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Venous Sinuses Surgery in Neurooncology
Correspondence
Venous Sinuses Surgery in Neurooncology LETTER: of venous sinuses surgery is relatively short. From T hethe history time of the ancient Incas, who avoided trephine in the parasagittal area, until the 20th century, no clear information about manipulations on venous sinuses exists, perhaps with 2 exceptions. Cushing (3) cited a report by Olof Acrel, who in 1768 operated on a Prussian soldier with a parasagittal mass, presumably a hemangiopericytoma; soon after finger inspection of the tumor followed by severe bleeding, the patient passed away in convulsions. Antoine Louis in 1774 described profuse bleeding from the superior sagittal sinus (SSS), which appeared in the course of a parasagittal meningioma removal; in this case the patient survived (10). The intracranial venous sinuses were first described by Herophilos of Chalcedon (335e280 BC), but their functional role seems to have been first mentioned by Macewen in 1893 (11). Trollard in 1868 (15) and Labbe in 1883 (8) described venous anastomoses, the role of which was undervalued before Dandy and Olivecrona. Compensatory changes of the venous system in intracranial hypertension were first described by Blumenau in 1889 (1). Another Russian scientist, Oppel (13), in 1911 proposed the opening and enlargement of normally “drowsy” collateral vessels in cases of venous sinus occlusion. Burdenko in 1927 described the increase of venous outflow velocity in intracranial hypertension (2). Therefore in the first decades of the 20th century, theoretical and even a practical base of knowledge on the subject appeared. We do not exactly know whether manipulations on venous sinuses were performed in the first half of the 20th century for head trauma or conditions other than neuro-oncology. It seems that suturing or ligation of the superior sagittal or transverse sinuses in traumatic injury were sometimes performed, but unfavorable results of such interventions made conservative tactics preferable, even nowadays. The first known interventions on the SSS were performed for tumor pathology, typically for meningiomas because these most frequent primary intracranial tumors (5) most commonly engage the venous sinuses.
tumor involving the venous sinuses, was considered radioresistant; radiotherapy was used rarely and only for malignant forms. Then in the last decade of the 20th century, it became evident that radiotherapy could significantly prolong recurrence-free survival in radically unresectable tumors. Rapid improvement of radiological techniques made treatment more safe and effective. At the same time, Lang et al. showed that extensive neurosurgery proved to be not so effective from the patient’s and caregiver’s points of view (9). Now, almost any intervention on the venous sinuses, including grafting, is technically feasible, using microsurgery, cell-savers, modern sewing and sealing materials, clips, etc. Anesthesiology allows meticulous manipulations without much worry concerning blood loss. However, we evaluated the effect of manipulations on the SSS on the results [mortality and change in Karnofsky score (7)] and found that after SSS reconstruction (34 cases from the experience of Burdenko Neurosurgical Institute in 1805 parasagittal meningioma microsurgical removals), the functional outcome was comparable with that after SSS resection and approximately 2-fold worse than after Simpson grade 2 to 3 surgeries. Therefore, we see that despite a time-consuming technique, the functional results of such interventions are not good. Moreover, if we keep in mind that each cubic millimeter of tumor tissue contains approximately 100,000,000 cells, it is difficult to imagine an absolutely radical removal of a tumor involving parasagittal venous structures, not to mention the cavernous sinus. Data obtained by Mathiesen et al. strongly confirm this point. Their conclusions, particularly concerning the rate of recurrences after seemingly complete tumor removal, sound very thorough. The authors use a nice expression, “Simpson4Gamma,” but the term seems restricted as aside from photon radiosurgery/radiotherapy, no less effective heavy particle technologies exist.
