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Endovascularly or surgically treated vertebral artery and posterior inferior cerebellar artery aneurysms: clinical analysis and results
© Masson, Paris, 2006
Neurochirurgie, 2006, 52, n° 1, 67-76
Échanges
RÉSUMÉS DES ARTICLES PARUS DANS ZENTRALBLATT FÜR NEUROCHIRURGIE, N° 1 À 4, 2005 Les rédacteurs en chef et les éditeurs de Zentralblatt für Neurochirurgie et Neurochirurgie ont décidé de publier leurs résumés d’articles respectifs. Cette publication portera sur tous les articles publiés au cours de l’année, dans chaque revue. Zentralblatt für Neurochirurgie est consultable en ligne sur le site www.thieme-connect.de. Nous sommes heureux d’offrir aux lecteurs cette ouverture des contenus entre les deux revues, pour une plus grande collaboration et un meilleur échange des connaissances dans notre spécialité. Marc Tadié Rédacteur en chef
Technique and image quality of intraoperative indocyanine green angiography during aneurysm surgery using surgical microscope integrated near-infrared video technology
plicity of the method and the speed with which the investigation can be performed indicate that this technique may help to improve the quality and outcome of surgical procedures and reduce the need for intra- or postoperative angiography in selected cases.
A. Raabe, J. Beck, V. Seifert
Key-words: Intraoperative angiography, flow, indocyanine green, surgical microscope.
Department of Neurosurgery, Neurocenter, Johann Wolfgang Goethe University, Frankfurt am Main, Germany. Zentralbl Neurochir 2005; 66(1): 1-6
Objective. To describe the technical integration of indocyanine green (ICG) near-infrared technology into the optical path of the surgical microscope and to report on the image quality achieved by this method. We hypothesized that ICG angiography permits a simple and quick intraoperative assessment of vessel patency and aneurysm occlusion after clip placement. Methods. A special arrangement of filters was designed to allow the passage of near-infrared light required for the excitation of ICG fluorescence (700-850 nm) from a modified microscope light source into the surgical field and the passage of ICG fluorescence (780-950 nm) from the surgical field back into the optical path of the surgical microscope (Carl Zeiss, Oberkochen, Germany). Thus, ICG angiography could be completely performed with a surgical microscope. 20 patients with intracranial aneurysms were included in the technical evaluation of the new method. Results. Image quality and spatial resolution were excellent and permitted a real-time assessment of vessel patency and aneurysm occlusion if the structures of interest were visible to the surgeon’s eye under the microscope, including perforating arteries with a diameter of less than 1 millimeter. In 1 patient, vessel occlusion by the clip was found and in 1 case residual filling of the aneurysm was diagnosed. Both cases could be treated by clip correction within 2 minutes after primary placement of the clip. In all cases, the intraoperative findings correlated with the postoperative digital subtraction angiography. Conclusions. ICG angiography using a surgical microscope is valuable for the intraoperative imaging of arterial and venous flow in all visible vessels including small perforating arteries. The sim-
Endovascularly or surgically treated vertebral artery and posterior inferior cerebellar artery aneurysms: clinical analysis and results I.E. Sandalcioglu (1), I. Wanke (2), B. Schoch (1), T. Gasser (1), J.P. Regel (1), A. Doerfler (2), M. Forsting (2), D. Stolke (1) (1) Department of Neurosurgery, University of Essen, Germany. (2) Department of Neuroradiology, University of Essen, Germany. Zentralbl Neurochir 2005; 66(1): 9-16
Objective. To describe the clinical results in patients with aneurysms of the vertebral artery and posterior inferior cerebellar artery complex (VA-PICA) treated by endovascular embolization or surgically in cases considered untreatable by endovascular methods. Patients and methods. During a 5-year-period a total of 28 patients with a VA-PICA complex aneurysm out of 600 patients received definitive treatment, 19 patients by endovascular embolization and 9 patients surgically. Mean age was 54 years (range 9-75 years). Clinical data, intraoperative observations and procedural complications were evaluated. The mean follow-up was 9 months. Results. Hunt-Hess (HH) grades were HH 0-II in 10 patients (35.7%), HH III in 6 patients (21.4%) and HH IV + V in 12 patients (42.9%). Aneurysm size ranged from 2 to 40 mm (mean size 5.5 mm). Aneurysm configuration was saccular 18, fusiform 7 and multilobed 3. Complete occlusion was achieved in all cases. Overall 67.9% (n=19) showed a favorable outcome (Glasgow Outcome Score IV + V). Overall procedure-related rate for permanent morbidity and mortality was 3.6% (n=1) and 3.6% (n=1), respectively. Predictive factors of clinical outcome were the initial clinical HH grade and the Fisher grade.
