Endovascular treatment of small cerebral arteriovenous malformations as a primary therapy.

PURPOSE: The patient population that would benefit most from endovascular curative treatment of intracranial arteriovenous malformations is not clearly established. The aim of the study was to determine the effect of curative embolization of cerebral arteriovenous malformations with special regard to radiographic and clinical outcomes and procedure-related complications. MATERIAL AND METHODS: Between January 2009 and December 2014, 18 patients with intracranial arteriovenous malformations were embolized with Onyx with intent to cure. There were 4 women and 14 men with a mean age of 40 years (range 10-62 years). Inclusion criteria were: maximal diameter of the lesions ≤ 3 cm and arterial supply consisting of no more than 2 major arteries. There were 5 (27.8 %) patients with ruptured and 13 (72.2%) with unruptured lesions. Mean arteriovenous malformations size was 2.3 cm (range 1.5-2.9 cm). RESULTS: Thirty-three procedures were performed in 18 patients. Total obliteration was achieved in 5 patients (27.8%). The most common reason for initial incomplete angiographic occlusion were unfavorable angioarchitectural features of arteriovenous malformations with the rate of 44.4%. The mean follow-up of patients with complete occlusion was 35.2 months (range 18-60 months). Complication rate was 12.1%. One patient had permanent neurological deficit with resulting morbidity of 5.6%. There were no deaths. CONCLUSIONS: Embolization of intracranial arteriovenous malformations plays a limited role as a sole therapeutic modality even in terms of small lesions with two or less arterial feeders, although larger prospective series are necessary to confirm your findings. Associated complications are not trivial and should be considered when choosing this form of treatment.

Endovascular Approach to Glomus Jugulare Tumors.

BACKGROUND: Paragangliomas are benign neuroendocrine tumors derived from the glomus cells of the vegetative nervous system. Typically, they are located in the region of the jugular bulb and middle ear. The optimal management is controversial and can include surgical excision, stereotactic radiosurgery and embolization. CASE REPORT: We report the endovascular approach to three patients harboring glomus jugulare paragangliomas. In all cases incomplete occlusion of the lesions was achieved and recanalization in the follow-up period was revealed. Two patients presented no clinical improvement and the remaining one experienced a transient withdrawal of tinnitus. CONCLUSIONS: It is technically difficult to achieve complete obliteration of glomus jugulare tumors with the use of embolization and the subtotal occlusion poses a high risk of revascularization and is not beneficial in terms of alleviating clinical symptoms.

Progressive regression of intracranial arteriovenous malformations after Onyx embolization.

Progressive regression of cerebral arteriovenous malformations (AVMs) is a rare phenomenon that may occur spontaneously or after previous surgical or endovascular incomplete obliteration. We present two cases of AVMs occluded partially with Onyx followed by the unexpected cure of the lesions with the angiographic evidences as well as multiannual follow-up.

Stent-Assisted Endovascular Treatment of Anterior Communicating Artery Aneurysms - Literature Review.

The anterior cerebral artery is a common location of intracranial aneurysms. The standard coil embolization technique is limited by its inability to occlude wide-neck aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes. In this article, various management strategies and techniques as well as angiographic outcomes and complications related to stent-assisted endovascular treatment of anterior communicating artery aneurysms are presented. This treatment method is safe and associated with low morbidity and mortality rates.

Stand-alone coil embolization of anterior communicating artery aneurysms: Efficacy and technical issues.

