Surgical management of anterior clinoidal meningiomas: consensus statement on behalf of the EANS skull base section.

BACKGROUND: The optimal management of clinoidal meningiomas (CMs) continues to be debated. METHODS: We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of these tumors. The data from the literature along with contemporary practice patterns were discussed within the task force to generate consensual recommendations. RESULTS AND CONCLUSION: This article represents the consensus opinion of the task force regarding pre-operative evaluations, patient's counselling, surgical classification, and optimal surgical strategy. Although this analysis yielded only Class B evidence and expert opinions, it should guide practitioners in the management of patients with clinoidal meningiomas and might form the basis for future clinical trials.

Pretherapeutic functional neuroimaging predicts tremor arrest after thalamotomy.

OBJECTIVE: Essential tremor (ET) represents the most common movement disorder. Drug-resistant ET can benefit from standard stereotactic procedures (deep brain stimulation or radiofrequency thalamotomy) or alternatively minimally invasive high-focused ultrasound or radiosurgery. All aim at same target, thalamic ventro-intermediate nucleus (Vim). METHODS: The study included a cohort of 17 consecutive patients, with ET, treated only with left unilateral stereotactic radiosurgical thalamotomy (SRS-T) between September 2014 and August 2015. The mean time to tremor improvement was 3.32 months (SD 2.7, 0.5-10). Neuroimaging data were collected at baseline (n = 17). Standard tremor scores, including activities of daily living (ADL) and tremor score on treated hand (TSTH), were completed pretherapeutically and 1 year later. We further correlate these scores with baseline inter-connectivity in twenty major large-scale brain networks. RESULTS: We report as predictive three networks, with the interconnected statistically significant clusters: primary motor cortex interconnected with inferior olivary nucleus, bilateral thalamus interconnected with motor cerebellum lobule V2 (ADL), and anterior default-mode network interconnected with Brodmann area 103 (TSTH). For all, more positive pretherapeutic interconnectivity correlated with higher drop in points on the respective scores. Age, disease duration, or time-to-response after SRS-T were not statistically correlated with pretherapeutic brain connectivity measures (P > .05). The same applied to pretherapeutic tremor scores, after using the same methodology described above. CONCLUSIONS: Our findings have clinical implications for predicting clinical response after SRS-T. Here, using pretherapeutic magnetic resonance imaging and data processing without prior hypothesis, we show that pretherapeutic network(s) interconnectivity strength predicts tremor arrest in drug-naïve ET, following stereotactic radiosurgical thalamotomy.

Lumbar discectomy with annulus fibrosus closure: A retrospective series of 53 consecutive patients.

INTRODUCTION: Lumbar disc herniation is most common degenerative alteration of the spine. Whenever surgical therapy proves to be necessary, recurrent disc herniation is most frequent concern. Here, primary aim was to determine the percentage of patients eligible for insertion of an annular closure device (ACD). Secondary aim to evaluate 12-month incidence of recurrent disc herniation at the operated level. Our hypothesis was that ACD might help in preventing recurrent disc herniation. METHODS: Patients in a single Swiss neurosurgical center underwent limited discectomy alone (n=41, group 1) versus limited discectomy plus ACD (n=12, group 2). Mean postoperative follow-up period was 12months. RESULTS: Twelve out of 53 patients (22.6%) were eligible for ACD implantation. Patients of group 2 were significantly taller (mean 176cm, P=0.007) as compared with group 1 (mean 170). The only statistically significant difference of intraoperative parameters between group 1 and 2 was amount of nucleus materiel removed (P=0.01), being greater in group 2 (mean 0.9) as compared with group 1 (mean 0.3). In group 1 six patients (6/41, 14.6%) presented with symptomatic reherniation at same level of surgery, while in group 2 only one patient experienced recurrence (1/12, 8.3%). No adverse events were reported. DISCUSSION: In the current study one out of five patients with lumbar disc herniation was considered suitable for ACD placement. In vast majority of these patients reherniation was precluded on the short-term basis. Patients with ACD were taller and had intraoperatively a higher volume of the nucleus pulposus materiel removed.

The relevance of the artery of Adamkiewicz for microsurgical resection of spinal tumors- short overview and case series: Technical note.

