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Four-Hand Endonasal Endoscopic Surgery for Anterior Skullbase Pathology: Our Lessons Learned Over 40 Cases
BELGIAN SOCIETY
OF
NEUROSURGERY: ABSTRACTS
OF THE
2011 ANNUAL MEETING
Belgian Society of Neurosurgery: Abstracts of the 2011 Annual Meeting Oral Communications Validation of the Intra-Operative Use of 5-Aminolevulinic Acid (5-ALA) in Patients With Suspected High Grade Glioma in the Two Belgian Gliolan® Training Centres 1,2
1
2
1
L. de Jong , F. Weyns , F. Van Calenbergh , K. Engelborghs , J. van Loon2, D. Peuskens1, B. Depreitere2, J. Wuyts1, J. Goffin2, J. Deckers1, T. Daenekindt1, S. De Vleeschouwer 2 1
ZOL Sint-Jan Genk 2UZ Leuven, Belgium
Key words: Gliolan, malignant glioma, extent of resection, diagnostic tool DOI: 10.1016/j.wneu.2011.12.018
䡲 INTRODUCTION: The extent of surgery is one of the significant, independent prognostic factors in patients with HGG. Gliolan® has been registered as a real-time intra-operative tool to enhance the extent of resection. 䡲 MATERIAL AND METHODS: We conducted a prospective analysis of 253 patients thought to have a malignant glioma on preoperative MRI over a 48-months period. 5-ALA was administered 3 hours before induction of anesthesia if an intentionally macroscopic complete resection was deemed possible by the surgeon and after informed consent of the patient. Safety, pathological specificity and extent of resection were examined. 䡲 RESULTS: The surgeon’s estimate on the completeness of the resection based on the intraoperative findings under blue light conditions seemed to be accurate in 80% of cases (PPV ⫽ 90%, NPV ⫽ 60%). An MRI-complete resection was established in 73% of cases. In terms of prediction of a HGG pathology, sensitivity of intra-operative Gliolan® was 94.8% and specificity 76.2% if only the presence of bright fluorescence was considered to be a positive test result. Sensitivity further increased, but specificity decreased if also faint fluorescence was being considered a positive test result. Permanent increased neurological deficit postoperatively was seen in 3% of the complete group. 䡲 CONCLUSION: Our results confirm that the intra-operative use of 5-ALA is a safe and effective tool improving the radicality of HGG resection with an acceptable low morbidity. The surgeons’ intra-operative impression of the extent of the resection correlates well with postoperative MRI findings. Intra-operative fluorescence induced by Gliolan is a very sensitive method to detect HGG.
Narciclasine, A Plant Growth Modulator, Shows Anti-Tumoral Activity in Vitro and In Vivo in Human Preclinical Models of Primary and Secondary Brain Tumors F. Lefranc1,2, V. Mathieu2, G. Van Goietsenhove2, R. Kiss2 ULB Bruxelles 1Hôpital Erasme, Service de Neurochirurgie 2Faculté de Pharmacie, Laboratoire de Toxicologie Key words: narciclasine, glioblastomas, brain metastases, migration DOI: 10.1016/j.wneu.2011.12.019
䡲 INTRODUCTION: Cell motility and resistance to apoptosis characterize glioblastoma growth and malignancy. Narciclasine extracted from Daffodil, an Amaryllidaceae isocarbostyril controlling plant growth by means of actin
WORLD NEUROSURGERY 77 [1]: 203-215, JANUARY 2012
cytoskeleton modulation could represent a powerful new weapon targeting the Achilles’ heel of brain tumors. 䡲 METHODS: The in vitro effects of narciclasine on cell proliferation, morphology,actincytoskeletonorganizationandtheRho/ROCK/LIMK/cofilinpathwayhave beendetermined.Invivo,weusedhumanglioblastomamodels(Hs683andprimary culture), primary culture of human melanoma brain metastases and a non small cell pulmonary cancer implanted into the brain of immunodeficient mice. 䡲 RESULTS: Narciclasine impairs glioblastoma growth by markedly decreasing mitotic rates without inducing apoptosis. The compound also modulates the Rho/ROCK/LIMK/cofilin signaling pathway; greatly increasing GTPase RhoA activity as well as inducing actin stress fiber formation in a RhoA dependent manner. A treatment of human glioblastoma orthotopic xenograft-bearing mice with non-toxic doses of narciclasine significantly increased their survival. Narciclasine anti-tumor effects (p ⫽ 0.004 on Hs683 and p ⫽ 0.02 on primary culture) were of the same magnitude as those of temozolomide (respectively p ⫽ 0.006 and p ⫽ 0.03). Narciclasine also significantly improve (p ⫽ 0.004) the survival of mice bearing metastatic apoptosis-resistant melanoma xenografts in their brain. We evidenced the narciclasine target, eEF1A elongation factor. 䡲 CONCLUSION: Our results demonstrate for the first time that narciclasine may be of potential use to treat glioma and metastatic brain tumor patients.
