Contemporary Treatment of Intracranial Blood Blister Aneurysms - A Systematic Review.

INTRODUCTION: Blood blister aneurysms (BBAs) are rare aneurysms affecting non-branched points of intracerebral arteries. Due to their small size and fragility, BBAs are prone to rupture, and can be challenging to diagnose and treat. Several treatment options have been suggested yet there is no consensus regarding the best modality to reduce morbidity and mortality. MATERIALS AND METHODS: A systematic review of the literature was conducted searching for articles discussing the treatment of BBAs. Inclusion criteria included: articles published between January 2010 and August 2020, English language, with each paper including at least 15 patients. Studies included required detailed reporting of patient demographics, treatment, and patient outcomes (including complications, recurrence, neurologic functional status, and mortality). RESULTS AND DISCUSSION: A total of 25 studies with 883 patients were included. Most were female (n = 594, 67.3%) and aneurysms were overwhelmingly located in the supraclinoid internal carotid artery (99%). Aneurysms were variable in size and mostly presented with subarachnoid haemorrhage. Endovascular treatment (n = 518, 58.7%) was more common than microsurgery (n = 365, 41.1%) while only 2 patients were managed conservatively. Complications were more common in patients treated microsurgically. Microsurgical procedures had an unfavorable outcome (mRS 4-6, GOS 1-3) rate of 27.8% (n = 100/360) while that of endovascular procedures was 14.7% (n = 70/477). Endovascular procedures had a lower mortality rate than microsurgical interventions (8.4% vs 11%). CONCLUSION: This review demonstrates that endovascular treatment of blood blister aneurysm has reduced morbidity and mortality when compared with microsurgical treatment. Small sample sizes and substantial study heterogeneity makes strong conclusions difficult.

Laser Microsurgery Versus Radiotherapy Versus Open Partial Laryngectomy for T2 Laryngeal Carcinoma: A Systematic Review of Oncological Outcomes.

INTRODUCTION: The aim of the current systematic review is to update the pooled survival outcome of patients with T2 glottic carcinoma treated with either laser surgery (CO2 transoral laser microsurgery [CO2 TOLMS]), radiotherapy (RT), or open partial laryngectomy (OPL). METHODS: A systematic search was performed using the MEDLINE database, Scopus, and Google scholar. The inclusion criteria were studies of patients with T2N0 glottic tumor, treated with either primary CO2 TOLMS, definitive curative RT, or primary OPL, and with reported oncological outcome at 5 years calculated with a Kaplan-Meier or Cox regression method. RESULTS: The results of the current review show that local control (LC) is higher with OPL 94.4%, while there are no differences in LC at 5-year posttreatment for patients treated with RT, compared to those treated with CO2 TOLMS (respectively, 75.6% and 75.4%). Primary treatment with OPL and CO2 TOLMS results in higher laryngeal preservation than primary treatment with RT (respectively 95.8%, 86.9%, and 82.4%). CONCLUSION: First-line treatment with OPL and CO2 TOLMS should be encouraged in selected T2 patients, because it results in higher laryngeal preservation and similar LC compared to primary treatment with RT. The involvement of the anterior commissure in the craniocaudal plane and T2b impaired vocal cord mobility have a poorer prognosis and LC compared to patients with T2a tumors for both CO2 TOLMS and RT.

Safety and efficacy of surgical treatment for brainstem hemangioblastoma: a meta-analysis.

Brainstem hemangioblastomas are benign, highly vascular tumors located in the mesencephalon, pons, and medulla oblongata. Although surgical resection is currently considered the main therapeutic option for symptomatic lesions, evidence supporting the application of microsurgery has not been systematically assessed. This meta-analysis aims to evaluate the safety and efficacy of surgical treatment for brainstem hemangioblastomas. A comprehensive search of the PubMed, Embase, and Web of Science databases was performed to identify all English language publications reporting the outcomes of surgical treatment for brainstem hemangioblastomas. Studies from January 1990 to July 2019 with ≥ 10 cases were included. We analyzed the surgical outcomes, including gross total resection, mortality, neurological morbidity, and functional outcome according to the McCormick Scale or Karnofsky Performance Scale. Thirteen studies with 473 cases were included. The pooled proportion of gross total resection was 98% (95% confidence interval (CI), 94-100%). Overall mortality and neurological morbidity were 4 (95% CI, 2-6%) and 13% (95% CI, 7-20%), respectively. Favorable functional outcomes at the last follow-up were achieved in 85% (95% CI, 78-92%) of all patients. Improved or stable functional outcomes at long-term follow-up were achieved in 94% (95% CI, 89-97%) of patients. This meta-analysis revealed that surgical treatment for brainstem hemangioblastomas is technically feasible and effective with lasting patient benefits and cure.

