Intradural extramedullary pleomorphic xanthoastrocytoma: A case report.

BACKGROUND: Pleomorphic xanthoastrocytomas (PXAs) are uncommon intradural and typically intramedullary astrocytic central nervous system tumors. Although they commonly occur supratentorially, they are rarely seen in the spine. CASE DESCRIPTION: A 43-year-old male presented with cervical neck pain and right-sided radicular symptoms. He was found to have an intradural extramedullary mass at the C5-C6 level. The lesion was fully excised and proved to be a PXA. Of interest, the lesion did not recur on postoperative MR imaging studies obtained 7 months later. CONCLUSION: While rare, primary intradural extramedullary spinal PXA has been reported. Here, we review such a lesion occurring in a 43-year-old male who did well following gross total excision of the tumor.

Microsurgical Clipping of an Anterior Communicating Artery Aneurysm Using a Novel Robotic Visualization Tool in Lieu of the Binocular Operating Microscope: Operative Video.

INTRODUCTION: The binocular operating microscope has been the visualization instrument of choice for microsurgical clipping of intracranial aneurysms for many decades. OBJECTIVE: To discuss recent technological advances that have provided novel visualization tools, which may prove to be superior to the binocular operating microscope in many regards. METHODS: We present an operative video and our operative experience with the BrightMatterTM Servo System (Synaptive Medical, Toronto, Ontario, Canada) during the microsurgical clipping of an anterior communicating artery aneurysm. To the best of our knowledge, the use of this device for the microsurgical clipping of an intracranial aneurysm has never been described in the literature. RESULTS: The BrightMatterTM Servo System (Synaptive Medical) is a surgical exoscope which avoids many of the ergonomic constraints of the binocular operating microscope, but is associated with a steep learning curve. The BrightMatterTM Servo System (Synaptive Medical) is a maneuverable surgical exoscope that is positioned with a directional aiming device and a surgeon-controlled foot pedal. While utilizing this device comes with a steep learning curve typical of any new technology, the BrightMatterTM Servo System (Synaptive Medical) has several advantages over the conventional surgical microscope, which include a relatively unobstructed surgical field, provision of high-definition images, and visualization of difficult angles/trajectories. CONCLUSION: This device can easily be utilized as a visualization tool for a variety of cranial and spinal procedures in lieu of the binocular operating microscope. We anticipate that this technology will soon become an integral part of the neurosurgeon's armamentarium.

Spinal vascular malformations: treatment strategies and outcome.

Spinal vascular malformations (SVMs) are a heterogeneous group that can cause acute, subacute, or chronic spinal cord dysfunction. The majority of the patients present to neurosurgical attention after a protracted course with severe neurological dysfunction. Spinal vascular lesions comprise approximately 3-4 % of all intradural spinal lesions. They are pathologically similar to their intracranial counterparts, but their clinical impact is often comparatively worse. Early, correct recognition of the pathology is mandatory to halt the progression of the disease and minimize permanent spinal cord injury. The first clinical observation of a SVM was published in 1890, but it was not until 1914 that the first successful surgical treatment of a spinal vascular malformation was reported. Intervention-either by microsurgical or endovascular means-aims to halt or reverse the progressive neurological deterioration by eliminating flow through the abnormal fistulous or nidal connections, and restoring normal spinal cord perfusion and intravascular pressures. In fact, complex spinal arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) frequently require a multimodality approach that utilizes both microsurgery and endovascular embolization effectively. The goal of this review is to describe the various types of vascular malformations of the spine, their pathophysiology, clinical presentation, treatment strategies, and outcome. For purposes of discussion on the current manuscript, vascular malformations of the spine were divided into arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs). Spinal cord aneurysms are extremely rare, and the majority of the lesions that come to the neurosurgeon's attention are concomitant to a spinal AVM.

Atypical Meningiomas: Recurrence, Reoperation, and Radiotherapy.