Olivecrona in 1934 (12) and Dandy in 1940 (4) substantiated the relative safety of resection of a completely blocked part of the SSS and the possibility of intrasinal tumor removal with SSS angle dissection and suturing. This last type of surgery gained special definition in Simpson grade 3 classification (1957) (14). After that, technical notes, recommendations, and case reports of successful interventions on intracranial venous sinuses and veins were published in a great number of papers, monographs, and textbooks. One of the most significant is the monograph edited by Hakuba (1996) (6). In 1980e1990, the further increase of surgical radicalness seemed to be the only solution to the problem of tumor recurrence. Simultaneously, technical progress engaged radiation oncology. For unclear reasons until the 1980s, meningioma, the most common
WORLD NEUROSURGERY 00 [0]: e1-e2, MONTH 2013
www.WORLDNEUROSURGERY.org
e1
CORRESPONDENCE
Briefly, we see no perspectives in direct venous surgery in modern neuro-oncology. It is not difficult to resect the involved SSS angle, providing the manipulation will allow Simpson grade 1 removal and does not narrow the sinus lumen for more than 40% back to the anterior Rolandic vein; if a clamp is not used, then continuous saline irrigation during manipulation of the open SSS must not be forgotten and the suture should be a monofilament one and nonresorbable. No temporary microelectrodes or anticoagulants are necessary after these manipulations. However, cases of limited venous sinus involvement allowing Simpson grade 1 surgery are rare. In the majority of situations, despite venous sinus opening or resection, surgery will not be radical and the rate of recurrences will tend to 50%. Furthermore, as one can see from the above figure, functional outcome in cases of completely blocked SSS resection was also about 2-fold worse in comparison with less radical surgeries. The explanation is that in the walls of the occluded SSS and close to them inside the convexital dura and falx, frequently there are newly formed venous structures compensating blood outflow disturbances. Damage to these structures in the course of SSS resection usually causes nonfatal but functionally significant consequences. Moreover, resection of the involved part of the SSS at the exception of its anterior third rarely leads to Simpson grade 1 tumor removal because infiltration of its walls almost always involves apertures of functioning veins forcing the surgeon to stop. Therefore, it is evident that radical surgery in cases of venous sinus involvement increases morbidity but hardly ever affects the rate of tumor recurrence. On the other hand, progress in radiation oncology made radiosurgery and stereotactic radiotherapy an effective supplement or sometimes an alternative to surgical intervention. In other words, subtotal tumor resection followed by radiotherapy/radiosurgery in cases of venous sinuses (like major arteries and cranial nerves) involvement is the best solution to date and for perspective. Surely unforeseen situations may occur, and a surgeon must be experienced in control of occasionally severe bleeding. Fortunately, in the vast majority of cases this is not a great problem because a simple atraumatic monofilament suture will solve it. In more severe cases, a periosteal or dural patch can be used. However, it is not advisable to search for even minor troubles in surgery for tumors involving major intracranial venous sinuses.
e2
www.SCIENCEDIRECT.com
Teamwork in collaboration with radiation oncologists provides significantly better results. Alexander N. Konovalov and Andrew V. Kozlov Burdenko Neurosurgical Institute, Moscow, Russian Federation To whom correspondence should be addressed: Alexander N. Konovalov, M.D., Ph.D. [E-mail: [email protected]] Published online 2 April 2013; http://dx.doi.org/10.1016/j.wneu.2013.03.076.
REFERENCES 1. Blumenau LV: To the study of pressure to the brain [in Russian]. Dissertation. St. Petersburg: Imperator’s Military-Medical Academy 1889. 2. Burdenko NN: Damages of dural sinuses [in Russian]. Zhurnal Sovremennoy Khirurgii (Journal of Modern Surgery) 2:1(7), 3e25, 1927. 3. Cushing H, Eisenhardt L: Meningiomas. Their classifications, regional behaviour, life history and surgical end results. Springfield, Illinois: Charles C. Thomas, 1938. 4. Dandy WE: Removal of longitudinal sinus involved in tumors. Arch Surg 41:244, 1940. 5. Dolecek TA, Propp JM, Stroup NE, Kruchko C: CBTRUS Statistical Report: Primary brain and central nervous system tumors diagnosed in the United States in 2005-2009. Neuro-Oncol 14(Suppl 5):v1-v49, 2012. 6. Hakuba A, ed: Surgery of the Intracranial Venous System. Tokyo: SpringerVerlag; 1996. 7. Karnofsky DA, Burchenal JH: The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, ed: Evaluation of Chemotherapeutic Agents. New York: Columbia University Press; 1949:196. 8. Labbe CH: Abnormalities of sinuses of the dura mater [in French]. Arch Phys Norm Path 3:1, 1883. 9. Lang DA, Neil-Dwyer G, Garfield J: Outcome after complex neurosurgery: the caregiver’s burden is forgotten. J Neurosurg 91:359-363, 1999. 10. Louis A: Notes on fungal neoplasms of the dura mater [in French]. Paris: Chez P. Fr. Didot jeune; Mem Acad Roy Chir 5:1-59, 1774. 11. Macewen W: Pyogenic Infective Diseases of the Brain and Spinal Cord. Glasgow: J. Maclehose, 1893. 12. Olivecrona H: The parasagittal meningiomas [in German]. Leipzig: Thieme; 1934:144. 13. Oppel VA: Collateral circulation [in Russian]. St. Petersburg: Typography of M.Merkushev; 1911. 14. Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22-39, 1957. 15. Trollard P: Research on the anatomy of the venous system of the brain and the skull [in French]. Paris: A. Parent; 1868.