The clinical application of microincision vein harvesting of the great saphenous vein in coronary artery bypass grafting.

BACKGROUND: The present study aimed to summarize the clinical application of microincision vein harvesting (MVH) of the great saphenous vein in coronary artery bypass grafting (CABG). METHODS: From July 2014 to October 2017, 160 patients underwent coronary artery bypass grafting. Among them, 80 patients received MVH of the great saphenous vein, and 80 received open venous harvesting (OVH). The results of the sampling operation, complications during hospitalization, and the long-term patency of the great saphenous vein were compared between the two groups. RESULTS: All the patients in both groups received successful operations. The difference in the length of the veins obtained and the injury of the veins was not statistically significant (P > 0.05). The difference in the long-term patency rate of the graft vessels between the two groups was not statistically significant. The in-hospital mortality rate was the same in both groups. The MVH group had noticeable advantages over the OVH group in terms of the vein collection times, the incision length, and the complications experienced when performing the leg incisions (P < 0.01). The time relating to the patients' observed early out-of-bed activity was significantly longer in the MVH group. Furthermore, the patients' hospitalization length was significantly shorter in the MVH group compared to the OVH group (P < 0.05). The MVH group had significant advantages in pain score and patient satisfaction, and this difference was also statistically significant (P < 0.05). CONCLUSIONS: The MVH procedure met the requirements of CABG in vein grafting. When compared with OVH, MVH can significantly reduce leg incision complications and improve patients' overall satisfaction with their hospital experience.

Updates in arteriovenous malformation management: the post-ARUBA era.

Brain arteriovenous malformations (AVMs) are complex and heterogeneous lesions that can rupture, causing significant morbidity and mortality. While ruptured lesions are usually treated, the management of unruptured AVMs remains unclear. A Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA) was the first trial conducted to compare the effects of medical and interventional therapy. Although it concluded that medical therapy was superior in preventing stroke and death over a follow-up period of 33 months, the findings were met with intense criticism regarding several aspects of study design, progression, and analysis/conclusion. Namely, the increased use of stand-alone embolisation relative to microsurgery in a cohort with predominantly low-grade lesions combined with a short follow-up period amplified treatment risk. Subsequently, several observational studies were conducted on ARUBA-eligible patients to investigate the safety and efficacy of microsurgery, radiosurgery, and endovascular embolisation over longer follow-up periods. These reports showed that favourable safety profiles and cure rates can be achieved with appropriate patient selection and judicious use of different treatment modalities in multidisciplinary centres. Since large prospective randomised trials on AVMs may not be feasible, it is important to make use of practice-based data beyond the flawed ARUBA study to optimise patients' lifetime outcomes.

A Propensity Score-Matched Comparison of Readmission Rates Associated With Microsurgical Clipping and Endovascular Treatment of Ruptured Intracranial Aneurysms.

BACKGROUND: In the treatment of aneurysmal subarachnoid hemorrhage (aSAH), microsurgical clipping, and endovascular therapy (EVT) with coiling are modalities for securing the ruptured aneurysm. Little data is available regarding associated readmission rates. We sought to determine whether readmission rates differed according to treatment modality for ruptured intracranial aneurysms. METHODS: The Nationwide Readmissions Database (NRD) was used to identify adults who experienced aSAH and underwent clipping or EVT. Primary outcomes of interest were the incidences of 30- and 90-day readmissions (30dRA, 90dRA). Propensity score matching was used to generate matched pairs based on age, comorbidities, hospital volume, and hemorrhage severity. RESULTS: We identified 13,623 and 11,160 patients who were eligible for 30dRA and 90dRA analyses, respectively. Among the patients eligible for 30dRA and 90dRA, we created 4282 and 3518 propensity score-matched pairs, respectively. There was no difference in the incidence of 30dRA (12.4% for clipping versus 11.2% for EVT; P = .094). However, 90dRA occurred more frequently after clipping (22.5%) compared to EVT (19.7%; P = .003). Clipping was associated with poor outcome after 30dRA (odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.21-1.88, P < .001) and after 90dRA (OR = 1.60, 95% CI 1.34-1.91, P = .001). Mean duration to readmission and cost of readmission did not vary, but clipping was associated with longer lengths of stay during readmission. CONCLUSIONS: Microsurgical clipping of ruptured aneurysms is associated with a greater incidence of 90dRA, but not 30dRA, compared to EVT. Poor outcomes after readmission are more common following clipping.

