Randomized Trial Comparing Burr Hole Craniostomy, Minicraniotomy, and Twist Drill Craniostomy for Treatment of Chronic Subdural Hematoma.

BACKGROUND: The mainstay of treatment for symptomatic or large chronic subdural hematoma (CSDH) is surgery, but controversy still exists regarding the best surgical technique. Three different techniques are commonly used: burr hole craniostomy (BHC), minicraniotomy (MC), and twist drill craniostomy (TDC). OBJECTIVE: To determine which surgical technique for drainage of CSDH offers best results. METHODS: We set up a multicenter prospective randomized trial (Comparison of Chronic Subdural Hematoma Treatment [COMPACT] trial) comparing BHC, MC, and TDC for the surgical treatment of CSDH. The primary end point was reoperation rate, and secondary end points included complication rates and clinical outcome. Patients were considered to have good outcome when they did not undergo reoperation, suffered no surgical or medical complication, and had no related mortality. Clinical outcome was also evaluated by evolution of the Markwalder score and the modified Rankin score. RESULTS: Two-hundred forty-five patients were included in the final analysis: 79 BHC, 84 MC, and 82 TDC. Mean duration of surgery was shorter for TDC than for BHC and MC ( P < .001). Reoperation rate was 7.6% for BHC, 13.1% for MC, and 19.5% for TDC ( P = .07). This trend toward better results for BHC was not statistically significant in logistic regression analysis. The proportion of patients with good outcome was 78.5% for BHC group, 76.2% for MC, and 69.5% for TDC ( P = .4). Evolution of the Markwalder score and modified Rankin score were not significantly different between treatment groups. CONCLUSION: All 3 techniques are effective at treating patients with CSDH with eventual 6-month outcome being similar. Although not reaching statistical significance in our study, BHC offers the lowest recurrence rate combined with manageable complication rate.

The Anterior Trans-Superior Temporal Gyrus Approach for Selective Amygdalohippocampectomy.

BACKGROUND: Different surgical approaches have been described for selective amygdalohippocampectomy in patients with pharmacoresistant temporal lobe epilepsy. The aim of this study was to report the results of the innovative anterior trans-superior temporal gyrus approach in a single-center series. METHODS: Patients' characteristics, postoperative outcomes, and complications were reviewed in a series of 8 consecutive patients with temporal lobe epilepsy operated on using the anterior trans-superior temporal gyrus approach between November 2015 and April 2017. RESULTS: Over a mean 2.5-year follow-up, 7 of 8 patients (87.5%) remained seizure-free (Engel class I). Only 1 patient (12.5%) was not cured (Engel class III) with no clear explanation for treatment failure. Mean operative time was 237 minutes, which was 80 minutes shorter compared with the classic transsylvian approach. No perioperative deaths were recorded and there were no visual field defects or visual acuity impairments secondary to the approach. One patient experienced a left posterior thalamocapsular stroke. CONCLUSIONS: The anterior trans-superior temporal gyrus approach is feasible, fast, and safe for selective amygdalohippocampectomy in patients with drug-refractory temporal lobe epilepsy. This approach allows preservation of the optic radiation but cuts part of the uncinate fasciculus and potentially the anterior aspect of the anterior bundle of the middle longitudinal fasciculus.

Recanalization and rupture after intracranial aneurysm treatment.

BACKGROUND: Treatment of intracranial aneurysm (ICA) can sometimes require several procedures. The aim of this study was to analyze the risk of recanalization and rupture recurrence after ICA treatment by endovascular coiling (EVC) or surgical clipping (SC) on a very long follow-up. METHODS: Clinical data of 373 consecutive patients treated in our group between January 1996 and December 2006 as well by EVC as by SC for ruptured (RIA) or unruptured intracranial aneurysm (UIA), were reviewed. Patients were followed-up at least to August 2009. First radiologic follow-up done six months after EVC and between three and five years after SC (median time: 5 years). All patients underwent a clinical follow-up after treatment, at least by telephonic communication (median time: 6 years). RESULTS: Out of 197 patients with 198 RIAs, 82 (42%) patients underwent an endovascular treatment and 115 (58%) were allocated to surgical treatment. From a total of 176 patients with 229 UIAs, 66 (37.5%) patients were treated by 74 EVC; and 110 (62.5%) patients were treated with 124 surgical procedures. Fifteen recanalizations of coiled RIAs were detected and only one in the surgical group (27% vs. 2%; P= 0.0008). Of the 15 recanalizations in the EVC group, 6 (40%) were initially completely occluded. We observed two rebleedings, one in each group (1.4% for EVC; 1% for SC; P=0.8). CONCLUSIONS: Our findings during the longest reported follow-up confirm a greater risk of recanalization for RIA treated by EVC without so far a significant difference in the rerupture risk.

