Nidus delineation and dosimetric comparison in arteriovenous malformation in stereotactic radiosurgery by using MRI and 3DCT angiography.

Purpose/Objectives: Accurate delineation of target is key to any successful radiosurgery. C-arm Dyna CT/ 3DCT angiography (3DCTA) has the potential of improving the accuracy of nidus delineation in intracranial arteriovenous malformations (AVM) due to high temporo-spatial resolution of vessel architecture. Here, we present a comparison of nidus delineation and dosimetric parameters between digital 3DCTA and MRI. Materials/Methods: Ten consecutive patients treated for intracranial AVMs were included in this study. All patients underwent MRI/MRA, and 3DCTA and all images were co-registered. AVM were delineated using 3DCTA (GTV3DCTA) and contrast enhanced MRI/MRA (GTVMRI). Hausdorff distance (HD) matrices and dice similarity coefficient (DSC) matrices were analysed. Stereotactic radiosurgery plans were developed for both the volumes for all patients and statistical analysis were performed with T-test. Results: Mean volumes of GTV3DCTA and GTVMRI were 1.771 cc (SD 1.794cc, range 0.124-4.191cc) and 2.183cc (SD 2.16cc, range 0.221-6.133cc), respectively. Significant deviation (p=0.018) was found when taking GTVMRI as a primary and comparing it to GTV3DCTA (MD=0.723cc±0.816cc). Similar result was observed with GTV3DCTA as primary and GTVMRI as secondary (MD=0.188cc, SD=0.193cc, p=0.024). Maximum HD was in the range of 1.71 to 7.44mm (mean=4.27mm, SD=1.56). For GTV3DCTA based plans, significant deviation was found between GTVMRI and GTV3DCTA in dose coverage and the mean difference was 22.17% (SD 16.73). In GTVMRI based plans, the mean CIRTOG deteriorated from 1.33 to 2.18 for GTVMRI and GTV3DCTA, respectively. Significant deviation was found in CIRTOG (0.005) and mean deviation was 0.86(SD=0.72) when comparing GTVMRI and GTV3DCTA. Highly significant (p=0.002) deviation was found in CIPaddick between GTVMRI and GTV3DCTA for GTVMRI based plans with mean difference of 0.26(SD=0.4, for GTVMRI=0.3, GTV3DCTA=0.46). Conclusion: Nidus volume was significantly altered with the use of 3DCTA compared to that of MRA/MRI images. Multimodality imaging is crucial for accurate target delineation, and successful radiosurgical obliteration of nidus.

Atypical central neurocytoma with leptomeningeal dissemination: a case report.

BACKGROUND: Central neurocytomas represent 0.25-0.5% of all intracranial tumors in adults. Leptomeningeal spread is uncommon, and the exact incidence of meningeal spread is unknown due to sparse literature. We present the clinical course and management outcome of a case of atypical central neurocytoma with leptomeningeal spread. CASE PRESENTATION: A young gentleman, who initially presented with memory loss, was found to have a right intra-axial periventricular mass on imaging. He underwent subtotal resection, and operative histopathology suggested a periventricular atypical neurocytoma. In view of subtotal resection, adjuvant focal radiation therapy was recommended, but he developed headache and blurring of vision 10 days postoperatively. Contrast enhanced craniospinal magnetic resonance imaging (MRI) showed residual primary tumor as well as diffuse leptomeningeal spread. Cerebrospinal fluid cytology also showed malignant cells. After tumor board discussion, craniospinal axis irradiation was advised and delivered. He remained disease-free for 10 months after radiation therapy, but then developed local and spinal recurrence, and offered salvage chemotherapy. His general condition deteriorated following chemotherapy with disease progression, and he was subsequently advised best supportive care. CONCLUSION: Leptomeningeal dissemination in atypical neurocytomas portends an aggressive course and adverse prognosis; management decisions may need tailoring as per individual presentation.

Dissecting Aneurysm of Vertebral Artery Involving the Origin of Posteroinferior Cerebellar Artery Treated with Retrograde Stent Placement and Coil Embolization in the Era of Flow Diverter.

