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Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex
Thu rsday, 10 July 1997
cortical responses. In group B (17 cases), there were negative responses. In 2 cases of group A, a deficit appeared. In other 3 cases ot group A. in which cortical incision were moved to nearby electrical silent area. no deficit occurred. In 5 cases of group B, a deficit appeared at the last stageof operation. But, deficits were mild. Patients did well tolerate the operation. Operation with cortical mappingis a safe procedure. The safety of the operation was increased by keeping the patients in alert state and talking about the new deficit.
I0-22-320 I Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex
R. Andrew Danks 1 • Peter M. Black, Linda S. Aglio, Lavem D. Gugino. Brigham & Women s Hospital. Boston, Massachusetts, USA, 1 Monash Medical Centre, Clayton, Australia Resection or even biopsy of an intra-axial mass lesion in close relationship to eloquent cortex carries a major risk of neurological deficit. We have assessed the safetyand effectiveness01craniotomyunder localanesthesiaand monitored conscious sedation for the resection of tumors involving eloquentcortex. We have performed a restrospective review of a consecutive series of 157 adult patients who underwent this procedure. In 122 cases, brain mapping was performed to identify eloquent cortex, whilst in the remainder, only neurological monitoring was performed. Of 76 patients with pre-operative neurological deficits, there was complete resolution 01these delicits in 33%, improvement in 32%, no change in 28%, and long-term worsening in 8%. Among 81 patients with no pre-operative neurologic deficits, 1 patient suffered a major permanent neurological deficit, and 2 developed minor deficits. Radiological gross total resection was achieved in 57% of patients, 23% had major subtotal resections, and 20% had biopsy only. Monitored conscious sedation was performed without anesthetic complications using midazolam, sufentanyl and fentanyl with or without propofol. One case needed to be converted to general anesthesia. Patient satisfaction with the procedure has been good. Operating time and hospitalstay were lowerthan the mean for brain tumor cranitomy at this hospital. This is a safe technique that allows maximal resection of lesions in close anatomical relationship to eloquent cortex, with a low risk of neurological deficit
I0-22-321 I technique MIN-biopsy of intracranial tumors: Operative and neuropathological results M. Scholz 1, M.K. Schwechheimer 2, M. Hardenack 1, A. Harders 1 . of Neurosurgery, Ruhr-University Bochum, Knappschafts-krankenhaus, In der Schornau 23-25. 44892 8ochum, , 2lns/itute of Neuropathology. University of Essen, Germany 1 Departmen/
Introduction: Stereotacticsurgery has been foundto be an establishedmethod in order to perform the biopsy of brain tumors. A disadvantage of this method is the lack of exact tumor visualization and haemostasis. In comparison MINbiopsy is defined as an open biopsy (under direct view) performed microsurgically after localization with the CT-topogram through a burrhole or trepanation with a maximum size of 3 x 3 em. The aim of this study was to compare the results of MIN-biopsywith stereotactic biopsy results in the literature. Materials and Methods: Between 1993 and 1996 15 patients (7 females, 8 males) with an age range of 36-84 years were operated by MIN-biopsy in the Department of Neurosurgery, Ruhr-University Bochum. Diameter of the operated lesion was between 1.5 and 4 em. The average duration of operation was 122 minutes. In 14 cases the tumor was located supratentorially and in one case infratentorially. Calculation of the exact approach was done by the CT-topogram using the method of Seeger. Results : In all patients a large amount of tumor tissue could be obtained (about 0.5 cern). Neuropathological examination of tumor specimen revealed exact neuropathological diagnosis in all 15 cases. Complications like infection, neurological deterioration or postoperative haemorrhage were not observed. Conclusion: MIN-biopsy is a safe methodto perform biopsy in patients with undefined intracranial tumors in order to find immediate diagnosis.
I0-22-322/ therapeutic Adult medulloblastoma: A study of the diagnostic, and prognostic criteria in 21 cases Nabil Mansour,A. EI-Demeri, M. EI-Bakry, M. Sellin. Mansoura University Hospital, Mansoura, Egyp/ Introduction: Medulloblastomas constitute only 1% of primary CNS tumors in adults. The aim of the present stUdy was to obtain a better understanding of the disease spectrum in the adult population and to assess whether it differs significantly from that reported in children. Method: This study was conducted on 21 adult patients (16 years or older) with medulloblastoma along a 8 years period (1988 through 1995). All cases were diagnosed bye.T.scan brain. In 10 cases, MAl was performedin addition.
