The Anterior Trans-Superior Temporal Gyrus Approach for Selective Amygdalohippocampectomy.

BACKGROUND: Different surgical approaches have been described for selective amygdalohippocampectomy in patients with pharmacoresistant temporal lobe epilepsy. The aim of this study was to report the results of the innovative anterior trans-superior temporal gyrus approach in a single-center series. METHODS: Patients' characteristics, postoperative outcomes, and complications were reviewed in a series of 8 consecutive patients with temporal lobe epilepsy operated on using the anterior trans-superior temporal gyrus approach between November 2015 and April 2017. RESULTS: Over a mean 2.5-year follow-up, 7 of 8 patients (87.5%) remained seizure-free (Engel class I). Only 1 patient (12.5%) was not cured (Engel class III) with no clear explanation for treatment failure. Mean operative time was 237 minutes, which was 80 minutes shorter compared with the classic transsylvian approach. No perioperative deaths were recorded and there were no visual field defects or visual acuity impairments secondary to the approach. One patient experienced a left posterior thalamocapsular stroke. CONCLUSIONS: The anterior trans-superior temporal gyrus approach is feasible, fast, and safe for selective amygdalohippocampectomy in patients with drug-refractory temporal lobe epilepsy. This approach allows preservation of the optic radiation but cuts part of the uncinate fasciculus and potentially the anterior aspect of the anterior bundle of the middle longitudinal fasciculus.

Additional clinical value of voxel-based morphometric MRI post-processing for MRI-negative epilepsies: a prospective study.

Magnetic resonance imaging is of paramount importance in the presurgical evaluation of drug resistant epilepsy. Detection of a potentially epileptogenic lesion significantly improves seizure outcome after surgery. To optimize the detection of subtle lesions, MRI post-processing techniques may be of essential help. In this study, we aimed to evaluate the detection rate of the voxel-based morphometric analysis program (MAP) in a prospective trial. We aimed to study the MAP+ findings in terms of their clinical value in the decision-making process of the presurgical evaluation. We included, prospectively, 21 patients who had negative MRI by visual analysis. In a first step, results of the conventional non-invasive presurgical evaluation were discussed, blinded to the MAP results, in multidisciplinary patient management conferences to determine the possible seizure onset zone and to set surgical or invasive evaluation plans. Thereafter, MAP results were presented, and the change of initial clinical plan was recorded. All MAP detections were reaffirmed by a neuroradiologist with epilepsy expertise. For the 21 patients included, mean age at the time of patient management conference was 26 years (SD 15 +/- years, range: 5-54 years). In total, 4/21 had temporal lobe epilepsy and 17/21 had extra-temporal lobe epilepsy. MAP was positive in 10/21 (47%) patients and in 6/10 (60%) a diagnosis of focal cortical dysplasia was confirmed after neuroradiologist review, corresponding to a 28% detection rate. MAP+ findings had a clear impact on the initial management in 7/10 patients (7/21, 33% of all patients), which included an adaptation of the intracranial EEG plan (6/7 patients), or the decision to proceed directly to surgery (1/7 patients). MRI post-processing using the MAP method yielded an increased detection rate of 28% for subtle dysplastic lesions in a prospective cohort of MRI-negative patients, indicating its potential value in epilepsy presurgical evaluation.

Clinical Outcome of Radiating Multiple Subpial Transections Alone for Drug Resistant Epilepsy After More Than 5 Years Follow-Up.

OBJECTIVE: Multiple subpial transection (MST) is a possible surgical treatment for patients with epileptogenic foci located in eloquent cortical areas. Commonly, it is performed in addition to other surgical techniques. In some cases, however, it is performed alone. We report the clinical results of 12 patients who received solely radiating MST with a minimal follow-up of 5 years. METHODS: All patients who underwent a surgical intervention between 2003 and 2012 for refractory epilepsy were studied. Among them, 12 had radiating MST (rMST) as the only surgical treatment with a follow-up of at least 5 years. RESULTS: At 5-year follow-up, 50% of the patients were Engel class I, 25% were Engel class II, 0% were Engel class III, and 25% were Engel class IV. At last follow-up, 8 patients (67%) were free of seizures, 1 patient (8%) had an over 75% decrease, and 3 patients (25%) did not improve after the procedure. None of the Engel I patients had seizure recurrence, and those belonging to an intermediate class improved during follow-up, in some cases in association with an antiepileptic drug modification. Two patients (17%) had a minor transient complication, and 1 patient (8%) had a minor permanent complication. CONCLUSIONS: rMST performed alone gives a favorable outcome in 75% of the patients at a minimum 5-year follow-up with few minor complications. This procedure appears to be effective even with a prolonged follow-up in drug resistant epilepsy with the epileptogenic foci located in eloquent areas.

Recanalization and rupture after intracranial aneurysm treatment.

