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PubMed2003

Microsurgical keyhole approach for middle fossa arachnoid cyst fenestration.

OBJECTIVE: The optimal surgical treatment for symptomatic temporal arachnoid cysts is controversial. Therapeutic options include cyst shunting, endoscopic fenestration, and craniotomy for fenestration. We reviewed the results for patients who were treated primarily with craniotomy and fenestration at our institution, to provide a baseline for comparisons of the efficacies of other treatment modalities. METHODS: A retrospective review of data for 50 children who underwent keyhole craniotomy for fenestration of temporal arachnoid cysts between 1994 and 2001 was performed after institutional review board approval. During that period, the first-line treatment for all symptomatic middle fossa arachnoid cysts was microcraniotomy for fenestration. Microsurgical dissection to create communications between the cyst cavity and basal cisterns was the goal. All patient records were reviewed and numerous variables related to presentation, cyst size and classification, treatment, cyst resolution, symptom resolution, follow-up periods, and cyst outcomes were recorded. RESULTS: Fifty temporal arachnoid cysts in 50 treated patients were identified. The average age at the time of surgery was 68 +/- 57.2 months. The follow-up periods averaged 36 months. There were 34 male and 16 female patients in the series. Twenty-six cysts were on the left side. Indications for surgery included intractable headaches (45%), increasing cyst size (21%), seizures (25%), and hemiparesis (8%). The symptoms most likely to improve were hemiparesis (100%) and abducens nerve palsies. Headaches (67%) and seizure disorders (50%) were less likely to improve. Nine patients exhibited progressive increases in cyst size in serial imaging studies. Those patients were monitored for a mean of 40 +/- 23 months before intervention. In the entire series, 82% of patients demonstrated decreases in cyst size in serial imaging studies. Of those patients, 18% demonstrated complete cyst effacement. Overall, 83% of patients with Grade II cysts and 75% of patients with Grade III cysts exhibited evidence of decreases in cyst size in long-term monitoring. Two patients required shunting after craniotomy (4%). Hospital stays averaged 3.4 days. Total surgical times averaged 115 minutes. No significant blood loss occurred (5-50 ml). Complications included spontaneously resolving pseudomeningocele (10%), transient Cranial Nerve III palsy (6%), cerebrospinal fluid leak (6%), subdural hematoma (4%), and wound infection (2%). CONCLUSION: A microsurgical keyhole approach to arachnoid cyst fenestration is a safe effective method for treating middle fossa cysts. This procedure can be performed with minimal morbidity via a minicraniotomy. Compared with an endoscopic approach, better control of hemostasis can be obtained, because of the ability to use bipolar forceps and other standard instruments. The operative time and length of hospital stay were not excessively increased.

Adolescent↗
PubMed2005

Herniation secondary to critical postcraniotomy cerebrospinal fluid hypovolemia.

OBJECTIVE: Cerebrospinal fluid hypovolemia resulting in postural headaches is a well-known clinical entity, but severe forms of cerebrospinal fluid hypovolemia with altered mental status and signs of transtentorial herniation ("brain sag") have rarely been reported. This article describes the clinical features of brain sag after craniotomy in an attempt to increase recognition of this syndrome. METHODS: Between April 2001 and January 2003, 220 consecutive patients with subarachnoid hemorrhage were prospectively enrolled in the Columbia Subarachnoid Hemorrhage Outcomes Project; 137 underwent craniotomy for aneurysm clipping. Among these patients, the diagnosis of brain sag was made when all three of the following criteria were present: clinical signs of transtentorial herniation, head computed tomographic scans revealing effacement of the basal cisterns with an oblong brainstem, and improvement of symptoms after placement of the patient in the Trendelenburg position (-15 to -30 degrees). For each patient, the symptoms, clinical course, and subsequent response to treatment were characterized. In addition, brainstem dimensions were measured on computed tomographic scans taken before, during, and after resolution of brain sag. A "sag ratio" was generated for these time points by dividing the maximum anteroposterior distance by the maximum bipeduncular distance. RESULTS: Eleven (8.0%) of 137 aneurysmal subarachnoid hemorrhage patients treated by craniotomy and an intraoperative spinal drain met the criteria for brain sag. Signs of transtentorial herniation developed most commonly between 2 and 4 days postoperatively. Pupillary asymmetry was noted in 10 (91.0%) of 11 patients, whereas the other patient demonstrated extensor posturing. The Trendelenburg position reversed the symptoms in all patients. The mean sag ratios before, during, and after resolution of brain sag were 0.91 +/- 0.03 (mean +/- standard error), 1.18 +/- 0.03, and 0.91 +/- 0.03, respectively. This represented a 30.9% elongation of the brainstem during sag (P < 0.001) and a 23.6% change back to baseline after resolution of the syndrome (P < 0.002). There was no significant difference between the presag and postsag ratios. CONCLUSION: Severe cerebrospinal fluid hypovolemia after craniotomy may produce a dramatic herniation syndrome that is completely reversed by the Trendelenburg position. Brain sag should be included in the differential diagnosis for acute postoperative clinical deterioration in this patient population.

