A keyhole middle fossa approach to large cholesterol granulomas of the petrous apex.

OBJECTIVE: In this article we review our surgical experience in a series of eight patients with large cholesterol granulomas of the petrous apex extending into the cerebellopontine angle. METHODS: All lesions, four primary and four recurrent, were studied with magnetic resonance imaging (MRI), and computed tomography (CT). The patients underwent pre- and postoperative audiographic testing. A keyhole middle fossa approach was used in all cases. RESULTS: There was no mortality. Surgery was complicated in one case by a subgaleal hematoma and in another by a transitory increase of a preexisting facial palsy. In five cases the granuloma was totally resected, whereas in the remaining three small remnants of the pseudocapsule were left in place. At follow-up (12-90 months), three patients were asymptomatic. In the remaining five patients, trigeminal neuralgias had subsided. Palsies of the VIth cranial nerve recovered more consistently than those of the VIIth. Hearing was unchanged postoperatively. So far, there has been no clinical or radiological evidence of a recurrence. CONCLUSION: Large cholesterol granulomas of the petrous apex can be effectively treated through a keyhole middle fossa approach. Despite its contained size the approach allows a rather large exposure of the granuloma. The resection of these lesions carries a low risk of compromising the facial or hearing function of the patient. Small remnants of the capsule, left in place to avoid potential complications, seem not to affect the long-term outcome of the patients, provided the cavity in the petrous bone is adequately ventilated.

Surgery, tamoxifen, carboplatin, and radiotherapy in the treatment of newly diagnosed glioblastoma patients.

A historically controlled phase II study was undertaken to investigate the efficacy and toxicity of a postoperative treatment consisting of high-dose continuous tamoxifen, carboplatin and radiotherapy in patients with newly diagnosed glioblastoma. Between 1995 and 1998, 50 patients with newly diagnosed glioblastomas underwent surgery and were subsequently treated with 200 mg day(-1) tamoxifen continuously, 3 cycles of carboplatin (300 mg m(-2)), and radiotherapy. Survival data for a historical control group were calculated from respective prognostic indices and were obtained from studies with comparable patient populations treated with operation and radiotherapy only. In our study, the median time to tumor progression was 30 weeks and the median survival time (MST) 55 weeks (95% confidence interval: 46-63 weeks). The MST of the control group (48 weeks) showed to be within this interval. In addition to already known prognostic factors in malignant gliomas (age, Karnofsky performance score, extent of tumor resection), the gender (females lived longer than males, p = 0.0025) showed to influence survival. Serious side effects (thrombosis, pulmonary embolism) occurred in 6 patients. A high incidence of multifocal tumor recurrences (33%), which might be related to study-treatment, was observed. In conclusion, the combined therapy failed to demonstrate a higher efficacy than standard treatment for glioblastoma patients.

A set of coaxial microneurosurgical instruments.

OBJECTIVE: In an effort to lessen surgical trauma, neurosurgeons are developing more contained approaches requiring minimal or no brain retraction. The mobility of traditional microsurgical tools within such narrow corridors is severely restricted. A substantial portion of the surgical field may be obscured by the relatively large size of these instruments. To overcome some of these problems, the author has designed a set of new, low-profile, coaxial microinstruments. DESCRIPTION OF INSTRUMENTATION: The coaxial shaft of these instruments is obtained by coupling a tube and a rod, rotating in opposite directions along their major axis. The rotational movement is delivered by compressing and releasing a spring-loaded, bayonet-shaped handle. The tips are obtained by flanging the two elements of the shaft. The initial set includes microscissors and microforceps, as well as tumor-grasping forceps. The two elements of the shaft can be disengaged easily by releasing a catch at the end of the shaft and disassembled for cleaning and basic maintenance purposes. DISCUSSION: The design of the present set of instruments combines a low-profile coaxial shaft with well-established ergonomic features, such as a pencil grip handle and an angled bayonet. CONCLUSION: The use of the least possible number of moving components enhances the reliability of these tools. The different profiles and angles of the tips partially compensate for the absence of a rotatable shaft, a potential shortcoming of these instruments.

Surgical management of intramedullary hemangioblastoma of the spinal cord.

