Surgical removal after first bleeding of an arteriovenous malformation previously obliterated with radiosurgery: case report.

BACKGROUND: Radiosurgery has been widely used to treat cerebral AVMs, providing angiographic evidence of obliteration of the malformation in 80% to 95% of patients, after a latency period of 2 to 5 years. CASE DESCRIPTION: We describe a case of hemorrhage, 6 years after radiosurgery and 4 years after complete angiographic obliteration of an AVM that had not previously bled and that persisted angiographically, obliterated after bleeding. RESULTS: Several treatment options have been reported for patients with completely obliterated AVMs that bled, including conservative treatment, repeated radiosurgery, and open surgery with resection of AVM remnants. In the present case, the decision to perform surgery based on the probable association of the enhancing area observed on the MRI and the histologic findings was finally confirmed. CONCLUSIONS: Magnetic resonance imaging enhancement areas on the obliterated AVMs may have a histopathologic correlation with persistence of permeable vessels and can be used as a guide for surgery and postoperative control. The follow-up of angiographically obliterated AVMs that bleed remains a matter of discussion twofold: regarding timing and use of a proper diagnostic test.

Endoscopic resection of cavernoma of foramen of Monro in a patient with familial multiple cavernomatosis.

Intraventricular cavernomas are extremely infrequent and only 11 cases of cavernous hemangioma to occur at the foramen of Monro have been reported in the literature. This 56 years old patient was admitted with progressive and intractable headache of 10 days of evolution. He was known to suffer familial multiple cavernomatosis. Magnetic resonance imaging (MRI), revealed obstructive hydrocephalus due to a cavernoma located in the area of the left foramen of Monro. Under neuronavigation guidance, complete endoscopic resection of the cavernoma was performed and normal ventricular size achieved. The patient experienced transient recent memory loss that resolved within a month after surgery. In the literature attempted endoscopic resection is reported to be abandoned due to bleeding and ineffectiveness of piecemeal endoscopic resection. In this case, the multiplicity of the lesions made it advisable to resect the lesion endoscopically, to avoid an open procedure in a patient with multiple potentially surgical lesions. Endoscopic resection was uneventful with easy control of bleeding with irrigation, suction, and bipolar coagulation despite dense vascular appearance of the lesion. During the procedure, precise visualization of the vascular structures around the foramen of Monro allowed complete resection with satisfactory control of the instruments. To the best of the authors' knowledge, this is the first published cavernoma of foramen of Monro successfully resected using an endoscopic approach.

Early surgical treatment of middle cerebral artery aneurysms associated with intracerebral haematoma.

OBJECTIVE: Patients with haematoma secondary to middle cerebral artery aneurysm often require urgent surgical treatment consisting of evacuation of the haematoma and aneurysmal clipping. METHODS: . We present our experience over 5 years with 12 patients who underwent surgery before the first 8h of bleeding. Surgery included craniotomy, evacuation of the haematoma, and aneurysmal clipping. Preoperative angiography was performed in all cases. RESULTS: All patients had a score of 4 or 5 on the scale of the World Federation of Neurological Surgeons. Five of the patients were evolving well after 1 year. Clinical status upon admission, temporal lobe versus sylvian location of the haematoma, right-hemisphere involvement, and a midline deviation of less than 2 cm, were all most frequently associated with a good prognosis. CONCLUSIONS: In our experience, and in the literature available to us, early surgery in patients with haematoma secondary to middle cerebral artery aneurysm offers acceptable results in patients with World Federation of Neurological Surgeons scores of 4 or 5.

Endoscopic biopsy of foramen of Monro and third ventricle lesions guided by frameless neuronavigation: usefulness and limitations.