BACKGROUND: Treatment of intracranial aneurysm (ICA) can sometimes require several procedures. The aim of this study was to analyze the risk of recanalization and rupture recurrence after ICA treatment by endovascular coiling (EVC) or surgical clipping (SC) on a very long follow-up. METHODS: Clinical data of 373 consecutive patients treated in our group between January 1996 and December 2006 as well by EVC as by SC for ruptured (RIA) or unruptured intracranial aneurysm (UIA), were reviewed. Patients were followed-up at least to August 2009. First radiologic follow-up done six months after EVC and between three and five years after SC (median time: 5 years). All patients underwent a clinical follow-up after treatment, at least by telephonic communication (median time: 6 years). RESULTS: Out of 197 patients with 198 RIAs, 82 (42%) patients underwent an endovascular treatment and 115 (58%) were allocated to surgical treatment. From a total of 176 patients with 229 UIAs, 66 (37.5%) patients were treated by 74 EVC; and 110 (62.5%) patients were treated with 124 surgical procedures. Fifteen recanalizations of coiled RIAs were detected and only one in the surgical group (27% vs. 2%; P= 0.0008). Of the 15 recanalizations in the EVC group, 6 (40%) were initially completely occluded. We observed two rebleedings, one in each group (1.4% for EVC; 1% for SC; P=0.8). CONCLUSIONS: Our findings during the longest reported follow-up confirm a greater risk of recanalization for RIA treated by EVC without so far a significant difference in the rerupture risk.

Granulomatous Reaction on a Double-Level Cervical Total Disc Arthroplasty.

BACKGROUND: Cervical total disc arthroplasty (TDA), or cervical artificial disc replacement, is an alternative technique to anterior cervical discectomy and fusion for treatment of symptomatic degenerative cervical spine disease. The main goal of TDA is to maintain cervical motion and lower the risk of deterioration of adjacent levels. Granuloma formation on a cervical TDA is exceptional. CASE DESCRIPTION: A 48-year-old woman with left cervicobrachialgia underwent a double-level TDA (M6-C Artificial Cervical Disc) on C5-C6 and C6-C7 at another hospital in 2010. Two years later, she reported a recurrence of cervicalgia, which was refractory to conservative treatment by rigid collar and analgesics. Cervical magnetic resonance imaging suggested a granulomatous formation on the C6-C7 prosthesis. She underwent removal of the C6-C7 prosthesis, which showed a rupture with nylon thread extrusion. An arthrodesis with plate was subsequently performed. Follow-up showed improvement of her clinical status. Histopathologic studies showed a giant cell granulomatous formation in contact with nylon threads described in hip, shoulder, and ankle arthroplasty. It has been described in 6 cases following lumbar TDA and 2 cases following cervical TDA. CONCLUSIONS: We report a third case of granulomatous reaction on nylon thread extrusion after partial breakdown of a prosthesis for cervical TDA.

Comparison of Dural Peeling versus Duraplasty for Surgical Treatment of Chiari Type I Malformation: Results and Complications in a Monocentric Patients' Cohort.

OBJECTIVE: Chiari malformation type I is typified by the downward herniation of the cerebellar tonsils through the foramen magnum, which can impede cerebrospinal fluid circulation and may lead to syringomyelia. The usual symptoms of this condition are neck pain and posterior headaches on Valsalva maneuver. Different surgical procedures have been described for cranio-cervical decompression (CCD), without a consensus being reached about the best suited technique. The primary end point of this study was to compare efficacy and complications rate of CCD using dural peeling (DPe) versus duraplasty (DP). The secondary end point was to find predictive factors of success of DPe. METHODS: Twenty-eight consecutive patients with Chiari malformation type I (12 women and 16 men) requiring CCD were enrolled at our institution between August 2011 and November 2015. Ten patients (35.7%) underwent DP, and 18 (64.3%) DPe. A standardized magnetic resonance imaging protocol was performed before and at least 3 months after surgery. Symptomatic outcome was evaluated at the last follow-up visit. RESULTS: Overall complications were more frequent in the DP (4 patients, 70%) group than in the DPe (none) group (P <0.05). All patients in the DP group improved clinically but only 12 patients (66.7%) in the DPe group (P = 0.1). Morphologic evolution at magnetic resonance imaging was similar in both groups. A moderate trend for changes in cerebellar tonsil conformation was shown in patients with clinical improvement (P = 0.07). Predictive factors of clinical improvement after DPe cannot be identified. CONCLUSIONS: CCD with DPe was less risky than with DP but had a lower responsive rate (66.7% vs. 100). Larger studies are therefore warranted to assess predictive factors of success of CCD with DPe.

Transsylvian Transuncal Approach for an Anterior Midbrain Cavernous Malformation Resection: A Case Report.

