The diagnosis of NF2 was confirmed either because the patient met the Manchester criteria or by the presence of genetic mutation. RESULTS: The mean follow-up period was 8.8 years (range 1 to 24 years; SD: ±0.8), and the mean age at diagnosis was 27.2 years (range 6 to 73 years; SD: ±1.7). Among all patients, 48 harbored spinal tumors. Twenty of them were symptomatic, and 21 were operated on. Patients with spinal tumors had a lower age at diagnosis (p = 0.02), a higher number of intracranial meningiomas (p = 0.028) and schwannomas (p = 0.03), and more nonsense and frameshift mutations (p = 0.04). CONCLUSION: Spinal tumors are common in NF2, and all patients should be regularly monitored by spinal MRI. The presence of spinal tumors seems to be a factor indicating poor prognosis. Clinical and radiological monitoring of spinal tumors could lead to early treatment both when clinical symptoms are present and in case of proven radiological evolution, maintaining a favorable functional prognosis as long as possible.