Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach. METHODS: Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally. RESULTS: There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001). CONCLUSION: We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

Pterional-subolfactory Approach for Treatment of High Positioned Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to compare the surgical outcomes of pterional-subolfactory approach for the high positioned anterior communicating artery (ACoA) aneurysm with the conventional pterional approach. METHODS: Between February 2005 and December 2012, 463 ACoA aneurysms were surgically treated in our institution. Forty eight high positioned ACoA aneurysms were treated with pterional-subolfactory or conventional pterional approach. High positioned ACoA aneurysms were defined as aneurysms located higher than 10 mm above the anterior clinoid process. Pterional-subolfactory approach is a procedure including dissection of olfactory tract and resection of the gyrus rectus inferior and medial to the olfactory tract. Thirty-four of the 48 cases were treated with pterional-subolfactory approach and 14 were treated conventionally. RESULTS: There were 2 postoperative cerebral infarction with the conventional pterional approach, but none with the pterional-subolfactory approach group (p = 0.026). Postoperative digital subtraction angiography revealed significant remnant aneurysm in the conventional pterional approach group. All patients with unruptured aneurysms had good clinical outcomes with Glasgow outcome score of 5. Among ruptured ACoA aneurysm patients, 2 patients with conventional pterional approach had postoperative cerebral infarctions but permanent neurologic deficit was found in only 1 patient. Three patients treated with the pterional-subolfactory approach, who had preoperative ruptured aneurysms had poor clinical outcomes. The mean operation time for the conventional pterional approach was 58 minutes longer than for the pterional-subolfactory approach (p = 0.001). CONCLUSION: We concluded that pterional-subolfactory approach is highly preferable for cases of high positioned ACoA aneurysm, giving a wide and effective operation view.

The Usefulness of Stereotactic Radiosurgery for Radioresistant Brain Metastases

OBJECTIVE: We investigated the effectiveness of stereotactic gamma knife Radiosurgery (GKR) for radioresistant brain metastases with the impact upon histology. METHODS: Between April 2004 and May 2011, a total of 23 patients underwent GKR for 67 metastatic brain tumors from 12 renal cell cancers, 5 sarcomas and 6 melanomas. The mean age was 56 years (range, 18 to 79 years). Most of the patients were classified as the Radiation Therapy Oncology Group recursive partitioning analysis class II (91.3%). The synchronous metastasis was found in 6 patients (26.1%) and metachronous metastasis in 17 patients (73.9%). We analyzed the local control rate, intracranial progression-free survival (PFS) and overall survival (OS). RESULTS: The mean tumor volume for GKR was 2.24 cc and the mean prescription dose was 19.4 Gy (range, 10 to 24) to the tumor margin. Out of metachronous metastases, the median duration to intracranial metastasis was 3.3 years in renal cell cancer (RCC), 2.4 years in melanoma and 1.1 years in sarcoma (p=0.012). The total local control rate was 89.6% during the mean 12.4 months follow-up. The six-month and one-year local control rate was 90.2% and 83% respectively. Depending on the pathology, the control rate of RCC was 95.7%, sarcoma 91.3% and melanoma 80.5% during the follow-up. The common cause of local failure was the tumor bleeding in melanoma. The median PFS and OS were 5.2 and 8.4 months in RCC patients, 6.5 and 9.8 months in sarcoma, and 3.8 and 5.1 months in melanoma. CONCLUSION: The GKR can be one of the effective management options for the intracranial metastatic tumors from the radioresistant tumors. The melanoma showed a poor local control rate compared to other pathologies because of the hemorrhage.

Two Cases of Primary Osteolytic Intraosseous Meningioma of the Skull Metastasizing to Whole Skull and the Spine

We report here two cases of primary intraosseous meningioma with aggressive behavior. A 68-year-old man presented with a one year history of a soft, enlarging mass in the right parietal region. Magnetic resonance image (MRI) revealed a 6 cm sized, heterogeneously-enhancing, bony expansile mass in the right parietal bone, and computed tomograph (CT) showed a bony, destructive lesion. The tumor, including the surrounding normal bone, was totally resected. Dural invasion was not apparent. Diagnosis was atypical meningioma, which extensively metastasized within the skull one year later. A 74-year-old woman presented with a 5-month history of a soft mass on the left frontal area. MRI revealed a 4 cm sized, multilobulated, strongly-enhancing lesion on the left frontal bone, and CT showed a destructive lesion. The mass was adhered tightly to the scalp and dura mater. The lesion was totally removed. Biopsy showed a papillary meningioma. The patient refused adjuvant radiation therapy and later underwent two reoperations for recurred lesions, at 19 and at 45 months postoperative. The patient experienced back pain 5 years later, and MRI showed an osteolytic lesion on the 11th thoracic vertebra. After her operation, a metastatic papillary meningioma was diagnosed. These osteolytic intraosseous meningiomas had atypical/malignant pathologies, which metastasized to whole skull and the spine.