Four-Hand Endonasal Endoscopic Surgery for Anterior Skullbase Pathology: Our Lessons Learned Over 40 Cases T. Van Havenbergh, T.H. Somers, D. Berghmans, K. De Smedt, R. Van Paesschen AZ Sint-Augustinus Antwerpen-Wilrijkg
Key words: anterior skull base, endoscopic endonasal DOI: 10.1016/j.wneu.2011.12.020
䡲 INTRODUCTION: To present the pitfalls and surgical difficulties we experienced performing the first 50 cases of endoscopic endonasal procedures for anterior skull base lesions. 䡲 MATERIAL AND METHODS: We collected all data concerning pathology, surgical procedure and surgical results. The treated pathology consisted of pituitary tumors (28), Rathke cleft cyst (1), craniopharyngeoma (1), meningioma (2), metastases (2), juvenile angiofibroma (3), chordoma (2) and chondroma (1). We focused on the peroperative difficulties encountered such as exposure, handling space, bleeding, surgery duration and complication management. 䡲 RESULTS: We found 5 factors influencing the four hand endonasal endoscopic procedure: 1) technical factors such as endoscope, neuro-navigation and bipolar coagulation instruments,2)anatomicalvariationofsinusesandtheknowledgeofitsanatomy,3) creation of handling space by removing conchae, amount of septum and anterior wall of sphenoid sinus, 4) tumor characteristics and site of origin and 5) reconstruction techniques with free fat graft or vascularised nasoseptal flap. 䡲 CONCLUSION We report a set of 5 categories of difficulties and pitfalls encountered in a first personal experience of 40 endoscopic endonasal
www.WORLDNEUROSURGERY.org
203
BELGIAN SOCIETY
OF
NEUROSURGERY: ABSTRACTS
procedures for anterior skull base lesions. We think these lessons learned can be of value to other colleagues starting or performing this surgery.
Endovascular and Surgical Treatment of Intracranial Aneurysms in A Non-Academic Centre: A Retrospective Analysis On Safety, Clinical Outcome And Costs J. Cotens1, E. Gielen1, Y. Palmers1,2, M. Vandersteen1, J. Wuyts3, L. Stockx 2 1
Universiteit Hasselt ZOL Sint-Jan Genk, Diensten 2Radiologie, 3Neurochirurgie
Key words: aneurysm, intracranial, endovascular, surgical DOI: 10.1016/j.wneu.2011.12.021
䡲 INTRODUCTION: This study validates the results of endovascular embolisation and neurosurgery treatment of intracranial aneurysms in an observative and retrospective way. Aim of the study was to evaluate morbidity, mortality and hospital costs of each technique for treatment of aneurysmal subarachnoid hemorrhage (aSAH) and unruptured aneurysms. 䡲 MATERIALS: Hospital files of all 336 endovascular and 202 neurosurgical procedures performed during a 8,5 year period at Ziekenhuis Oost-Limburg were evaluated to obtain information about morbidity, mortality, adverse events, duration of hospital stay and hospital costs. Diagnostic angiographical reports were reviewed to determine aneurysm characteristics. 䡲 RESULTS: In the aSAH group permanent morbidity rates following endovascular and surgical treatment were respectively 21.6% and 31.6%. 7.7% of endovascular treated patients died within one month after the intervention versus 17.1% of surgical patients. Endovascular treatment required a shorter hospital stay (33.6 versus 38.3 days). Average hospital costs were 32,377 for endovascular treatment and 33,668 for surgical treatment. In the group with unruptured aneurysms permanent morbidity rates following endovascular and surgical treatment were 3.0% and 11.6%. Mortality rates for endovascular and surgical treatment were 0.6% and 0.9%. Endovascular treatment required a shorter hospital stay. Average hospital costs were 17,799 for endovascular treatment and 8360 for surgical treatment. 䡲 CONCLUSIONS: The overall combined morbidity and mortality in aSAH patients was 42.0%. Hospital costs did not differ between both treatments. Patients with unruptured aneurysms whom were judged to require endovascular therapy had higher charges than patients treated by surgery. The benefits of apparent decrease in length of stay in the endovascular group were offset by higher procedural costs. A difference in clinical outcome was found in favor of the endovascular group.