Adult↗
PubMed2006

Intraoperative language localization in multilingual patients with gliomas.

OBJECTIVE: Intraoperative localization of speech is problematic in patients who are fluent in different languages. Previous studies have generated various results depending on the series of patients studied, the type of language, and the sensitivity of the tasks applied. It is not clear whether languages are mediated by multiple and separate cortical areas or shared by common areas. Globally considered, previous studies recommended performing a multiple intraoperative mapping for all the languages in which the patient is fluent. The aim of this work was to study the feasibility of performing an intraoperative multiple language mapping in a group of multilingual patients with a glioma undergoing awake craniotomy for tumor removal and to describe the intraoperative cortical and subcortical findings in the area of craniotomy, with the final goal to maximally preserve patients' functional language. METHODS: Seven late, highly proficient multilingual patients with a left frontal glioma were submitted preoperatively to a battery of tests to evaluate oral language production, comprehension, and repetition. Each language was tested serially starting from the first acquired language. Items that were correctly named during these tests were used to build personalized blocks to be used intraoperatively. Language mapping was undertaken during awake craniotomies by the use of an Ojemann cortical stimulator during counting and oral naming tasks. Subcortical stimulation by using the same current threshold was applied during tumor resection, in a back and forth fashion, and the same tests. RESULTS: Cortical sites essential for oral naming were found in 87.5% of patients, those for the first acquired language in one to four sites, those for the other languages in one to three sites. Sites for each language were distinct and separate. Number and location of sites were not predictable, being randomly and widely distributed in the cortex around or less frequently over the tumor area. Subcortical stimulations found tracts for the first acquired language in four patients and for the other languages in three patients. Three of these patients decreased their fluency immediately after surgery, affecting the first acquired language, which fully recovered in two patients and partially in one. The procedure was agile and well tolerated by the patients. CONCLUSION: These findings show that multiple cortical and subcortical language mapping during awake craniotomy for tumor removal is a feasible procedure. They support the concept that intraoperative mapping should be performed for all the languages in which the patient is fluent in to preserve functional integrity.

Adult↗
PubMed2004

Navigation as a tool to visualize bone-covered hidden structures in transfrontal approaches.

A retrospective analysis of 10 patients was performed to evaluate navigation systems in extranasal frontal skull base surgery. When performing a craniotomy following a bicoronal skin incision, the surgeon has to calculate the extent of the frontal sinus to avoid unnecessary damage to the dura or mucoceles later. Due to surgical morbidity including compression of the frontal lobe, many skull base surgeons have refused to use such an approach. Malformation or bone-destruction complicates the identification of the borders and increases the risk of side-effects. Navigation systems can be an alternative for calculating the frontal sinus outlines during surgery. In the authors' surgical procedure two different navigation systems were used. Conventional surgery using the transfrontal, transbasal or subcranial approach consisting of trepanation and craniotomy were performed, while the navigated surgical procedure was evaluated. The analysis showed that computer-assisted surgery (CAS) is applicable to extranasal frontal skull base surgery. In comparison to X-ray beam-controlled craniotomy, CAS is beneficial as it constitutes a noninvasive instrument of quality management. Furthermore, the analysis indicated that under the guidance of a navigation system a precise pre-surgical simulation is available in order to perform an optimal craniotomy and reconstruction of the frontal skull base.

Adult↗
PubMed2003

A role for advanced glycation end products in diminished bone healing in type 1 diabetes.

