ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTTHE DECISION-MAKING PROCESS whereby treatment is offered to a patient with an arteriovenous malformation (AVM) must be supported by an understanding of the risks related to the natural history of the AVM and the risks related to the treatment of that particular AVM. The ability to estimate the treatment risk for an individual patient is hampered by the marked variability in the complexity of AVMs. In 1986, an AVM grading system was proposed to predict surgical morbidity and mortality. This system is based on the AVM size, the neurological eloquence of adjacent brain, and the pattern of venous drainage. Grade I malformations are small, superficial, and located in noneloquent cortex; Grade V lesions are large, deep, and situated in neurologically critical areas; and Grade VI lesions are considered inoperable AVMs. A retrospective application of this grading scheme demonstrated its correlation with the incidence of postoperative neurological complications. A prospective application of the AVM grading system has been performed in 120 consecutive patients who had a complete microsurgical excision of their AVM, with or without AVM embolization. The AVM grading system accurately correlated with both new-temporary (P< 0.0001) and new-permanent (P= 0.008) neurological deficits. The permanent major neurological morbidity rates for Grades I through III were 0%, increasing to 21.9% in patients with Grade IV and 16.7% in patients with Grade V AVMs (P< 0.0001). One patient with a Grade III AVM died from an esophageal hemorrhage 15 months after her AVM was treated. This prospective evaluation confirms the accuracy and utility of the proposed AVM grading system to assist with the process of management decision making. In addition, the continued application of this standardized grading scheme will enable a comparison among various clinical series and among different treatment techniques.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTTHE MAJORITY OF intracranial arteriovenous malformations (AVMs) do not require acute surgical intervention. Some patients, however, require emergent surgical treatment because of a profound neurological deterioration from a mass effect. We report 10 patients who underwent emergency AVM surgery after experiencing neurological deterioration from an intracranial hemorrhage. Two patients bled spontaneously, whereas eight had an intracranial hemorrhage secondary to an embolization procedure. When the patients demonstrated neurological deterioration, they were intubated, hyperventilated, and underwent osmotic diuresis. Barbiturate anesthesia was initiated, and surgery was performed within 30 minutes in most cases. The hematomas were evacuated, and an attempt was made to excise the AVMs at the same time. Postoperatively, intracranial pressure was monitored, and barbiturate coma was maintained until the intracranial pressure returned to normal. Cerebral perfusion pressure was maintained above 55 mm Hg. The operation was confined to evacuating the hematoma in two patients with inoperable AVMs. The other eight patients underwent concomitant total AVM resection. Because of the severity of neurological deterioration, one patient who bled spontaneously underwent surgery based only on a computed tomographic scan of the brain. Nine patients made a good-to-excellent recovery. One patient with a large motor-strip AVM remained hemiplegic. We conclude that in patients presenting with profound neurological deterioration after a spontaneous intracranial hemorrhage or one associated with an embolization procedure, prompt hematoma evacuation with simultaneous AVM excision as well as perioperative intracranial pressure control with mannitol and barbiturates can yield a good-to-excellent outcome.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTONE HUNDRED EIGHTY patients affected by cerebral arteriovenous malformations (AVMs) underwent radiosurgical treatment in our department. One hundred fifty-three patients have been treated with complete irradiation of the entire AVM nidus. In 27 patients (with large and/or three-dimensional irregular target volumes), only part of the nidus was covered with a dose adequate for obliteration. Follow-up ranged from 88 to 1 months (mean, 43.1 mo). Angiographic control was performed at 12, 24, and 36 months until complete obliteration was attained. The complete obliteration rate was 46% at 1 year and 80% at 2 years. We observed 15 hemorrhages after treatment, and five patients died from them. No bleeding took place after complete angiographic obliteration. The aim of this study is to evaluate the effect of irradiation on bleeding risk after radiosurgery and before complete obliteration. Inclusive parameters of patients considered at risk were as follows: 1) all patients in the time lapse between irradiation and demonstrated complete angiographic obliteration; 2) all patients in the time lapse between irradiation and definitive treatment either by surgery or embolization; and 3) all patients in the time lapse between irradiation and death. These groups include all irradiated patients who still had incompletely obliterated AVMs. They were stratified starting from 0 time (the date of radiosurgery), and the hemorrhages were evaluated every 6 months. In totally irradiated cases, the bleeding risk decreased from 4.8% in the first 6 months after radiosurgery to 0% starting from the 12th month of the follow-up. In partially irradiated cases, the bleeding risk increased from 4% in the first 6 months to 12 to 10% from the 6th to the 18th month and decreased to 5.5% from the 18th to the 24th month; no bleeding was observed after the 24th month.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTTEMPORARY OCCLUSION OF intracranial arteries has emerged as a valuable technical adjunct in the management of intracranial aneurysms. The current study considered 121 patients (from a group of 234 consecutive aneurysm patients treated during a 2-yr period) who underwent elective temporary arterial occlusion. Twenty-one patients were excluded from further study because of an intraoperative rupture of an aneurysm, the elective sacrifice of afferent or efferent vessels, or the performance of an extracranial-intracranial arterial bypass graft; the remaining 100 patients underwent elective temporary occlusion under a standard neuroanesthetic regimen, including etomidate-induced burst suppression, normotension, normovolemia, and normothermia. In the postoperative period, radiographic evidence of ischemic brain injury in the distribution of the arteries occluded was selected as the end point for the failure of occlusion tolerance. The parameters evaluated with respect to this end point included the duration and nature of the temporary arterial occlusion, the number of the occlusive episodes, the specific vascular territory occluded, patient age, neurological status, presence of subarachnoid hemorrhage, vasospasm, and aneurysm size. Several parameters were found to be related to the postoperative development of ischemic injury. Patients more than 61 years of age and those in poor neurological condition (Hunt and Hess Grades III to IV) did not tolerate temporary occlusion as well as patients who were younger and in better condition. Patients occluded for less than 14 minutes routinely tolerated the iatrogenic ischemia; the 95% confidence level for the toleration of occlusion without the development of infarction occurred at 19 minutes. All patients occluded for more than 31 minutes had both clinical and radiographic evidence of cerebral infarction. In patients undergoing periods of occlusion greater than 14 minutes, the use of incomplete occlusion appeared to be associated with the development of cerebral infarction. Relative, although not statistically significant, associations with poor tolerance of temporary occlusion were found with increasing episodes of temporary occlusion and occlusion of perforator-bearing segments of middle cerebral or basilar arteries.