Recanalization and SAH Recurrence After Treatment By Endovascular Coiling or Surgical Clipping of Ruptured Intracranial Aneurysms
OF THE
2011 ANNUAL MEETING
coiling (EVC) or surgical clipping (SC) of ruptured intracranial aneurysms (RIA). 䡲 MATERIAL AND METHODS: Clinical data of 373 consecutive patients treated by EVC or SC for RIA or unruptured intracranial aneurysm between January 1996 and December 2006, were reviewed. The data base was prospectively designed. Patients were followed up at least to August 2009. Aneurysm recanalization was monitored by angio-CT or angiography through femoral catheterisation (6 months after EVC and 1 year after SC; Median time: 5 years). All patients underwent a minimal follow-up of 2 years after treatment, at least by telephonic communication (median time: 6 years). 䡲 RESULTS: Out of 197 patients with 198 RIAs, 82 (42 %) patients underwent an endovascular treatment and 115 (58%) were allocated to surgical treatment. Aneurysm occlusion was total for 110 (94%) RIAs treated by SC and for 56 (67.4%) treated by EVC. 15 recanalizations of embolized RIAs were detected, only one in the surgical group (27% vs. 2%; p ⫽ 0.0008). Of the 15 recanalizations in the EVC group, 6 (40%) were initially completely occluded. We observed two reruptures, one in each group (1.4% for EVC; 1% for SC; p ⫽ 0.8). 䡲 CONCLUSION: Our findings confirm a greater risk of recanalization for RIA treated by EVC without so far a significant difference in the rerupture risk.
Intraoperative Assessment of Incomplete Clipping of An Aneurysm and of Vascular Patency in The Surrounding Vessels By a Near-Infrared Indocyanine Green Video-AngiographyIntegrated Microscope J. Van Oostveldt1, J. Wuyts1, F. Weyns1,2, K. Engelborghs1, D. Peuskens1 1
ZOL Sint-Jan Genk 2Universiteit Hasselt
Key words: indocyanine green, video-angiography DOI: 10.1016/j.wneu.2011.12.023
䡲 INTRODUCTION: First described in 2003 the application of microscopeintegrated near-infrared (NIR) indocyanine green video-angiography (ICG VA) is a relatively new technique of blood-flow measurement that may help to improve the final result of cerebrovascular surgery. 䡲 MATERIAL AND METHODS: ICG VA is integrated with a surgical microscope made by Carl Zeiss Ltd. The surgical field is illuminated by a light source (NIR light) with a wavelenght covering the ICG absorption band (700 – 850 nm). After intravenous injection of ICG dye, its fluorescence is induced and recorded by videocamera. As a result, realtime video images of arterial, capillary and venous phase of angiography can be seen.
DOI: 10.1016/j.wneu.2011.12.022
䡲 RESULTS: ICG VA has been used 19 times in our centre since September 2010. In 5 cases the result of the ICG VA led to supplementary clipping or repositioning of the initial clip. We present an illustrative case of a pericallosal artery aneurysm clipping in which the use of ICG VA completely altered the course of the procedure and prevented incomplete clipping of the aneurysm and postoperative ischemia.