The effect of type 1 diabetes on bone healing and bone formation in standardized craniotomy defects created in BALB/cByJ mice was determined. The hypothesis that advanced glycation end products (AGEs) contribute to diminished bone healing in diabetes was evaluated by assessing for the presence of the receptor for advanced glycation end products (RAGE) by immunohistochemistry in healing craniotomy defects in diabetic animals. The effect of local application of a known RAGE protein ligand, N(epsilon)-(carboxymethyl)lysine (CML)-mouse serum albumin (MSA), on craniotomy defect healing in normal animals was then assessed and compared to the effects of control MSA. Finally, evidence in support of the expression of RAGE mRNA and protein in osteoblastic cells was obtained. The results indicated that craniotomy defects in diabetic animals healed approximately 40% of the degree to which they healed in nondiabetic animals (P < 0.05). RAGE was expressed at higher levels in healing bone tissues in diabetic compared to control animals. Further studies in nondiabetic animals indicated that bone healing was reduced by 63 and 42% in lesions treated with 900 and 90 micro g CML-MSA, respectively, compared to in animals treated with MSA alone (P < 0.05). Evidence for the expression of RAGE was obtained in mouse and rat osteoblastic cultures. These results support the contribution of AGEs to diminished bone healing in type 1 diabetes, possibly mediated by RAGE.

3T3 Cells↗
PubMed1992

Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly.

In order to determine the factors influencing outcome following craniotomy for trauma in patients over the age of 65 and to establish criteria for surgical intervention, the authors carried out a retrospective analysis of the hospital and general practice records of all head injury patients over the age of 65 who underwent a craniotomy for evacuation of a post-traumatic haematoma within 7 days of injury at Frenchay Hospital during a 10-year period (1980-89). Outcome was measured using the Glasgow Outcome Scale and patients were allotted to a good outcome group (good recovery or moderate disability but independent) or a poor outcome group (severe disability, vegetative state of death). There were 35 men and 31 women with a mean age of 72.5 years (range 65-85 years). The mortality rate was 61% and 9% of patients survived in a severely disabled or vegetative state. All 20 (30%) patients with a good outcome had a Glasgow Coma Score (GCS) of 5 or more immediately before surgery. All 18 (27%) patients with a GCS of 4 or less and all 22 (33%) patients with unilateral or bilateral pupillary dilatation had a poor outcome. Outcome was significantly worse in the older patients (75-85 years) compared with the younger patients (65-74 years) and in those patients requiring craniotomy within 24 hours of injury, but the mechanism of injury (fall or road traffic accident), the presence or absence of skull fractures and limb fractures and the pre-operative CT scan appearances did not influence outcome. This study confirms the high probability of poor outcome following surgical evacuation of traumatic intracranial haematomas for elderly head-injured patients with pupillary dilatation or extensor motor responses. Craniotomy under these circumstances is not justified.

Aged↗
PubMed2003

Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion.

OBJECT: The authors studied patients with aneurysmal subarachnoid hemorrhage (SAH) to determine whether the incidence of symptomatic vasospasm or overall clinical outcomes differed between patients treated with craniotomy and clip application and those treated by endovascular coil occlusion. METHODS: The authors reviewed 415 consecutive patients with aneurysmal SAH who had been treated with either craniotomy and clip application or endovascular coil occlusion at a single institution between 1990 and 2000. Three hundred thirty-nine patients underwent surgical clip application procedures, whereas 76 patients underwent endovascular coil occlusion. Symptomatic vasospasm occurred in 39% of patients treated with clip application, 30% of patients treated with endovascular coil occlusion, and 37% of patients overall. Compared with patients treated with clip application, patients treated with endovascular coil occlusion were more likely to suffer acute hydrocephalus (50 compared with 34%, p = 0.008) and were more likely to harbor aneurysms in the posterior circulation (53 compared with 20%, p < 0.001). Logistic regression models controlling for patient age, admission World Federation of Neurosurgical Societies (WFNS) grade, acute hydrocephalus, aneurysm location, and day of treatment revealed that, among patients with an admission WFNS grade of I to III, endovascular coil occlusion carried a lower risk of symptomatic vasospasm (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14-0.8) and death or permanent neurological deficit due to vasospasm (OR 0.28, 95% CI 0.08-1) compared with craniotomy and clip application. Similar models revealed no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less at the longest follow-up review (median 6 months) between treatment groups (OR 0.58, 95% CI 0.28-1.21). CONCLUSIONS: Patients with better clinical grades (WFNS Grades I-III) at hospital admission were less likely to suffer symptomatic vasospasm when treated by endovascular coil occlusion, compared with craniotomy and clip application. Nevertheless, there was no significant difference in overall outcome at the longest follow-up examination between the two treatment groups.