INTRODUCTION: Atypical meningiomas (World Health Organization [WHO] grade II) represent a therapeutic challenge given their high recurrence rate and greater mortality compared with WHO grade I meningiomas. Traditionally, treatment has entailed attempts at gross total resection with radiation therapy reserved for residual disease or recurrences. METHODS: We retrospectively reviewed our patient database of atypical meningioma (AM) patients over the past 10 years to assess surgical and radiotherapeutic treatments administered, treatment-related complications, radiographic-clinical progression after treatment, and mortality. We identified 45 patients with AMs and excluded 2 patients with incomplete hospital records. RESULTS: The average age of our patients was 59.7 years. Forty-three AM patients underwent a total of 62 surgeries. Thirty patients underwent one initial surgical resection; 8 patients underwent a second resection for recurrence; 4 patients underwent 3 resections; and 1 patient underwent 4 resections for recurrences. The rate of postoperative complication was 12.9% (8/62). Five patients had postoperative wound infections requiring treatment, and 1 patient had a postoperative hematoma requiring surgical evacuation. There was 1 case of wound breakdown in a patient with a previously irradiated scalp and 1 case of lower-extremity venous thrombosis. Clinical follow-up ranged from 11-120 months with average follow-up of 43 months and median follow-up of 65 months. Nineteen patients (44%) developed clinical-radiographic evidence of recurrence at an average of 32.4 months after surgical resection. Of the recurrences, 12 were treated with repeat surgery and radiation therapy, 3 were treated with radiation therapy alone, and 2 with surgery alone. Radiation therapy included Gamma Knife (GK), CyberKnife (CK), intensity-modulated radiation therapy (IMRT), or some combination of these. There was one case of symptomatic radiation necrosis (1/15 or 6.6%). The survival rate at last follow-up of our patient cohort was 95.3%. CONCLUSIONS: Given their high rates of recurrence, AMs require close clinical follow-up and an individualized treatment strategy. Reoperation, radiotherapy, or combination therapy can be effective strategies at managing disease progression while minimizing treatment-related morbidity. Treatment planning that attempts to anticipate future therapies in the form of further surgery or radiotherapy may improve clinical outcomes in these patients. Seventeen patients underwent adjuvant radiation therapy: 7 patients with intensity-modulated radiation therapy (IMRT), 4 patients with Gamma Knife (GK), and 2 with CyberKnife (CK). Four patients underwent multiple treatments.

Management of intracranial aneurysms associated with arteriovenous malformations.

Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%-58%), with 10%-20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%-4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients' risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.

Autologous and acrylic cranioplasty: a review of 10 years and 258 cases.

INTRODUCTION: Cranioplasty is a well-accepted neurosurgical procedure that has application to a wide range of pathologies. Given the varied need for both autologous and synthetic cranial grafts, it is important to establish rates of procedural complication. METHODS: A retrospective review identified 282 patients undergoing cranioplasty at our institution over a 10-year period, of which 249 patients underwent 258 cranioplasties with either autologous or acrylic flaps. A database including patient age, gender, presenting diagnosis, hospital of surgery, presence of a drain, and surgical complications was created in order to analyze the autologous and acrylic cranioplasty data. RESULTS: A total of 28 complications were noted, yielding a rate of 10.9% (28/258). There was no statistically significant difference in infection rate between autologous and acrylic cranioplasty (7.2% vs. 5.8%, P=0.80). Male patients (P=0.007), tumor patients (P=0.02), and patients undergoing surgery at the county hospital (P=0.06) sustained a statistically higher rate of infection. Among traumatic brain injury patients, complex injuries and surgical involvement of the frontal sinus carried a significantly higher infection rate of 17% and 38.5%, respectively (P=0.03, P=0.001). Postoperative epidural hematoma requiring reoperation occurred in 3.5% (9/258) with no difference in hematoma rate with placement of a drain (P=1). CONCLUSIONS: Cranioplasty carries a significant risk of infection and postoperative hematoma. In this large series comparing autologous and acrylic flaps, male patients, tumor patients, and those undergoing surgery at the county hospital were at increased risk of postoperative infection. Among traumatic brain injury cases, complex injuries and cases with surgical involvement of the frontal sinus may portend a higher risk.

The far-lateral approach for foramen magnum meningiomas.