OBJECTIVE: We report our experience with endovascular coiling of anterior communicating artery aneurysms with special consideration of angiographic and clinical outcomes and periprocedural complications. MATERIALS AND METHODS: The analysis included treatment results of 28 patients with ruptured and unruptured aneurysms. The aneurysm size ranged from 1.8 to 9.8 mm (mean 5.2, SD 1.7). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially post-embolization and at a minimum follow-up of six months. RESULTS: Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 27 (96%) cases and incomplete occlusion in one (4%) case. Imaging follow-up, performed in 15 (53.6%) patients, showed no change in the degree of occlusion in 11 (73%), coil compaction in one (7%) and progressive occlusion in three (20%) patients. Three (20%) patients underwent a second coil embolization. The procedure-related severe morbidity and mortality rate was 6.4% (2/31). Coil prolapse was present in one (3.2%) case and intraprocedural aneurysm rupture in three (9.6%) cases. The clinical follow-up evaluation achieved in 19 (67.9%) patients showed no change in 17 (89.5%) patients and improvement in two (10.5%) patients. CONCLUSIONS: Although the efficacy of coil embolization of anterior communicating artery aneurysms is unquestionable and the procedure-related complications are acceptable, they should not be neglected. Further investigations are needed to better understand protective factors, as well as to establish unequivocally appropriate management strategy of these complications.

Stent-assisted embolization of wide-neck anterior communicating artery aneurysms: Review of consecutive 34 cases.

OBJECTIVE: We report our experience with stent-assisted coiling of anterior communicating artery aneurysms with special consideration of angiographic and clinical outcomes, retreatment rate and periprocedural complications. MATERIALS AND METHODS: The analysis included 34 consecutive ruptured and unruptured wide-neck aneurysms. The aneurysm size ranged from 2 to 18mm (mean 5.47). Clinical examinations with the use of modified Rankin Score and angiographic outcomes were evaluated initially post-embolization and at a minimum follow-up of 6 months. RESULTS: Initial post-treatment complete and near-complete aneurysm occlusion was achieved in 32 (94%) and 2 (6%) cases, respectively. Imaging follow-up, performed in 28 (82%) patients, showed no change in the degree of occlusion in 25 (89%) cases and coil compaction in 3 (11%) patients. Of these, one (3.6%) patient underwent a second coil embolization. The periprocedural severe complication rate was 2.9% (1/35) and was associated with prolonged attempt of retrieval of migrated coil resulting in anterior cerebral artery infarct with serious clinical consequences. In another 3 patients periprocedural adverse events without delayed clinical consequences were noticed. The clinical follow-up evaluation achieved in 33 (97%) patients showed no change in 30 (91%) cases, one patient (3%) with clinical improvement and two (6%) cases of neurological deterioration. CONCLUSIONS: The use of stent is feasible and effective for coil embolization of wide-necked anterior communicating artery aneurysms. Although periprocedural complications resulting in severe morbidity are rare, they should be noted, since in terms of thromboembolic events some of them presumably have a potential to be avoidable.

[Evaluation of the cochlear efferent system in patients with cerebello-pontine angle tumor]. / Ocena ukladu eferentnego slimaka u pacjentów z guzem kata mostowo-mózdkowego.

The aim of the study was to estimate a cochlear efferent system in the group of patents with cerebello-pontine angle tumor (CPA). The size of an efferent effect was defined as the difference of the amplitudes in click evoked otoacoustic emissions (CEOAEs) during without contralateral acoustic stimulation (CAS) and with broad-bond noise (BBN) was estimated. The research was also conducted on the influence of tumor dimensions, age, sex, and the hearing level in tonal audiometry on the size of the efferent effect. The research was carried out on a group of 14 patients with cerebello-pontine angle tumor and on an appropriate fourteen-person test group. Having our results analyzed we were able to state that, compared with the test group, in the group of patients with CPA tumor significant reduce suppressions of otoacoustic emission response during CAS occurred both in an ear on the tumor side and in an ear on the healthy side. However, the tumor dimensions, sex, and the hearing level in tonal audiometry seemed not to affect significantly the size of the efferent effect.

Intraoperative monitoring of cochlear function using distortion product otoacoustic emissions (DPOAEs) in patients with cerebellopontine angle tumors.