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTFROM 1983 TO 1990, 234 patients with one or several cerebral arterial aneurysms were surgically treated in our department. Since 1983, we have been performing surgery as early as possible. As soon as the subarachnoid hemorrhage diagnosis is confirmed by computed tomography (or if unconfirmed, by lumbar puncture), we assume that each patient may have an aneurysm. Between 1987 and 1990, 111 patients were treated by vascular volume expansion (maintenance of central venous pressure above 5 cm H2O with 4% albumin or Ringer-lactate or, if necessary, with 20% albumin), which we supplemented with calcium antagonists (nimodipine in 60 patients and nicardipine in 51 patients). Two months after being discharged, each patient is examined by a neurosurgeon and, on the same day, is subjected to a neuropsychological evaluation and a computed tomographic scan of the brain. A few months after this consultation, a working-position/family-activities questionnaire is issued to the patient. All of the results studied on the basis of postoperative mortality, second-month computed tomographic scan ischemia, neuropsychological evaluation, and return to work show no significant difference between the groups with or without calcium antagonists or between the nimodipine and nicardipine subgroups.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTTHE CURRENT LITERATURE reports many measurements (arteriovenous oxygen content difference and cerebral metabolic rate of oxygen, etc.) with samples from the internal jugular veins (IJs), obtained from either side of the neck, based on the assumption that a reliable sample of mixed venous blood can be drawn. We compared oxygen saturation in both IJs in 32 patients with head injuries to establish the similarities or discrepancies in the two veins. Both IJs were cannulated with 20-G catheters; in five patients, a fiberoptic catheter was used to obtain a continuous recording of the hemoglobin saturation. Blood samples were taken simultaneously from the two IJs and immediately processed; the total number of samples processed was 342, with an average of 5.34 paired samples from each patient. The mean and the standard deviation of the differences between the saturation of the two IJs were, respectively, 5.32 and 5.15. Fifteen patients showed differences greater than 15% in hemoglobin saturation; three more patients showed differences greater than 10% at some point during the investigation. Ultimately, only eight patients had differences of less than 5%. No relationship was found among the computed tomographic scan data and the pattern of hemoglobin saturation detected. Therefore, we were not able to identify the side more appropriate for monitoring in patients with bilateral, predominantly monolateral, cortical, or deeply located lesions. The 95% confidence limits for the percentage of patients with a difference higher than 15% were between 30 and 64%; the limits for the percentage of patients with a difference higher than 10 were between 39 and 73%; ultimately, the limits for the percentage of patients with a difference higher than 5 were between 60 and 90%. The proportion of patients with relevant discrepancies between the two IJs is higher than suspected, and the reliability of a single item of data obtained from a single IJ is questionable.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTIN THE VAST majority of studies that address the role of surgery in the management of high-grade gliomas, the degree of tumor removal accomplished is solely based on the intraoperative perception of the neurosurgeon. Despite its fundamental importance for a comparison of different treatment modalities, little systematic effort has been made to evaluate the residual gross tumor by neuroimaging methods immediately after surgery. We report the results of a prospective study using contrast-enhanced computed tomography and magnetic resonance imaging (MRI) to monitor 60 patients after the resection of a high-grade glioma. In each case, the first scans were obtained between Days 1 and 5 after surgery, followed by serial imaging every 2 to 3 months, usually until the condition of the patient deteriorated severely or the patient died. Gadolinium-enhanced MRI proved to be extremely valuable for assessing gross residual tumor when performed during Days 1 to 3 after the resection of a preoperatively enhancing high-grade glioma. This timing avoided surgically induced contrast enhancement and minimized interpretative difficulties. In delineating residual tumor, MRI was vastly superior to computed tomography. About 80% of tumor “recurrences” emerged from definitely enhancing remnants, as revealed by early postoperative MRI. The neurosurgeon's estimation of gross tumor burden reduction could be shown to be much less accurate (by a factor of 3) than the postoperative assessment by modern neuroimaging. In our series, residual tumor enhancement was the most predictive prognostic factor of survival in patients with glioblastoma, followed by radiotherapy. Patients with a residual tumor postoperatively had a 6.595-times higher risk of death in comparison to patients without a residual tumor. Patients undergoing radiotherapy had a 0.258-times lower risk of death in comparison to patients who were not treated with radiation. Concerning survival, the prognostic significance of both variables surpassed age and performance.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTIN THIS RETROSPECTIVE, consecutive series of 128 elderly patients (over 65 years of age) with histologically proven Grade 4 astrocytomas, 88 patients underwent stereotactic biopsy and 40 patients underwent stereotactic volumetric resection of the mass lesion defined by contrast enhancement on computed tomography. There were no significant differences in age (average age in the biopsy group, 71.6 yr; resection group, 70.15 yr) or Karnofsky Performance Scores (biopsy group, 84.33; resection group, 83.88) between the two groups. Four of the biopsy patients and one of the resection patients died within 30 days of surgery. The overall mean survival was 126 days; 108 days (15.4 wk) in the patients who had biopsies and 189 days (27 wk) in the patients who had resections. Radiation therapy was completed in 62 of the patients who had biopsies (mean survival, 118 d or 16.9 wk) and 34 of the patients undergoing resection (mean survival, 210 d or 30 wk) (log rankP= 0.0215; SmirnovP= 0.006). Although some prolongation of survival is noted after resection (more than after a biopsy) in selected patients over 65 years of age, that benefit is modest.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