Long-term survival after glioblastoma resection: hope despite poor prognosis factors.

BACKGROUND: In spite of aggressive multimodal treatment, survival for patients with glioblastoma (GBM) remains short. Nevertheless, some patients survive much longer than expected and become long-term survival patients. The extent of resection (EoR), Karnofsky Performance Scale (KPS), age and methyl-guanine methyltransferase gene (MGMT) methylation are well-defined prognostic factors, but the characteristics of patients with long-term survival (LTS, survival of at least three years after diagnosis) has not been fully determined yet. That is the reason why we analyzed the GBM patients with LTS at our center. METHODS: We retrospectively reviewed all consecutive patients who underwent surgery for GBM between January 2002 and November 2011, including patients treated with surgical resection under neuronavigation with or without intraoperative MRI (ioMRI) and those who had stereotactic biopsy. We identified and further analyzed those patients with LTS. RESULTS: A total of 127 patients underwent surgery for GBM during the study period. 101 (79.6%) of whom had surgical resection and 26 (20.4%) of whom had stereotactic biopsy. Of the 101 patients who were treated with surgical resection, 12 had LTS. After two other pathologists reviewed the patients' cases, they confirmed that 11 (11%) of the 12 patients had a GBM (female/male ratio 4.5; average age 50 years; preoperative Karnofsky Score 82%), and one patient had an anaplastic glioma. The mean survival in the LTS patients with confirmed GBM was 74 (36-150) months. Seven of the LTS patients (63.6%) had a gross total resection (GTR), including two with an additional resection after ioMRI. Three (27.3%) had a near total resection (NTR: residue ≤5%) and one (9.1%) had a partial resection. Ten (90.9%) patients had a methylation of MGMT, only two (18.8%) had an IDH1 mutation, and seven (63.6%) received a full Stupp protocol. CONCLUSIONS: Among patients with a GBM who were treated with one or more resections, 11% had LTS with 90.9% with at least a near total resection (36% with ioMRI) and a methylated MGMT. 50% of the patients with a second surgery survived at least two years postoperatively. Those encouraging observations emphasize the importance of maximizing the resection by using, if possible, an intraoperative guidance method like ioMRI with an analysis of biomarkers such as MGMT and if necessary, multiple surgical procedures.

Granulomatous Reaction on a Double-Level Cervical Total Disc Arthroplasty.

BACKGROUND: Cervical total disc arthroplasty (TDA), or cervical artificial disc replacement, is an alternative technique to anterior cervical discectomy and fusion for treatment of symptomatic degenerative cervical spine disease. The main goal of TDA is to maintain cervical motion and lower the risk of deterioration of adjacent levels. Granuloma formation on a cervical TDA is exceptional. CASE DESCRIPTION: A 48-year-old woman with left cervicobrachialgia underwent a double-level TDA (M6-C Artificial Cervical Disc) on C5-C6 and C6-C7 at another hospital in 2010. Two years later, she reported a recurrence of cervicalgia, which was refractory to conservative treatment by rigid collar and analgesics. Cervical magnetic resonance imaging suggested a granulomatous formation on the C6-C7 prosthesis. She underwent removal of the C6-C7 prosthesis, which showed a rupture with nylon thread extrusion. An arthrodesis with plate was subsequently performed. Follow-up showed improvement of her clinical status. Histopathologic studies showed a giant cell granulomatous formation in contact with nylon threads described in hip, shoulder, and ankle arthroplasty. It has been described in 6 cases following lumbar TDA and 2 cases following cervical TDA. CONCLUSIONS: We report a third case of granulomatous reaction on nylon thread extrusion after partial breakdown of a prosthesis for cervical TDA.

Outcome of Transsphenoidal Surgery for Cushing Disease: A Single-Center Experience over 20 Years.