Ruptured vertebral artery (VA) dissecting aneurysm carries high risk of rerupture and mortality if not treated immediately. Dissecting aneurysm of the VA involving the posteroinferior cerebellar artery (PICA) origin is difficult to treat by surgical and endovascular route. With the availability of flow diversion device for reconstructive procedure, endovascular treatment has now become easy to treat difficult aneurysm while maintaining the patency of the PICA. However, instead of using flow diverter (FD) in our case, we successfully treated dissecting VA aneurysm involving the PICA origin with retrograde stent placement from distal right VA to the left PICA to maintain the patency of PICA and occlusion of dissecting aneurysm of VA with detachable coils instead of performing surgical bypass and FD placement.

Surpass Flow Diverter in the Treatment of Ruptured Intracranial Aneurysms-A Single-Center Experience.

BACKGROUND: Use of a Surpass flow diverter (FD) device in the treatment of acutely ruptured aneurysm has not been well studied and reported in the literature. METHODS: We retrospectively reviewed patients with subarachnoid hemorrhage who were treated by Surpass FD placement at our hospital between June 2016 and March 2018. Detailed analysis of medical records was performed to obtain patient age, gender, clinical history, Hunt and Hess grade, Fisher grade, results of radiographic and procedural details including technical success and complication, clinical outcome, and follow-up angiographic results. RESULTS: Our search identified 16 patients with 16 aneurysms who were treated with Surpass FD, of which 13 aneurysms (81%) were in the anterior circulation and 3 (19%) were in the posterior circulation. Aneurysm size ranged from 1.1 to 16 mm, with a mean of 4 mm. The mean delay between subarachnoid hemorrhage and endovascular treatment was 5 days (range, 3-20 days). Only 1 Surpass FD was used in each patient, ranging in size from 3 × 25 mm to 4 × 50 mm. Fifteen patients (94%) achieved favorable clinical outcome (modified Rankin Scale score 0-1) at 3 months. One patient died of invasive fungal infection. Angiographic follow-up results were assessed by O'Kelly-Marotta grading scale in 15 surviving patients and showed a grade D result (no filling) in 13/15 aneurysms (87%) at 3 and 6 months. CONCLUSIONS: A Surpass FD device is a feasible option for the treatment of ruptured intracranial aneurysms that are difficult to treat by conventional clipping and coiling; however, larger and comparative studies with long-term follow-up are needed to confirm its safety and efficacy.

Enhanced resection of primary high-grade gliomas using a combination of intraoperative magnetic resonance imaging and intraoperative fluorescence (5-aminolevulinic acid): A single-centre experience.

BACKGROUND: The extent of resection (EOR) of a tumor is a proven prognostic factor in patients undergoing surgery for suspected high grade glioma. A few recent publications have shown the importance of intraoperative magnetic resonance imaging (iMRI) with 5-aminolevulinic acid (5-ALA) fluorescence-guidance in order to maximally increase the EOR. AIM: The objective of our study was to calculate the effect on survival of patients with high grade gliomas of resection using both iMRI and 5-ALA fluorescence-guidance as intraoperative adjuncts. METHODS: Thirty-seven patients with gadolinum-enhancing high gliomas on preoperative MRI undergoing surgical excision were included in a prospective study. Surgeries began under white-light conditions. Intermittently, a blue light filter was switched on to search for remaining tumor tissue not visible to the naked eye. When gross total resection (GTR) was thought to have been achieved, iMRI was done to check for any contrast-enhancing part left behind. Surgery was concluded or resumed based on the iMRI findings. Histopathological examination of the tumor tissue was done. All patients underwent immediate postoperative MRI at the end of the surgery to calculate the EOR. RESULTS: Our results showed that out of the total of 37 patients, 17 patients died during the follow up period and 11 patients were still alive. The mean survival was 587.1 days and median survival was 491 days with a range of 342 to 943 days. When we compared these figures with the average survival in patients with a high grade glioma, i.e., 9 to 14 months, it showed that both the above mentioned modalities were very helpful in increasing the EOR, and in turn, the overall survival. CONCLUSIONS: The use of iMRI as well as fluorescence-guidance are appropriate methods to improve the extent of resection in surgery of contrast-enhancing gliomas. Best results can be achieved by the complementary use of both modalities.

Recanalized Left Internal Carotid Artery Bifurcation Aneurysm with Adherent Thrombus at Aneurysm Neck and M1 Origin Diagnosed on 2-Dimensional Angiography-Cause of Embolic Stroke.

