Surgical Management of Aneurysmal Hematomas: Prognostic Factors and Outcome.

From 1991 until 2013, 304 patients with intracranial hematomas from aneurysmal rupture were managed surgically in our department, constituting 17 % of all patients with aneurysmal rupture. Of them, 242 patents presented with isolated intracerebral hematomas (in 69 cases associated with significant intraventricular hemorrhage), 50 patients presented with combined intracerebral and subdural hematomas (in 11 cases associated with significant intraventricular hemorrhage), and 12 presented with an isolated subdural hematoma. The surgical procedure consisted of simultaneous clipping of the aneurysm and evacuation of the hematoma in all cases. After surgery, 16 patients (5 %) submitted to an additional decompressive hemicraniectomy, and 66 patients (21 %) submitted to a ventriculo-peritoneal shunt. Clinical outcomes were assessed at discharge and at 6 months, using the modified Rankin Scale (mRS); a favorable outcome (mRS 0-2) was observed in 10 % of the cases at discharge, increasing to 31 % at 6 months; 6-month mortality was 40 %. Applying uni- and multivariate analysis, the following risk factors were associated with a significantly worse outcome: age >60; preoperative Hunt-Hess grades IV-V; pupillary mydriasis (only on univariate); midline shift >10 mm; hematoma volume >30 cc; and the presence of hemocephalus (i.e., packed intraventricular hemorrhage). Based on these results, an aggressive surgical treatment should be adopted for most cases with aneurysmal hematomas, excluding patients with bilateral mydriasis persisting after rescue therapy.

Surgical exclusion of unruptured middle cerebral artery aneurysms: experience of 126 cases.

A group of 126 surgical patients with 143 unruptured MCA aneurysms was evaluated in order to determine the risks of treatment and possible adjuncts for safer surgery. The precise location and size of the aneurysms were determined in each case; 21 aneurysms were located on the M1 tract, 109 on the main division - which consisted of more than two branches in 10 cases and was proximally located in 12 cases - and 13 were distal; 36 aneurysms were small (<7 mm), 90 standard, and 17 large or giant (>15 mm); 45 patients harbored multiple aneurysms (12 on the ipsilateral MCA). The aneurysms were excluded by clip in most cases, with the assistance of intraoperative flowmetry in 78 patients. Temporary proximal vessel occlusion was used in 57 patients (>10 min in 8 cases), without significant effects on radiological or clinical outcome. After surgery, newly occurring minor deficits were observed in 5 patients and significant deficits in 4; one patient died from an intractable coagulopathy. The low rate (3.9 %) of unfavorable results (modified Rankin Score > 2) linked to surgery justifies serious consideration for treatment in these patients, especially when facing the high disability rate after the rupture of aneurysms in this anatomical location.

Surgery after embolization of cerebral arterio-venous malformation: experience of 123 cases.

A group of 123 patients with large or critically located arterio-venous malformations (AVMs), operated on between 1990 and 2011 and who underwent preoperative embolization, was assessed in order to clarify the risks of this combined treatment. AVM location, volume, and Spetzler's grade were assessed in each case; AVM volume was over 20 cm(3) in 49 % of the cases; Spetzler's grade was 3 or above in 76 % of the cases (with 34 cases in grades 4-5). A mean of 2.3 embolization procedures per patient were carried out, using bucrylate and, more recently, Onyx and/or Glubran; a 4.5 % procedure-related complication rate was observed. Complications occurring after surgery were classified as hemorrhagic (16 cases, 8 requiring surgical evacuation) or ischemic (4 cases); hemorrhagic complications were more common for AVMs with volumes >20 cm(3) and/or deep feeders. Surgery-related unfavorable results (modified Rankin Score > 2) were observed in 6 % of patients in Spetzler's grade 3, and in 20-25 % of patients in grades 4-5. More recently, a triple treatment (radiosurgery + embolization + surgery) allowed for obtaining favorable results (mRS 0-2) in all patients. It has been concluded that a combined treatment with embolization and surgery constitutes a reasonable choice for complex cerebral AVMs; the association of radiosurgery may improve the patients outcome.

Results of surgery for cavernomas in critical supratentorial areas.

A total of 121 patients surgically treated between 1991 and 2011 for cavernomas in critical supratentorial areas were evaluated. Anatomical location, size and the possible association with developmental venous anomalies (DVA) were assessed in each case: 43 cavernomas were in the speech area, 39 were rolandic (or peri-rolandic), 14 insular, 10 nuclear, 9 calcarine and 6 ventricular. In 49 % of the cases, the cavernoma was <1.5 cm; in 6 patients, radiological growth was documented. A method of intraoperative localization was adopted in 78 cases: B-mode echography or a stereotactic guide in 22 cases, and a neuronavigation system in 56 cases; preoperative angiography was done in 22 cases. Early postoperative epilepsy (within 7 days of surgery) was observed in 15 cases. As for clinical outcome, 14 patients presented with mild symptoms (modified Rankin Scale 1-2); significant deficits occurred ex-novo in 5 patients. The presence of epilepsy at follow-up was assessed through the Maraire Scale: 44 % of patients presenting with epilepsy were free of seizures and without therapy at a mean follow-up of 4.6 years, and an additional 55 % had complete control of seizures with therapy. It is concluded that surgery is indicated in the management of cavernomas in critical supratentorial locations, with a caveat for insula and especially basal ganglia.

Cognitive outcome as part and parcel of clinical outcome in brain tumor surgery.

Although validated tools (neuropsychological tests, patient reported outcomes, mood and psychological profile) were first introduced many years ago in clinical practice, the impact of the tumor itself on patient cognition has not been extensively studied. Furthermore, while outcome research is evolving in an attempt to adapt the use of different tools to the preoperative and postoperative phases, the standard guidelines for evaluating outcome after brain surgery, by neurological examination and complication assessment, are frequently neglected in the current literature. This article attempts to provide an appraisal of the evidence for the impact of surgical treatment on cognitive function of brain tumor patients within the context of general outcome.