Can Young Vascular Neurosurgeons Become Proficient in Microsurgical Clip Reconstruction in the Endovascular Era? A Rotterdam Cohort Spanning 2 Decades with Propensity Score Matching for Complexity.

BACKGROUND: Little is known about the results of young vascular neurosurgeons who perform only microsurgical clip reconstruction in the era since the International Subarachnoid Aneurysm Trial (ISAT) or about the training and caseload required to equivocate the results of senior, more experienced colleagues. The aim of this study was to compare clinical outcomes of patients treated by young and senior vascular neurosurgeons at Erasmus MC University Medical Center Rotterdam, adjusting for case mix. METHODS: A partially prospective and partially retrospective database was used. Hierarchical mixed models with a random intercept for surgeon were used for confounder adjustment, and propensity score matching for complexity was used to create comparable groups. RESULTS: The study included 609 patients harboring 767 aneurysms. Most (86%) of the aneurysms had at least 1 complexity characteristic, with the majority having 3 characteristics. The most often encountered complexity characteristics were the presence of a broad neck and the presence of branches emerging from the aneurysm. Use of temporary clipping and skull base approaches was significantly higher in the young vascular neurosurgeons group (P < 0.0001). The complexity score differed significantly between senior and young vascular neurosurgeons (P < 0.001). After propensity score matching for complexity, multivariable logistic regression showed young vascular neurosurgeons to be significantly associated with better outcomes for ruptured aneurysms (propensity score weighted odds ratio 0.55 [95% confidence interval 0.35-0.88], P = 0.01). CONCLUSIONS: In a high-volume neurovascular center where both endovascular and microsurgical treatment options are available, young vascular neurosurgeons can be trained to achieve at least the same results as their senior colleagues despite increased complexity.

A randomised trial of high and low pressure level settings on an adjustable ventriculoperitoneal shunt valve for idiopathic normal pressure hydrocephalus: results of the Dutch evaluation programme Strata shunt (DEPSS) trial.

BACKGROUND: In treating idiopathic normal pressure hydrocephalus (INPH) with a shunt there is always a risk of underdrainage or overdrainage. The hypothesis is tested whether patients treated using an adjustable valve preset at the highest opening pressure leads to comparable good clinical results with less subdural effusions than in a control group with an opening pressure preset at a low pressure level. METHODS: A multicentre prospective randomised trial was performed on a total of 58 patients suspected of INPH. Thirty patients were assigned to (control) group 1 and received a Strata shunt (Medtronic, Goleta, USA) with the valve preset at a performance level (PL) of 1.0, while 28 patients were assigned to group 2 and received a Strata shunt with the valve preset at PL 2.5. In this group the PL was allowed to be lowered until improvement or radiological signs of overdrainage were met. RESULTS: Significantly more subdural effusions were observed in the improved patients of group 1. There was no statistically significant difference in improvement between both groups overall. CONCLUSIONS: On the basis of this multicentre prospective randomised trial it is to be recommended to treat patients with INPH with a shunt with an adjustable valve, preset at the highest opening pressure and lowered until clinical improvement or radiological signs of overdrainage occur although slower improvement and more shunt adjustments might be the consequence.

Cavernous hemangioma of the mesencephalon: tonsillouveal transaqueductal approach.

OBJECTIVE: Recent advances in microsurgical techniques facilitate surgical resection of brainstem lesions that were previously considered inoperable. In this article we present, for the first time, the tonsillouveal transaqueductal approach to access a progressively symptomatic cavernoma within the depth of the tegmentum of the mesencephalon. METHODS: A 52-year-old woman presented with a history of slowly progressive right-sided hemiparesis and ataxia. On magnetic resonance imaging, a relatively large cavernoma involving the tegmentum of the mesencephalon was shown. The sylvian aqueduct was patent and there was no secondary ventriculomegaly. The patient underwent surgery via a suboccipital craniotomy and C1 laminectomy. The right tonsillouveal and medullotonsillar spaces were opened to the level of the choroidal point of the posteroinferior cerebellar artery. The tela choroidea was incised from the foramen of Magendie to the telovelar junction. Looking through the aqueduct and at a point 5 mm superior to its inferior inlet, there was a small cherry-like blister protruding into the aqueductal anterior surface. This was used as an entry point to access the cavernoma. The space around the cavernoma was gently dissected and the cavernoma was circumferentially coagulated to shrink it in a concentric manner toward its center. RESULTS: The total removal of the lesion was achieved and the histopathological findings were consistent with a cavernoma. As a result of noncommunicating hydrocephalus, the patient needed a ventriculoperitoneal shunt. The 1-year postoperative neurological examination was consistent with preoperative findings. CONCLUSION: This report shows, for the first time, direct surgical removal of a cavernous hemangioma in the mesencephalic tegmentum via the aqueduct. This approach adds to contemporary microneurosurgery, respecting functional anatomy and minimizing neurological deficits.

Desmoplastic infantile astrocytoma and ganglioglioma: a search for genomic characteristics.

In the present study the clinical data, histology, proliferation rate, DNA ploidy status and the results of TP53 mutation analysis and comparative genomic hybridization (CGH) of three typical cases of desmoplastic infantile astrocytoma and ganglioglioma are presented. Postoperative disease-free intervals of 11, 8 and 3 years were recorded and in none of the cases were radiological signs of tumor recurrence. No TP53 mutations (exons 5-8) were found. CGH analysis revealed loss of 8p22-pter in one case, while in another case gain of 13q21 was detected. In the case with the follow-up of 11 years an aneuploid DNA-flow cytogram along with slightly increased MIB-1 labeling index (LI) was found. The results demonstrate little genetic instability in these low-grade lesions. DNA-aneuploidy seems not to be indicative of tumor progression. It is concluded that the genetic aberrations found in desmoplastic infantile ganglioglioma differ from those encountered in common astrocytomas.