68
ZENTRALBLATT FÜR NEUROCHIRURGIE, N° 1 À 4, 2005 : RÉSUMÉS
Conclusion. Endovascular embolization is an effective method for the treatment of VA-PICA aneurysms. Surgical clipping is still an alternative and should be considered for “uncoilable” lesions. Outcomes showed a close correlation to the initial clinical state and were not dependent on the treatment modality. Key-words: Cerebral aneurysms, vertebral artery, posterior inferior cerebellar artery, endovascular therapy, aneurysm surgery.
Volumetric analysis of the growth rate of incompletely resected intracranial meningiomas M. Nakamura (1), F. Roser (1), J. Michel (1), C. Jacobs (1), M. Samii (1, 2) (1) Department of Neurosurgery, Nordstadt Hospital Hannover, Germany. (2) International Neuroscience Institute, Hannover, Germany. Zentralbl Neurochir 2005; 66(1): 17-23
Objective. Intracranial meningiomas are mostly considered to be slow growing tumors. However, only a few previous reports provide information on the growth rate of these tumors. The aim of this study was to determine the growth rates of intracranial meningiomas after subtotal resection, analysing their relation to radiological appearance and histological features. Results are compared with our previous analysis of growth rates in incidental meningiomas. Methods. The hospital charts, follow up records and imaging studies were reviewed in 36 patients with subtotally resected intracranial meningiomas. The tumor growth rates were determined by calculating the absolute and relative growth rates and the tumor volume doubling times. Results. In the group of 33 patients with histologically verified grade 1 meningiomas, the mean absolute growth rate was 1.51 cm3/ year, the median relative growth rate and tumor doubling time was 14.18%/year and 5.228 years. In young patients annual relative growth rates were significantly higher. The median annual relative growth rate of meningiomas with calcification was significantly lower than in tumors without calcification. Also tumors with hypo— or isointense T2-signals on MRI revealed a lower growth rate. There was no significant difference between males and females. Histological studies revealed 22 meningiomas of a meningotheliomatous subtype, 8 fibrous and 3 psammomatous meningiomas. The comparison of growth rates between these subtypes did not show any significant differences. In atypical meningiomas (WHO grade 2), absolute and relative growth rates were significantly higher and tumor doubling times shorter. Conclusion. The majority of intracranial meningiomas are slow growing tumors, although the growth rates may vary widely even among benign grade 1 meningiomas. In meningiomas after subtotal surgical resection, the age of the patients seems to present a predictive factor for tumor growth in analogy to our previous observation in incidental meningiomas. Significantly higher relative growth rates were detected in younger patients. Gender does not seem to play a major role as a predictive factor. Radiological features such as calcification or T2-signal intensity may provide additional information to predict the growth potential of meningiomas. Close clinical and radiological observation should be performed in young patients harboring tumors with absence of calcification or high T2-signal intensities due to the higher growth potential in this patient group. Key-words: Meningioma, natural history, tumor growth rate, subtotal resection.
