摘要:

OBJECTIVETo demonstrate that well-trained neurosurgeons can successfully treat patients with basilar apex aneurysms, to encourage young neurosurgeons in appropriate clinical environments to develop this expertise, and to describe a personal experience with an initial series.METHODSIn a consecutive series of 500 aneurysms treated surgically over 3.5 years, 57 aneurysms in 56 patients were located at the basilar apex, 47% of which were large or giant in size.RESULTSMost aneurysms (77%) were treated by direct clipping through an orbitozygomatic-pterional transsylvian approach. The surgical mortality rate was 9%, and permanent neurological morbidity associated with treatment occurred in 5%. Good outcomes (Glasgow Outcome Scale score 5 or 4) were achieved in 84%. Good outcomes increased from 79% in the first half of the series to 90% in the second half, and the mortality rate decreased from 21 to 4%.CONCLUSIONYoung neurosurgeons can acquire technical proficiency with basilar apex aneurysms while achieving optimal patient outcomes. Young neurosurgeons with the right training, talent, and temperament are needed to deal with those patients with basilar aneurysms who require surgery and with a possible shortage of basilar aneurysm surgeons in the future. The learning curve is characterized by increased temporary clipping, better perforator dissection, and more sophisticated permanent clipping technique. The path to proficiency can be as demanding mentally as it is technically.

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

OBJECTIVETo assess the technical feasibility of treating ruptured pericallosal artery aneurysms with detachable coils and to evaluate the anatomic and clinical results.METHODSOver a period of 27 months, 12 patients with a ruptured pericallosal artery aneurysm were treated with detachable coils. A retrospective review was performed to assess the clinical and angiographic results. The three men and nine women had a mean age of 46.6 years (range, 35–75 yr). Seven patients presented in Hunt and Hess Grade II, three in Grade III, and two in Grade IV. Six patients had a concomitant intracerebral hematoma, and four had at least one additional aneurysm.RESULTSIn all 12 patients, the pericallosal aneurysm could be reached with a microcatheter and the coils delivered. No procedure-related complications occurred. Angiography demonstrated that the initial occlusion was complete in 11 aneurysms and near-complete in 1. At follow-up angiography at 6 months, one aneurysm had become partially recanalized owing to coil compaction. At a mean clinical follow-up of 9.2 months, 11 patients had an excellent outcome and one patient had mild hemiparesis and aphasia.CONCLUSIONCoiling of ruptured pericallosal artery aneurysms can be considered an alternative to surgical clipping.

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

OBJECTIVEWe report 81 patients with a traumatic intracerebellar hemorrhagic contusion or hematoma managed between 1996 and 1998 at 13 Italian neurosurgical centers.METHODSEach center provided data about patients’ clinicoradiological findings, management, and outcomes, which were retrospectively reviewed.RESULTSA poor result occurred in 36 patients (44.4%). Forty-five patients (55.6%) had favorable results. For the purpose of data analysis, patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (39/81 cases; GCS score, ≥8), the outcome was favorable in 95% of cases. In Group 2 (42/81 cases; GCS score, <8), the outcome was poor in 81% of cases. Twenty-seven patients underwent posterior fossa surgery. Factors correlating with outcome were GCS score, status of the basal cisterns and the fourth ventricle, associated supratentorial traumatic lesions, mechanism of injury, and intracerebellar clot size. Multivariate analysis showed significant independent prognostic effect only for GCS score (P= 0.000) and the concomitant presence of supratentorial lesions (P= 0.0035).CONCLUSIONThis study describes clinicoradiological findings and prognostic factors regarding traumatic cerebellar injury. A general consensus emerged from this analysis that a conservative approach can be considered a viable, safe treatment option for noncomatose patients with intracerebellar clots measuring less than or equal to 3 cm, except when associated with other extradural or subdural posterior fossa focal lesions. Also, a general consensus was reached that surgery should be recommended for all patients with clots larger than 3 cm. The pathogenesis, biomechanics, and optimal management criteria of these rare lesions are still unclear, and larger observational studies are necessary.

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

OBJECTIVEThe value of combined diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) for detecting ischemic lesions of patients with acute ischemic injury was analyzed. Combined pre- and posttreatment DWI and PWI studies were used to assess the efficacy of intra-arterial thrombolysis.METHODSIntra-arterial thrombolysis was performed within 6 hours of onset in 10 patients who presented with acute middle cerebral artery or internal carotid artery occlusion. DWI and PWI obtained before and after treatment were studied. The final T2-weighted magnetic resonance scans were obtained 1 month after onset. Thrombolysis resulted in recanalization in seven patients. The mismatch ratio percentage ([initial PWI − initial DWI/initial PWI] × 100) and the rescued ratio percentage ([initial PWI − final T2/initial PWI] × 100) were calculated. The National Institutes of Health Stroke Scale (NIHSS) was used for neurological assessment of stroke severity at admission and at 1 month after onset.RESULTSIn all patients, the mismatch ratio was greater than 60% (mean ± standard deviation, 81.7 ± 16.7%) and was significantly correlated with initial NIHSS score (−0.74;P= 0.03), and the rescued ratio was significantly correlated with the NIHSS score 1 month after the insult (r= −0.83;P= 0.01). In patients who exhibited recanalization of the occluded artery (n = 7), the mean rescued ratio was 89.6 ± 12.8% (range, 63–100%). In addition, the lesion volume on posttreatment DWI scans and final T2-weighted magnetic resonance images was not enlarged; on posttreatment PWI scans, it was significantly decreased. The NHISS score at 1 month after the insult (2.3 ± 2.1) was markedly improved as compared with the initial NHISS score (10.7 ± 3.9).CONCLUSIONIn a small number of patients who presented with internal carotid artery or middle cerebral artery occlusion, the DWI/PWI mismatch ratio correlated with the initial neurological severity. The rescued ratio may be an objective indicator of the efficacy of treatment.