BACKGROUND AND IMPORTANCE: Cavernous malformations (CMs) are vascular abnormalities with a hemorrhage risk of 0.2% to 5% per year, according to their location. Brainstem CMs seem to have a greater hemorrhagic risk and represent a neurosurgical challenge. We report here the first transsylvian transuncal (TS-TU) approach for an anteromedial mesencephalic CM resection. CLINICAL PRESENTATION: A 29-yr-old female suddenly presented a left hemiparesis and central facial paresis with a diplopia in the upward gaze. A cerebral imagery revealed an 18-mm right cerebral peduncle CM with signs of acute hemorrhage. Two months later, she rebleed while pregnant. The pregnancy was interrupted. Five months later, a 3.0 Tesla magnetic resonance imaging (MRI) with diffusion tensor imaging sequences was realized for preoperative planning followed by a gross total resection of the CM through a TS-TU approach to avoid the perforating arteries of the anterior perforated substance. The patient presented postoperatively again a left hemiparesis and central facial paresis with a right oculomotor nerve paresis. On the tenth postsurgical day, she developed a Holmes' tremor of the left upper limb, for which a Levodopa treatment was initiated. Three months postoperative, MRI showed a gross total resection of the mesencephalic CM without complications. A complete clinical recovery was observed 1 yr later. CONCLUSION: We describe here the first performance of a TS-TU approach for an anterior mesencephalic CM resection. This surgical approach allowed direct access to the CM, avoiding the vascularization of the anterior perforated substance.

Patients with refractory epilepsy treated using a modified multiple subpial transection technique.

BACKGROUND: : Multiple subpial transection (MST) is a potential surgical treatment for patients with epileptogenic foci located in cortical areas with higher functions. As neurosurgical teams have become more experienced with MST, the original technique has adapted. OBJECTIVE: : To report our 6-year experience with a modified MST technique. METHODS: : The population included 62 consecutive patients with medically refractory epilepsy treated by MST, with a follow-up period ranging from 2 to 9 years. MST was performed on gyri under neuronavigation and guided by intraoperative electrocorticography. We performed radiating MST from a single cortical entry point. The MST technique was described according to the number of transections performed and the Brodmann areas (BAs) involved. Any MST-related complications were registered and followed up. Clinical outcome was described in terms of seizure suppression or reduction according to the Engel modified classification. RESULTS: : Twelve patients underwent MST alone (MSTa), and 50 had MST with another procedure. The main MST sites were BA 4 (61%) and 3, 1, 2 (58%); in 22% of cases, MST was performed in BA 44, 22, 39, and 40. Permanent neurological deficits were observed in 4 (6.4%) patients; 2 minor deficits were MST related (3.2%). A reduction in the seizure rate of at least 50% was seen in 79% of patients (MSTa group, 75%), and 42% became seizure free (MSTa group, 33%). CONCLUSION: : This study demonstrates the efficacy and low morbidity of radiating MST performed under neuronavigation and intraoperative electrocorticography. ABBREVIATIONS: : BA, Brodmann areaEEG, electroencephalogramFDG, 18-fluorodeoxyglucoseioECoG, intraoperative electrocorticographyMRE, medically refractory epilepsyMST, multiple subpial transectionMSTa, multiple subpial transection aloneMST+, multiple subpial transection with other procedures.

Long term outcome of anterior cervical discectomy and fusion using coral grafts.

BACKGROUND: To determine the long term efficacy of coral grafts in anterior cervical discectomy and fusion. METHODS: In this prospective longitudinal study, All patients presenting with myelopathy and/or radiculopathy due to discal hernia or cervical spondylosis underwent anterior cervical microdiscectomy, arthrodesis with coral, and stabilization with anterior cervical locking plates. Clinical and radiological post-operative evaluations were performed at 2 days, 3, 6, and 12 months, and then yearly. The visual analogue scale was used for the evaluation of pain. Fusion was defined as the absence of motion on dynamic imaging combined with the disappearance of radio-lucent lines around the graft. The mean follow-up period was 44 months. In 83.3%, 91.2% and 93.7% of patients there was a satisfactory outcome for neck pain, arm pain, and motor deficit, respectively. The overall complication rate was 17.5%, all of which were transient. Additional surgery was required in nine cases. The occurrence of complications is correlated with less satisfactory outcomes for both neck and arm pain. While 95.5% of patients expressed overall satisfaction with their surgery, 70.5% stated that they had returned to their previous activities. The fusion rate was 45%; which was not correlated with clinical outcome and more likely in patients with of cervical spondylosis and one-level arthrodesis. CONCLUSIONS: Despite satisfactory clinical results and a long follow-up period, coral implants yield low fusion rates, particularly in patients with discal hernia of two-level arthrodesis. The use of coral grafts cannot be recommended when fusion is one of the post-operative endpoints.

Surgical management of unruptured intracranial aneurysms that are inappropriate for endovascular treatment: experience based on two academic centers.