Adolescent↗
PubMed2002

Decompressive craniectomy in trauma patients with severe brain injury.

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.

APACHE↗
PubMed2003

Anatomic and clinical study of the orbitopterional approach to anterior communicating artery aneurysms.

OBJECTIVE: To evaluate the orbitopterional approach to anterior communicating artery (AComA) aneurysms, on the basis of the quantification of this surgical exposure, compared with the pterional approach, in a cadaveric study and a retrospective review of data for 40 patients who underwent clipping of AComA aneurysms via the orbitopterional approach. METHODS: In an anatomic study, four cadaveric heads underwent pterional craniotomies on the left side and orbitopterional craniotomies on the right side. A fifth head was initially subjected to bilateral pterional craniotomies and then underwent bilateral orbital osteotomies, for direct comparison of these approaches. Using frameless stereotaxy, we quantified the angles of exposure and surgical field depths provided by the pterional and orbitopterional craniotomies. In a clinical study, 40 patients who underwent clipping of AComA aneurysms via orbitopterional approaches were evaluated for basal brain injury, the need for resection of the gyrus rectus, dissection of the sylvian fissure, and approach-related complications. The incidence of postoperative hydrocephalus among patients with subarachnoid hemorrhage who underwent lamina terminalis fenestration was also reviewed. RESULTS: The angles of observation were increased 46% in the axial plane (orbitopterional, 72.92 +/- 6.57 degrees; pterional, 49.75 +/- 2.27 degrees; P < 0.01) and 137.5% in the projection plane (orbitopterional, 8 +/- 2.19 degrees; pterional, 19 +/- 1.78 degrees; P < 0.01). The surgical window depth was decreased 13% with the orbitopterional approach (P < 0.05). Clinically, there was no incidence of frontobasal hypodensities on postoperative computed tomographic scans. Three patients (7.5%) required resection of the gyrus rectus. No patient required sylvian fissure dissection for aneurysm exposure. Two of 29 patients (6.9%) who survived subarachnoid hemorrhage required ventriculoperitoneal shunts despite lamina terminalis fenestration. No approach-related complications were recognized. CONCLUSION: The orbitopterional approach improved the observation of the AComA complex and seemed to decrease the risk of intraoperative brain damage.

Adult↗
PubMed1974

Postoperative assessment of cerebral neoplasms: the need for an early brain scan.

Brain scans were performed on 40 patients who had had craniotomies for nonmalignant disease during the preceding 11 years. A significant decrease in radioactivity at the craniotomy site with time was found, and in nine patients studied five years post craniotomy there was no activity at all. Because of the frequent difficulty in interpreting the postcraniotomy brain scan when searching for recurrent tumours, it is recommended that baseline scans be obtained a few months after the operation to allow comparison of increased radioactivity at the craniotomy site with what may be seen on future brain scans.

Brain Neoplasms↗
PubMed1977

[Surgical treatment of distal anterior cerebral artery aneurysms (author's transl)].

Forty-five patients with aneurysms of the anterior cerebral artery distal to the anterior communicating artery were operated on by a direct approach method in the years 1960-1973. The incidence of aneurysms in this location was 4.8% of the total 1,000 aneurysms. It is of upmost importance in the treatment of aneurysms to insure the parent artery for the purpose of temporary occlusion. This makes it easier and safer to approach the aneurysmal neck and to handle possible premature aneurysmal rupture. From this technical standpoint, the aneurysms in this location were classified into two types, ascending and horizontal. Aneurysms of the pericallosal artery between the origin of the anterior communicating artery and the knee of the corpus callosum were designated as the aneurysms of the ascending portion, whereas the aneurysms of the pericallosal artery from the knee of the corpus callosum and beyond were designated as the aneurysms of the horizontal portion. Depending on the location of the aneurysm, craniotomy was performed at one of two different sites. For aneurysms of the ascending portion, bifrontal craniotomy was determined and applied as the safest approach. A small parasagittal craniotomy was determined to be sufficient for aneurysms of the horizontal portion. Although the total operative mortality was 4 of 45 cases (9.0%), no mortalities nor morbidities occurred in the last 12 cases since 1972, when the sites of craniotomies were differenciated.

