Left Transsylvian-Transinsular Approach for Radiation-Induced Cavernous Malformation: 3-Dimensional Operative Video

2018 ◽  
Vol 17 (2) ◽  
pp. E62-E63
Author(s):  
Jan-Karl Burkhardt ◽  
Sirin Gandhi ◽  
Halima Tabani ◽  
Arnau Benet ◽  
Michael T Lawton
Keyword(s):  
De Novo ◽  
Cavernous Malformation ◽  
Insular Cortex ◽  
High Grade ◽  
En Bloc ◽  
Bifurcation Aneurysm ◽  
Patient Consent ◽  
Radiation Induced ◽  
Transinsular Approach ◽  
Mca Aneurysm

Abstract De novo cavernous malformation (CM) formation after radiation therapy for brain tumors is well known, but CM formation adjacent to a radiosurgically treated arteriovenous malformation (AVM) is rare.1 This video demonstrates the microsurgical resection of a de novo CM adjacent to a previously treated high-grade AVM and clipping of a middle cerebral artery (MCA) aneurysm. A 70-yr-old male with history of radiosurgery for AVM presented with aphasia and confusion. Preoperative angiography showed complete occlusion of the AVM. MRI showed multiple cystic lesions suspicious for radiation-induced necrosis and CM. IRB approval and patient consent was obtained. A pterional craniotomy was performed with transsylvian exposure of the insula. The radiated feeding arteries were followed to the occluded AVM nidus. A CM was noted deep to this candelabra of the MCA vessels, which were mobilized to access and resect the CM. A small incision was made in this insular cortex underneath the malformation circumferentially freeing it of adhesions. The sclerotic AVM nidus was circumferentially dissected and removed en bloc. Thorough exploration of the resection cavity revealed no residual CM or AVM nidus. Attention was then turned to the M2-MCA bifurcation aneurysm, which was occluded with a straight clip. Postoperative imaging confirmed complete CM resection. The patient recovered from his aphasia. This case demonstrates the management of a radiation-induced de novo CM following treatment of a high-grade AVM. Radiographic follow-up for radiosurgically treated AVM is needed to rule out long-term complications. Bleeding from a de novo CM mimics bleeding from residual AVM nidus, requiring careful angiographic evaluation.

Transsylvian-Transinsular Approach for an Insular Cavernous Malformation Resection: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (2) ◽  
pp. E50-E50
Author(s):  
Justin Mascitelli ◽  
Sirin Gandhi ◽  
Ernest Wright ◽  
Michael T Lawton
Keyword(s):  
Cavernous Malformation ◽  
Cerebral Arteries ◽  
Internal Capsule ◽  
Acute Onset ◽  
Sylvian Fissure ◽  
Posterior Limb ◽  
Postoperative Mri ◽  
Patient Consent ◽  
Transinsular Approach ◽  
Surgical Corridor

Abstract Surgical resection of insular lesions is challenging due to their proximity to critical neurovascular structures such as the middle cerebral arteries (MCA), Sylvian veins, thalamus, internal capsule (IC), and lenticulostriate arteries. A surgical series using the transsylvian-transinsular approach to treat cerebrovascular pathologies reported ∼5% permanent neurological morbidity.1,2 This case demonstrates the utility of this approach for resecting an insular cavernous malformation (CM). A 25-yr-old female presented with an acute-onset right homonymous hemianopsia. Neuroimaging revealed a large left insular CM, adjacent to the posterior limb of IC. After obtaining IRB approval and patient consent, a left pterional craniotomy with a wide distal Sylvian fissure split was completed. Using neuronavigation, an insular entry point was chosen for corticectomy. The CM was opened with subsequent hematoma evacuation and intracapsular resection technique. Inspection of the cavity revealed remnants anteromedially near the IC, which were removed meticulously, mobilizing the CM away from the IC. Postoperative MRI demonstrated gross total resection of the CM. The patient was discharged home on postoperative day 5 with persistent homonymous hemianopia. This case describes the use of a transsylvian-transinsular approach to access deep lesions with the shortest surgical distance and minimal cortical transgression. A wide Sylvian fissure split exposes the M2 MCA and accesses a safe insular zone, keeping the most eloquent structures deep to the lesion in the surgical corridor. This approach can safely expose vascular pathologies in the insular region without the risk of injury to overlying eloquent frontal and temporal lobes, even in the dominant hemisphere.