Tumours of the eNS - Miscellaneous
S191
All patients underwent craniospinal irradiation using 6 MeV linear accelerator. Some torrn of chemotherapy was given to 10 patients. Statistical analysis for prognostic factors was performed using the 2 tailed test. Results: There were 13 males and 8 females ranging in age from 16 to 47 years (mean 26.5 years). Five tumors were vermian in location. 6 were paramedian and 10 were lateral tumors. The incidence of total tumor resection was 71.4%.The desmoplastic pathology was identifiedin 38% of cases. Survival rates were 78.6%. 70% and 50% at 2.3 and 5 years respectively. We failed to identify prognostic significance of age, sex, histologic type or extent of resection (P > 0.05). On the other hand, brainstem involvement was judged to be present radiologically and or preoperatively in 6 cases. The latter was a highly significant factor for survival (P < 0.01). Discussion and Conclusions: Although, similar to other studies, we identitied distinctdifferences between adult and pediatric medulloblastomas regarding location, radiological features, pathology and incidence of hydrocephalus, the survival rates in our material are not different from those recently reported in children. With our increased utilization of MRI and aiming to completely resect these tumors, we identified brainstem involvement at a higher incidence than that previously reported in adults. Tumors without brainstern involvement are amenable to complete excision, are usually hemispheric more than median and accordingly have a higher incidence of desmoplastic pathology. It is our contention that authors reporting better survival rates with the latter factors in adult medulloblastomas were probably reporting their results in a segment of patients with less incidence of brainstern involvement which, to our opinion, is more likely to be the determinantlactor for survival.
=
I0-22-3231 Cerebellar clear cell ependymoma mimicking hemangioblastoma: Its clinical and pathological features Nobuyuki Kawano,Tomoco Tanaka, Satoshi Utsuki, Ikuo Kobayashi, Hidehiro Oka, Tomonari Suwa, Kiyotaka Fuiii. Kitasato University Sch. of Moo., Sagamihara. Japan Introduction: As the clinical and pathological significance of cerebellar clear cell ependymoma (CCE) has n01 been recognized in the past, eight cases 01 cerebellar CCEs were studied. Methods: Subjects were six men and two women, and their ages ranged from 23 to 24 years. Their clinical features including neuroradiological and operative findings and pathological features were reviewed. Results: Most tumors [l18 cases) showed high vascularity in angiography and marked enhancement in computerized tomography (CT). Grossly, six tumors exhibited a "cyst with mural nodule" and two were mostly solid containing small cysts. At operation, the tumor nodules were dark red in color and the cysts contained xanthochromic fluid. Pathologically, all tumors displayed mostly clear round cells and abundant blood vessels. Although they commonly lacked the characteristic features of ependymomas, immunostaining and electron microscopy confirmedtheir ependymal origin. Discussion: The study showed that cerebellar CCEs mimic hemangioblastoma so much both clinically and pathologically that hemangioblastomas in the past are likely to contain CCE. To avoid erroneous diagnosis. immunostain for GFAP and electron microscopy are helpful. Clinically, CCE should be considered in the differential diagnosis01vascular tumors of the cerebellum and some diagnostic clues to differentiate CCE from hemangioblastoma will be discussed.
I0-22-3241 identical MUltiple intracerebral hemangioblastomas in twins with von Hippel-Lindau disease: A clinical and molecular genetic study S.B. Sobottka1 , S. Frank 2, M. Hampl2, A. Steinmetz 1 , H.K. Schackert 2, G. Schackert 1 . 1 Dept. of Neurosurgery, Carl Gustav Carus University of Dresden, Germany, 2 Dept. of SurgicalResearch, Carl Gustav Carus University of Dresden, Germany Von Hippel-Lindau (VHL) disease is an autosomal dominant inherited neoplastic disorder causing central nervous system hemangioblastomas. The VHL gene (3p25-3p26) is known to be a tumor suppressor gene with its inactivation being responsible for predisposition to the disease. We report the presently unique case of a primary manifestation of VHL disease in identical twins. The 42-year-
cortical responses. In group B (17 cases), there were negative responses. In 2 cases of group A, a deficit appeared. In other 3 cases ot group A. in which cortical incision were moved to nearby electrical silent area. no deficit occurred. In 5 cases of group B, a deficit appeared at the last stageof operation. But, deficits were mild. Patients did well tolerate the operation. Operation with cortical mappingis a safe procedure. The safety of the operation was increased by keeping the patients in alert state and talking about the new deficit.