Prognostic impact of initial treatment in surgically salvaged recurrences of early glottic cancer.

OBJECTIVE: The purpose of this study was to analyze the outcomes of surgically salvaged early glottic cancer (EGC) recurrences after initial radiotherapy (RT) or transoral laser microsurgery (TLM). METHODS: A matched pair analysis by recurrent tumor-node-metastasis stage (rTNM) considering 27 patients who had TLM as initial treatment and 54 patients who failed after primary RT was performed. Post-recurrence overall and disease-specific survival (DSS) were evaluated. RESULTS: The RT-failed group showed worse post-recurrence overall survival (P < .001) and DSS (P = .005) compared to TLM-first group despite the same rTNM stage. The RT failed patients also showed more postoperative complications (longer mean decannulation time, P = .005; nasogastric feeding tube dependence, P = .012) and a higher rate of second locoregional recurrences (P = .004). CONCLUSION: The RT-failed EGC showed worse outcomes in terms of survival, complications, and locoregional recurrences compared to same recurrent TNM stage TLM-failed cases. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:2328-2333, 2019.

Long-term outcomes among octogenarians with aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Data evaluating the long-term outcomes, particularly with regard to treatment modality, of aneurysmal subarachnoid hemorrhage (SAH) in octogenarians are limited. The primary objectives were to evaluate the disposition (living at home vs institutional settings) and analyze the predictors of long-term survival and return to home for octogenarians after SAH. METHODS: Data pertaining to patients age 80 and older who underwent microsurgical clipping or endovascular coiling for SAH were extracted from 100% nationwide Medicare inpatient claims and linked with the Minimum Data Set (2008-2011). Patient disposition was tracked for 2 years after index SAH admission. Multivariable logistic regression stratified by aneurysm treatment modality, and adjusted for patient factors including SAH severity, evaluated predictors of return to home at 60 and 365 days after SAH. Survival 365 days after SAH was analyzed with a multivariable Cox proportional hazards model. RESULTS: A total of 1298 cases were included in the analysis. One year following SAH, 56% of the patients had died or were in hospice care, 8% were in an institutional post-acute care setting, and 36% had returned home. Open microsurgical clipping (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.54-0.81), male sex (aHR 0.70, 95% CI 0.57-0.87), tracheostomy (aHR 0.63, 95% CI 0.47-0.85), gastrostomy (aHR 0.60, 95% CI 0.48-0.76), and worse SAH severity (aHR 0.94, 95% CI 0.92-0.97) were associated with reduced likelihood of patients ever returning home. Older age (aHR 1.09, 95% CI 1.05-1.13), tracheostomy (aHR 2.06, 95% CI 1.46-2.91), gastrostomy (aHR 1.55, 95% CI 1.14-2.10), male sex (aHR 1.66, 95% CI 1.20-2.23), and worse SAH severity 1.51 (95% CI 1.04-2.18) were associated with reduced survival. CONCLUSIONS: In this national analysis, 56% of octogenarians with SAH died, and 36% returned home within 1 year of SAH. Coil embolization predicted returning to home, which may suggest a benefit to endovascular treatment in this patient population.

Surgical morbidity and mortality in patients after microvascular reconstruction for head and neck cancer.

