Surgical results of 158 petroclival meningiomas with special focus on standard craniotomies.

OBJECTIVE: The goal of this retrospective study is the evaluation of risk factors for postoperative neurological deficits after petroclival meningioma (PCM) surgery with special focus on standard craniotomies. MATERIALS AND METHODS: One-hundred-fifty-eight patients were included in the study, of which 133 patients suffered from primary and 25 from recurrent PCM. All patients were operated on and evaluated concerning age, tumor size, histology, pre- and postoperative cranial nerve (CN) deficits, morbidity, mortality, and surgical complications. Tumor-specific features-e.g., consistency, surface, arachnoid cleavage, and location-were set in a four-grade classification system that was used to evaluate the risk of CN deficits and tumor resectability. RESULTS: After primary tumor resection, new CN deficits occurred in 27.3% of patients. Preoperative ataxia improved in 25%, whereas 10% developed new ataxia. Gross total resection (GTR) was achieved in 59.4%. The morbidity rate, including hemiparesis, shunt-dependence, postop-hemorrhage, and tracheostomy was 22.6% and the mortality rate was 2.3%. In recurrent PCM surgery, CN deficits occurred in 16%. GTR could be achieved in three cases. Minor complications occurred in 20%. By applying the proposed new classification system to patients operated via standard craniotomies, the best outcome was observed in type I tumor patients (soft tumor consistency, smooth surface, plane arachnoid cleavage, and unilateral localization) with GTR in 78.7% (p < 0.001) and 11.9% new CN deficits (p = 0.006). CONCLUSION: Standard craniotomies as the retrosigmoid or subtemporal/pterional approaches are often used for the resection of PCMs. Whether these approaches are sufficient for GTR-and avoidance of new neurological deficits-depends mainly on the localization and intrinsic tumor-specific features.

Peripheral nerve field stimulation for trigeminal neuralgia, trigeminal neuropathic pain, and persistent idiopathic facial pain.

OBJECTIVE: Peripheral nerve field stimulation (PNFS) is a promising modality for treatment of intractable facial pain. However, evidence is sparse. We are therefore presenting our experience with this technique in a small patient cohort. METHODS: Records of 10 patients (five men, five women) with intractable facial pain who underwent implantation of one or several subcutaneous electrodes for trigeminal nerve field stimulation were retrospectively analyzed. Patients' data, including pain location, etiology, duration, previous treatments, long-term effects and complications, were evaluated. RESULTS: Four patients suffered from recurrent classical trigeminal neuralgia, one had classical trigeminal neuralgia and was medically unfit for microvascular decompression. Two patients suffered from trigeminal neuropathy attributed to multiple sclerosis, one from post-herpetic neuropathy, one from trigeminal neuropathy following radiation therapy and one from persistent idiopathic facial pain. Average patient age was 74.2 years (range 57-87), and average symptom duration was 10.6 years (range 2-17). Eight patients proceeded to implantation after successful trial. Average follow-up after implantation was 11.3 months (range 5-28). Using the visual analog scale, average pain intensity was 9.3 (range 7-10) preoperatively and 0.75 (range 0-3) postoperatively. Six patients reported absence of pain with stimulation; two had only slight constant pain without attacks. CONCLUSION: PNFS may be an effective treatment for refractory facial pain and yields high patient satisfaction.

Vestibular Schwannoma Surgery: Outcome and Complications in Lateral Decubitus Position versus Semi-sitting Position-A Personal Learning Curve in a Series of 544 Cases over 3 Decades.

OBJECTIVE: To retrospectively evaluate influence of intraoperative positioning (semisitting vs. lateral decubitus) and surgeon's learning curve with regard to functional outcome of patients with vestibular schwannoma. METHODS: This study included 544 patients (median age 57 years) and spanned 3 decades: 1991-1999 (n = 103), 2000-2009 (n = 210), and 2010-2019 (n = 231). Surgery was performed in the lateral decubitus position in 318 patients and the semisitting position in 163 patients. Large T3 and T4 tumors were present in 77% of patients. RESULTS: Complete tumor removal was achieved in 94.3% of patients. A significant reduction in surgery duration and blood loss was observed over 3 decades for T3 (from 325 to 261 minutes, P < 0.001) and T4 (from 440 to 330 minutes, P < 0.001), but not for T1 and T2, tumors. The semisitting position diminished surgical time in T3 and T4 tumors by 1 more hour (P < 0.001). Over 3 decades, facial nerve outcome improved significantly from 59.8% House-Brackmann grade 1-2 in the first decade to 81.7% in the last decade (P < 0.001). Furthermore, hearing was preserved in 45.3%: 23.3% of patients in the first decade and 50.5% in the last decade (P = 0.03). However, neither facial nerve outcome nor hearing preservation significantly differed in patients operated on in the lateral decubitus versus the semisitting position. The most common complication was cerebrospinal fluid leak (6.1%) followed by hemorrhage (3.5%) and pulmonary embolism (2.2%). CONCLUSIONS: Follow-up over 3 decades illustrates a learning curve with significantly improved results. While the semisitting position accelerates the procedure and is associated with reduced blood loss, it does not significantly influence functional outcome.

The influence of contractures and variation in measurement stretching velocity on the reliability of the Modified Ashworth Scale in patients with severe brain injury.

OBJECTIVE: To determine the influence of contractures and different stretching velocities on the reliability of the Modified Ashworth Scale (MAS) in patients with severe brain injury and impaired consciousness. DESIGN: Cross-section observational study. SETTING: A rehabilitation centre for adult persons with neurological disorders. SUBJECTS: Fifty patients with impaired consciousness due to severe cerebral damage of various aetiologies. MEASUREMENT PROTOCOL: Three experienced and trained medical professionals rated each patient in a randomized order once daily for two consecutive days. Shoulder, elbow, wrist, knee and ankle spasticity were assessed by the use of the MAS with different stretching velocities. The presence of contractures was assessed by a goniometer. MAIN OUTCOME MEASURES: Retest and inter-rater reliability (k(w) = weighted kappa) of the MAS. RESULTS: The retest reliability of the MAS was good (shoulder joints (k(w) 0.74), elbow joints (k(w) 0.74), wrist joints (k(w) 0.72), knee joints (k(w) 0.72), ankle joints (k(w) 0.77)) and the inter-rater reliability was moderate (shoulder joints (k(w) 0.49), elbow joints (k(w) 0.52), wrist joints (k(w) 0.51), knee joints (k(w) 0.54) ankle joints (k(w) 0.49)). The presence of contractures significantly influenced the reliability of MAS in shoulder and wrist joints. No influence of stretching velocity on the reliability of the MAS was found. CONCLUSION: In patients with impaired consciousness due to severe brain injury the MAS has good retest, but only limited inter-rater, reliability. The presence of contractures may influence reliability of the MAS, but stretching velocity does not.