BACKGROUND: This study investigated the outcome of transsphenoidal surgery (TSS) for Cushing disease (CD) and the influence of our surgical strategy on remission rates and postoperative pituitary function. PATIENTS AND METHODS: We retrospectively reviewed data from 71 patients with CD who underwent microscope navigation TSS (MN-TSS) in Saint-Luc Hospital between 1996 and 2017. True remission was defined as normal fasting cortisol level, normal 24-hour urinary free cortisol, or continued need for hydrocortisone replacement for 1 year after surgery. RESULTS: Overall remission rate after 1 or repeated MN-TSS was 83%. Highest remission rate was found in patients with macroadenomas (92%). Successful first MN-TSS was correlated with a high final remission rate (95%), whereas failed first MN-TSS was correlated with a low final remission rate (36%). Although day 1 cortisol levels were significantly lower in patients with long-term remission, high levels were still observed in a few patients, especially those who had had CD for many years. We found a low rate of postoperative pituitary long-term hypofunction (9.7%). CONCLUSIONS: MN-TSS is a safe and effective procedure to treat CD, allowing remission rates of 83%. One-year remission period after first surgery is correlated with a final remission rate of 95%. Although day 1 morning cortisol value is the most significant predictor for long-term remission, some patients with CD for many years may keep high postoperative cortisol levels and be in later remission, likely because of secondary adrenal hyperplasia. Our focused approach with microscope navigation resulted in low rates of postoperative pituitary hypofunction and kept a recurrence rate comparable to that in the literature.

Morfologia dos pré-estômagos e de papilas ruminais de cordeiras Santa Inês em crescimento submetidas a dois planos nutricionais / Morphology of pre-stomach and ruminal papillae of growing Santa Inês female lambs under two nutritional schemes

Para se avaliar o efeito do plano nutricional e crescimento sobre a massa dos pré-estômagos, morfologia e quantificação de papilas ruminais, trinta e seis cordeiras da raça Santa Inês foram submetidas a dois planos nutricionais (ad libitum ou restrito) sendo abatidas em diferentes pesos vivo (20, 30 ou 40 kg de peso vivo), em um delineamento inteiramente casualizado balanceado em arranjo fatorial 2x3. Feito o abate, as vísceras foram pesadas livres de seu conteúdo em seguida mediu-se o volume de repleção do rúmen e retículo. Amostras do tecido ruminal oriundas dos sacos cranial e ventral foram coletadas para posteriormente serem realizadas com auxílio de lupa estereoscópica as medidas morfométricas das papilas ruminais, altura, largura da base, área, papilas por cm² e área absortiva por cm². Os resultados obtidos foram submetidos a análise de variância e as médias resultantes por tratamento foram comparadas por meio de teste de Student Newmann Keuls. Os diferentes planos nutricionais não influenciaram a massa das vísceras rúmen, retículo e omaso (P>0,05), no entanto, observou-se crescimento dessas vísceras em função do aumento do peso ao abate. O volume dessas vísceras foi afetado pelo peso ao abate, e observou-se menores volumes para animais com alimentação ad libitum (P<0,10). O número de papilas por cm² foi reduzido com o aumento do peso ao abate, sendo que altura e área foram aumentadas quando em pesos maiores. O plano nutricional afetou apenas a área e altura das papilas ruminais oriundas do saco cranial. A área absortiva não foi afetada pelos tratamentos. Plano nutricional e diferentes pesos vivos influenciam a morfologia dos pré-estômagos de cordeiras da raça Santa Inês.

For the evaluation of nutritional schemes and change on the pre-stomach morphology and quantification of rumen papillae, 36 Santa Inês female lambs were submitted to two nutritional schemes (ad libitum or restrict) and slaughtered with different live weights (20, 30 or 40 kg) in a completely randomized factorial design 2x3. After slaughter, the viscera were weighed empty and their volume was measured. Samples of ruminal wall from the cranial and ventral sacs were collected and with a stereomicroscope photographed and analyzed regarding height, basal width, area, papillae per cm² and absorptive area per cm². The results were submitted to analyses of variance and the means were compared by Student Newman Keuls test. The different nutritional schemes did not influence the weight of rumen, reticulum or omasum (P>0.05), although, growth of the viscera was observed by increase in live weight. The viscera volume was affected by live weight, and smaller volume was observed in the animals fed ad libitum diet (P<0.10). The number of papillae per cm² was reduced by the increase in live weight. Height and area of papillae were larger in heavier animals. The nutritional scheme only affected height and area of papillae of the cranial sac. The absorptive area was not affected by the treatments. Different nutritional schemes and live weights affect the pre-stomach morphology of Santa Ines female lambs.