䡲 INTRODUCTION: To analyze the risk of recanalization and subarachnoidal haemorrhage (SAH) recurrence after treatment by endovascular
䡲 CONCLUSION: ICG VA is a simple, fast and cost-effective method of blood-flow assessment with acceptable reliability. Although inferior to peroperative digital substraction angiography ICG VA can provide realtime in-
E. Costa, G. Vaz, C. Raftopoulos UCL Saint-Luc Bruxelles
Key words: rerupture recanalization intracranial aneurysm
204
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY 77 [1]: 203-215, JANUARY 2012
OF
NEUROSURGERY: ABSTRACTS
OF THE
2011 ANNUAL MEETING
Belgian Society of Neurosurgery: Abstracts of the 2011 Annual Meeting Oral Communications Validation of the Intra-Operative Use of 5-Aminolevulinic Acid (5-ALA) in Patients With Suspected High Grade Glioma in the Two Belgian Gliolan® Training Centres 1,2
1
2
1
L. de Jong , F. Weyns , F. Van Calenbergh , K. Engelborghs , J. van Loon2, D. Peuskens1, B. Depreitere2, J. Wuyts1, J. Goffin2, J. Deckers1, T. Daenekindt1, S. De Vleeschouwer 2 1
ZOL Sint-Jan Genk 2UZ Leuven, Belgium
Key words: Gliolan, malignant glioma, extent of resection, diagnostic tool DOI: 10.1016/j.wneu.2011.12.018
䡲 INTRODUCTION: The extent of surgery is one of the significant, independent prognostic factors in patients with HGG. Gliolan® has been registered as a real-time intra-operative tool to enhance the extent of resection. 䡲 MATERIAL AND METHODS: We conducted a prospective analysis of 253 patients thought to have a malignant glioma on preoperative MRI over a 48-months period. 5-ALA was administered 3 hours before induction of anesthesia if an intentionally macroscopic complete resection was deemed possible by the surgeon and after informed consent of the patient. Safety, pathological specificity and extent of resection were examined. 䡲 RESULTS: The surgeon’s estimate on the completeness of the resection based on the intraoperative findings under blue light conditions seemed to be accurate in 80% of cases (PPV ⫽ 90%, NPV ⫽ 60%). An MRI-complete resection was established in 73% of cases. In terms of prediction of a HGG pathology, sensitivity of intra-operative Gliolan® was 94.8% and specificity 76.2% if only the presence of bright fluorescence was considered to be a positive test result. Sensitivity further increased, but specificity decreased if also faint fluorescence was being considered a positive test result. Permanent increased neurological deficit postoperatively was seen in 3% of the complete group. 䡲 CONCLUSION: Our results confirm that the intra-operative use of 5-ALA is a safe and effective tool improving the radicality of HGG resection with an acceptable low morbidity. The surgeons’ intra-operative impression of the extent of the resection correlates well with postoperative MRI findings. Intra-operative fluorescence induced by Gliolan is a very sensitive method to detect HGG.
Narciclasine, A Plant Growth Modulator, Shows Anti-Tumoral Activity in Vitro and In Vivo in Human Preclinical Models of Primary and Secondary Brain Tumors F. Lefranc1,2, V. Mathieu2, G. Van Goietsenhove2, R. Kiss2 ULB Bruxelles 1Hôpital Erasme, Service de Neurochirurgie 2Faculté de Pharmacie, Laboratoire de Toxicologie Key words: narciclasine, glioblastomas, brain metastases, migration DOI: 10.1016/j.wneu.2011.12.019
䡲 INTRODUCTION: Cell motility and resistance to apoptosis characterize glioblastoma growth and malignancy. Narciclasine extracted from Daffodil, an Amaryllidaceae isocarbostyril controlling plant growth by means of actin
WORLD NEUROSURGERY 77 [1]: 203-215, JANUARY 2012
cytoskeleton modulation could represent a powerful new weapon targeting the Achilles’ heel of brain tumors. 䡲 METHODS: The in vitro effects of narciclasine on cell proliferation, morphology,actincytoskeletonorganizationandtheRho/ROCK/LIMK/cofilinpathwayhave beendetermined.Invivo,weusedhumanglioblastomamodels(Hs683andprimary culture), primary culture of human melanoma brain metastases and a non small cell pulmonary cancer implanted into the brain of immunodeficient mice. 䡲 RESULTS: Narciclasine impairs glioblastoma growth by markedly decreasing mitotic rates without inducing apoptosis. The compound also modulates the Rho/ROCK/LIMK/cofilin signaling pathway; greatly increasing GTPase RhoA activity as well as inducing actin stress fiber formation in a RhoA dependent manner. A treatment of human glioblastoma orthotopic xenograft-bearing mice with non-toxic doses of narciclasine significantly increased their survival. Narciclasine anti-tumor effects (p ⫽ 0.004 on Hs683 and p ⫽ 0.02 on primary culture) were of the same magnitude as those of temozolomide (respectively p ⫽ 0.006 and p ⫽ 0.03). Narciclasine also significantly improve (p ⫽ 0.004) the survival of mice bearing metastatic apoptosis-resistant melanoma xenografts in their brain. We evidenced the narciclasine target, eEF1A elongation factor. 䡲 CONCLUSION: Our results demonstrate for the first time that narciclasine may be of potential use to treat glioma and metastatic brain tumor patients.