Neurochirurgie
Experience with five different intervertebral disc spacers for cervical spondylodesis D. Kemmesies (1), U. Meier (2) (1) Neurochirurgische Klinik, Humaine Klinikum Bad Saarow, Germany. (2) Klinik für Neurochirurgie, Unfallkrankenhaus Berlin, Germany. Zentralbl Neurochir 2005; 66(1): 24-33
The ventral spondylodesis with autologeous bone graft for degenerative disease of the cervical spine bears the disadvantage of complications and heavy pain at the superior pelvic straight. To reduce these problems the intervertebral disc spacer was developed. Between September 1997 and January 2002 we operated on 207 patients suffering from degenerative disease — osteochondrosis and/or disc prolapse — of the cervical spine. Without any patient selection, e. g. according to a randomized sample, we implanted the different disc spacer by a ventral approach after microsurgical discectomy and removal of the dorsal osteophytes by a high-speed drill. The Titanium disc spacer by Aesculap, Weber, Intromed, and Medinorm were used in 66, 54, 52 and 18 cases and the Carbonium disc spacer of AcroMed in 17 cases. We evaluated the handling, X-ray contrast, costs of implantation and the clinical results after 3 months and 1 year. All the five disc spacers are suitable for the ventral spondylodesis of the cervical spine. The titanium spacer from Weber is characterized by its comfortable handling and a price in the mean range. A good cost effectiveness and an easy handling is given by the Intromed-cage. The X-ray contrast of the Carbonium spacer by AcroMed is insufficient in the lower cervical spine. The handling is good, but the price is too high. The AcroMed, Medinorm and Intromed spacer have the tendency to migrate into the vertebral endplates. A final statement can only be given after the achievement of longterm results. Key-words: Intervertebral disc spacer, spondylodesis, cervical spine, degenerative disease, clinical outcome.
Metastatic meningioma WHO grade II of the cervical spine: case report and review of the literature M.O. Pinsker, R. Buhl, H.-H. Hugo, H.M. Mehdorn Department of Neurosurgery, University of Schleswig-Holstein, Campus Kiel, Germany. Zentralbl Neurochir 2005; 66(1): 35-38
The authors report a rare case of metastatic atypical meningioma WHO grade II involving the dorso-lateral region of the cervical spine and causing spinal cord compression in a 76-year-old man. The patient was treated surgically in June 1998 for an atypical parasagittal meningioma in the right frontal lobe. Local recurrence with extension to the left hemisphere required surgical treatment in January 2000, and in December 2000 recurrence caused paraplegia of the lower extremities and paresis of the left arm. A 3rd operation was carried out in January 2001, followed by radiotherapy with a total dose of 45 Gy. The patient presented again in March 2003 because of pain in the neck and a progredient new paresis and paresthesia of the right arm. Computed tomogram of the cervical spine showed a large tumor with compression of the spinal cord. MRI was not possible due to a pacemaker which had been implanted in the meantime. Surgical subtotal removal of the tumor via hemilaminectomy of the
Neurochirurgie, 2006, 52, n° 1, 67-76
Échanges
RÉSUMÉS DES ARTICLES PARUS DANS ZENTRALBLATT FÜR NEUROCHIRURGIE, N° 1 À 4, 2005 Les rédacteurs en chef et les éditeurs de Zentralblatt für Neurochirurgie et Neurochirurgie ont décidé de publier leurs résumés d’articles respectifs. Cette publication portera sur tous les articles publiés au cours de l’année, dans chaque revue. Zentralblatt für Neurochirurgie est consultable en ligne sur le site www.thieme-connect.de. Nous sommes heureux d’offrir aux lecteurs cette ouverture des contenus entre les deux revues, pour une plus grande collaboration et un meilleur échange des connaissances dans notre spécialité. Marc Tadié Rédacteur en chef
Technique and image quality of intraoperative indocyanine green angiography during aneurysm surgery using surgical microscope integrated near-infrared video technology
plicity of the method and the speed with which the investigation can be performed indicate that this technique may help to improve the quality and outcome of surgical procedures and reduce the need for intra- or postoperative angiography in selected cases.
A. Raabe, J. Beck, V. Seifert
Key-words: Intraoperative angiography, flow, indocyanine green, surgical microscope.