We report a unique case of recanalized left internal carotid artery aneurysm with thrombus adherent to the aneurysm neck and M1 origin diagnosed on 2-dimensional angiography causing embolic stroke in a 66-year-old female who was successfully treated with stent-assisted coiling. This is important to recognize as a cause of embolic stroke.

Survival trends in glioma: Experience at a tertiary care centre.

BACKGROUND: Even after decades of research in the field of gliomas, the overall prognosis is still quite dismal. Several factors have been proposed that affect the outcome and survival length of patients with a glioma. Here, we present a series of 471 patients, who underwent surgical resection of their glioma at a tertiary level neurosurgical centre. MATERIALS AND METHODS: We noted retrospective data of patients' age, histological tumor grade, and whether or not intraoperative magnetic resonance imaging (MRI) was used, and assessed the survival length of these patients from the day of surgery. RESULTS: The overall survival in our series was approximately 14 months. Predictably, those with age less than 40 years and those with Karnofsky performance score (KPS) ≥80 had longer survival than those with a higher age and KPS <80; those with World Health Organisation (WHO) grade IV lesions had the shortest survival length compared to all the other grades. However, while comparing survival among other tumor grades, we did not find significant difference. Further, use of intraoperative MRI did not offer any statistically significant difference in survival. CONCLUSION: In addition to the conventional prognostic factors we need more definate ways to accurately predict survival in patients harbouring a glioma. Probably, assessing molecular characteristics of the individual tumors, such as presence of isocitrate dehydrogenase (IDH) mutation versus wild-type IDH, would help us in predicting survival more accurately.

Endovascular glue embolization of dissecting aneurysm of type-3 accessory middle cerebral artery: A contralateral approach.

Pediatric intracranial aneurysms are rare with a reported prevalence of 0.5-4.6%. Likewise, anomalous arterial patterns are uncommon in the cerebral circulation. Recognition of these variations and knowledge of vascular territory forms the key to managing pathological conditions associated with these anomalous vessels. Ruptured dissecting aneurysm of type-3 accessory middle cerebral artery (aMCA) has not been reported in the pediatric age group. In addition to type-3 aMCA, the child in this case report had an ipsilateral type-1 aMCA with cortical supply. We describe the patterns of accessory MCA and their vascular territory, state the perplexity involved in deciding the best management strategy, and describe the technical approach we undertook to catheterize this small caliber recurrent artery (type-3 aMCA) originating at an acute angle from the anterior cerebral artery.

Coil embolization of intracranial aneurysms with ipsilateral carotid stenosis: technical considerations.

Simultaneous occurrence of carotid atherosclerotic disease and ipsilateral cerebral aneurysm is known because of common risk factors. When interventional neuroradiologists encounter such cases, issue of 'in which order to treat these lesions ' is raised. If carotid artery disease is treated first, then acute increase in perfusion pressure and high dose antiplatelets might increase the risk of aneurysm rupture. If aneurysm coiling is performed first, the stroke risk may increase due to manipulations through plaque and compromise of cerebral flow secondary to catheter placement through stenotic vessel. Even though aneurysm coiling first is a rational approach, there are technical problems like crossing the carotid lesion safely and making sure that placement of catheter through the stenosed vessel will not compromise the cerebral blood flow. This technical report describes our protocol in performing safe and successful coil embolization in three cases with moderate carotid stenosis and ipsilateral intracranial aneurysm. Our emphasis is mainly on technical considerations with the aim of avoiding cerebral embolism during crossing of carotid plaque and to avoid compromise of cerebral blood flow using 'syngo iflow'. These technical considerations may have important implications in treatment of intracranial aneurysm in patients with moderate ipsilateral cervical carotid stenosis.

Isolated contralateral post-ictal oculomotor nerve palsy following supratentorial craniotomy. Case report.

The authors report the unique occurrence of an isolated post-ictal contralateral oculomotor nerve (OCN) palsy following excision of a medial frontal oligoastrocytoma. A 45-year-old male presented with a history of generalized tonic clonic seizures (GTCS) for 8 years. His neurological examination was unremarkable. Magnetic resonance imaging (MRI) of the brain revealed a left frontopolar low grade glioma. Nine hours after an uneventful near total microsurgical excision, the patient had a GTCS, following which he was noted to have an isolated right-sided OCN palsy. The immediate post-ictal computed tomographic scan and magnetic resonance images acquired 2 weeks after surgery failed to reveal any abnormality. The palsy had recovered completely by the 9-month follow-up.