De Novo Cavernous Malformation Associated with a Pre-existing Developmental Venous Anomaly

2019 ◽  
Vol 30 (1) ◽  
pp. 181-184
Author(s):  
Daniel García-Pérez ◽  
Irene Panero ◽  
Alfonso Lagares ◽  
Pedro González
Keyword(s):  
De Novo ◽  
Cavernous Malformation ◽  
Developmental Venous Anomaly ◽  
Venous Anomaly

scholarly journals Cumulative incidence and risk factors for radiation induced leukoencephalopathy in high grade glioma long term survivors

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Robert Terziev ◽  
Dimitri Psimaras ◽  
Yannick Marie ◽  
Loic Feuvret ◽  
Giulia Berzero ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cumulative Incidence ◽  
High Grade Glioma ◽  
High Grade ◽  
Nucleotide Polymorphisms ◽  
Increased Risk ◽  
Radiation Induced ◽  
Long Term Survivors

AbstractThe incidence and risk factors associated with radiation-induced leukoencephalopathy (RIL) in long-term survivors of high-grade glioma (HGG) are still poorly investigated. We performed a retrospective research in our institutional database for patients with supratentorial HGG treated with focal radiotherapy, having a progression-free overall survival > 30 months and available germline DNA. We reviewed MRI scans for signs of leukoencephalopathy on T2/FLAIR sequences, and medical records for information on cerebrovascular risk factors and neurological symptoms. We investigated a panel of candidate single nucleotide polymorphisms (SNPs) to assess genetic risk. Eighty-one HGG patients (18 grade IV and 63 grade III, 50M/31F) were included in the study. The median age at the time of radiotherapy was 48 years old (range 18–69). The median follow-up after the completion of radiotherapy was 79 months. A total of 44 patients (44/81, 54.3%) developed RIL during follow-up. Twenty-nine of the 44 patients developed consistent symptoms such as subcortical dementia (n = 28), gait disturbances (n = 12), and urinary incontinence (n = 9). The cumulative incidence of RIL was 21% at 12 months, 42% at 36 months, and 48% at 60 months. Age > 60 years, smoking, and the germline SNP rs2120825 (PPARg locus) were associated with an increased risk of RIL. Our study identified potential risk factors for the development of RIL (age, smoking, and the germline SNP rs2120825) and established the rationale for testing PPARg agonists in the prevention and management of late-delayed radiation-induced neurotoxicity.

De Novo Development of a Cavernous Malformation of the Brain: Significance of Factors with Paracrine and Endocrine Activity: Case Report

Neurosurgery ◽  
2002 ◽  
Vol 50 (3) ◽  
pp. 646-650 ◽  
Author(s):  
Wolf Lüdemann ◽  
Verena Ellerkamp ◽  
Alexandru C. Stan ◽  
Sami Hussein
Keyword(s):  
Case Report ◽  
De Novo ◽  
Cavernous Malformation ◽  
Endocrine Activity ◽  
The Brain

scholarly journals A133 GASTRIC ESD: PRELIMINARY EXPERIENCE IN A TERTIARY CENTER IN QUEBEC

2021 ◽  
Vol 4 (Supplement_1) ◽  
pp. 117-118
Author(s):  
D Maillet ◽  
E Desilets ◽  
T Maniere
Keyword(s):  
Curative Resection ◽  
Residual Disease ◽  
High Grade Dysplasia ◽  
R0 Resection ◽  
Low Grade ◽  
High Grade ◽  
En Bloc ◽  
Delayed Bleeding ◽  
Tertiary Center ◽  
Intramucosal Adenocarcinoma