This is a study on 19 patients, who underwent complete excision of an intramedullary hemangioblastoma of the spinal cord during the period 1984-1997. The study was conducted to evaluate their functional outcome. Some peculiarities of their clinical presentation and surgical treatment are discussed as well. There were 12 males and 7 females whose age ranged from 16 to 69 years. Five of 6 patients were affected by Lindau's disease had multiple intramedullary tumors. The length of their history averaged 22.6 months. While pain was the most common complaint at presentation, 12 out of 19 patients had progressive sensorimotor deficits. A total of 22 operation was performed. One patient underwent resection of a minute tumor residue a few months after the first operation. In 2 patients with multiple tumors a second tumor, which became clinically relevant, was resected 17 and 36 months after the first operation. There was no mortality. One patients developed a wound infection which required secondary closure. The functional status of the patients registered at discharge was worse in 22.7%, unchanged in 59.1%, and improved in 18.2% of the patients. At follow-up (6-142 months), the status of 9.1% of the patients was still worse, in 50% was unchanged and in 40.9% better than the preoperative one. All but one patients had complete postoperative pain relief. The data support the concept that radical excision of intramedullary hemangioblastomas can be achieved at low levels of surgical mortality and morbidity. Symptomatic patients should undergo surgery before they develop extensive sensorimotor deficits. In patients with multiple lesions, tumors distant from the symptomatic one should not be tackled.

Radical excision of intramedullary cavernous angiomas.

OBJECTIVE: This is a retrospective study of patients with surgically treated, intramedullary cavernous malformations. We conducted the study to elucidate the outcomes of the patients, as well as potential pitfalls in their care. METHODS: A series of 12 patients underwent radical excision of intramedullary cavernous malformations between 1986 and 1996. All lesions were diagnosed by magnetic resonance imaging. Although seven patients experienced recurrent episodes of pain and sensorimotor disturbances, the histories of the other five patients were relevant for slowly progressing deficits (mostly sensory). RESULTS: All cavernomas were completely resected. No deaths were recorded. In follow-up examinations (5-102 mo after discharge), there was no evidence of recurrence, either clinically or in control magnetic resonance imaging scans. In follow-up examinations, two patients demonstrated sensory deficits that were slightly more pronounced than the preoperative deficits. The postoperative neurological status of 3 of 12 patients was unchanged, compared with the preoperative status. The status of the remaining seven patients had improved. For four patients there was effective functional improvement, and for three others there was complete postoperative relief of pain. Deficits of the long tracts were less prone to recover. CONCLUSION: The clinical course of cavernous malformations may be difficult to distinguish from that of spinal dural arteriovenous malformations or focal demyelinating disease. In the latter case, even magnetic resonance imaging results could be deceptive. Radical resection of these malformations is feasible, with relatively low surgical morbidity, provided that the preoperative deficits of the patients are limited. Given the generally progressive course of the illness and the few acute catastrophic myelopathies, complete excision is advocated whenever malformations are symptomatic.

Malignant chiasmal glioma: a rare cause of rapid visual loss.

The clinical, neuroradiological, and histological findings of an adult patient suffering from malignant optic glioma is reported. Rapid visual deterioration was misdiagnosed for several months until biopsy confirmed the tumor. The patient died despite radiation therapy nine months after first symptoms. Our presentation will focus on the problems of diagnosing and establishing therapeutic procedures in this rare malignant neoplasm.

Surgical management of intramedullary spinal cord tumors: functional outcome and sources of morbidity.

We are reporting the functional outcome of 69 of 86 patients affected by intramedullary spinal cord tumors who underwent surgery at our department during the period of 1984 to 1992. The results on 17 patients affected by hemangioblastomas and cavernomas were excluded from this study and will be published separately. Twenty-eight patients had astrocytic processes; 34 had ependymoma; 4 had lipoma; 2 had neurofibroma; and 1 had oligodendroglioma. The overall rate of "radically" resected tumors was 55.1%, as opposed to 17.4% "quasiradically," and 27.5% of "partially" resected processes. There was one postoperative death. Five other patients, affected by anaplastic astrocytomas, died because of tumor progress within 16 months from the operation. A postoperative functional assessment showed that the function of the upper and lower extremities had deteriorated in 65.4 and 55.1% of the patients; a respective functional deterioration by 1 degree of the scale of Cooper and Epstein was registered in 88.8 and 86.8% of the patients. The patients who recovered improved within a period of 6 to 18 months, whereas the function of the dorsal columns was impaired the longest. At follow-up (mean, 54 mo; range, 8-107 mo), the functional recovery (as compared with the preoperative status) was as follows: upper extremity, 17.1% of the patients were improved, 55.5% were unchanged, and 31.5% were worse (89.4% by 1 degree); lower extremity, 22.4% of the patients were improved, 51.5% were unchanged, and 29.4% were worse (most by 1 degree). Surgery on tumors of the cervicothoracic and upper thoracic region carried a relatively higher morbidity in this series.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypothalamic hamartomas: with special reference to gelastic epilepsy and surgery.

