摘要:

OBJECTIVEGiant arteriovenous malformations (AVMs) (i.e., those greater than 6 cm at maximum diameter) are difficult to treat and often carry higher treatment morbidity and mortality rates than do smaller AVMs. In this study, we reviewed the treatment, angiographic results, and clinical outcomes in 53 patients with giant AVMs who were treated at Stanford between 1987 and 2001.METHODSThe patients selected included 20 males (38%) and 33 females (62%). Their presenting symptoms were hemorrhage (n = 20; 38%), seizures (n = 18; 34%), headaches (n = 8; 15%), and progressive neurological deficits (n = 7; 13%). One patient was in Spetzler-Martin Grade III, 9 were in Spetzler-Martin Grade IV, and 43 were in Spetzler-Martin Grade V. The mean AVM size was 6.8 cm (range, 6–15 cm). AVM venous drainage was superficial (n = 7), deep (n = 20), or both (n = 26). At presentation, 31 patients (58%) were graded in excellent neurological condition, 17 were graded good (32%), and 5 were graded poor (9%).RESULTSThe patients were treated with surgery (n = 27; 51%), embolization (n = 52; 98%), and/or radiosurgery (n = 47; 89%). Most patients received multimodality treatment with embolization followed by surgery (n = 5), embolization followed by radiosurgery (n = 23), or embolization, radiosurgery, and surgery (n = 23). Nineteen patients (36%) were completely cured of their giant AVMs, 90% obliteration was achieved in 4 patients (8%), less than 90% obliteration was achieved in 29 patients (55%) who had residual AVMs even after multimodality therapy, and 1 patient was lost to follow-up. Of the 33 patients who either completed treatment or were alive more than 3 years after undergoing their most recent radiosurgery, 19 patients (58%) were cured of their AVMs. The long-term treatment-related morbidity rate was 15%. The clinical results after mean follow-up of 37 months were 27 excellent (51%), 15 good (28%), 3 poor (6%), and 8 dead (15%).CONCLUSIONThe results in this series of patients with giant AVMs, which represents the largest series reported to date, suggest that selected symptomatic patients with giant AVMs can be treated successfully with good outcomes and acceptable risk. Multimodality treatment is usually necessary to achieve AVM obliteration.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEAneurysms arising from the internal carotid artery in close relation to the clinoid process have been called paraclinoid aneurysms. The surgical management of these aneurysms poses technical challenges, and such patients are frequently referred for endovascular treatment. We reviewed our experience with endovascular coil embolization of paraclinoid aneurysms to evaluate the safety and efficacy of this treatment modality.METHODSFrom December 1993 to May 2002, 70 patients underwent endovascular procedures with detachable coils for 73 paraclinoid aneurysms (8 ruptured, 65 unruptured) at the University of Pittsburgh Medical Center and the University of Texas Southwestern Medical Center. A retrospective review of the medical records, outpatient charts, and operative reports was performed. Angiographic outcome was determined at the end of each procedure and by review of follow-up angiograms. Clinical assessments and outcomes are reported according to the Glasgow Outcome Scale (GOS).RESULTSImmediate angiographic outcomes for 73 paraclinoid aneurysms demonstrated complete occlusion in 53 (72.6%), near-complete occlusion in 6 (8.2%), and partial occlusion in 14 (19.2%). Nine aneurysms required more than one coiling session to complete treatment; 8 of these aneurysms required two sessions and 1 required four, for a total of 84 endovascular procedures. Follow-up angiograms could be obtained in 49 patients with 52 paraclinoid aneurysms. During the follow-up period, 6 aneurysms demonstrating partial occlusion and 3 demonstrating near-complete occlusion showed spontaneous progression of thrombosis to complete occlusion. Twelve aneurysms initially demonstrating complete occlusion (5 aneurysms), near-complete occlusion (3 aneurysms), or partial occlusion (4 aneurysms) showed coil compaction requiring retreatment. Of these 12 aneurysms that demonstrated coil compaction, 3 were treated with surgery and 9 with coil repacking. The final angiographic outcomes, determined on the last available follow-up angiograms of 49 aneurysms, excluding 3 surgically clipped aneurysms, showed complete occlusion in 43 (87.8%), near-complete occlusion in 3 (6.1%), and partial occlusion in 3 (6.1%). The angiographic follow-up period ranged from 4 to 54 months (mean, 13.9 mo). Morbidity and mortality rates related to 84 endovascular procedures were 8.3 and 0%, respectively. There were no recurrent or new subarachnoid hemorrhages in 63 patients in whom clinical follow-up could be performed during a mean clinical follow-up period of 14.4 months. The final clinical outcomes demonstrated a GOS score of 5 (good recovery) in 56 patients (88.9%), a GOS score of 4 (moderate disability) in 2 (3.2%), and a GOS score of 3 (severe disability) in 1 (1.6%). Four patients (6.3%) died of unrelated causes. The average period of hospitalization was 17.8 days in patients with acutely ruptured aneurysms and 3.5 days in patients with unruptured or retreated aneurysms.CONCLUSIONThe results of this study indicate that endovascular treatment is a safe and effective therapeutic alternative in ruptured and unruptured paraclinoid aneurysms. The endovascular treatment may also confer a positive impact in terms of the length of hospital stay.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVETo determine the usefulness of endovascular embolization for treatment of dural arteriovenous fistulae of the superior petrosal sinus.METHODSWe performed a retrospective review of 18 patients treated during a 16-year period. Transarterial and/or transvenous embolizations were performed as a preoperative adjunct or definitive therapy. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores.RESULTSFourteen patients (78%) were treated with a combination of endovascular therapy and open surgery, and 4 were treated by embolization alone (22%). Angiographic cure was achieved in all patients (100%). Thirty-day morbidity and mortality were 11 and 0%, respectively. The mean follow-up period was 5.4 years. At the latest follow-up examination, all patients had returned to independent clinical status (Glasgow Outcome Scale scores of 1 or 2).CONCLUSIONEndovascular treatment of dural arteriovenous fistulae of the superior petrosal sinus can result in cure when access to the site of the fistula can be achieved. Preoperative embolization is a safe and effective adjunct to minimize bleeding during open neurosurgery.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVECoagulopathy is a significant contraindication for neurosurgery. Unfortunately, many coagulopathic patients require urgent neurosurgical intervention. Standard use of blood products, including fresh-frozen plasma or prothrombin complexes, to correct the coagulopathy often leads to significant delays in treatment. Recombinant activated factor VII (rFVIIa) is a medication originally designed to treat bleeding in hemophiliacs but also seems to correct a wide variety of coagulopathies rapidly and safely in nonhemophilic patients.METHODSThe medical records of nine patients with coagulopathy requiring urgent neurosurgical intervention were reviewed retrospectively. Each patient was given a dose ranging from 40 to 90 &mgr;g/kg of rFVIIa before undergoing surgery. Pre-rFVIIa coagulation and post-rFVIIa coagulation parameters were obtained. Once correction of the coagulopathy was verified, each patient underwent the appropriate neurosurgical procedure.RESULTSThe average age of the patients was 40.9 years; six were women. The causes of the coagulopathy included anticoagulant medication, liver dysfunction, and dilutional coagulopathy after traumatic hemorrhage. Neurosurgical indications included intraparenchymal/intraventricular hemorrhage, hydrocephalus, diffuse cerebral edema, and epidural hematoma. Post-rFVIIa coagulation parameters obtained as early as 20 minutes after infusion of the medication showed normalization of values. There were no procedural or operative complications and no postoperative hemorrhagic complications. No associated thromboembolic or other complications with the use of rFVIIa were observed.CONCLUSIONThe use of rFVIIa for the urgent surgical treatment of coagulopathic patients is quite promising. Further studies, including randomized, prospective trials using rFVIIa to address issues such as optimal dosing, efficacy, surgical indications, cost-effectiveness, morbidity, and mortality are needed.