Abstract Background Endoscopic submucosal dissection (ESD) is an endoscopic procedure developed in Asian countries to treat early gastric cancer (EGC). Western countries have less experience with this challenging technique. Aims The goal of this study is to evaluate the effectiveness of ESD as a preliminary experience. Methods This is an unicentric retrospective study of all consecutive gastric ESD for adenomas or EGC from 07/2017 to 08/2020. The primary endpoints were en bloc and R0 resection rates. Results Nineteen patients (mean age 74.2 (54–88), sex ratio 3F/16M) and 23 lesions were included. Mean diameter was 25 mm (10–90). Treatment was previously performed in 7 cases (30.4%), by ESD (5) or EMR (2). The procedure, performed under general anaesthesia, lasted on average 148 minutes (45–412). En bloc resections were performed in 16 cases (69.6%); 5 cases (21.7%) were converted to P-EMR and there was a failure to resect the lesion because of deep invasion or perforation in 2 cases (8.7%). Pathologic examination demonstrated 2 low-grade dysplasia, 4 high-grade dysplasia and 15 adenocarcinomas: intramucosal (8), sm1 (2), sm2 (2), sm3 (1) or sm deep (2). R0 and curative resection rates were 43.5% and 39.1% respectively. The complication rate related to the procedure was 30.4% including 5 perforations and 2 delayed bleeding: all were managed endoscopically. Five patients (21.7%) underwent subsequent gastrectomy for non-curative resection (4) or failed resection (1); 3 had no residual disease on final pathology, 1 had high grade dysplasia and 1 had intramucosal adenocarcinoma. One patient went to palliative care because he was unfit for surgery. Follow-up endoscopy was completed in all 17 patients who underwent endoscopic resection (mean 10 months (2–24)). Recurrence occurred in 23.5% (4/17); all were successfully treated by another ESD. Conclusions In our preliminary experience, the rate of en bloc and R0 resection were 70% and 44%. Compared to other studies, these low en bloc and curative resection rates may be explained by technically difficult lesions during the learning curve and might improve with experience. Nevertheless, surgery has been avoided in 13/19 patients (68%) with endoscopic intervention. Funding Agencies None

Thrombectomy and Clip Occlusion of a Giant, Stent-Coiled Basilar Bifurcation Aneurysm: 3-Dimensional Operative Video

2021 ◽  
Author(s):  
Fabio A Frisoli ◽  
Joshua S Catapano ◽  
S Harrison Farber ◽  
Jacob F Baranoski ◽  
Rohin Singh ◽  
...  
Keyword(s):  
Circulatory Arrest ◽  
Ventricular Pacing ◽  
Indocyanine Green Videoangiography ◽  
Aneurysm Neck ◽  
3 Dimensional ◽  
Bifurcation Aneurysm ◽  
Patient Consent ◽  
Rapid Ventricular Pacing ◽  
Proximal Occlusion ◽  
Clip Occlusion

Abstract Giant basilar apex aneurysms are associated with significant therapeutic challenges.1–6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7–9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals A121 UNDERWATER EMR FOR NON-LIFTING SESSILE COLORECTAL LESIONS

2021 ◽  
Vol 4 (Supplement_1) ◽  
pp. 102-103
Author(s):  
C Galts ◽  
R Barclay ◽  
D Percy
Keyword(s):  
Surgical Resection ◽  
De Novo ◽  
Lesion Size ◽  
Colorectal Polyps ◽  
Invasive Cancer ◽  
Previous Attempt ◽  
Tubular Adenoma ◽  
En Bloc ◽  
Clinical Role ◽  
Submucosal Injection

Abstract Background Sessile colorectal lesions which do not elevate with submucosal injection — “non-lifting” lesions — are considered poor candidates for EMR due to concerns of possible invasive cancer and increased procedural risk. However, a non-lifting sign is an unreliable predictor of malignancy, relegating many benign lesions to surgical resection. Underwater EMR (UEMR), which obviates submucosal injection, is effective for sessile colorectal polyps but has not been evaluated specifically for non-lifting lesions. Aims The aim of this study was to assess the efficacy of UEMR for “non-lifting” large sessile colorectal lesions with the hypothesis that UEMR may have a clinical role in managing complex lesions. Methods We reviewed our database from 2016 to 2019 for patients referred for large (≥ 20 mm) non-lifting colorectal lesions without overt signs of invasive cancer, who subsequently underwent UEMR. Results Thirty-two cases were successfully treated with single session UEMR. 18 (56%) were de novo lesions whereas the remainder had undergone previous attempt(s) at conventional EMR. The mean lesion size was 37 ± 17 mm. 4 cases (13%) were resected en bloc; the remainder piecemeal. Final pathology was T1 adenocarcinoma, N=3 (9%); tubulovillous adenoma, N=15 (47%); tubular adenoma, N=8 (25%); sessile serrated, N=6 (19%); high-grade dysplasia, N=2 (6%). One patient with cancer underwent surgical resection (T1N0); the remainder had endoscopic follow-up over 8 ± 3 months with benign recurrent/residual lesions in 8%, all amenable to UEMR. There were no procedural complications. Conclusions In this series of large sessile non-lifting colorectal lesions, UEMR was effective for both de novo and previously treated lesions, obviating surgery in the majority of cases. Funding Agencies None

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