OBJECTIVES: The aim was to evaluate the importance of clinical factors in the prediction of postoperative complications in patients with microvascular reconstruction for head and neck squamous cell cancer (HNSCC). DESIGN: A retrospective review of case notes was performed. SETTING: Patients treated at a single institute. PARTICIPANTS: This study included 259 patients with HNSCC treated with radical surgery and microvascular reconstruction between 1993 and 2014. MAIN OUTCOME MEASURES: We allocated the patients to three groups using a preoperative comorbidity score based on risk factors: group A (≥3 risk factors, n = 16), group B (2 risk factors, n = 49) and group C (0 or 1 risk factor, n = 194). RESULTS: Surgical mortality in this cohort was 1.9% (5 of 259 patients). The preoperative comorbidity score was associated with surgical mortality (P < .001). Pharyngocutaneous fistula (P = .001) and flap compromise (P = .023) were more frequent as preoperative comorbidity score increased. Preoperative comorbidity score (P < .001), advanced age (P = .007), advanced pathologic T stage (P = .028), advanced pathologic N stage (P = .005), preoperative (chemo) radiotherapy (P < .001), history of cardiovascular disease (P = .015) and pulmonary disease (P = .007), and diabetes (P < .001) had significant adverse effects on 5 year disease-specific survival (DSS) in a univariate analysis. The 5-DSS rates of groups A, B and C were 30%, 37% and 70%, respectively. Multivariate analysis showed that preoperative comorbidity score was significantly correlated with 5 year DSS (hazard ratio [HR], 3.56; 95% confidence interval [CI], 1.81-6.99; P < .001 for group A and HR, 1.91; 95% CI, 1.15-3.18; P = .013 for group B compared with group C). CONCLUSION: Patients with a high preoperative comorbidity score have an increased risk of surgical mortality and morbidity after microvascular reconstruction for HNSCC.

Treatment Outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformation-Eligible Unruptured Brain Arteriovenous Malformation Patients.

BACKGROUND: The guideline for treating unruptured brain arteriovenous malformations (ubAVMs) remains controversial. A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) reported lower risk of stroke or death with conservative management compared to interventional treatment. There were numerous limitations to the study, including short follow-up period and disproportionate number of patients treated with surgery and embolization. OBJECTIVE: To evaluate whether treatment of ARUBA-eligible patients have acceptable outcomes at our institution. METHODS: Retrospective analysis was performed on 673 patients with brain AVMs treated at our institution between 2001 and 2014. One hundred five patients were ARUBA eligible and included in the study. Patients were divided into the microsurgery or Gamma Knife Radiosurgery (GKS; Elekta, Stockholm, Sweden) arm depending on their final treatment. Mean follow-up period was 43 mo (range 4-136 mo). Primary outcome was stroke or death. RESULTS: A total of 8 (7.6%) patients had a stroke or died. The overall risk of stroke or death was 11.4% (5 of 44 patients) for the microsurgery arm and 4.9% (3 of 61 patients) for the GKS arm. The annual rates of stroke or death were 2.1%, 4.0%, and 1.2% for the entire patient cohort, microsurgery arm, and GKS arm, respectively. AVM obliteration rates at the end of the follow-up period were 95.5% and 47.5% for the microsurgery and GKS arms, respectively. CONCLUSION: We report a lower overall risk of stroke or death in our ARUBA-eligible patients following treatment than ARUBA. Our results suggest that microsurgery and GKS may be appropriate treatments for patients with ubAVM.

Four-Hand Suction-Irrigation Technique Leads to Gross Total Resection and Long-Term Progression-Free Survival in Fourth Ventricular Ependymoma.

BACKGROUND: Gross total resection is often avoided in posterior fossa ependymoma surgery because of the fear of permanent neurologic deficits after operation. However, the extent of resection is a major prognostic factor for progression-free and overall survival. This study evaluates the outcome of posterior fossa ependymoma gross total resection in adult patients using a 4-hand suction-irrigation technique at the floor of the fourth ventricle. METHODS: All surgical procedures for posterior fossa ependymomas performed since 2001 in the Department of Neurosurgery, University Medicine Greifswald were analyzed. RESULTS: Eight patients (2 women and 6 men; mean age, 41.9 years; range, 29-56 years) underwent surgery for posterior fossa ependymoma. All tumors were World Health Organization grade II. Tumor adherence was found to be in the caudal rhomboid fossa (between the obex and striae medullare, but below the facial colliculus) in all patients. The 4-hand suction-irrigation technique led to gross total resection in all patients (100%), without significant permanent neurologic deficits after surgery. None of the patients got further treatment (chemotherapy, radiation therapy, or second surgery). In none of these patients, tumor recurrence was seen on magnetic resonance imaging after a mean follow-up of 102 months (range, 14-181 months). CONCLUSIONS: Long-term progression-free survival in adult patients suffering from posterior fossa ependymoma is possible by gross total resection without adjuvant radio- or chemotherapy. By careful bimanual microsurgical dissection using the 4-hand suction-irrigation technique and avoidance of bipolar coagulation on the floor of the fourth ventricle, the risk for permanent neurologic deficits is low.