OBJECTIVE: To analyze the results of the surgical management of unruptured intracranial aneurysms (UIA) when coil embolization (CE) was considered first but deemed inappropriate by our multidisciplinary groups. METHOD: In two institutions, all UIAs recommended for treatment were considered first for a CE procedure if accessibility, neck width, and fundus-to-neck ratio were appropriate. Patients with UIAs considered inappropriate for CE were to undergo a surgical clipping procedure. We reviewed the medical records of all patients who underwent surgical clipping between February 1996 and February 2006. RESULTS: A total of 325 patients with 440 UIAs were treated. Of them, 149 patients were selected by our multidisciplinary staff for treatment by CE, and 176 patients with 238 UIAs were treated by 207 surgical procedures. Angiographic studies revealed complete occlusion in 95% and near total occlusion in 2.5% of surgically treated UIAs. No deaths related to surgery occurred. Sixteen patients (9.1%) experienced postoperative complications, four of which persisted 1 year after surgery (two cases of diplopia and two aphasic disorders). The 1-year morbidity rate was 2.2% (four of 176) by patient and 1.7% (four of 238) by aneurysm. For UIAs smaller than 10 mm in patients younger than 65 years old, the morbidity rate was 0.56%. CONCLUSION: Our results gathered from two centers with the same management of UIAs show that SC remains a safe and effective treatment for UIAs even when CE is considered first.

Intraoperative magnetic resonance imaging at 3-T using a dual independent operating room-magnetic resonance imaging suite: development, feasibility, safety, and preliminary experience.

OBJECTIVE: A twin neurosurgical magnetic resonance imaging (MRI) suite with 3-T intraoperative MRI (iMRI) was developed to be available to neurosurgeons for iMRI and for independent use by radiologists. METHODS: The suite was designed with one area dedicated to neurosurgery and the other to performing MRI under surgical conditions (sterility and anesthesia). The operating table is motorized, enabling transfer of the patient into the MRI system. These two areas can function independently, allowing the MRI area to be used for nonsurgical cases. We report the findings from the first 21 patients to undergo scheduled neurosurgery with iMRI in this suite (average age, 51 +/- 24 yr; intracranial tumor, 18 patients; epilepsy surgery, 3 patients). RESULTS: Twenty-six iMRI examinations were performed, 3 immediately before surgical incision, 9 during surgery (operative field partially closed), and 14 immediately postsurgery (operative field fully closed but patient still anesthetized and draped). Minor technical dysfunctions prolonged 10 iMRI procedures; however, no serious iMRI-related incidents occurred. Twenty-three iMRI examinations took an average of 78 +/- 20 minutes to perform. In three patients, iMRI led to further tumor resection because removable residual tumor was identified. Complete tumor resection was achieved in 15 of the 18 cases. CONCLUSION: The layout of the new complex allows open access to the 3-T iMRI system except when it is in use under surgical conditions. Three patients benefited from the iMRI examination to achieve total resection. No permanent complications were observed. Therefore, the 3-T iMRI is feasible and appears to be a safe tool for intraoperative surgical planning and assessment.

Surgical clipping may lead to better results than coil embolization: results from a series of 101 consecutive unruptured intracranial aneurysms.

OBJECTIVE: Recent reports in the literature have described a significant discrepancy in adverse outcomes between coil embolization (CE; 10%) and surgical clipping (SC; 25%) for the management of unruptured intracranial aneurysms (UIA). This discrepancy led us to analyze our experience. METHODS: In 1996, we designed a prospective study of patients with UIA in which CE was considered the treatment of choice and was performed if the interventional neuroradiologists deemed the aneurysm's fundus-to-neck ratio accessible for CE. SC was performed only if complete CE was unlikely to be achieved or in patients in whom CE already had failed. RESULTS: CE was performed in 38 patients with at least one UIA (41 UIAs, 83% in the anterior circulation). SC was performed in 39 patients with at least one UIA unsuitable for CE (59 UIAs, including 6 after failed CE, 96.5% in the anterior circulation). For CE, the total obliteration rate was 56.1%, the subtotal was 14.6%, and CE failed in 29.3%. There were transient complications in 10% of the cases and permanent complications in 7.5%. Of the 12 failed CE procedures, 7 (58%) were performed for middle cerebral artery aneurysms. For SC, the total obliteration rate was 93.2%, the subtotal was 1.7%, and SC failed (wrapping) in 5.1%. There were transient complications in 16.3% of the patients and permanent complications in 1.7%. The success rate for CE was similar to that for SC only when CE was used for aneurysms with a fundus-to-neck ratio of at least 2.5. CONCLUSION: SC can produce better results than CE in patients with UIA of the anterior circulation. CE as a first-line treatment should be reserved for patients with UIAs with a fundus-to-neck ratio of 2.5 or greater.