A retrospective study of bevacizumab for treatment of brainstem glioma with malignant features.

Brainstem glioma is impossible to resect completely, and patients with this type of glioma show a poor prognosis. Therefore, a more effective adjuvant therapy is required to prolong survival. Bevacizumab is an endothelial growth factor monoclonal antibody with strong anti-vascular effects, which may suppress tumor progression. We performed a retrospective study of data from 6 patients with brainstem glioma showing malignant features who were treated with bevacizumab. Tumor-associated lesions, as evaluated by T2 weighted or fluid-attenuated inversion-recovery magnetic resonance imaging, were reduced in all patients, although the timing of the start of bevacizumab administration and pretreatment were not uniform. Clinical symptoms improved in 4 patients and progression was inhibited in 2 patients. The Karnofsky performance status improved from 56.7 to 71.7 on average. The median reduction ratio of tumor-associated lesions was 76.3%, but tumor suppression did not last in any of the cases. Furthermore, 5 patients died of tumor progression, and 1 patient died of a complication of necrotizing colitis. The median progression-free survival after bevacizumab administration was 7 months. The median overall survival after diagnosis was 16.5 months. Bevacizumab might be a potential therapeutic option for progressive brainstem gliomas with malignant features.

Role of endoscopy in multi-modality monitoring during aneurysm surgery: A single center experience with 175 consecutive unruptured aneurysms.

OBJECTIVE AND BACKGROUND: Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery. METHODS: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented. RESULTS: No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm. CONCLUSIONS: Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.

Clinical characteristics and risk factors of chronic subdural haematoma associated with clipping of unruptured cerebral aneurysms.

Chronic subdural haematoma (CSDH) is an uncommon but potentially serious complication of clipping unruptured cerebral aneurysms. We conducted a study to identify the patients who are at risk of developing postoperative CSDH. The data from 713 consecutive patients who underwent clipping of unruptured anterior circulation aneurysms were reviewed, and risk factors correlated with CSDH were identified by multivariate regression analysis of demographic variables. Fifteen patients (2.1%) developed CSDH after the surgery. Advanced age (odds ratio [OR] 1.151, 95% confidence interval [CI] 1.051-1.261) and male gender (OR 3.167, 95% CI 1.028-9.751) were correlated with CSDH. Subsequently, all 713 patients were quadrichotomized on the basis of gender and age, with 70 years as the cut-off value for age. The frequency of CSDH in men <70 years of age was 1.3% and that in men ≥70 years of age was 15.1%, with risk of CSDH was significantly higher in the older men (OR 13.39; 95% CI: 3.42-52.44). The frequency of CSDH in women <70 years of age was 0.6% and that in women ≥70 years of age was 3.7%. As in men, the risk of CSDH was significantly higher in the older women (OR 6.69, 95% CI 1.10-40.73). The interval between the aneurysm clipping and CSDH development was 0.5-6 months, suggesting that clinical observation should be continued up to 6 months after surgery. Although prognosis for patients with a postoperative CSDH complication is generally favourable, the risk of CSDH should be taken into account when considering elective clipping of unruptured aneurysms in patients ≥70 years of age.

Early seizures after clipping of unruptured aneurysms of the anterior circulation: analysis on consecutive 1,000 cases.