Four-Hand Endonasal Endoscopic Surgery for Anterior Skullbase Pathology: Our Lessons Learned Over 40 Cases T. Van Havenbergh, T.H. Somers, D. Berghmans, K. De Smedt, R. Van Paesschen AZ Sint-Augustinus Antwerpen-Wilrijkg
Key words: anterior skull base, endoscopic endonasal DOI: 10.1016/j.wneu.2011.12.020
䡲 INTRODUCTION: To present the pitfalls and surgical difficulties we experienced performing the first 50 cases of endoscopic endonasal procedures for anterior skull base lesions. 䡲 MATERIAL AND METHODS: We collected all data concerning pathology, surgical procedure and surgical results. The treated pathology consisted of pituitary tumors (28), Rathke cleft cyst (1), craniopharyngeoma (1), meningioma (2), metastases (2), juvenile angiofibroma (3), chordoma (2) and chondroma (1). We focused on the peroperative difficulties encountered such as exposure, handling space, bleeding, surgery duration and complication management. 䡲 RESULTS: We found 5 factors influencing the four hand endonasal endoscopic procedure: 1) technical factors such as endoscope, neuro-navigation and bipolar coagulation instruments,2)anatomicalvariationofsinusesandtheknowledgeofitsanatomy,3) creation of handling space by removing conchae, amount of septum and anterior wall of sphenoid sinus, 4) tumor characteristics and site of origin and 5) reconstruction techniques with free fat graft or vascularised nasoseptal flap. 䡲 CONCLUSION We report a set of 5 categories of difficulties and pitfalls encountered in a first personal experience of 40 endoscopic endonasal
www.WORLDNEUROSURGERY.org
203
BELGIAN SOCIETY
OF
NEUROSURGERY: ABSTRACTS
procedures for anterior skull base lesions. We think these lessons learned can be of value to other colleagues starting or performing this surgery.
Endovascular and Surgical Treatment of Intracranial Aneurysms in A Non-Academic Centre: A Retrospective Analysis On Safety, Clinical Outcome And Costs J. Cotens1, E. Gielen1, Y. Palmers1,2, M. Vandersteen1, J. Wuyts3, L. Stockx 2 1
Universiteit Hasselt ZOL Sint-Jan Genk, Diensten 2Radiologie, 3Neurochirurgie
Key words: aneurysm, intracranial, endovascular, surgical DOI: 10.1016/j.wneu.2011.12.021
䡲 INTRODUCTION: This study validates the results of endovascular embolisation and neurosurgery treatment of intracranial aneurysms in an observative and retrospective way. Aim of the study was to evaluate morbidity, mortality and hospital costs of each technique for treatment of aneurysmal subarachnoid hemorrhage (aSAH) and unruptured aneurysms. 䡲 MATERIALS: Hospital files of all 336 endovascular and 202 neurosurgical procedures performed during a 8,5 year period at Ziekenhuis Oost-Limburg were evaluated to obtain information about morbidity, mortality, adverse events, duration of hospital stay and hospital costs. Diagnostic angiographical reports were reviewed to determine aneurysm characteristics. 䡲 RESULTS: In the aSAH group permanent morbidity rates following endovascular and surgical treatment were respectively 21.6% and 31.6%. 7.7% of endovascular treated patients died within one month after the intervention versus 17.1% of surgical patients. Endovascular treatment required a shorter hospital stay (33.6 versus 38.3 days). Average hospital costs were 32,377 for endovascular treatment and 33,668 for surgical treatment. In the group with unruptured aneurysms permanent morbidity rates following endovascular and surgical treatment were 3.0% and 11.6%. Mortality rates for endovascular and surgical treatment were 0.6% and 0.9%. Endovascular treatment required a shorter hospital stay. Average hospital costs were 17,799 for endovascular treatment and 8360 for surgical treatment. 䡲 CONCLUSIONS: The overall combined morbidity and mortality in aSAH patients was 42.0%. Hospital costs did not differ between both treatments. Patients with unruptured aneurysms whom were judged to require endovascular therapy had higher charges than patients treated by surgery. The benefits of apparent decrease in length of stay in the endovascular group were offset by higher procedural costs. A difference in clinical outcome was found in favor of the endovascular group.