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

OBJECTIVEThe long-term results of transsphenoidal surgery for microprolactinoma, with particular reference to the question of permanence of relapse of hyperprolactinemia after biochemical cure, are examined.METHODSPatients whose operations were performed in the city of Glasgow, Scotland, by one neurosurgeon (GMT) have been followed up for between 15 and 21 years after surgery was performed.RESULTSOf a cohort of 44 patients with confirmed microprolactinoma at the time of surgery, 8 patients (18.2%) who experienced recurrent hyperprolactinemia postoperatively continued to be monitored. Selective hypophysectomy resulted in normal prolactin levels in all patients initially. Relapse occurred at 2 to 10 years (mean, 5.3 yr) postoperatively, but was permanent in only two patients (4.5%). Of the remaining six patients (13.6%), four (9.1%) became normoprolactinemic after 6 or 7 years’ recurrence, and two (4.5%) are now only marginally hyperprolactinemic (prolactin >500 but <700 mU/L) at 15 and 18 years after transsphenoidal hypophysectomy.CONCLUSIONThe recurrence of hyperprolactinemia after transsphenoidal surgery for microprolactinoma is not necessarily a permanent feature and does not inevitably indicate operative failure.

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

OBJECTIVEStereotactic radiosurgery (SRS) has become an effective therapeutic modality for the treatment of patients with glioblastoma multiforme (GBM). This retrospective review evaluates the impact of SRS delivered on a gamma knife (GK) unit as an adjuvant therapy in the management of patients with GBM.METHODSBetween August 1993 and December 1998, 82 patients with pathologically confirmed GBM received external beam radiotherapy (EBRT) at the University of Maryland Medical Center. Of these 82 patients, 64 with a minimum follow-up duration of at least 1 month are the focus of this analysis. Of the 64 assessable patients, 33 patients were treated with EBRT alone (Group 1), and 31 patients received both EBRT plus a GK-SRS boost (Group 2). GK-SRS was administered to most patients within 6 weeks of the completion of EBRT. The median EBRT dose was 59.7 Gy (range, 28–70.2 Gy), and the median GK-SRS dose to the prescription volume was 17.1 Gy (range, 10–28 Gy). The median age of the study population was 50.4 years, and the median pretreatment Karnofsky performance status was 80. Patient-, tumor-, and treatment-related variables were analyzed by Cox regression analysis, and survival curves were generated by the Kaplan-Meier product limit.RESULTSMedian overall survival for the entire cohort was 16 months, and the actuarial survival rate at 1, 2, and 3 years were 67, 40, and 26%, respectively. When comparing age, Karnofsky performance status, extent of resection, and tumor volume, no statistical differences where discovered between Group 1 versus Group 2. When comparing the overall survival of Group 1 versus Group 2, the median survival was 13 months versus 25 months, respectively (P= 0.034). Age, Karnofsky performance status, and the addition of GK-SRS were all found to be significant predictors of overall survival via Cox regression analysis. No acute Grade 3 or Grade 4 toxicity was encountered.CONCLUSIONThe addition of a GK-SRS boost in conjunction with surgery and EBRT significantly improved the overall survival time in this retrospective series of patients with GBM. A prospective, randomized validation of the benefit of SRS awaits the results of the recently completed Radiation Therapy Oncology Group’s trial RTOG 93-05.

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

OBJECTIVEThe risk of hematoma formation in stereotactic procedures is generally considered to range between 1 and 4%, and it has been speculated that morphological procedures may have a higher risk of bleeding than functional procedures.METHODSBetween 1989 and 1999, all patients who underwent a stereotactic procedure performed by the same surgeon were enrolled sequentially onto the study. All patients had normal preoperative prothrombin time, partial thromboplastin time, and platelet count. High-resolution computed tomography or magnetic resonance imaging with a 1.5-T machine were used for the target definition. None of the patients had an angiogram before surgery.RESULTSA total of 361 procedures was performed comprising 175 morphological procedures (139 biopsies, 18 lesion evacuations [cysts, abscesses, and hematomas], and 18 drain implantations) and 186 functional procedures (137 lesions [thalamotomy or pallidotomy], 47 deep brain electrode implantations, and two physiological explorations without lesions or implantations). There were no infections or seizures in either group. Three hematomas (1.7%) occurred in the morphological group, two of them in inflammatory lesions in immunocompromised patients (one death) and one in a pineal tumor. Three hematomas (1.6%) occurred in the functional group (no mortality). There was no statistically significant difference (P> 0.05; Fisher’s exact test) in the risk of hematoma formation between morphological and functional stereotactic procedures. The morbidity and mortality related to bleeding also were not statistically different (P> 0.05; Fisher’s exact test) between these two groups.CONCLUSIONIn this series, the risk of bleeding was not higher for morphological procedures than for functional procedures. This suggests that the risk of bleeding for stereotactic procedures is related more to the patient than to the type of procedure performed. Our study confirms an overall risk of bleeding of 1.7% for any type of stereotactic procedure, resulting in a mortality of 0.3% and a morbidity of 1.4%.

ISSN:0148-396X    

出版商:OVID    

年代:2002

数据来源: OVID