HYPOTHESIS: Intraoperative monitoring by distortion-product otoacoustic emissions reflects the cochlear function changes in the real-time domain during removal of cerebellopontine angle tumors. BACKGROUND: Cerebellopontine angle tumor surgery is associated with a significant risk of damaging internal auditory canal contents. Although monitoring facial nerve function intraoperatively has already been effectively developed, such efficacious monitoring of auditory function remains to be established. The aim of this study was to investigate the utility of distortion-product otoacoustic emissions for intraoperative monitoring of the cochlear function in humans during removal of cerebellopontine angle tumors. METHODS: Continuous intraoperative monitoring of distortion-product otoacoustic emissions was performed in 20 of 62 patients undergoing surgical removal of cerebellopontine angle tumors. All of these 20 patients, who underwent the retrosigmoid approach, had distortion-product otoacoustic emissions present preoperatively. Depending on the amplitude and frequency band at which distortion-product otoacoustic emissions were present, monitoring was carried out at 2.0 to 6.0 kHz with primary stimulus tone amplitudes of 60 to 70 dB sound pressure level. RESULTS: In patients operated on for cerebellopontine angle tumors, various patterns of distortion-product otoacoustic emission amplitude reductions and recoveries were observed. Distortion-product otoacoustic emissions recorded from the basal part of the cochlea (i.e., high frequencies) changed earlier and more profoundly than those from the middle and apical sections (i.e., lower frequencies). In some cases, cochlear function was affected irreversibly as reflected by loss of distortion-product otoacoustic emissions. Microcoagulation of small vessels, tumor debulking, and compression or stretch of the internal auditory canal contents were found to be procedures affecting distortion-product otoacoustic emissions. The status of distortion-product otoacoustic emissions at the conclusion of tumor dissection correlated with postoperative hearing levels. CONCLUSION: Distortion-product otoacoustic emissions were used to monitor in the real-time domain auditory function during cerebellopontine angle tumor removal operations. The status of distortion-product otoacoustic emissions at the conclusion of the operations was related to postoperative hearing.

Non-neoplastic, degenerative brain pathologies and fibroses diagnosed on the basis of ultra-small samples obtained by stereotactic biopsy.

Brain biopsy and other stereotactic procedures have evolved over the last decades. Recently, the morbidity and mortality decreased radically along with an increase in the number of successful histopathological diagnoses. Therefore, applications of appropriate treatments in neoplastic brain pathologies are now possible, especially of those located in deep regions. Stereotactic biopsy may also be used as a diagnostic method followed by appropriate management in conditions where a non-neoplastic pathology is suspected. Between December 2000 and February 2004, we performed 116 stereotactic procedures based on the system of stereotactic planning and Brain-Lab treatment, which was equipped with automatic CT/MR image fusion software. In this report, we have focused on 10 cases of non-neoplastic brain pathologies diagnosed on the basis of ultra-small samples obtained from stereotactic biopsy. Among them there were 4 cases of gliosis, 3 cases of brain degenerative disorders, 2 cases of hippocampal fibroses, and 1 case of normal brain tissue. We have presented all these cases in detail by discussing their histology, clinical manifestations, localisation, management and follow-up.

Correlation of facial nerve paresis and histopathological type of vestibular schwannoma.

The objective of the study was to evaluate the dependence of facial nerve paresis, as a symptom of cerebellopontine angle tumour, on the histopathological subtype of vestibular schwannoma, diagnosed from a post-operative histopathological examination. We retrospectively analysed 91 surgically treated patients with vestibular schwannoma. We studied the histopathological subtype and the preoperative condition of the facial nerve. The following WHO 2000 subtypes were distinguished: neurinoma cellular (51 cases), neurinoma conventional (23 cases), neurinoma ancient (11 cases), (other types: 2 neurofibroma and 2 ganglioneuroma). We analysed the dependence of facial nerve paresis on the histological subtype of tumours and their sizes. The analysis was based on the traditional classification: Antoni A (11 cases), Antoni B (12 cases) Antoni A/B (23 cases) and Antoni B/A (40 cases). 30 patients (30%) in the analysed group had paresis of the facial nerve preoperatively. Preoperative facial paresis occurred frequently in subtypes "cellular" and Antoni B, and rarely in subtypes conventional and Antoni A and B/A. In the small tumour cases (up to 20 mm), facial nerve paresis occurred frequently in subtypes cellular and conventional, as well as in Antoni A and A/B.