OBJECTIVES: To describe our institution experience regarding the usefulness and limitations of frameless neuronavigation in the endoscopic biopsy of foramen of Monro and third ventricle lesions. METHODS: We report our experience with 22 patients harbouring intraventricular lesions located in the region of the foramen of Monro or the third ventricle who underwent endoscopic biopsy guided by the neuronavigation system. Nine lesions were located on the posterior aspect of the third ventricle or at the pineal region, and thirteen lesions were located at the foramen of Monro or anterior third ventricle region. The endoscopes were introduced via an operating sheath, which had previously been inserted with a trocar under neuronavigational control. After approaching the foramen of Monro from the planned angle, surgery was continued under direct visualisation until the lesion was reached, if it was located on the third ventricle. In cases where the lesion was located at the foramen of Monro, an excellent view of the lesion was obtained and neuronavigation was used to determine the location of critical areas. RESULTS: Histological examination of biopsy specimens obtained endoscopically was diagnostic in all cases. Open surgery following endoscopic biopsy was only needed in 1 patient out of 22. CONCLUSION: In our experience, image-guided neuroendoscopy can improve the accuracy of the endoscopic approach, minimising brain trauma. It can be particularly helpful when performing a brain biopsy in the absence of clear intraventricular landmarks or in the event of adverse visual conditions such as intraventricular bleeding.

Impact of the combined use of tractography, functional magnetic resonance imaging and brain neuronavigation on high grade glioma extent of resection / Impacto del uso combinado de la tractografía, resonancia magnética funcional y la neuronavegación cerebral en el grado de resección de gliomas de alto grado

Introduction: Maximal surgical resection of brain high grade glioma, involves the risk of damaging either eloquent cortical areas or efferent subcortical white matter tracts. Identification of the anatomical and functional relation between the tumor and adjacent functional cortical areas or eloquent white matter bundles may provide critical information to guide tumor resection and prevent surgical morbidity. The main objective of this study was to assess the combined use of diffusion tensor (DT) tractography and functional magnetic resonance (fMR) imaging to assist in the extent of resection of brain high grade glioma (HGG) with preservation of eloquent areas. Material and methods: 42 consecutive patients harboring brain HGG underwent surgery with the purpose of maximal resection. Patients were randomly divided in two groups: Group A (22 cases): control group, and group B (20 cases), where surgery was performed with navigation and combined use of DT imaging and fMR imaging. Results: Extent of resection in group A was 81.5 percent and 90.5 percent in group B (ANOVAs test p=0, 03). We did not observed differences in postoperative neurological deficit and surgical time between both groups. Conclusion: The combined use of tractography, functional MRI and neuronavigation may provide critical information to guide brain high grade glioma resection without increasing surgical morbidity or surgical time.

Introducción: La resección radical de los gliomas cerebrales de alto grado (GCAG) comporta el riesgo de afectación tanto de áreas corticales elocuentes como de los tractos subcorticales de sustancia blanca. La identificación de la relación anatómica y funcional entre el tumor y las áreas corticales o los tractos de sustancia blanca elocuentes, puede proporcionar una información fundamental para guiar la resección quirúrgica y contribuir a reducir la morbilidad postquirúrgica. El principal objetivo del estudio es el análisis del uso combinado de la tractografía y la resonancia magnética funcional (RMf) en el grado de resección de gliomas cerebrales de alto grado con preservación de áreas elocuentes. Material y métodos: Presentamos 42 pacientes con diagnóstico de GCAG y localización próxima a córtex motor o áreas del lenguaje, que fueron intervenidos quirúrgicamente con el objetivo de llevar a cabo una resección radical de la lesión. Los pacientes se distribuyeron de forma aleatoria en 2 grupos: el grupo A (22 pacientes) fue el grupo control y el grupo B (20 casos) fue también intervenido pero utilizando la neuronavegación y el uso combinado de tractografía y RMf. Resultados: El grado de resección en el grupo A fue de un 81,5 por ciento y del 90,5 en el grupo B (test de ANOVA p=0,03). No observamos diferencias en la incidencia de morbilidad postquirúrgica o del tiempo de cirugía entre ambos grupos. Conclusiones: El uso combinado de la tractografía, RMf y neuronavegación proporciona una información funcional que facilita la cirugía de los GCAG sin incrementar la morbilidad o el tiempo de cirugía.