Seizures occurring after clipping of unruptured cerebral aneurysms have rarely been documented in the literature. The objective of this retrospective study is to clarify whether the frequency of early seizures, i.e., seizures occurring within 14 days of surgery, is influenced by patient- or aneurysm-specific characteristics. Data on 1,000 consecutive patients who underwent clipping of unruptured anterior circulation aneurysms were reviewed. They consisted of 387 men and 613 women with mean age of 59.8 ± 9.7 years. Fifty-one patients (5.1 %) developed early seizures. Interestingly, the frequency was similar to that occurring after clipping of unruptured posterior circulation aneurysms (n = 20, 5.0 %). Multivariate regression analysis revealed that younger age was correlated with early seizures (odds ratio (OR) 0.902; 95 % confidence interval (CI) 0.891-0.989). However, other variables, including aneurysm size and operation length, were not correlated. Although patients with history of epilepsy exhibited relatively high frequency of early seizures, the difference was not statistically significant. The frequency was unaffected by location or multiplicity of aneurysms. Thirty-one patients (61 %) developed seizures within 24 h of clipping. Regarding seizure types, 34 (67 %) developed generalized seizures and the other 17 (33 %) experienced partial seizures. Patients with generalized seizures were significantly more likely to harbor an iatrogenic brain lesion than those with partial seizures (47 vs. 18 %; OR 4.148; 95 % CI 1.005-17.113). Among 40 patients with follow-up period >12 months, seizures were temporary without recurrence in 38 (95 %). Although early seizures are mostly benign, a small possibility of them becoming a permanent morbidity needs to be explained to patients undergoing elective clipping.

Decompressive hemicraniectomy for malignant hemispheric stroke in the elderly: comparison of outcomes between individuals 61-70 and >70 years of age.

BACKGROUND: Malignant hemispheric infarction is a life-threatening condition with a high mortality rate. Decompressive hemicraniectomy (DHC) is frequently a life-saving procedure that has shown the highest grade of evidence for patients 18 to 60 years of age. However, the efficacy of DHC in patients>60 years of age has rarely been investigated. METHODS: A retrospective study was conducted in a single academic institution. Surrogates of patients with clinical signs of impending brain herniation despite standard medical therapy were offered the option of DHC regardless of age or the side of the lesion. The clinical data from 18 patients>60 years of age who underwent DHC for malignant hemispheric infarction in our institution were analyzed. Patients were classified into the following 2 groups: 61-70 and >70 years of age, and their demographics and surgical outcomes were compared. The variables compared included the male:female ratio, side of the lesion, type of stroke, site of vascular occlusion, use of thrombolytic therapy, National Institutes of Health Stroke Scale score, stroke onset-to-DHC interval, duration of hospital stay, infectious complications, and 90-day mortality rate. RESULTS: There were no significant intergroup differences in any of the demographic variables evaluated. However, the 30-day mortality rate was significantly higher in the group that was >70 years of age (0% v 60%; P=.01) than in the group that was 61 to 70 years of age. CONCLUSIONS: We suggest that the efficacy of DHC in malignant hemispheric stroke patients between 61 and 70 years of age be further investigated in future randomized trials. By contrast, it appears unlikely that patients>70 years of age would benefit from DHC.

Detection of pulsation in ruptured and unruptured cerebral aneurysms by electrocardiographically gated 3-dimensional computed tomographic angiography with a 320-row area detector computed tomography and evaluation of its clinical usefulness.

BACKGROUND: In ruptured cerebral aneurysms (RCAs), identification of the rupture point of a cerebral aneurysm is useful for treatment planning. In unruptured cerebral aneurysms (URCAs), detection of the risk of aneurysmal rupture is also useful for patient management. OBJECTIVE: Electrocardiographic (ECG)-gated 3D-CT angiography was performed for patients with RCAs and URCAs using 320-row area detector CT (ADCT) to detect pulsation of the cerebral aneurysms. The clinical usefulness of this method was then evaluated. METHODS: Twelve patients had 12 RCAs, and 39 patients had 53 URCAs. A 320-row ADCT system was used to scan. ECG-gated reconstruction was then performed with the R-R interval divided into 20 phases. RESULTS: Pulsation was observed in 10 of the 12 RCAs. The bleeding site was considered to correspond to the area of pulsation. Pulsation was observed in 14 of 53 URCAs. Thirteen patients with 18 URCAs were followed. Of the 11 URCAs in which pulsation was not observed, 1 showed a change in shape. Of the 7 URCAs in which pulsation was observed, 3 showed a change in shape. URCAs in which pulsation was observed were more likely to show a change in shape (P = .082). CONCLUSION: The area of pulsation was found to correspond to the bleeding site in many RCAs. This information would be extremely useful for treatment planning. The detection of pulsation in an URCA is therefore considered to provide useful information for patient management.