00 [0]: e1-e2, MONTH 2013 WORLD NEUROSURGERY
Venous Sinuses Surgery in Neurooncology LETTER: of venous sinuses surgery is relatively short. From T hethe history time of the ancient Incas, who avoided trephine in the parasagittal area, until the 20th century, no clear information about manipulations on venous sinuses exists, perhaps with 2 exceptions. Cushing (3) cited a report by Olof Acrel, who in 1768 operated on a Prussian soldier with a parasagittal mass, presumably a hemangiopericytoma; soon after finger inspection of the tumor followed by severe bleeding, the patient passed away in convulsions. Antoine Louis in 1774 described profuse bleeding from the superior sagittal sinus (SSS), which appeared in the course of a parasagittal meningioma removal; in this case the patient survived (10). The intracranial venous sinuses were first described by Herophilos of Chalcedon (335e280 BC), but their functional role seems to have been first mentioned by Macewen in 1893 (11). Trollard in 1868 (15) and Labbe in 1883 (8) described venous anastomoses, the role of which was undervalued before Dandy and Olivecrona. Compensatory changes of the venous system in intracranial hypertension were first described by Blumenau in 1889 (1). Another Russian scientist, Oppel (13), in 1911 proposed the opening and enlargement of normally “drowsy” collateral vessels in cases of venous sinus occlusion. Burdenko in 1927 described the increase of venous outflow velocity in intracranial hypertension (2). Therefore in the first decades of the 20th century, theoretical and even a practical base of knowledge on the subject appeared. We do not exactly know whether manipulations on venous sinuses were performed in the first half of the 20th century for head trauma or conditions other than neuro-oncology. It seems that suturing or ligation of the superior sagittal or transverse sinuses in traumatic injury were sometimes performed, but unfavorable results of such interventions made conservative tactics preferable, even nowadays. The first known interventions on the SSS were performed for tumor pathology, typically for meningiomas because these most frequent primary intracranial tumors (5) most commonly engage the venous sinuses.
tumor involving the venous sinuses, was considered radioresistant; radiotherapy was used rarely and only for malignant forms. Then in the last decade of the 20th century, it became evident that radiotherapy could significantly prolong recurrence-free survival in radically unresectable tumors. Rapid improvement of radiological techniques made treatment more safe and effective. At the same time, Lang et al. showed that extensive neurosurgery proved to be not so effective from the patient’s and caregiver’s points of view (9). Now, almost any intervention on the venous sinuses, including grafting, is technically feasible, using microsurgery, cell-savers, modern sewing and sealing materials, clips, etc. Anesthesiology allows meticulous manipulations without much worry concerning blood loss. However, we evaluated the effect of manipulations on the SSS on the results [mortality and change in Karnofsky score (7)] and found that after SSS reconstruction (34 cases from the experience of Burdenko Neurosurgical Institute in 1805 parasagittal meningioma microsurgical removals), the functional outcome was comparable with that after SSS resection and approximately 2-fold worse than after Simpson grade 2 to 3 surgeries. Therefore, we see that despite a time-consuming technique, the functional results of such interventions are not good. Moreover, if we keep in mind that each cubic millimeter of tumor tissue contains approximately 100,000,000 cells, it is difficult to imagine an absolutely radical removal of a tumor involving parasagittal venous structures, not to mention the cavernous sinus. Data obtained by Mathiesen et al. strongly confirm this point. Their conclusions, particularly concerning the rate of recurrences after seemingly complete tumor removal, sound very thorough. The authors use a nice expression, “Simpson4Gamma,” but the term seems restricted as aside from photon radiosurgery/radiotherapy, no less effective heavy particle technologies exist.