Adult↗
PubMed1994

Acute subdural hematoma: nonsurgical management of selected patients.

There is a current trend toward nonsurgical therapy for small, minimally symptomatic acute subdural hematomas (ASDH), but data supporting such a scheme have been lacking. We evaluated 83 patients with minimally symptomatic ASDH (Glasgow Coma Scale scores of 11-15) and found 58 managed nonsurgically (70%) and 25 managed with craniotomy (30%). Patients managed without surgery had a lower incidence of focal neurologic deficits (12% vs. 40%; p < .01), open cisterns (90% vs. 28%; p < .001), and small (< or = 1 cm) ASDHs (92% vs. 62%; p < .001). Ninety-three percent of patients managed nonsurgically had functional recovery compared with 84% of patients with craniotomy. Age and injury Severity Score were significantly associated with patient outcome. Timing of surgery had no association with outcome. Six percent of patients managed nonsurgically developed chronic SDH requiring craniotomy. We conclude that unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction, there appears to be no advantage in evacuating the clot. Selected patients with ASDH and GCS scores of 11-15 can safely be managed without craniotomy.

Acute Disease↗
PubMed1994

Surgical management of radiated scalp in patients with recurrent glioma.

Patients with malignant brain tumors requiring multiple craniotomies and external beam radiotherapy are at risk of scalp wound breakdown secondary to fibrosis and radiation damage. We present three cases to illustrate the nature of the problem and the surgical approaches to scalp repair. When a bicoronal incision has been used for the initial craniotomy, the plastic repair can be performed with a bipedicle visor scalp flap and split-thickness skin graft to cover the pericranium at the donor site. When a curvilinear (U-shaped or horseshoe) flap has been used for the initial craniotomy, a single-pedicle flap may be rotated to achieve closure without tension. In anticipation of the risk of scalp wound breakdown in patients with malignant brain tumors, the planning of the operative incision for the first craniotomy needs to take into account the long-term viability of the scalp. We recommend linear scalp incisions parallel to the arterial distribution instead of the traditional curvilinear (U-shaped or horseshoe) flaps; linear incisions are less likely to break down, and in the event of breakdown, linear wounds offer better therapeutic surgical options for plastic repair.

Adult↗
PubMed1995

Interconnecting the posterior and middle cranial fossae for tumors that traverse Meckel's cave.

Meckel's cave is an avenue for tumor to spread between the posterior and middle cranial fossae. The most common neoplasms that traverse this channel are trigeminal schwannomas and meningiomas. The classic approach to address disease in both cranial fossae involves separate craniotomies. Recent innovations in skull base surgery have made it possible to perform a single opening with simultaneous exposure of the posterior and middle fossae, without undue brain retraction. Tumors with a large middle fossa component and a smaller posterior fossa portion are exposed via subtemporal craniotomy with petrosectomy and tentorium division. However, tumors with a large posterior fossa component and a smaller middle fossa portion in the setting of serviceable hearing are addressed with retrosigmoid craniotomy and petrosectomy. For bilobed tumors with substantial components in both fossae, subtemporal craniotomy combined with varying degrees of transtemporal petrosectomy and tentorium division is employed. The evolution of techniques to address tumors that traverse Meckel's cave is reviewed and a treatment algorithm is proposed.

Brain Neoplasms↗
PubMed2000

Surgery for primary supratentorial intracerebral haemorrhage.