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEWe sought to analyze the results of embolization in patients with intradural spinal cord arteriovenous shunts.METHODSThe clinical and radiological files of 69 of a population of 155 patients treated with embolization between 1981 and 1999 were reviewed retrospectively. The patients’ clinical status was evaluated according to Karnofsky Performance Scale score. Twenty-one (14%) of 155 patients were treated surgically because they were thought to be poor candidates for embolization. Twenty-four (15%) of 155 patients were considered untreatable with surgery or embolization; in these patients, follow-up was proposed, but only 8 of them were followed appropriately and remained stable after the first consultation. Forty-one (26%) of 155 patients consulted our group, but no follow-up could be obtained. In 69 (45%) of 155 patients, comprising 20 children and 49 adults, endovascular treatment was performed with the patients under general anesthesia and without provocative tests, mainly with acrylic glue, in 99% of these patients.RESULTSThe mean number of diagnostic and therapeutic sessions was 3.5 per patient, and the mean number of pure therapeutic sessions was 1.5 per patient. Follow-up ranged between 6 months and 18 years (mean, 5.6 yr). In 16% of patients, anatomic obliteration of spinal cord arteriovenous shunts was obtained. Embolization reduced more than 50% of the spinal cord arteriovenous shunts in 86% of cases. No recanalization was noted on follow-up angiograms. Good clinical outcomes were obtained in 83% of the patients: 15% of them were asymptomatic, 43% were improved, and 25% were stable. In 4% of patients, embolization failed to stabilize the disease. Transient deficits were seen after embolization in 14% of the patients, and permanent severe complications occurred in 4% of the patients (Karnofsky Performance Scale score ≤70). Mild worsening was seen in 9% of the patients (Karnofsky Performance Scale score, 80). No bleeding or rebleeding was seen after endovascular treatment was considered to have been completed.CONCLUSIONThis study proves that embolization with acrylic glue is a therapeutic option that compares favorably with surgery or embolization with other agents (particles, coils, or balloons). It offers stable long-term clinical results, despite not necessarily achieving total cure. Studies of larger series with longer follow-up are necessary to confirm these encouraging therapeutic data.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVEIn recent years, gamma knife radiosurgery (GKRS) has emerged as an important treatment modality in the management of pituitary adenomas. Treatment results after performing GKRS and the complications of this procedure are reviewed.METHODSBetween 1994 and 2002, a total of 78 patients with pituitary adenomas underwent a total of 84 GKRS procedures in our medical center. This patient group comprised 46 men (59%) and 32 women (41%). All patients were treated for recurrent or residual disease after surgery or radiotherapy, with 83% presenting with extensive tumor involvement. The cavernous sinus was involved in 75 patients (96%), and 22 patients (28%) had hormone-secreting adenomas. This latter subset of patients included 12 prolactinomas (15%), 6 growth-hormone secreting tumors (8%), and 4 adrenocorticotropic hormone-secreting tumors (5%). The median tumor volume was 2.3 cm3, and the median radiation dose was 15 Gy defined to the 50% isodose line. The mean and median follow-up periods were 41 and 36 months, respectively.RESULTSGKRS was tolerated well in these patients; acute toxicity was uncommon and of no clinical significance. Late toxicity was noted in three patients (4%) and consisted of VIth cranial nerve palsy. In two patients, there was spontaneous resolution of this palsy, and in one patient, it persisted for the entire 3-year duration of follow-up. Of the 15 patients who presented with cranial nerve dysfunction, 8 (53%) experienced complete recovery and 3 (20%) showed major improvement within 12 months of therapy. Tumor volume reduction was slow, with 30% of patients showing decreased tumor volume more than 3 years after undergoing GKRS. None of the 56 patients with nonfunctioning tumors showed progression in the treated volume, and 4 (18%) of the 22 hormone-secreting tumors relapsed (P= 0.008). Of the four patients with adrenocorticotropic hormone-secreting adenomas, therapy failed in two of them. All six patients with growth hormone-producing tumors responded well to therapy. Of the 12 patients with prolactinomas 10 (83%) had normalization of hormone level and 2 patients experienced increasing prolactin level. Two patients with prolactinomas had three normal pregnancies after undergoing GKRS.CONCLUSIONGKRS is a safe and effective therapy in selected patients with pituitary adenomas. None of the patients in our study experienced injury to the optic apparatus. A radiation dose higher than 15 Gy is probably needed to improve control of hormone-secreting adenomas. Longer follow-up is required for a more complete assessment of late toxicity and treatment efficacy.