How Relevant Is Occlusion of Associated Developmental Venous Anomaly in Cerebral Cavernoma Surgery? A Clinical and Radiographic Comparison Study.

BACKGROUND: A developmental venous anomaly (DVA) associated with cerebral cavernous malformation (CCM) is the most common combined vascular malformation. Microsurgical resection of the CCM and avoidance of damage to the adjacent DVA is an overall accepted treatment regimen. Several publications have demonstrated serious consequences that possibly occur after damage of the associated DVA. Conversely, some authors have reported cases of injured DVAs without any relevant postoperative complications. This study compared the clinical and radiologic outcome in patients with and without occlusion of an associated DVA, following microsurgical removal of intracerebral cavernomas. METHODS: In this single-center evaluation, all consecutive CCM surgical patients from January 1, 2006, to December 31, 2011, were reviewed in a retrospective cohort study. Follow-up was from 12 months to 7 years. The patients were divided into three groups: group I, CCM without associated DVA; group II, damage and occlusion of the associated DVA during CCM removal; and group III, preservation of the associated DVA following CCM removal. Preservation and damage, respectively, of the DVA were defined by evaluation of the corresponding pre- and postoperative magnetic resonance (MR) image sequences. The clinical and radiographic findings in all three groups were evaluated and compared. RESULTS: A total of 38 patients underwent microsurgical resection of a CCM. Overall, 24 patients (63%) had no associated DVA (group I), in 10 patients (26%) the associated DVA was impaired and occluded (group II), and in 4 patients (11%) the associated DVA was surgically not impaired and confirmed as preserved (group III). The rate of postoperative neurologic deficits was 37.5% in group I, 10% in group II, and 75% in group III (p = 0.05). Subgroup analysis in patients with preserved DVA (group III) showed a higher incidence of new postoperative neurologic deficits than in patients with impaired DVA (group II) (p = 0.041). However, no significant difference was seen in patients with no associated DVA (group I) and patients with impaired DVA (group II) (p =0.215). The average postoperative Karnofsky score was 88.33 ± 9.17 in group I, 92.0 ± 6.32 in group II,; and 90.0 ± 8.16 in group III (p =0.51). The peri-resectional edema volume in group I was 8.90 ± 9.75 cm(3); in group II, 8.16 ± 3.78 cm(3); and in group III, 2.48 ± 1.48 cm(3) (p = 0.35). The location (eloquent or noneloquent region) of the CCM and the DVA, respectively, was the only significant factor for any additional neurologic deficit (p = 0.001). CONCLUSION: Our results demonstrated similar postoperative clinical outcomes and radiographic findings between patients with impaired and unimpaired DVA after resection of CCMs. Postoperative MR images showed less peri-resectional edema in patients with preserved and unimpaired DVA. However, these results will not convert the paradigm in cavernoma surgery to preserve the associated DVA. The overall goal is still preservation of unimpaired venous drainage, but our results show that the occlusion of a DVA adjacent to a CCM can be tolerated because of a low risk of complications.

Clipping of a partially thrombosed giant VA aneurysm.

Microsurgical aspects of clipping of a giant partially thrombosed VA aneurysm in a 57-year-old female are presented and explained in the form of a short video. The presentation includes preparation of the VA, PICA and perforating arteries, the clipping of the aneurysm itself as well as the reduction of the aneurysm mass using ultrasonic tissue ablation. In addition pre- and post-operative imaging and superimposed text is used to illustrate the presented anatomy. The video can be found here: http://youtu.be/7so8qPMQ1Jk .

The past, present and future of minimally invasive spine surgery: a review and speculative outlook.

In the last 25 years of spinal surgery, tremendous improvements have been made. The development of smart technologies with the overall aim of reducing surgical trauma has resulted in the concept of minimally invasive surgical techniques. Enhancements in microsurgery, endoscopy and various percutaneous techniques, as well as improvement of implant materials, have proven to be milestones. The advancement of training of spine surgeons and the integration of image guidance with precise intraoperative imaging, computer- and robot-assisted treatment modalities constitute the era of reducing treatment morbidity in spinal surgery. This progress has led to the present era of preserving spinal function. The promise of the continuing evolution of spinal surgery, the era of restoring spinal function, already appears on the horizon. The current state of minimally invasive spine surgery is the result of a long-lasting and consecutive development of smart technologies, along with stringent surgical training practices and the improvement of instruments and techniques. However, much effort in research and development is still mandatory to establish, maintain and evolve minimally invasive spine surgery. The education and training of the next generation of highly specialized spine surgeons is another key point. This paper will give an overview of surgical techniques and methods of the past 25 years, examine what is in place today, and suggest a projection for spine surgery in the coming 25 years by drawing a connection from the past to the future.

Training models for vascular microneurosurgery.

INTRODUCTION: The number of microsurgical clippings of cerebral aneurysms is continuously decreasing. This will lead to fewer possibilities for practical training in aneurysm surgery, especially for the younger generation. Accordingly, realistic models for microsurgical training are mandatory. METHODS: We present a microsurgical setup for training on a PVC rat and on a lifelike vascular training model with specific plastic vessels (PVA), and an anatomical head as well as an experimental animal model (rabbit carotid artery bifurcation model). End-to-end and end-to-side anastomoses were performed with three different levels of difficulty and three different levels of expertise on the PVC rat model. The results of the animal bifurcation aneurysm model are also described. RESULTS: With increasing surgical complexity, the duration of surgery and rate of incorrect sutures of the vessel wall rise significantly. The overall patency rate of anastomosis is clearly reduced in the setup with increasing complexity grades. CONCLUSION: The PVC rat model as well as the PVA vascular kit with realistic skull and craniotomy sites is a perfect tool for advanced microvascular anastomosis training. The experimental animal model represents a higher level of vascular surgery expertise and additionally is a perfect model for practicing appropriate clip application and clip occlusion of aneurysms.