BACKGROUND: There is considerable international variation in the rate and indications of surgery for primary supratentorial intracerebral haematoma, reflecting the uncertainty about the effects of surgery. OBJECTIVES: The objective of this review was to assess the effects of surgery plus routine medical management, compared with routine medical management alone, in patients with primary supratentorial intracerebral haematoma. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, Current Opinion in Neurology and Neurosurgery, and Neurosurgical Clinics of North America (1991 to July 1993) and reference lists of articles. SELECTION CRITERIA: Randomised and quasi-randomised trials of routine medical treatment plus intracranial surgery compared with routine medical treatment, in patients with presumed or confirmed primary supratentorial intracerebral haematoma. Intracranial surgery included craniotomy, stereotactic endoscopic evacuation or stereotactic aspiration. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria, assessed trial quality and extracted the data. MAIN RESULTS: Four trials were included. No trial had blinded outcome assessment. Craniotomy and endoscopic evacuation were analysed separately. Craniotomy showed a non-significant trend towards increased odds of death and dependency among survivors (odds ratio 1.99, 99% confidence interval 0.92 to 4. 31). The result was inconclusive in the two trials with patients confirmed as having primary supratentorial intracerebral haematoma by CT. Endoscopic evacuation was not shown to significantly decrease the odds of death and dependency among survivors in one trial involving 100 patients (odds ratio 0.45, 99% confidence interval 0. 15 to 1.33). REVIEWER'S CONCLUSIONS: There is not enough evidence to evaluate the effect of craniotomy or stereotactic surgery, or endoscopic evacuation in patients with supratentorial intracerebral haematoma.

Cerebral Hemorrhage↗
PubMed1996

Surgical resection of brain metastases from lung cancer.

The role of surgical resection for brain metastases is evolving. The most common primary for brain metastases is lung; in the US in 1992, for example, there were nearly 40,000 deaths with symptomatic brain metastases from lung cancer. We reviewed a series of 25 consecutive patients with non small cell lung cancer (NSCLC) undergoing open resection of one or more symptomatic brain metastases to consider the role of open resection. Twenty-three of the 28 resected lesions were 3 cm or greater in diameter; 19 were solid and nine cystic. Surgical adjuncts included (where indicated): stereotactic biopsy, cyst drainage, and craniotomy; intra-operative ultrasound; and intra-operative evoked potential mapping of the sensorimotor area. Six patients underwent thoracotomy for resection of the lung primary (in all but one case, prior to craniotomy). Except for two patients who had whole brain radiation therapy (WBXRT) prior to referral to Neurosurgery, all patients underwent WBXRT (30 to 60 Gy) postoperatively. The mean survival from date of craniotomy was 13.1 months, with two patients still alive at ten and seventeen months post-craniotomy. Survival comparisons which were significantly different included (1) lung surgery versus no lung surgery (25.7 months versus 9.1 months, P < 0.001), and (2) metachronous presentation of the lung primary and brain metastasis versus synchronous presentation (17.6 months versus 9.5 months, P = 0.025). Survival comparisons which were not significantly different included single versus multiple metastases, complete versus incomplete resection, adenocarcinoma versus large or squamous or cell histology, supratentorial versus infratentorial location, solid versus cystic metastasis, and age < or = 60 years versus > 60 years. These results, when compared with the literature on brain metastases, suggest that aggressive resection of symptomatic metastases from lung cancer (even if multiple) can improve functional survival over conservative management, and that small, asymptomatic lesions are well-controlled by WBXRT. They also confirm the previous finding that surgical treatment of both the lung primary and the brain metastases may afford the greatest period of functional survival for these patients.

Adult↗
PubMed2004

Course of brain shift during microsurgical resection of supratentorial cerebral lesions: limits of conventional neuronavigation.