Transoral laser microsurgery or total laryngectomy for recurrent squamous cell carcinoma of the larynx: Retrospective analysis of 199 cases.

BACKGROUND: Surgical treatment options for local recurrences of laryngeal cancer can be either organ-preserving surgery or total laryngectomy. The purpose of this study was to present our evaluation of the treatment with transoral laser microsurgery (TLM) in comparison to laryngectomy. METHODS: We conducted a retrospective review of 199 consecutive patients with recurrent laryngeal cancer at 1 tertiary referral center. RESULTS: The 5-year overall survival, disease-specific survival, and local control rates were 64.8%, 79.6%, and 57.5%, respectively, for 93 patients with early tumors treated by TLM, 28.9%, 41.7%, and 43.7%, respectively, for 52 patients with advanced tumors treated by TLM as well as 39.4%, 44.6%, and 68.8%, respectively, for 54 patients with advanced tumors treated by total laryngectomy. Five-year larynx-preservation rate was 77.7% for early as well as 68.4% for advanced tumors treated by TLM. CONCLUSION: TLM is an option in early and in selected cases of advanced locally recurrent laryngeal cancer. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1166-1176, 2017.

Manejo de la enfermedad aneurismática múltiple. Experiencia en un Hospital de Especialidades.

Objective: To establish the frequency and results in patients carriers with multiple aneurysms (MA) treated by microsurgery and/or neurological endovascular therapy (NET) in the Hospital of Specialties on The National Medical Center La Raza. Method: It is an ambispective, descriptive and longitudinal study that includes patients carriers of MA treated in the National Medical Center La Raza from March the 1st of 2009 to April the 30th of 2014. Results: 62 patients carriers of 151 aneurysms were treated. According to the type of treatment, 30 patients (49%) were included in the surgical group (GQ), 25 (40%) in the endovascular group (GE) and 7 (11%) in the combinated group (GC). The number of aneurysms was distributed this way: 69 (46%) in the GQ, 61 (40%) in the GE and 21 (14%) in the GC. At GQ, it was not possible to exclude all their aneurysms on 21% of the patients, while it was feasible in only 27%. In all GE patients (40%) the exclusion of all aneurysms was achieved. The GC, meaning surgical cases that were not completed by NET, formed 11% of the cases. At GQ there was a rate of 6% of complications, meanwhile at GE it was 0.5%.

Evaluating organ preservation outcome as treatment endpoint for T1aN0 glottic cancer.

OBJECTIVES/HYPOTHESIS: Common endpoints in reporting the outcomes for early glottic cancer do not highlight the importance of organ preservation. We evaluated the treatment outcomes among patients with T1aN0 laryngeal cancer with laryngectomy-free disease-specific survival (LFS-DSS), which is defined as time to total laryngectomy or time to death from cancer cause, against all other endpoints. STUDY DESIGN: Outcome research on an institutional database. METHODS: A retrospective review covered all consecutive patients from 2003 to 2013. Patients with T1a laryngeal squamous cell carcinoma (SCC) were offered the options of either radiation treatment (RT) or transoral laser microsurgery (TLM). Tumor control, survival outcomes, standard definition laryngectomy-free survival (LFS), and LFS-DSS were calculated. RESULTS: There were 105 patients, of whom 53 were treated with TLM and 52 were treated with RT. There were 11 recurrences within the TLM group, of which four were successfully salvaged with repeated TLM and two were salvaged with RT. Among the four recurrences within the RT group, all four patients had salvage total laryngectomies. The 5-year overall survival for patients treated with TLM versus RT was 86% versus 85% (P = .887), disease-free survival was 69% versus 78% (P = .151), LFS was 65% versus 77% (P = .198), LFS-DSS was 100% versus 88% (P = .030), and ultimate locoregional control was 100% in both groups. CONCLUSIONS: Patients with T1aN0 glottic SCC treated with RT or TLM have similar survival outcomes. Patients with T1a tumor treated with TLM have better organ preservation compared to RT, when measured with LFS-DSS. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1322-1327, 2017.

