Predictive factors of postoperative outcome in the elderly after resective epilepsy surgery.

OBJECTIVE: To evaluate the efficiency of resective epilepsy surgery (RES) in patients over 50 years and determine prognostic factors. RESULTS: Over the 147 patients over 50 years (54.9±3.8 years [50-69]) coming from 8 specialized French centres for epilepsy surgery, 72.1%, patients were seizure-free and 91.2% had a good outcome 12 months after RES. Seizure freedom was not associated with the age at surgery or duration of epilepsy. In multivariate analysis, seizure freedom was associated with MRI and neuropathological hippocampal sclerosis (HS) (P=0.009 and P=0.028 respectively), PET hypometabolism (P=0.013), temporal epilepsy (P=0.01). On the contrary, the need for intracranial exploration was associated with a poorer prognosis (P=0.001). Postoperative number of antiepileptic drugs was significantly lower in the seizure-free group (P=0.001). Neurological adverse event rate after surgery was 21.1% and 11.7% of patients had neuropsychological adverse effects overall transient. CONCLUSIONS: RES is effective procedure in the elderly. Even safe it remains at higher risk of complication and population should be carefully selected. Nevertheless, age should not be considered as a limiting factor, especially when good prognostic factors are identified.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients.

BACKGROUND: Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS: This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS: The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION: Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS: From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS: At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION: In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.

[Pial synangiosis for moyamoya disease. The Bordeaux experience]. / Traitement de la maladie de Moya-Moya par synangiose piale. L'expérience bordelaise.

BACKGROUND: Different surgical methods may be used for the treatment of moyamoya disease. The authors report their experience with pial synangiosis revascularization. MATERIAL AND METHODS: We reviewed the clinical, surgical as well as radiographic records of all patients who underwent cerebral revascularization surgery using pial synangiosis for a symptomatic moyamoya disease at a single institution, Bordeaux University Hospital. RESULTS: Over a 6-year period (2007-2013), 17 procedures were performed in 9 patients. Median age at presentation was 11.5 years and six patients presented with an ischemic event. As regards previous medical history, five patients were diagnosed with moyamoya syndrome. Median time between the symptoms onset and the first surgical procedure was 5.9 months. The average age of the first surgery was 11.8 years and the median time between the two synangiosis was 3.5 months. One patient died of a malignant ischemic stroke after the second procedure. At long-term follow-up, no patient experienced any symptoms recurrence. CONCLUSION: Pial synangiosis typically results in an increase in collaterals from the superficial temporal artery or middle meningeal artery to the brain. It is a simple and effective surgical technique to prevent further moyamoya manifestation and to stabilize or improve the neurologic prognosis.

Intraoperative monitoring by imaging and electrophysiological techniques during giant intracranial aneurysm surgery.

Difficulties in giant intracranial aneurysm surgery are the consequence of aneurysmal wall histology and the complex angioarchitecture of the vascular tree. In order to reduce complications and risks of those procedures, various imaging and electrophysiological techniques can be implemented perioperatively. The authors review the principles, goals and main results in this context of micro-Doppler and flowmeter techniques, near-infrared spectroscopy, operative microscope-integrated indocyanine green video-angiography, neuro-endoscopy, selective intraoperative angiography and electrophysiological monitoring.

French collaborative group series on giant intracranial aneurysms: Current management.

OBJECTIVES: Giant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management. PATIENTS AND METHODS: This retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004-2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P<0.25 in the univariate analysis (P<0.05). RESULTS: A total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16-79) were divided into two groups, with the ruptured group (n=26, 32.9%) significantly younger (P<0.05, Student's-t-test) than the unruptured group (n=53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P<0.002), the endovascular treatment (P<0.005), and the absence of neurological deterioration (P<0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion. CONCLUSION: The overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.

Collaborative retrospective multicentre series of giant intracavernous carotid aneurysms.