BACKGROUND: The authors have conducted a prospective study to evaluate the amount and course of brain shift during microsurgical removal of supratentorial cerebral lesions, and to assess factors which potentially influence these shifts. METHOD: In 61 patients the displacement of 2-3 cortical landmarks on the cerebral surface was dynamically quantified during surgery, i.e. during dissection of the tumour at the estimated half-time of surgery, and at the end of microsurgical removal of the cerebral lesion using the neuronavigation system EasyGuide Neuro. In 14 of these patients the displacement of a subcortical landmark was additionally analysed. Age of the patients, preoperative midline shift, location of the lesion, lesion volume, depth of the lesion below the cortical surface, presence or absence of oedema, and size of the craniotomy were analysed for potential influence on the amount of brain shift. Correlations were analysed for all patients together and for the subgroups of vault meningiomas (n=10), gliomas (n=30), and nonglial intra-axial lesions (n=21). FINDINGS: The mean displacement of the cortical landmarks ranged between 0.8 and 14.3 mm (mean: 6.1 mm, standard deviation: 3.4 mm) during surgery (10-210 minutes [mean: 50.7 minutes, standard deviation: 34.5 minutes] after dura opening) and between 2.4 and 15.2 mm (mean: 6.6 mm, standard deviation: 3.2 mm) at the end of microsurgical removal of the tumourous cerebral lesions (20-375 minutes [mean: 107.2 minutes, standard deviation: 65.6 minutes] after dura opening). Significant correlations (p<0.01) for the entire patient group were found between brain shift and tumour volume, midline shift, and size of the craniotomy, respectively. For the subgroup of vault meningiomas a significant correlation (p<0.01) between brain shift and patient age was found. For the subgroup of gliomas a significant correlation (p<0.01) between brain shift and tumour volume, midline shift and size of the craniotomy, respectively, was found. For the subgroup of nonglial intra-axial lesions a significant correlation (p<0.01) between brain shift and midline shift and between brain shift and size of the craniotomy was found. The quantity of shared common variance ranged between 10-50%. Performing a discriminant analysis, lesion volume was the only certain factor influencing brain shift intra-operatively as well as at the end of lesion removal. 58.5% of the extent of brain shift could be correctly classified by the tumour volume as the only discriminating variable during dissection of the tumour and at the end of surgery. Comparing superficial with subcortical brain shift over the same time period, a mean superficial shift of 4.6 mm (1.6-10.8 mm, standard deviation: 2.8 mm) and a mean subcortical shift of 3.5 mm (1.0-7.7 mm, standard deviation: 2.3 mm) was found. A highly significant Spearman correlation (Rho:.97, p<0.001) between superficial and subcortical brain shift emerged. Shifting of superficial landmarks exceeded shifting of subcortical structures in all patients. CONCLUSIONS: The data demonstrate the dynamics of brain shift and the limits of conventional neuronavigation and add additional support for the unavoidable inaccuracy of contemporary neuronavigational systems once the cranium is opened. Brain shift leads to a significant loss of reliability of neuronavigation systems during microsurgical removal of intracranial lesions and there are differences of the course and the amount of brain shift in relation to special subgroups of supratentorial cerebral lesions. However, because of the heterogeneous nature of lesions neurosurgeons have to remove, the modest quantity of shared common variance, and the differences between superficial and subcortical brain shift, it seems unlikely that the amount and course of brain shift become exactly predictable pre-operatively. Only an intra-operative update of image data should have the capacity to overcome this fundamental problem of modern neuronavigation.

Adolescent↗
PubMed1999

Burr hole evacuation of chronic subdural haematomas followed by continuous inflow and outflow irrigation.

Chronic subdural haematomas are prone to recollect, increasing the risk of further complications and death. Burr hole evacuation followed by continuous irrigation of a Ringer solution into the remaining subdural cavity, allows remaining blood to be washed out and the brain to re-expand. This technique was compared with burr hole evacuation either without or with a passive drainage and craniotomy, respectively. Reformation of haematomas after continuous irrigation occurred in 2.6% (2/77); more than a twelve (32.6%; 15/46) and a nine (23.8%; 5/21) times rate reduction compared to burr hole evacuation without and with passive drainage, respectively. Compared to the craniotomy results, the rate dropped seventeen times (44.4%; 4/9). Expect from the two rebleedings in 77 haematomas operated on through burr holes followed by irrigation, all patients recovered including nine recurrent haematomas re-operated on by this method. Recurrent haematomas operated on through burr hole evacuation alone or with insertion of a passive drainage, recollected in 50% (2/4) and 33.3% (2/6). Similar rate after craniotomies was 11.1% (1/9). Neither infections nor deaths followed burr hole evacuation combined with continuous irrigation, whereas 5.3% (2/38) and 5.9% (1/17) suffered from empyema after burr hole evacuation alone or combined with a passive drainage, respectively. Five (9.1%) of these 55 patients died either from empyemas (three) or rebleedings (two). Recurrent haematomas evacuated through a craniotomy had no complications from infections. Compared to other methods, continuous irrigation reduces the need for re-operation significantly by preventing haematoma recurrence and empyema formation. Contrary to other surgical techniques, haematoma recurrence after second time surgery did not occur.

Adult↗