This study presents six patients with hypothalamic hamartomas diagnosed on the basis of magnetic resonance imaging. Histological confirmation was performed in three patients who underwent surgery. Immunohistological assays were used to determine the neurosecretory pattern. Four patients presented with epilepsy, including gelastic seizures. Other symptoms included behavioral abnormalities in four patients and precocious puberty and visual impairment in two patients. One patient presented associated developmental defects. Good results without morbidity were achieved with surgical resectioning in two patients with large hamartomas associated with behavioral abnormalities and gelastic epilepsy that was unresponsive to conventional medical treatment and in one patient with visual impairment. We propose a classification of the hypothalamic hamartomas based on topographical and clinical data obtained from 36 selected cases in the literature and six of our own cases. This classification should help to classify the various treatment methods and the surgical risks into four subgroups (Types la, lb, lla, and llb). We conclude that the surgical approach is a realistic alternative in certain cases, including large and broad-based Type llb hamartomas associated with gelastic epilepsy and behavioral disorders.

Treatment of cerebral arteriovenous malformations by neuroradiological intervention and surgical resection.

We present the results of a series of 105 patients with cerebral arteriovenous malformations (AVMs) who were treated by a combined protocol including endovascular occlusive measures and open surgical resection. 25 patients were treated only by surgical intervention, 72 patients underwent preoperative endovascular embolization and 8 patients were treated only by embolization, seven of which were only treated for palliation. After superselective angiography the vascular territories suitable for endovascular or microsurgical approach were defined, and in most cases these territories were complementary to each other. In 56 cases, only one embolization was necessary and due to an advantageous co-localization of the departments the whole combined endovascular/neurosurgical procedure was done in one anesthesia. If several endovascular sessions were necessary (16 patients), the resection was mostly carried out immediately after the last neuroradiological session in the same anesthesia with total time of such combined procedure now averaging about 7 hours. According to the proposed grading system by Spetzler we treated 25 grade 1, 24 grade 2, 40 grade 3, 11 grade 4, and 5 grade 5 lesions. The overall success rate defined as complete resection without additional permanent neurological deficit was 89.6% (87 out of 97 surgical cases). The benefits of such combined approach to cerebral AVMs become apparent in shortened and safer surgical procedures as well as in a low complication rate.

Cranio-cervical decompression for Chiari I malformation. A retrospective evaluation of functional outcome with particular attention to the motor deficits.

We report a series of 26 patients affected by a Chiari I malformation treated at our department between 1987 and 1993. All patients underwent pre- and postoperative evaluation by magnetic resonance imaging (MRI). Sequential perioperative motor evoked potential (MEP) recordings were performed in 8 patients. The preoperative symptoms can be divided into four subgroups: cephalgias (84.6%), cranial nerve deficits (69.2%), motor deficits (76.9%), sensory deficits (73%). Twenty-five out of 26 patients underwent craniovertebral decompression, 1 a transoral anterior decompression. One patient died 2 months after surgery because of progressive pulmonary failure. We registered following postoperative complications transient hypoglossal palsy (1 case), vertigo (2 cases), meningitis (1 case), minor CSF leaks (3 cases). Cephalgias subsided in 17 and improved in 4 out of 22 patients. Cranial nerve deficits improved in 8 and were stabilized in 7 out of 18 patients. A limited recovery of trigeminal function was possibly due to nuclear lesions. Five patients whose vestibular disturbances were not relieved by surgery were put on a course of carbazepine. Vertigo resolved in one case and in two others improved. While hypesthesia improved after decompression, the other sensory deficits were stabilized in 5% of the patients. Spasticity improved in 12 out of 18 patients, but weakness only in 7 out of 17 patients. Motor disturbances were always detected by MEP-recording. MEP-characteristics were not specific, resembling those of patients with other intra-, extramedullary myelopathies. Functional recovery was not matched by an improvement of the MEP parameters. MEP may be used as tool for surveillance of patients whose clinical findings are not progressive and are not at first surgical candidates.

Surgical treatment of meningiomas of the orbit and optic canal: a retrospective study with particular attention to the visual outcome.

A series of 57 patients affected either by optic nerve sheath meningiomas (15 patients) or by secondary meningiomas extending into the orbital apex or optic canal (42 patients) has been reviewed. Proptosis (80%), progressive visual loss (76%), and visual fields defects (63%) were the most common pre-operative complaints. All patients underwent transcranial surgery. Radical tumour resection was possible in 9 out of 15 primary and 22 out of 32 secondary tumours. Overall, 27% of the patients obtained improved postoperative visual acuity, 62% remained unchanged, and 11% were worse. The postoperative visual outcome was related to the degree of pre-operative visual impairment. In a period between 38 and 68 months, 5 meningiomas recurred. The time to progression of partially resected lesions ranged between 9 and 68 months.