Giant intracavernous carotid aneurysms (GICCA) occur with very unusual clinical symptoms often resulting from a compressive mechanism that may possibly resolve although seldom from a rupture or haemorrhage. In fact, due to their clinical presentation their treatment is different from that of the intracranial subarachnoid aneurysms. The aim of this study was to analyze the clinical symptoms, therapeutic decisions, and the clinical state at 6 months follow up in a retrospective consecutive multicentre series of 27 GICCA between 2004 and 2008. All the patients in the series were female, mean age 65 years (21 to 82 years). A pseudo tumoural cavernous sinus syndrome revealed the disease in 25 patients (92.6%), an atypical headache in one patient, and in another patient an intraoperative haemorrhage led to the diagnosis. In most of the cases the aneurysms were sacciform in shape (89%), with a size between 25 and 30 millimeters (66.6%) and contained a blood clot due to intrasacular thrombosis (57.5%). An occlusion test of the internal carotid artery was performed during the diagnostic angiography in 24 cases (88.8%) and good tolerance of occlusion was observed in 16 of them. An endovascular procedure was performed in 21 patients (77.7%): selective coiling of the aneurysm facilitated by stenting or by remodeling techniques in 2 cases, whereas internal carotid artery occlusion was performed on the 19 other cases. Among these latter patients, 2 of them (10.5%) presented with a poor tolerance during the pre-therapeutic carotid occlusion test, necessitating a surgical intra-extra cranial by-pass prior to the carotid endovascular occlusion. In 1 other case of these 19, the internal carotid endovascular occlusion was carried-out in emergency because the aneurysm was revealed by a major haemorrhage during the surgical transsphenoidal approach of a hypophyseal tumour. No treatment was decided in the remaining 6 cases of the series (22.2%). At 6 months follow-up, 18 of the 21 treated patients experienced a clinical recovery of their symptoms and 10 of them (50%) had a complete clinical recovery. Among the 6 untreated patients, 4 had a partial recovery but no complete recovery of oculomotor deficits was observed in this group of patients. No clinical worsening was observed in the entire series, neither among the treated patients nor among the untreated patients. In conclusion, this study underlines the need of a treatment for symptomatic GICCA in order to achieve a complete clinical recovery of the symptoms due to intracavernous compression, although only partial recovery may be expected from spontaneous evolution.

Microsurgical neurovascular anastomosis: the example of superficial temporal artery to middle cerebral artery bypass. Technical principles.

The superficial temporal artery to the middle cerebral artery (STA-MCA) bypass is a good example of cerebrovascular anastomosis. In this article, we describe the different stages of the procedure: patient installation, superficial temporal artery harvesting, recipient artery exposure, microsurgical anastomosis, and closure of the craniotomy. When meticulously performed, with the observance of important details at each stage, this technique offers a high rate of technical success (patency>90%) with a very low morbi-mortality (respectively 3% and 1%). Some anesthetic parameters have to be considered to insure perioperative technical and clinical success. STA-MCA bypass is a very useful technique for the management of complex or giant aneurysms where surgical treatment sometimes requires the sacrifice and revascularization of a main arterial trunk. It is also a valuable option for the treatment of chronic and symptomatic hemispheric hypoperfusion (Moyamoya disease, carotid or middle cerebral artery occlusion).

Brain Metastasis of Cardiac Myxoma : Case Report

Cardiac myxoma is the most common benign heart tumor. Cardiac myxoma can be a sporadic lesion (93of cases) and usually occurs in women over 30 years. Complete surgical removal of the myxoma and its cardiac attachement is usually curative. The frequency of recurrences in cardiac myxomas was varies between 3for sporadic cases and 22for cases of Carney complex. Recurrence has been related to incomplete excision multifocality and embolism of tumor fragments. We report a case with multiple brain metastases revealed by mycotic aneurysm and seizure intractable

Use of intraoperative monitoring of somatosensory evoked potentials to prevent ischaemic stroke after surgical exclusion of middle cerebral artery aneurysms.

OBJECTIVE: The aim of this study was to assess the value of monitoring somatosensory evoked potentials (SEP) in the prevention of ischaemic stroke occurring during surgical exclusion of middle cerebral artery aneurysms. METHODS: SEP monitoring was performed during the surgical exclusion of 131 aneurysms in 122 patients. All SEP variations over 30% were notified to the surgeon and those over 50% were considered as highly significant. If this happened, and in concert with the conduct of the operation, a return to the basal level was systematically sought. RESULTS: Post-operative ischemic stroke was observed after 15 (11.4%) operations, leading to a permanent neurological deficit in 12 (9.2%). During nine (6.9%) operations there was a highly significant SEP change that persisted, or was only partially reversed, after corrective procedure. Nine of these patients had a post-operative ischaemic stroke. In 25 (19%), operations there was a highly significant SEP change followed by complete recovery. Of these 25 patients, 2 suffered a post-operative ischemic stroke. Following 49 operations (37.4%) with less significant SEP modifications, 4 patients suffered a post-operative stroke (8%). A stroke did not occur in the 48 (36.6%) operations during which there was not a variation in SEP. The strokes were related to temporary clipping in 9 patients to definitive clipping in 3 to sylvian fissure opening in 1 to brain retraction in and to dissection of the aneurysm in 1 (1 case). CONCLUSION: Changes in the SEP correlated well with the occurrence of post-operative stroke. This early detection of ischemia directs attention to the need for measures such as withdrawal of temporary clipping or identification of another factor (e.g. release of brain retraction or repositioning of an occlusive clip) so that the risk of post-operative is reduced.