ABSTRACTTHE AUTHORS PRESENT their experience with six children who developed anaplastic astrocytomas after receiving treatment for low-grade astrocytomas. Five children were from a series of 55 children with optic chiasmatic-hypothalamic gliomas who have been studied since 1976. The sixth child initially had a low-grade astrocytoma of the thalamus. The mean age of the children at initial presentation was 5.3 years. Five children were treated with surgery and radiation therapy; one child with a chiasmatic-hypothalamic glioma received radiation therapy alone. The amount of external radiation therapy used in all children was 50–52.5 Gy delivered in standard fractionations over approximately 6 weeks to include the volume of the original tumor plus a margin of 2 cm. The time to anaplastic transformation varied between 2 and 10 years (mean, 6.4 years). At tumor recurrence, the children had seizures or symptoms and signs of raised intracranial pressure. The location of the second tumor in all patients was either at the primary site or within the field of radiation therapy. Five of the six children underwent a second craniotomy and subtotal resection of their malignant gliomas. One child had positive cerebrospinal fluid cytology and multiple intraspinal metastatic tumor nodules detected by magnetic resonance imaging. On histopathological examination, four children had anaplastic astrocytoma, and two had glioblastoma multiforme. Four of the six children have died of their anaplastic astrocytomas (mean time from diagnosis of anaplastic astrocytoma to death, 10 months). Two children underwent chemotherapy and spinal irradiation for their anaplastic astrocytomas, and are currently alive and undergoing treatment. The possible mechanisms by which anaplastic tumors have developed in children treated previously for low-grade astrocytomas is discussed. The data suggest that radiation therapy may have played an integral role in the genesis of anaplastic astrocytomas in these children.

ISSN:0148-396X    

出版商:OVID    

年代:1994

数据来源: OVID