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.

Association between decreased disc signal intensity in preoperative T2-weighted MRI and a 5-year outcome after lumbar minimally invasive discectomy.

A total of 39 patients who had undergone microdiscectomy or percutaneous nucleotomy for lumbar disc herniation were examined after a follow-up of 5 years. The overall outcome was satisfactory in 80% of the patients treated, and only 1 (3%) patient had been reoperated during the follow-up. Clinical signs and symptoms of lumbar instability were detected in 10 (26%) patients. All these 39 patients had been examined with lumbar magnetic resonance imaging (MRI) on the day preceding the operation; the presence of disc degeneration was graded as severe, mild or non-existent depending on the visual brightness of the discs on T2-weighted images, as compared to the signal intensity of the lumbar vertebrae. None of the 12 patients with no preoperative disc degeneration in MRI suffered from postoperative clinical signs and symptoms of instability as compared to 10 (37%) of the 27 patients with mild or severe disc degeneration suffering from instability (p = 0.04). Thus, the results of the present study imply that the grade of the disc degeneration in preoperative T2-weighted MR images significantly predicted the occurrence of postoperative clinical instability.

Cerebrospinal fluid flow in patients with dilated ventricles studied with MR imaging.

The purpose of this study was to measure the cerebrospinal fluid (CSF) velocity and flow in the aqueduct in patients with wide ventricles with or without signs of normal pressure hydrocephalus (NPH) before and after shunt surgery. We studied 18 patients with wide ventricles with MRI and measured the CSF velocity values in the aqueducts. Twelve patients with the clinical triad of NPH were examined. Six patients were studied only before shunt surgery and 6 patients were studied both before and after shunt surgery. Three patients with wide ventricles without clinical triad of NPH, and 3 patients with hydrocephalus following subarachnoid hemorrhage were also examined. Seven NPH patients with hyperdynamic CSF flow and three NPH patients with normal CSF velocity and flow values showed a positive clinical response to shunt surgery. Two of the three patients with hydrocephalus and hyperdynamic CSF flow values in the aqueduct secondary to subarachnoid bleeding responded to shunt surgery. One patient with same disease and low CSF velocity and flow values did not respond. No change was detected in the CSF flow values of the aqueduct when measurements before and after shunt surgery were compared. Ventriculoperitoneal shunting does not change the CSF dynamics in the aqueduct.

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.

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.

Tissue characterisation of intracranial tumours: the value of magnetisation transfer and conventional MRI.

We performed MRI on 85 patients with intracranial tumours to evaluate quantitative analysis in tumour characterisation. Signal intensities were measured on standard T2- and T1-weighted images, Gd-enhanced T1-weighted images and magnetisation transfer (MT) images. Statistically significant differences between tumour types were observed, but overlapping reduces their value. T2-weighted imaging was superior to T1-weighted imaging for tumour characterisation. Quantification of Gd enhancement was useful in the diagnosis of pituitary adenomas and haemangioblastomas, but of minor importance in other tumours, because of large nonspecific variation. The contribution of MT contrast to tumour characterisation resembled that of T2 contrast. However, MT imaging was superior to other sequences in the classification of intra-axial tumours. Low-grade astrocytomas, haemangioblastomas and craniopharyngiomas could be differentiated from other tumours on the basis of MT contrast. Reliable discrimination between meningiomas, high-grade astrocytomas and metastases was not possible by any of the methods.

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.

Cross-sectional areas of lumbar muscles after surgical treatment of lumbar disc herniation. A study with magnetic resonance imaging after microdiscectomy or percutaneous nucleotomy.

We assessed in this study the potential development of postoperative muscle atrophy in the operation area in 39 patients treated by either microdiscectomy or percutaneous nucleotomy for lumbar disc herniation. The cross-sectional areas of the lumbar muscles were measured on magnetic resonance images created on the day preceding the operation and 6 months postoperatively. The cross-sections of the lumbar muscles remained unchanged during the observation period in all treated patients indicating that no muscle atrophy had developed in the operation area. Since peroperative tissue trauma may correlate with subsequent muscle denervation and atrophy, this finding may be due to the tissue sparing nature of microdiscectomy and percutaneous nucleotomy, thus encouraging the use of these techniques in the treatment of lumbar disc herniation.

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.

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.

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.

Microsurgical treatment of lumbar disc herniation: follow-up of 237 patients.

We have reviewed retrospectively the results of 237 consecutive patients who underwent microsurgical discectomy for a virgin lumbar disc herniation. Included were 128 (54%) mean and 109 (46%) women, with the mean age of 42 years. Intra-operatively, protrusion was found in 60 (25%) patients, prolapse in 127 (54%) patients and sequestration in 50 (21%) patients. The median post-operative follow-up time was 2 years. During the observation period, sciatic pain had completely recovered or markedly diminished in 218 (92%) patients, and 187 (79%) patients had returned to work. The mean duration of preoperative sciatica was 3.8 months in those patients who finally returned to work. In contrast, it was as long as 6.3 months in those patients who lost their working capacity as a consequence of low back pain. The patients operated on for a prolapse or a sequestrum recovered better than those who underwent surgery for a protrusion. Of the patients operated on for a protrusion, 68% returned to work, while 76% of those operated on for a sequestrum and 85% of those operated on for a prolapse returned to work during the follow-up. Difference was seen also in the occupational outcome: only 37% of the patients operated on for a protrusion reported to manage their work well, while 47% of those with a prolapse and 58% of those with a sequestrum managed well. Surgical complications were infrequent in this study. Dural tear appeared in 10 (4%) patients and post-operative discitis in 4 (1.7%) patients. Of all patients, 9 (4%) required re-operation for a true recurrent disc.

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.

Acute surgery for intracerebral haematomas caused by rupture of an intracranial arterial aneurysm. A prospective randomized study.

In a randomized prospective study, 15 patients with an intracerebral haematoma caused by an intracranial aneurysm were treated concervatively and 15 operated on as an emergency. Mortality was 12/15 (80%) in the conservative group and 4/15 (27%) in the surgical group. The difference is statistically significant. The deaths in the conservative group were caused by both the primary haematoma and rebleeding. The results suggest that intracerebral haematomas caused by rupture of an intracranial aneurysm should be evacuated immediately, and that the aneurysm should be clipped at the same operation.

[Can mortality in severe traumatic brain damage be generally reduced?]. / Kann die Mortalität bei schweren traumatischen Hirnschäden überhaupt mehr reduziert werden?

A total of 272 cases with fatal traumatic brain injuries were retrospectively analysed. 68% of the cases were outside of any form of therapy. Only the third of these fatal cases are ever seen by a neurosurgeon. In 12% of these fatal cases the outcome might have been improved by an optimum diagnosis and therapy. Prevention of these severe head injuries seems to be the only potential therapy.