Olivecrona in 1934 (12) and Dandy in 1940 (4) substantiated the relative safety of resection of a completely blocked part of the SSS and the possibility of intrasinal tumor removal with SSS angle dissection and suturing. This last type of surgery gained special definition in Simpson grade 3 classification (1957) (14). After that, technical notes, recommendations, and case reports of successful interventions on intracranial venous sinuses and veins were published in a great number of papers, monographs, and textbooks. One of the most significant is the monograph edited by Hakuba (1996) (6). In 1980e1990, the further increase of surgical radicalness seemed to be the only solution to the problem of tumor recurrence. Simultaneously, technical progress engaged radiation oncology. For unclear reasons until the 1980s, meningioma, the most common
WORLD NEUROSURGERY 00 [0]: e1-e2, MONTH 2013
www.WORLDNEUROSURGERY.org
e1
CORRESPONDENCE
Briefly, we see no perspectives in direct venous surgery in modern neuro-oncology. It is not difficult to resect the involved SSS angle, providing the manipulation will allow Simpson grade 1 removal and does not narrow the sinus lumen for more than 40% back to the anterior Rolandic vein; if a clamp is not used, then continuous saline irrigation during manipulation of the open SSS must not be forgotten and the suture should be a monofilament one and nonresorbable. No temporary microelectrodes or anticoagulants are necessary after these manipulations. However, cases of limited venous sinus involvement allowing Simpson grade 1 surgery are rare. In the majority of situations, despite venous sinus opening or resection, surgery will not be radical and the rate of recurrences will tend to 50%. Furthermore, as one can see from the above figure, functional outcome in cases of completely blocked SSS resection was also about 2-fold worse in comparison with less radical surgeries. The explanation is that in the walls of the occluded SSS and close to them inside the convexital dura and falx, frequently there are newly formed venous structures compensating blood outflow disturbances. Damage to these structures in the course of SSS resection usually causes nonfatal but functionally significant consequences. Moreover, resection of the involved part of the SSS at the exception of its anterior third rarely leads to Simpson grade 1 tumor removal because infiltration of its walls almost always involves apertures of functioning veins forcing the surgeon to stop. Therefore, it is evident that radical surgery in cases of venous sinus involvement increases morbidity but hardly ever affects the rate of tumor recurrence. On the other hand, progress in radiation oncology made radiosurgery and stereotactic radiotherapy an effective supplement or sometimes an alternative to surgical intervention. In other words, subtotal tumor resection followed by radiotherapy/radiosurgery in cases of venous sinuses (like major arteries and cranial nerves) involvement is the best solution to date and for perspective. Surely unforeseen situations may occur, and a surgeon must be experienced in control of occasionally severe bleeding. Fortunately, in the vast majority of cases this is not a great problem because a simple atraumatic monofilament suture will solve it. In more severe cases, a periosteal or dural patch can be used. However, it is not advisable to search for even minor troubles in surgery for tumors involving major intracranial venous sinuses.
e2
www.SCIENCEDIRECT.com
Teamwork in collaboration with radiation oncologists provides significantly better results. Alexander N. Konovalov and Andrew V. Kozlov Burdenko Neurosurgical Institute, Moscow, Russian Federation To whom correspondence should be addressed: Alexander N. Konovalov, M.D., Ph.D. [E-mail: [email protected]] Published online 2 April 2013; http://dx.doi.org/10.1016/j.wneu.2013.03.076.
REFERENCES 1. Blumenau LV: To the study of pressure to the brain [in Russian]. Dissertation. St. Petersburg: Imperator’s Military-Medical Academy 1889. 2. Burdenko NN: Damages of dural sinuses [in Russian]. Zhurnal Sovremennoy Khirurgii (Journal of Modern Surgery) 2:1(7), 3e25, 1927. 3. Cushing H, Eisenhardt L: Meningiomas. Their classifications, regional behaviour, life history and surgical end results. Springfield, Illinois: Charles C. Thomas, 1938. 4. Dandy WE: Removal of longitudinal sinus involved in tumors. Arch Surg 41:244, 1940. 5. Dolecek TA, Propp JM, Stroup NE, Kruchko C: CBTRUS Statistical Report: Primary brain and central nervous system tumors diagnosed in the United States in 2005-2009. Neuro-Oncol 14(Suppl 5):v1-v49, 2012. 6. Hakuba A, ed: Surgery of the Intracranial Venous System. Tokyo: SpringerVerlag; 1996. 7. Karnofsky DA, Burchenal JH: The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, ed: Evaluation of Chemotherapeutic Agents. New York: Columbia University Press; 1949:196. 8. Labbe CH: Abnormalities of sinuses of the dura mater [in French]. Arch Phys Norm Path 3:1, 1883. 9. Lang DA, Neil-Dwyer G, Garfield J: Outcome after complex neurosurgery: the caregiver’s burden is forgotten. J Neurosurg 91:359-363, 1999. 10. Louis A: Notes on fungal neoplasms of the dura mater [in French]. Paris: Chez P. Fr. Didot jeune; Mem Acad Roy Chir 5:1-59, 1774. 11. Macewen W: Pyogenic Infective Diseases of the Brain and Spinal Cord. Glasgow: J. Maclehose, 1893. 12. Olivecrona H: The parasagittal meningiomas [in German]. Leipzig: Thieme; 1934:144. 13. Oppel VA: Collateral circulation [in Russian]. St. Petersburg: Typography of M.Merkushev; 1911. 14. Simpson D: The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 20:22-39, 1957. 15. Trollard P: Research on the anatomy of the venous system of the brain and the skull [in French]. Paris: A. Parent; 1868.
00 [0]: e1-e2, MONTH 2013 WORLD NEUROSURGERY