Department of Neurosurgery, Neurocenter, Johann Wolfgang Goethe University, Frankfurt am Main, Germany. Zentralbl Neurochir 2005; 66(1): 1-6
Objective. To describe the technical integration of indocyanine green (ICG) near-infrared technology into the optical path of the surgical microscope and to report on the image quality achieved by this method. We hypothesized that ICG angiography permits a simple and quick intraoperative assessment of vessel patency and aneurysm occlusion after clip placement. Methods. A special arrangement of filters was designed to allow the passage of near-infrared light required for the excitation of ICG fluorescence (700-850 nm) from a modified microscope light source into the surgical field and the passage of ICG fluorescence (780-950 nm) from the surgical field back into the optical path of the surgical microscope (Carl Zeiss, Oberkochen, Germany). Thus, ICG angiography could be completely performed with a surgical microscope. 20 patients with intracranial aneurysms were included in the technical evaluation of the new method. Results. Image quality and spatial resolution were excellent and permitted a real-time assessment of vessel patency and aneurysm occlusion if the structures of interest were visible to the surgeon’s eye under the microscope, including perforating arteries with a diameter of less than 1 millimeter. In 1 patient, vessel occlusion by the clip was found and in 1 case residual filling of the aneurysm was diagnosed. Both cases could be treated by clip correction within 2 minutes after primary placement of the clip. In all cases, the intraoperative findings correlated with the postoperative digital subtraction angiography. Conclusions. ICG angiography using a surgical microscope is valuable for the intraoperative imaging of arterial and venous flow in all visible vessels including small perforating arteries. The sim-
Endovascularly or surgically treated vertebral artery and posterior inferior cerebellar artery aneurysms: clinical analysis and results I.E. Sandalcioglu (1), I. Wanke (2), B. Schoch (1), T. Gasser (1), J.P. Regel (1), A. Doerfler (2), M. Forsting (2), D. Stolke (1) (1) Department of Neurosurgery, University of Essen, Germany. (2) Department of Neuroradiology, University of Essen, Germany. Zentralbl Neurochir 2005; 66(1): 9-16
Objective. To describe the clinical results in patients with aneurysms of the vertebral artery and posterior inferior cerebellar artery complex (VA-PICA) treated by endovascular embolization or surgically in cases considered untreatable by endovascular methods. Patients and methods. During a 5-year-period a total of 28 patients with a VA-PICA complex aneurysm out of 600 patients received definitive treatment, 19 patients by endovascular embolization and 9 patients surgically. Mean age was 54 years (range 9-75 years). Clinical data, intraoperative observations and procedural complications were evaluated. The mean follow-up was 9 months. Results. Hunt-Hess (HH) grades were HH 0-II in 10 patients (35.7%), HH III in 6 patients (21.4%) and HH IV + V in 12 patients (42.9%). Aneurysm size ranged from 2 to 40 mm (mean size 5.5 mm). Aneurysm configuration was saccular 18, fusiform 7 and multilobed 3. Complete occlusion was achieved in all cases. Overall 67.9% (n=19) showed a favorable outcome (Glasgow Outcome Score IV + V). Overall procedure-related rate for permanent morbidity and mortality was 3.6% (n=1) and 3.6% (n=1), respectively. Predictive factors of clinical outcome were the initial clinical HH grade and the Fisher grade.
68
ZENTRALBLATT FÜR NEUROCHIRURGIE, N° 1 À 4, 2005 : RÉSUMÉS
Conclusion. Endovascular embolization is an effective method for the treatment of VA-PICA aneurysms. Surgical clipping is still an alternative and should be considered for “uncoilable” lesions. Outcomes showed a close correlation to the initial clinical state and were not dependent on the treatment modality. Key-words: Cerebral aneurysms, vertebral artery, posterior inferior cerebellar artery, endovascular therapy, aneurysm surgery.
