Tuberculum and diaphragma sella meningioma--surgical technique and visual outcome in a series of 20 cases operated over a 2.5-year period.

BACKGROUND: A retrospective analysis of 20 cases of tuberculum sella meningioma with emphasis on the surgical technique and visual outcome. METHODS: Between 2003 and 2006 twenty patients with tuberculum and diaphragma sella meningioma were treated at the Tel Aviv medical center. There were 17 females and 3 males. The age range was 28-83. Most patients presented with visual deterioration. Surgery was performed using the subfrontal approach. The visual function before and after surgery was evaluated as the main outcome parameter of the surgical treatment of these tumours. FINDINGS: In 16 patients complete tumour resection was achieved and in 4 subtotal removal was performed. Visual acuity improved in 32% of the eyes and deterioration was observed in two eyes (5%). Visual field improved in 28% of the eyes and deteriorated in 14%. There was no complete vision loss as a result of surgery. There was no mortality in our series. CONCLUSIONS: Tuberculum and diaphragma sella meningioma can be safely resected using the subfrontal approach with preservation and even improvement of visual function after surgery. Early surgery with better pre-operation visual function and smaller tumour size were associated with a better outcome.

Brain arteriovenous malformation treatment using a combination of Onyx and a new detachable tip microcatheter, SONIC: short-term results.

BACKGROUND AND PURPOSE: Endovascular embolization with Onyx is one of the tools used in the treatment of intracerebral AVMs. The recent introduction of a new microcatheter with detachable tip has led us to adopt a new treatment approach by using endovascular embolization with Onyx as the main treatment for brain AVM with curative intent. The purpose of the present study is to evaluate our initial results by using this new treatment strategy with special emphasis on the safety and feasibility of the technique. MATERIALS AND METHODS: Forty-three consecutive patients were treated by embolization for brain AVM over a 14-month period, mostly by using Onyx and a microcatheter with detachable tip. Twenty-six of these patients (60%) harbored Spetzler-Martin AVMs of grades 4-5. RESULTS: Endovascular treatments were completed in 29 out of 43 patients; the median number of procedures per patient was 2 (range, 1-4). Complete obliteration by using embolization exclusively was achieved in 16 patients, resulting in a 55% cure rate in patients who concluded treatments (16/29) and 37% in the cohort (16/43). The amount of Onyx injected by using microcatheters with detachable tips was significantly larger than that injected with the nondetachable microcatheters (mean volume, 2.5 +/- 2.2 versus 1.7 +/- 1.3 mL, respectively, P < .05, t test). Seven clinical complications were observed in a total of 76 embolization sessions (9.2%). CONCLUSIONS: Endovascular embolization of brain AVM by using Onyx and SONIC results in a relatively high complete obliteration. The use of the microcatheter with detachable tip adds several advantages, mainly in that higher volumes of Onyx can be safely injected.

Peri-operative brainstem infarct in a patient with antiphospholipid antibody (APLA) syndrome.

Antiphospholipid antibody (APLA) syndrome is a major risk factor for arterial and venous thrombosis. Surgical risks in patients known to suffer from APLA syndrome are usually related to haemorrhage or to thrombo-embolic events, such as deep venous thrombosis and pulmonary emboli. The rare published reports of patients with APLA syndrome undergoing neurosurgical procedures relate to haemostatic complication, with none alerting to the peri-operative risk of stroke in these patients. We present a case of a peri-operative stroke in a patient undergoing resection of a foramen magnum meningioma. We discuss the association of peri-operative stroke and APLA syndrome and emphasize the high risk it imposes for neurosurgical procedures in these patients. In addition, we suggest an anticoagulation treatment algorithm for APLA syndrome patients undergoing craniotomies.

Cardiac output assessed by arterial thermodilution during exsanguination and fluid resuscitation: experimental validation against a reference technique.

BACKGROUND AND OBJECTIVE: The arterial thermodilution technique offers the ability to measure cardiac output using only central venous and arterial catheters. However, the technique has been reported to overestimate cardiac output because of a higher loss of cold indicator due to the increased distance between the sites of injection and measurement. In this study, the two techniques were compared with respect to conditions of low cardiac output in which a longer passage time may further increase loss of indicator. METHODS: Seventeen anaesthetized dogs were studied during hypovolaemic shock and fluid resuscitation. Cardiac output measurements were carried out simultaneously by arterial and pulmonary artery thermodilution techniques. RESULTS: One-hundred-and-two measurements were performed. The mean cardiac output was 2.28 +/- 1.4Lmin(-1) by the pulmonary arterial technique and 2.29 +/- 1.56Lmin(-1) by the arterial thermodilution technique. The correlation coefficient between the two measurements was 0.95, the precision -0.04 +/- 0.41 Lmin(-1) and the limits of agreement from -0.86 to 0.78Lmin(-1). The agreement was also consistent at low cardiac outputs. CONCLUSIONS: The arterial thermodilution technique may serve as a less invasive cardiac output monitor in conditions of severe bleeding and shock.

Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery.

UNLABELLED: Changes in arterial blood pressure induced by mechanical ventilation allow assessment of cardiac preload. In this study, stroke volume variation (SVV), which is the percentage change between the maximal and minimal stroke volumes (SV) divided by the average of the minimum and maximum over a floating period of 30 s, continuously displayed by the PiCCO continuous cardiac output monitor, was evaluated as a predictor of fluid responsiveness. Fifteen patients undergoing brain surgery were included. During surgery, graded volume loading was performed with each volume loading step (VLS) consisting of 100 mL of 6% hydroxyethylstarch given for 2 min. Successive responsive VLSs were performed (increase in SV > 5% after a VLS) until a change in SV of < 5 % was reached (nonresponsive). A total of 140 VLSs were performed. Responsive and nonresponsive VLSs differed in their pre-VLS values of systolic blood pressure, SV, and SVV, but not in the values of heart rate and central venous pressure. By using receiver operating characteristic analysis, the area under the curve for SVV (0.870, 95% confidence interval [CI]: 0.809 to 0.903) was statistically more than those for central venous pressure (0.493, 95% CI: 0.397 to 0.590, P = 7 x 10(-10)), heart rate (0.593, 95% CI: 0.443 to 0.635, P = 5.7 x 10(-10)), and systolic blood pressure (0.729, 95% CI: 0.645 to 0.813, P: = 4.3 x 10(-3)). An SVV value of 9.5% or more, will predict an increase in the SV of at least 5% in response to a 100-mL volume load, with a sensitivity of 79% and a specificity of 93%. IMPLICATIONS: Stroke volume variation may be used as a continuous preload variable and in combination with the continuously measured cardiac output, defining on-line the most important characteristics of cardiac function, allowing for optimal fluid management.