[Microsurgical techniques for dorsal wall aneurysms in the internal carotid artery].

OBJECTIVE: To seek a reasonable microsurgical technique for dorsal wall aneurysms in the internal carotid artery (ICA), and to evaluate its efficacy.
 Methods: A total of 21 patients with dorsal wall aneurysms in the ICA who received microsurgical techniques were retrospectively analyzed. The directive surgical clapping was applied for saccular aneurysm, while the techniques of stitching and wrapping, simple wrapping, and trapping with extracranial-intracranial bypass were used for cystic and blood blister false aneurysms.
 Results: One patient died after operation, 1 patient suffered rebleeding and gave up treatment, the remaining 19 patients achieved saticfactory outcomes.
 Conclusion: According to types of aneurysm wall, the different microsurgical treatments should be applied, and good outcomes can be achieved for patients with dorsal wall aneurysms in the ICA.

Gamma Knife Radiosurgery in Sphenopetroclival Meningiomas: Preliminary Experience at the Iran Gamma Knife Center.

OBJECTIVE: The aims of this study were to characterize the epidemiologic, histologic, and radiologic aspects of sphenopetroclival meningiomas (SpPCMs) and to evaluate the outcome of Gamma Knife radiosurgery (GKRS) either as an adjunct to microsurgery or as a primary SpPCM treatment modality. METHODS: In this retrospective study, medical records of patients with SpPCM who underwent GKRS at the Iran Gamma Knife Center between April 2003 and March 2012 were analyzed. RESULTS: We assessed 122 patients with SpPCMs, including 101 women and 21 men, aged 24-94 years. The mean tumor volume was 12.24 ± 9.30 mL. Patients received 22.32 ± 3.29 Gy and 13.18 ± 1.02 Gy maximal and average marginal dose of GKRS, respectively. The most common complaint was visual impairment, followed by facial sensory impairment and headache. The most frequently involved cranial nerves were III, IV, and VI in 72.1% of patients, followed by II in 52.9%, and V in 35.5%. After radiosurgery, headaches improved in 90.0%, diplopia in 75.0%, and ptosis in 63.0% of patients. On magnetic resonance imaging, tumor size was reduced, unchanged, or increased in 77, 44, and 1 patient, respectively. Progression-free survival at the 5-year follow-up was 56.6%. Younger age (hazard ratio = 0.972, P = 0.011) and lower tumor volume (hazard ratio = 0.959, P = 0.009) were the main prognostic factors for progression-free survival. CONCLUSION: GKRS can be an effective alternative treatment for controlling the progression of SpPCM tumors, producing appropriate clinical outcomes and few complications.

The extended pterional approach allows excellent results for removal of anterior cranial fossa meningiomas.

Objective To describe a unique operative strategy, instead the classical pterional approach, and to analyses it safety and effectiveness for removal of anterior cranial fossa meningiomas. Method We identify 38 patients with tuberculum sellae and olphactory groove meningiomas operated between 1986 and 2013. Medical charts, operative reports, imaging studies and clinical follow-up evaluations were reviewed and analyzed retrospectively. The pterional craniotomy is extended toward the frontal bone providing access through the subfrontal route, besides the usual anterolateral view provided by the classical pterional approach. Results Surgical mortality occurred in one patient (2.6%). Gross total resection was achieved in 27 patients (86.8%). Median time of follow-up was 69.4 months. Conclusion The extended pterional approach allows excellent results. Total removal of meningiomas of the anterior cranial fossa was obtained in 86.8 % of patients, with low morbidity and mortality.