INTRODUCTION: There is of major interest to know the exact anatomical location of artery of Adamkiewicz (AKA) for many spinal microsurgical procedures, so as to avoid postoperative ischemia of the spinal cord, with further devastating clinical impact. METHODS AND RESULTS: We detail the interest of preoperative angiography for medullary lesions in our experience. We further report two cases where the AKA was located at the same level and side with the treated lesion. The first case underwent an intracapsular decompression. The second patient undertook radiosurgery by Cyberknife. CONCLUSION: For spinal tumor where the AKA is exactly on the same level and side, an intracapsular decompression can be safely performed, with an immediate decrease of the symptomatic mass effect, while decreasing the risk of neurological injury. A second valuable alternative in such situations can also be radiosurgery, for small to medium size tumors. In our experience, this proved safe and effective both for tumor and eventual pain control.

A rare condition: Spontaneous subarachnoid haemorrhage due to spinal hemangioblastoma: Report of 2 cases and review of the literature.

INTRODUCTION: Subarachnoid haemorrhage (SAH), secondary to spinal hemangioblastoma (HBL), is extremely rare, with only a few case reports to date. We report the experience of our reference centre for spinal tumours and Von Hippel-Lindau (VHL) disease in patients with spinal HBL presenting with SAH. We further performed a systematic review of the literature. METHODS: We report two cases. A systematic search was performed using the PubMed, Embase and Cochrane databases, with no limit for publication date. Inclusion criteria were: patients with HBL presenting with SAH, with or without VHL. The systematic review retrieved only 10 studies, including 16 patients. RESULTS: In our centre, the first case concerned radicular HBL at D12 level, presenting with spinal and brain SAH. The patient underwent uneventful microsurgical en bloc resection. Postoperative course was normal. The second case concerned HBL with SAH at the cervico-medullary junction, with rapidly fatal course. The systematic review revealed female predominance, at a median age of 40 years, with HBL predominantly located at cervical level, common preoperative symptoms being headache and signs of meningeal irritation. CONCLUSIONS: In conclusion, spinal HBL is an extremely rare cause of SAH. The systematic review found putative risk factors: female gender, age 40-50 years, cervical location, and median size 2cm. Diagnosis can be difficult when presentation mimics intracerebral SAH. We advocate early surgical removal. The risk of rapidly fatal course, in case of major haemorrhage, needs to be borne in mind.

Gamma Knife surgery for a hemangioma of the cavernous sinus in an adult: Case report and short review of the literature.

Cavernous sinus hemangiomas (CSH) are rare benign extra-axial vascular lesions. Both radiological and clinical aspects are important, for deciding a therapeutic modality, including medical treatment, radiation therapy or microsurgery. In the particular case of CSH, a radical removal of the tumor often cannot be achieved and is associated with a considerable risk for intraoperative uncontrollable bleeding. An alternative treatment modality is radiosurgery. Here we report the case of a 45-year-old patient, who presented with diplopia due to left abducens nerve palsy. A left-sided cavernous sinus lesion was found, initially considered to be a meningioma. However, after serial MR acquisitions, a progressive and heterogeneous enhancement was observed. In order to clarify the diagnosis between meningioma and hemangioma, a diagnostic Tc-99m labeled red blood cells (RBC) scintigraphy (Tc-99m RBC scintigraphy) was performed and showed a typical perfusion blood pool mismatch, with accumulation of the RBC at the level of the left CS, which is typical for a hemangioma. The patient underwent Gamma Knife surgery. The CSH showed a significant reduction in size starting 6 months after treatment and a full regression of the left abducens nerve palsy was observed within 1 year. These clinical and radiological results persisted over the next 3 years.

Biphasic response of a tecto-mesencephalic pilocytic astrocytoma after Gamma Knife surgery--A case report.

Biphasic response (shrinkage-regrowth-shrinkage) of tumors has never previously been reported in the postoperative course, neither after microsurgery, nor after Gamma Knife surgery (GKS). We present the case of an adult with dorsal midbrain syndrome resulting from a pilocytic astrocytoma centered on the mesencephalic tectum. The tumor extended to the third ventricle and the thalamus. Initially, due to tumor growth, a biopsy was performed and histology established. Later, a ventriculocisternostomy for obstructive hydrocephalus was performed. Finally, GKS was performed, as the tumor continued to grow. After GKS, the lesion exhibited a biphasic response, with a major shrinkage at 3 months, regrowth within the target volume at 6 and 9 months and a second phase of important shrinkage at 12 months, which persisted for the next two years. The possible mechanisms for this particular response pattern are discussed.