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVELittle information about the natural history of incidental meningiomas exists in the literature. The aim of this study was to determine the natural history of asymptomatic meningiomas by comparing different methods of growth rate calculation to establish a strategy for dealing with these tumors.METHODSIn 47 asymptomatic patients, hospital charts, follow-up records, and imaging studies were reviewed. Of these patients, 6 underwent surgery. Tumor growth rates were determined by calculating the absolute and relative growth rates and the tumor volume doubling times.RESULTSIn 41 patients with conservative management, the average tumor size was 9 cm3, and the majority (66%) of growth rates were less than 1 cm3/yr. The absolute growth rate ranged from 0.03 to 2.62 cm3/yr (mean, 0.796 cm3/yr). Relative annual growth rates ranged from 0.48 to 72.8% (mean, 14.6%). The tumor doubling time ranged from 1.27 to 143.5 years (mean, 21.6 yr). A moderate correlation between the age and growth rates was found. In young patients, annual growth rates tended to be higher and tumor doubling times shorter. There was no clear correlation between the initial tumor size and tumor doubling time. The mean annual growth rate of meningiomas with calcification was lower than in tumors without calcification. Also, tumors with hypointense or isointense T2 signals on magnetic resonance imaging had a lower growth rate. In the group of six patients with surgical excision, tumor growth rates were higher and tumor doubling times shorter than in the nonsurgical group.CONCLUSIONThe majority of incidental meningiomas show minimal growth; thus, they may be observed without surgical intervention unless specific symptoms appear. Tumor growth is associated with patient age. The initial tumor size is not considered a predictive factor for tumor growth. Radiological features, such as calcification or T2 signal intensity, may provide useful information to predict the growth potential of meningiomas.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

OBJECTIVETo investigate the benefit of intraoperative low-field magnetic resonance imaging (MRI) in craniopharyngioma surgery.METHODSWe used a 0.2-T Magnetom Open scanner (Siemens Medical Solutions, Erlangen, Germany) that was located in a radiofrequency-shielded operating theater for intraoperative MRI. The head of the patient was placed in the fringe field of the scanner, so that standard microinstruments could be used. In transsphenoidal surgery, T1-weighted coronal and sagittal images were acquired. In transcranial surgery, a three-dimensional, gradient echo, T1-weighted, fast low-angle shot sequence was measured, thus allowing multiplanar reformatting.RESULTSA total of 21 surgical procedures in craniopharyngioma patients were investigated. In 10 patients, a bifrontal-translaminar approach was used; in 6 patients, the craniopharyngioma was removed via a transsphenoidal approach; and in 5 patients, intraoperative MRI was used to monitor cyst puncture and aspiration. In the craniotomy group, intraoperative imaging depicted a clear tumor remnant in one patient, which was subsequently removed. In another patient, an area of contrast enhancement was interpreted as artifact; however, postoperative follow-up at 3 months was suspicious for a minor remnant. Two of the eight patients with complete removal developed a recurrence during the follow-up period. In the group of patients who underwent primary transsphenoidal surgery (n = 4), complete removal was estimated by the surgeon in three cases. Intraoperative imaging depicted a remaining tumor in one case, leading to further tumor removal; however, follow-up revealed recurrent cysts.CONCLUSIONIntraoperative low-field MRI allows an ultraearly evaluation of the extent of tumor removal in craniopharyngioma surgery in most cases. Imaging showing an incomplete resection offers the chance for further tumor removal during the same operation. However, intraoperative low-field MRI depicting a complete resection does not exclude craniopharyngioma recurrence.

ISSN:0148-396X    

出版商:OVID    

年代:2003

数据来源: OVID