The extended pterional approach allows excellent results for removal of anterior cranial fossa meningiomas / O acesso pterional extendido permite excelente resultado para a ressecção dos meningiomas da fossa craniana anterior

ABSTRACT Objective To describe a unique operative strategy, instead the classical pterional approach, and to analyses it safety and effectiveness for removal of anterior cranial fossa meningiomas. Method We identify 38 patients with tuberculum sellae and olphactory groove meningiomas operated between 1986 and 2013. Medical charts, operative reports, imaging studies and clinical follow-up evaluations were reviewed and analyzed retrospectively. The pterional craniotomy is extended toward the frontal bone providing access through the subfrontal route, besides the usual anterolateral view provided by the classical pterional approach. Results Surgical mortality occurred in one patient (2.6%). Gross total resection was achieved in 27 patients (86.8%). Median time of follow-up was 69.4 months. Conclusion The extended pterional approach allows excellent results. Total removal of meningiomas of the anterior cranial fossa was obtained in 86.8 % of patients, with low morbidity and mortality.

RESUMO Objetivo Descrever a craniotomia pterional estendida, ao invés da abordagem pterional clássica, e analisar sua segurança e eficácia para a remoção dos meningiomas da fossa anterior. Método Identificamos 38 pacientes com meningiomas do tubérculo da sela e da goteira olfatória operados entre 1986 e 2013. Os prontuários, relatórios cirúrgicos, exames de imagem e acompanhamento pós-operatório foram analisados retrospectivamente. A craniotomia pterional com extensão para o osso frontal permite acesso pela via subfrontal além da via anterolateral do acesso pterional clássico. Resultados A mortalidade cirúrgica foi de 2,6% (um paciente). A remoção total foi alcançada em 86,8% (27 pacientes) com um tempo médio de seguimento de 69,4 meses. Conclusão A abordagem pterional estendida permite excelentes resultados. A remoção total dos meningiomas da fossa craniana anterior foi obtida em 86,8% dos pacientes, com baixa morbi-mortalidade.

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: A paradigm shift in therapeutic approach.

BACKGROUND: The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM). METHODS: A consecutive series of patients (n = 153) undergoing primary TLM for oropharyngeal SCC from 2006 to 2013 was studied. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry and high-risk HPV DNA in situ hybridization. Survival analyses were evaluated using Kaplan-Meier statistics. RESULTS: Tumor subsites included tonsil (n = 94; 61.5%), tongue base (n = 38; 24.8%), and soft palate (n = 21; 13.7%), with the majority being American Joint Committee on Cancer (AJCC) stage III/IVa (n = 124; 81.0%) and HPV-positive (n = 101; 66.0%). Three-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 84.5%, 91.7%, and 78.2%, respectively. HPV-positivity portended favorable oncologic outcomes. One-year gastrostomy tube (G-tube) dependency was 1.3%. CONCLUSION: To the best of our knowledge, this is the largest single-center TLM oropharyngeal SCC series to date. Our data suggest that TLM +/- postoperative radiotherapy (PORT) results in at least as good oncologic outcomes as chemoradiotherapy (CRT), while conferring swallowing function advantages. © 2016 Wiley Periodicals, Inc. Head Neck , 2016 © 2016 Wiley Periodicals, Inc. Head Neck 38:1263-1270, 2016.

Microsurgery and endovascular treatment of posterior inferior cerebellar artery aneurysms.

Aneurysms located on the posterior inferior cerebellar artery are rare, and treatment guidelines for them have not yet been established. In this paper, we present the results of a retrospective study which analyzes the management and treatment of 15 patients with posterior inferior cerebellar artery aneurysms from 2004 to 2013. The aneurysms were ruptured and presented with a subarachnoid hemorrhage. Of the 15 aneurysms, ten were of saccular, three fusiform, and two were dissecting. Computed tomography angiography or digital subtraction angiography revealed other aneurysms or intracerebral artery hypoplasia in seven patients. Either surgical or endovascular treatment was performed depending on the localization and morphology of the aneurysm. Six aneurysms were coiled, and surgery was performed in nine cases. Of the nine surgically treated patients, six (75%) had good outcomes. Of the six patients treated using endovascular procedures, three patients (50%) recovered. Patient outcomes were classified using the Hunt&Hess scale. Patients with Hunt&Hess 1-3 recovered without a neurological deficit. On the other hand, patients with Hunt&Hess 4-5 had a risk of up to 93% of death or a poor outcome. In two cases of endovascular and in two cases before any therapy, aneurysmal rebleeding occurred and resulted in deterioration of clinical state of the patient and a poor prognosis with high risk of death. This study shows the necessity of acute treatment of posterior inferior cerebellar artery aneurysm, of thorough diagnostic, and of interdisciplinary cooperation.