I0-22-320 I Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex
R. Andrew Danks 1 • Peter M. Black, Linda S. Aglio, Lavem D. Gugino. Brigham & Women s Hospital. Boston, Massachusetts, USA, 1 Monash Medical Centre, Clayton, Australia Resection or even biopsy of an intra-axial mass lesion in close relationship to eloquent cortex carries a major risk of neurological deficit. We have assessed the safetyand effectiveness01craniotomyunder localanesthesiaand monitored conscious sedation for the resection of tumors involving eloquentcortex. We have performed a restrospective review of a consecutive series of 157 adult patients who underwent this procedure. In 122 cases, brain mapping was performed to identify eloquent cortex, whilst in the remainder, only neurological monitoring was performed. Of 76 patients with pre-operative neurological deficits, there was complete resolution 01these delicits in 33%, improvement in 32%, no change in 28%, and long-term worsening in 8%. Among 81 patients with no pre-operative neurologic deficits, 1 patient suffered a major permanent neurological deficit, and 2 developed minor deficits. Radiological gross total resection was achieved in 57% of patients, 23% had major subtotal resections, and 20% had biopsy only. Monitored conscious sedation was performed without anesthetic complications using midazolam, sufentanyl and fentanyl with or without propofol. One case needed to be converted to general anesthesia. Patient satisfaction with the procedure has been good. Operating time and hospitalstay were lowerthan the mean for brain tumor cranitomy at this hospital. This is a safe technique that allows maximal resection of lesions in close anatomical relationship to eloquent cortex, with a low risk of neurological deficit
I0-22-321 I technique MIN-biopsy of intracranial tumors: Operative and neuropathological results M. Scholz 1, M.K. Schwechheimer 2, M. Hardenack 1, A. Harders 1 . of Neurosurgery, Ruhr-University Bochum, Knappschafts-krankenhaus, In der Schornau 23-25. 44892 8ochum, , 2lns/itute of Neuropathology. University of Essen, Germany 1 Departmen/
Introduction: Stereotacticsurgery has been foundto be an establishedmethod in order to perform the biopsy of brain tumors. A disadvantage of this method is the lack of exact tumor visualization and haemostasis. In comparison MINbiopsy is defined as an open biopsy (under direct view) performed microsurgically after localization with the CT-topogram through a burrhole or trepanation with a maximum size of 3 x 3 em. The aim of this study was to compare the results of MIN-biopsywith stereotactic biopsy results in the literature. Materials and Methods: Between 1993 and 1996 15 patients (7 females, 8 males) with an age range of 36-84 years were operated by MIN-biopsy in the Department of Neurosurgery, Ruhr-University Bochum. Diameter of the operated lesion was between 1.5 and 4 em. The average duration of operation was 122 minutes. In 14 cases the tumor was located supratentorially and in one case infratentorially. Calculation of the exact approach was done by the CT-topogram using the method of Seeger. Results : In all patients a large amount of tumor tissue could be obtained (about 0.5 cern). Neuropathological examination of tumor specimen revealed exact neuropathological diagnosis in all 15 cases. Complications like infection, neurological deterioration or postoperative haemorrhage were not observed. Conclusion: MIN-biopsy is a safe methodto perform biopsy in patients with undefined intracranial tumors in order to find immediate diagnosis.
I0-22-322/ therapeutic Adult medulloblastoma: A study of the diagnostic, and prognostic criteria in 21 cases Nabil Mansour,A. EI-Demeri, M. EI-Bakry, M. Sellin. Mansoura University Hospital, Mansoura, Egyp/ Introduction: Medulloblastomas constitute only 1% of primary CNS tumors in adults. The aim of the present stUdy was to obtain a better understanding of the disease spectrum in the adult population and to assess whether it differs significantly from that reported in children. Method: This study was conducted on 21 adult patients (16 years or older) with medulloblastoma along a 8 years period (1988 through 1995). All cases were diagnosed bye.T.scan brain. In 10 cases, MAl was performedin addition.