Recanalization and SAH Recurrence After Treatment By Endovascular Coiling or Surgical Clipping of Ruptured Intracranial Aneurysms
OF THE
2011 ANNUAL MEETING
coiling (EVC) or surgical clipping (SC) of ruptured intracranial aneurysms (RIA). 䡲 MATERIAL AND METHODS: Clinical data of 373 consecutive patients treated by EVC or SC for RIA or unruptured intracranial aneurysm between January 1996 and December 2006, were reviewed. The data base was prospectively designed. Patients were followed up at least to August 2009. Aneurysm recanalization was monitored by angio-CT or angiography through femoral catheterisation (6 months after EVC and 1 year after SC; Median time: 5 years). All patients underwent a minimal follow-up of 2 years after treatment, at least by telephonic communication (median time: 6 years). 䡲 RESULTS: Out of 197 patients with 198 RIAs, 82 (42 %) patients underwent an endovascular treatment and 115 (58%) were allocated to surgical treatment. Aneurysm occlusion was total for 110 (94%) RIAs treated by SC and for 56 (67.4%) treated by EVC. 15 recanalizations of embolized RIAs were detected, only one in the surgical group (27% vs. 2%; p ⫽ 0.0008). Of the 15 recanalizations in the EVC group, 6 (40%) were initially completely occluded. We observed two reruptures, one in each group (1.4% for EVC; 1% for SC; p ⫽ 0.8). 䡲 CONCLUSION: Our findings confirm a greater risk of recanalization for RIA treated by EVC without so far a significant difference in the rerupture risk.
Intraoperative Assessment of Incomplete Clipping of An Aneurysm and of Vascular Patency in The Surrounding Vessels By a Near-Infrared Indocyanine Green Video-AngiographyIntegrated Microscope J. Van Oostveldt1, J. Wuyts1, F. Weyns1,2, K. Engelborghs1, D. Peuskens1 1
ZOL Sint-Jan Genk 2Universiteit Hasselt
Key words: indocyanine green, video-angiography DOI: 10.1016/j.wneu.2011.12.023
䡲 INTRODUCTION: First described in 2003 the application of microscopeintegrated near-infrared (NIR) indocyanine green video-angiography (ICG VA) is a relatively new technique of blood-flow measurement that may help to improve the final result of cerebrovascular surgery. 䡲 MATERIAL AND METHODS: ICG VA is integrated with a surgical microscope made by Carl Zeiss Ltd. The surgical field is illuminated by a light source (NIR light) with a wavelenght covering the ICG absorption band (700 – 850 nm). After intravenous injection of ICG dye, its fluorescence is induced and recorded by videocamera. As a result, realtime video images of arterial, capillary and venous phase of angiography can be seen.
DOI: 10.1016/j.wneu.2011.12.022
䡲 RESULTS: ICG VA has been used 19 times in our centre since September 2010. In 5 cases the result of the ICG VA led to supplementary clipping or repositioning of the initial clip. We present an illustrative case of a pericallosal artery aneurysm clipping in which the use of ICG VA completely altered the course of the procedure and prevented incomplete clipping of the aneurysm and postoperative ischemia.
䡲 INTRODUCTION: To analyze the risk of recanalization and subarachnoidal haemorrhage (SAH) recurrence after treatment by endovascular
䡲 CONCLUSION: ICG VA is a simple, fast and cost-effective method of blood-flow assessment with acceptable reliability. Although inferior to peroperative digital substraction angiography ICG VA can provide realtime in-
E. Costa, G. Vaz, C. Raftopoulos UCL Saint-Luc Bruxelles
Key words: rerupture recanalization intracranial aneurysm
204
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY 77 [1]: 203-215, JANUARY 2012