Foramen magnum meningiomas (FMMs) are slow growing, most often intradural and extramedullary tumors that pose significant challenges to the skull base neurosurgeon. The indolent clinical course of FMMs and their insidious onset of symptoms are important factors that contribute to delayed diagnosis and relative large size at the time of presentation. Symptoms are often produced by compression of surrounding structures (such as the medulla oblongata, upper cervical spinal cord, lower cranial nerves, and vertebral artery) within a critically confined space. Since the initial pathological description of a FMM in 1872, various surgical approaches have been described with the aim of achieving radical tumor resection. The surgical treatment of FMMs has evolved considerably over the last 4 decades due to the progress in microsurgical techniques and development of a multitude of skull base approaches. Posterior and posterolateral FMMs can be safely resected via a standard midline suboccipital approach. However, controversy still exits regarding the optimal management of anterior or anterolateral lesions. Independently of technical variations and the degree of bone removal, all modern surgical approaches to the lower clivus and anterior foramen magnum derive from the posterolateral (or far-lateral) craniotomy originally described by Roberto Heros and Bernard George. This paper is a review of the surgical management of FMMs, with emphasis on the far-lateral approach and its variations. Clinical presentation, imaging findings, important neuroanatomical correlations, recurrence rates, and outcomes are discussed.

The treatment of cavernous sinus meningiomas: evolution of a modern approach.

Cavernous sinus meningiomas (CSMs) are challenging lesions for the skull base neurosurgeon to manage given their close association with cranial nerves II-VI and the internal carotid artery. In the 1980s and early 1990s, with advancements in microsurgical techniques, increasing knowledge of the relevant microsurgical neuroanatomy, and the advent of advanced skull base surgical approaches, the treatment of CSMs involved attempts at gross-total resection (GTR). Initial fervor for a surgical cure waned, however, as skull base neurosurgeons demonstrated the limits of complete resection in this region, the ongoing issue of potential tumor recurrences, and the unacceptably high cranial nerve and vascular morbidity associated with this strategy. The advent of radiosurgery and its documented success for tumor growth control and limited morbidity in cavernous lesions has helped to shift the treatment goals for CSMs from GTR to tumor control and symptom relief while minimizing treatment- and lesion-associated morbidity. The authors review the relevant microanatomy of the cavernous sinus with anatomical and radiographic correlates, as well as the various treatment options. A modernized, multimodality treatment algorithm to guide management of these lesions is proposed.

Development of contrast-induced nephropathy in subarachnoid hemorrhage: a single center perspective.

BACKGROUND AND PURPOSE: The use of iodinated contrast-enhanced imaging studies is increasing in acute cerebrovascular diseases, especially in subarachnoid hemorrhage (SAH). In SAH, such studies are essential for both diagnosis and treatment of the cause and sequela of hemorrhage. These patients are often subjected to multiple contrast studies such as computed tomographic angiography, computed tomographic perfusion, and cerebral angiography. They are also predisposed to intravascular volume depletion as a part of the disease process from cerebral salt wasting (CSW) and as a result of multiple contrast exposure can develop contrast-induced nephropathy (CIN). Data regarding CIN in this population are scarce. We aimed to examine the incidence of CIN in SAH and identify potential associative risk factors. METHODS: We analyzed data from a prospectively collected patient database of patients with SAH admitted to the neurocritical intensive care unit in a single center over a period of 1 year. CIN was defined as an increase in serum creatinine by >1.5 times or >0.3 mg/dl greater than the admission value, or urine output <0.5 ml/kg/h during one 6-h block. RESULTS: In this cohort of 75 patients with SAH who had undergone at least one contrast study, the mean age was 57.3 ± 15.6 years and 70.7% were women. Four percent developed CIN which resolved within 72 h and none required renal replacement therapy or dialysis. Patients older than 75 years (20%, p < 0.05), those with borderline renal function (14.3%, p = 0.26), diabetics (11.1%, p = 0.32), and those with lower recommended "maximum contrast dose" volume (33.3%, p = 0.12) had a trend toward development of CIN, although most were not statistically significant. Twenty-seven patients (36 %) were on 3% hypertonic saline (HTS) for CSW during the contrasted study but none developed CIN. CONCLUSIONS: The incidence of CIN in SAH patients is comparable to previously published reports on non-neurological cohorts. No definite association was noted with any predisposing factors postulated to be responsible for CIN, except for advanced age. Concurrent use of 3% HTS was not associated with CIN in this population.