Effects of butorphanol and fentanyl on cerebral pressures and cardiovascular hemodynamics during tunneling phase for ventriculoperitoneal shunt insertion.

PURPOSE: Subcutaneous tunneling for ventriculoperitoneal shunt insertion is the most painful step of this surgery. It is associated with intense hemodynamic response, may influence the intracranial pressure, and thus may worsen the existing intracranial pathology. The purpose of this report is to evaluate the commonly used opioid fentanyl, along with butorphanol, an agonist-antagonist compound. METHODS: Twenty adult patients undergoing ventriculoperitoneal shunt surgery were induced with fentanyl 2-mcg.kg(-1) and thiopentone 4-5 mg.kg(-1). Intubation followed the administration of rocuronium 1 mg.kg(-1). All patients were put on mechanical ventilation to maintain end-tidal carbon dioxide levels of 32 +/- 2 mmHg. Anesthesia was maintained with isoflurane in N2O and O2 (MAC 1.0 +/- 0.2). Routine monitoring, arterial blood pressure and intracranial pressures were measured. Three minutes prior to the tunneling phase, patients received either fentanyl 1 mcg.kg(-1) or butorphanol 1 mg in a randomized manner. Thereafter hemodynamic and intracranial pressure changes were noted during tunneling and each minute in the post-tunneling period for 5 minutes. The duration of the tunneling phase was also noted. Data were presented as number (proportion) or mean +/- SD/median (range) as appropriate. Statistical analysis was done using Wilkoxon ranksum test and the repeated measures of ANOVA. The value of p < 0.05 was considered significant. RESULTS: A significant rise in the intracranial pressure and cerebral perfusion pressure along with the hemodynamic parameters was noted during the tunneling phase in both groups. The changes were of longer clinical duration in the butorphanol group. CONCLUSION: Butorphanol must be used with caution in neurosurgical patients. The ventricular end of the shunt catheter should preferably be put before the tunneling phase to avoid rise in intracranial pressure.

Visual outcome after surgery in patients with suprasellar tumors and preoperative blindness.

OBJECTIVES: The purpose of this paper was to study the visual outcome after surgery in patients with suprasellar tumors who experienced preoperative blindness in 1 or both eyes. METHODS: All patients with suprasellar tumors and no perception of light in 1 or both eyes and who underwent surgery between May 2002 and May 2006 were included in this retrospective study. Outcome was analyzed at discharge from the hospital and at follow-up. There were a total of 79 patients (51 males and 28 females, age range 5-70 years). There were 37 cases of pituitary adenomas, 19 craniopharyngiomas, 18 meningiomas, and 5 other tumors. Preoperatively 61 patients had uniocular blindness and 18 patients had binocular blindness. Of all 158 eyes, 97 (61.4%) were blind at admission and these eyes were analyzed. Sixty-three patients (79.7%) presented with headache and 14 (17.7%) with hypothalamic symptoms. Nearly one fourth (24%) of patients with a pituitary adenoma had a history of apoplexy. The duration of visual decline ranged from 3 days to 7 years, and the duration of blindness ranged from 1 day to 3 years. Patients underwent either transcranial or transsphenoidal tumor decompression. RESULTS: At discharge from the hospital visual improvement was exhibited in 23 (29%) of 79 patients and 27 (27.8%) of 97 eyes. Improvement to serviceable vision occurred in 7 (8.9%) of 79 patients and in 8 (8.2%) of 97 eyes with pre-operative blindness. After surgery, visual improvement was noted in 15 (24.6%) of 61 patients with uniocular blindness and 8 (44.4%) of 18 patients with binocular blindness. However, serviceable vision was restored in 5 (8.2%) of 61 patients with uniocular and 2 (11.1%) of 18 patients with binocular blindness. Bivariate analysis revealed male sex, shorter duration of blindness, presence of apoplexy, sellar tumor extension, soft tumor consistency, operative evidence of hemorrhage in tumor, and tumor histopathology (pituitary adenoma) to have significant impact on the outcome. Multivariate analysis revealed duration of blindness for > 12 weeks, apoplexy, and sellar extension to have a significant impact on visual outcome. CONCLUSIONS: The present study is the largest in the existing medical literature to evaluate the factors affecting visual outcome after surgery of suprasellar tumors with preoperative blindness.