Stereotactic methods in interdisciplinary diagnosis and treatment of posterior fossa tumours.

For over 2 years, we have had access to latest generation apparatus and software for planning and stereotactic treatment as well as for x-rays treatment. Until now, we have carried out over 100 procedures. These included 52 stereotactic biopsies of neoplasms, some of them located within the structures of the posterior fossa. In this report, we have discussed the possibilities and effectiveness of diagnosis and treatment of tumours located in different structures, including posterior cave. In the study, we used stereotactic methods. We have described biopsies of the following tumours: cerebellar hemisphere tumour (diagnosed as "metastatic atypic planoepitheliale carcinoma" in a patient with coexisting orbit lymphoma), a bifocal lesion (located in cerebellar hemisphere and cerebellar peduncle, diagnosed as pilocytic astrocytoma of WHO malignancy grade II/III), and lesion (located in the pons, diagnosed as pilocytic astrocytoma WHO grade II).

[Multimodal intraoperative electrophysiological monitoring during cerebellopontine angle tumor surgery. Benefit or loss?]. / Wielomodalne sródoperacyjne monitorowanie elektrofizjologiczne w trakcie operacji guzów kata mostowo-mózdzkowego. Zysk czy strata?

In the Neurosurgery Department, Silesian University School of Medicine, continuous monitoring of selected neurophysiological functions of the central and peripheral nervous system was introduced in 1998 as a routine procedure in cerebellopontine angle surgery and some other operations performed in the petroclival region. Such benefits from this method as increased patient safety, availability of information about dynamic changes in the monitored structures, and the possibility of cranial nerves localization using stimulation in the operating area, are quite obvious. The paper presents results of a detailed statistical analysis of the amount of time required for preparation and for operating in 174 cerebellopontine angle tumor surgeries performed in the years 1986-2002 with (group M) and without (group BM, before the year 1998) intraoperative monitoring. Subgroups distinguished according to the histological type of tumor were evaluated. Out of 95 procedures performed in group M, 57 were operations of acoustic neurinoma cases, 15 meningiomas, 8 cases of epidermal cyst, and 15 other growth processes in the cerebellopontine angle region. Among 79 operations in group BM, there were 57 cases of acoustic neurinoma, 4 cases of meningioma, 8 cases of epidermal cyst, and 10 of other types of neoplastic growth. In group M as compared to group BM the pre-op. preparation time was found to be significantly longer in cases of the VIII-th nerve neurinoma, and of other tumors. No statistically significant differences in the amount of operating time in were found between any of the subgroups. Both radicality of tumor removal and facial nerve status have clearly improved since intraoperative monitoring was introduced.

[Endoscopic ventriculostomy of the third ventricle in adults. Own experience]. / Wentrikulostomia endoskopowa komory III u doroslych. Doswiadczenia wlasne.

Only few reports can be found on endoscopic third ventriculostomy (ETV) in the Polish literature, and the majority of other reports concern paediatric or mixed population. This has induced the authors to report their experience with ETV in adults, reporting the results and discussing the usefulness and effectiveness of this procedure, causes of complications and failure. ETV was carried out in 20 patients aged over 18 years in a two-year period, beginning in 1999. In 13 cases (64%) the cause was external compression of CSF system by tumour leading to hydrocephalus. In 3 cases aqueduct stenosis was producing hydrocephalus, in 3 cases arachnoid cyst, perisellar or situated in posterior part of the third ventricle, was the cause, and in one case colloidal cyst of the third ventricle. The outcome were analysed according to clinical and radiological criteria finding that the ETV was successful in 90% of cases by clinical criteria, and in 88% by radiological criteria. Only unimportant clinical complications were reported without major consequences. It is concluded that ETV is a very useful method for hydrocephalus treatment in adults, especially if caused by blockade of CSF pathways by tumour or arachnoid cysts in the vicinity of the third ventricle.