Volumetric analysis of the growth rate of incompletely resected intracranial meningiomas M. Nakamura (1), F. Roser (1), J. Michel (1), C. Jacobs (1), M. Samii (1, 2) (1) Department of Neurosurgery, Nordstadt Hospital Hannover, Germany. (2) International Neuroscience Institute, Hannover, Germany. Zentralbl Neurochir 2005; 66(1): 17-23
Objective. Intracranial meningiomas are mostly considered to be slow growing tumors. However, only a few previous reports provide information on the growth rate of these tumors. The aim of this study was to determine the growth rates of intracranial meningiomas after subtotal resection, analysing their relation to radiological appearance and histological features. Results are compared with our previous analysis of growth rates in incidental meningiomas. Methods. The hospital charts, follow up records and imaging studies were reviewed in 36 patients with subtotally resected intracranial meningiomas. The tumor growth rates were determined by calculating the absolute and relative growth rates and the tumor volume doubling times. Results. In the group of 33 patients with histologically verified grade 1 meningiomas, the mean absolute growth rate was 1.51 cm3/ year, the median relative growth rate and tumor doubling time was 14.18%/year and 5.228 years. In young patients annual relative growth rates were significantly higher. The median annual relative growth rate of meningiomas with calcification was significantly lower than in tumors without calcification. Also tumors with hypo— or isointense T2-signals on MRI revealed a lower growth rate. There was no significant difference between males and females. Histological studies revealed 22 meningiomas of a meningotheliomatous subtype, 8 fibrous and 3 psammomatous meningiomas. The comparison of growth rates between these subtypes did not show any significant differences. In atypical meningiomas (WHO grade 2), absolute and relative growth rates were significantly higher and tumor doubling times shorter. Conclusion. The majority of intracranial meningiomas are slow growing tumors, although the growth rates may vary widely even among benign grade 1 meningiomas. In meningiomas after subtotal surgical resection, the age of the patients seems to present a predictive factor for tumor growth in analogy to our previous observation in incidental meningiomas. Significantly higher relative growth rates were detected in younger patients. Gender does not seem to play a major role as a predictive factor. Radiological features such as calcification or T2-signal intensity may provide additional information to predict the growth potential of meningiomas. Close clinical and radiological observation should be performed in young patients harboring tumors with absence of calcification or high T2-signal intensities due to the higher growth potential in this patient group. Key-words: Meningioma, natural history, tumor growth rate, subtotal resection.
Neurochirurgie
Experience with five different intervertebral disc spacers for cervical spondylodesis D. Kemmesies (1), U. Meier (2) (1) Neurochirurgische Klinik, Humaine Klinikum Bad Saarow, Germany. (2) Klinik für Neurochirurgie, Unfallkrankenhaus Berlin, Germany. Zentralbl Neurochir 2005; 66(1): 24-33
The ventral spondylodesis with autologeous bone graft for degenerative disease of the cervical spine bears the disadvantage of complications and heavy pain at the superior pelvic straight. To reduce these problems the intervertebral disc spacer was developed. Between September 1997 and January 2002 we operated on 207 patients suffering from degenerative disease — osteochondrosis and/or disc prolapse — of the cervical spine. Without any patient selection, e. g. according to a randomized sample, we implanted the different disc spacer by a ventral approach after microsurgical discectomy and removal of the dorsal osteophytes by a high-speed drill. The Titanium disc spacer by Aesculap, Weber, Intromed, and Medinorm were used in 66, 54, 52 and 18 cases and the Carbonium disc spacer of AcroMed in 17 cases. We evaluated the handling, X-ray contrast, costs of implantation and the clinical results after 3 months and 1 year. All the five disc spacers are suitable for the ventral spondylodesis of the cervical spine. The titanium spacer from Weber is characterized by its comfortable handling and a price in the mean range. A good cost effectiveness and an easy handling is given by the Intromed-cage. The X-ray contrast of the Carbonium spacer by AcroMed is insufficient in the lower cervical spine. The handling is good, but the price is too high. The AcroMed, Medinorm and Intromed spacer have the tendency to migrate into the vertebral endplates. A final statement can only be given after the achievement of longterm results. Key-words: Intervertebral disc spacer, spondylodesis, cervical spine, degenerative disease, clinical outcome.
Metastatic meningioma WHO grade II of the cervical spine: case report and review of the literature M.O. Pinsker, R. Buhl, H.-H. Hugo, H.M. Mehdorn Department of Neurosurgery, University of Schleswig-Holstein, Campus Kiel, Germany. Zentralbl Neurochir 2005; 66(1): 35-38
The authors report a rare case of metastatic atypical meningioma WHO grade II involving the dorso-lateral region of the cervical spine and causing spinal cord compression in a 76-year-old man. The patient was treated surgically in June 1998 for an atypical parasagittal meningioma in the right frontal lobe. Local recurrence with extension to the left hemisphere required surgical treatment in January 2000, and in December 2000 recurrence caused paraplegia of the lower extremities and paresis of the left arm. A 3rd operation was carried out in January 2001, followed by radiotherapy with a total dose of 45 Gy. The patient presented again in March 2003 because of pain in the neck and a progredient new paresis and paresthesia of the right arm. Computed tomogram of the cervical spine showed a large tumor with compression of the spinal cord. MRI was not possible due to a pacemaker which had been implanted in the meantime. Surgical subtotal removal of the tumor via hemilaminectomy of the