Tumours of the eNS - Miscellaneous
S191
All patients underwent craniospinal irradiation using 6 MeV linear accelerator. Some torrn of chemotherapy was given to 10 patients. Statistical analysis for prognostic factors was performed using the 2 tailed test. Results: There were 13 males and 8 females ranging in age from 16 to 47 years (mean 26.5 years). Five tumors were vermian in location. 6 were paramedian and 10 were lateral tumors. The incidence of total tumor resection was 71.4%.The desmoplastic pathology was identifiedin 38% of cases. Survival rates were 78.6%. 70% and 50% at 2.3 and 5 years respectively. We failed to identify prognostic significance of age, sex, histologic type or extent of resection (P > 0.05). On the other hand, brainstem involvement was judged to be present radiologically and or preoperatively in 6 cases. The latter was a highly significant factor for survival (P < 0.01). Discussion and Conclusions: Although, similar to other studies, we identitied distinctdifferences between adult and pediatric medulloblastomas regarding location, radiological features, pathology and incidence of hydrocephalus, the survival rates in our material are not different from those recently reported in children. With our increased utilization of MRI and aiming to completely resect these tumors, we identified brainstem involvement at a higher incidence than that previously reported in adults. Tumors without brainstern involvement are amenable to complete excision, are usually hemispheric more than median and accordingly have a higher incidence of desmoplastic pathology. It is our contention that authors reporting better survival rates with the latter factors in adult medulloblastomas were probably reporting their results in a segment of patients with less incidence of brainstern involvement which, to our opinion, is more likely to be the determinantlactor for survival.
=
I0-22-3231 Cerebellar clear cell ependymoma mimicking hemangioblastoma: Its clinical and pathological features Nobuyuki Kawano,Tomoco Tanaka, Satoshi Utsuki, Ikuo Kobayashi, Hidehiro Oka, Tomonari Suwa, Kiyotaka Fuiii. Kitasato University Sch. of Moo., Sagamihara. Japan Introduction: As the clinical and pathological significance of cerebellar clear cell ependymoma (CCE) has n01 been recognized in the past, eight cases 01 cerebellar CCEs were studied. Methods: Subjects were six men and two women, and their ages ranged from 23 to 24 years. Their clinical features including neuroradiological and operative findings and pathological features were reviewed. Results: Most tumors [l18 cases) showed high vascularity in angiography and marked enhancement in computerized tomography (CT). Grossly, six tumors exhibited a "cyst with mural nodule" and two were mostly solid containing small cysts. At operation, the tumor nodules were dark red in color and the cysts contained xanthochromic fluid. Pathologically, all tumors displayed mostly clear round cells and abundant blood vessels. Although they commonly lacked the characteristic features of ependymomas, immunostaining and electron microscopy confirmedtheir ependymal origin. Discussion: The study showed that cerebellar CCEs mimic hemangioblastoma so much both clinically and pathologically that hemangioblastomas in the past are likely to contain CCE. To avoid erroneous diagnosis. immunostain for GFAP and electron microscopy are helpful. Clinically, CCE should be considered in the differential diagnosis01vascular tumors of the cerebellum and some diagnostic clues to differentiate CCE from hemangioblastoma will be discussed.
I0-22-3241 identical MUltiple intracerebral hemangioblastomas in twins with von Hippel-Lindau disease: A clinical and molecular genetic study S.B. Sobottka1 , S. Frank 2, M. Hampl2, A. Steinmetz 1 , H.K. Schackert 2, G. Schackert 1 . 1 Dept. of Neurosurgery, Carl Gustav Carus University of Dresden, Germany, 2 Dept. of SurgicalResearch, Carl Gustav Carus University of Dresden, Germany Von Hippel-Lindau (VHL) disease is an autosomal dominant inherited neoplastic disorder causing central nervous system hemangioblastomas. The VHL gene (3p25-3p26) is known to be a tumor suppressor gene with its inactivation being responsible for predisposition to the disease. We report the presently unique case of a primary manifestation of VHL disease in identical twins. The 42-year-