[Extra-hippocampal temporal lesions inducing symptomatic drug-resistant epilepsies. Which surgical procedure?]. / Epilepsie temporale pharmaco-résistante symptomatique d'une lésion temporale extra-hippocampique. Quelle stratégie chirurgicale?

In partial symptomatic epilepsy due to discrete brain lesion, total removal of the epileptogenic lesion generally yields major reduction of seizures, achieved in 85% of the patients. However, prognosis is worse in patients with symptomatic temporal lobe epilepsy. Implication of the temporo-mesial structures in the seizures genesis is generally considered. Careful electroclinical and radiological analysis can provide useful but insufficient information. In order to evaluate the criteria we used to guide our surgical strategy, we analyzed retrospectively a series of 47 patients with drug-resistant symptomatic extra hipocampic temporal epilepsy surgically treated either by isolated lesionectomy (group 1, n=17) or by resection of temporo-mesial structures and associated lesionectomy (group 2, n=30). Patients with extrahippocampal lesions and hippocampal sclerosis (dual pathology) were excluded from this study. With a mean follow-up of 72 months, overall results showed that 84% of group 2 patients (Engel's grade Ia) were seizure-free compared with only 47% of group 1 patients. Statistical analysis showed that the type of surgical procedure was the main prognostic factor. In conclusion, the optimal surgical procedure cannot be defined only with the criteria usually retained for temporo-mesial involvement in seizure genesis. Taking into account the prognostic value of such implication, although complex, is of paramount importance. Our results could be explained by the presence of an acquired dual functional pathology.

[Guillain-Barré syndrome secondary to cranial surgery: direct or fortuitous relationship?]. / Syndrome de Guillain-Barré secondaire à une craniectomie: association fortuite ou relation directe?

The Guillain-Barré syndrome, an acute polyradiculonevritis (PRN), usually appears after a post-infectious immuno-allergic reaction. We report a case of acute PRN following cranial surgery. Post-surgical Guillain-barré syndrome is rarely described. We reviewed the pathophysiological mechanisms possibly involved in this disease that have to be evoked in patients with abnormal post-surgical neurological symptoms.

[Chronic bilateral subdural hematomas]. / Hématomes sous-duraux chroniques bilatéraux.

BACKGROUND AND PURPOSE: Are chronic bilateral subdural hematomas different from unilateral forms in terms of delay of diagnosis, clinical presentation and post-operative recovery or recurrence? METHODS: Etiological, clinical, and radiological aspects and management outcome of bilateral chronic subdural hematomas consecutively managed from 1990 to 1995 were retrospectively analyzed and compared with unilateral forms managed in the same neurosurgical unit during the same period of time. RESULTS: There were 236 cases. Bilateral subdural hematomas occurred in 41 patients (17.4%). A good outcome was obtained in 97.5% of the cases and morbidity was 14.6%. The differences significantly observed between unilateral and bilateral subdural hematomas were duration of the prediagnostic period, pneumatoceles and recurrence rates (12%). Recurrences were all observed during the first postoperative month and treated with the same initial standardized procedure. The rate of infection or epileptic seizures was low. CONCLUSIONS: There are few limited differences between uni- and bilateral chronic subdural hematomas. In the latter, a possible correlation between the duration of prediagnostic period and an increased rate of recurrence could be explained by poorer cerebral reexpansion. The overall prognosis of bilateral hematomas is comparable with that observed in unilateral forms. A simple and routinely used burr hole procedure either under local or general anesthesia associated with closed drainage is a safe surgical procedure for either bilateral or unilateral forms and can be performed in all the cases including recurrences. Systematic antiepileptic drugs or antibiotherapy are unnecessary in the medical management of chronic subdural hematomas. One late delayed postoperative clinical control seems to be sufficient.