Surgical management of giant pediatric craniopharyngiomas

2010 ◽  
Vol 6 (5) ◽  
pp. 403-416 ◽  
Author(s):  
Robert E. Elliott ◽  
Jeffrey H. Wisoff
Keyword(s):  
Disease Control ◽  
Functional Outcomes ◽  
Visual Fields ◽  
Radical Resection ◽  
Neurological Complications ◽  
Senior Author ◽  
Neurological Deficits ◽  
Primary Tumors ◽  
Recurrent Tumors

Object Prior work by the authors' group and reports of other authors suggest worse functional outcomes and decreased survival in children with larger craniopharyngiomas. The purpose of this study was to assess the oncological, endocrinological, and functional outcomes in children who underwent radical resection of giant craniopharyngiomas (defined as 5 cm or greater in largest diameter). Methods Between 1986 and 2006, 26 children under the age of 18 (14 boys, 12 girls; mean age 10.5 years) underwent radical resection of giant craniopharyngiomas performed by the senior author. Data were retrospectively collected to assess the outcome of surgical treatment. Results Twenty (77%) of 26 patients underwent gross-total resection (GTR) confirmed by intraoperative inspection and postoperative imaging. All primary tumors (17 of 17) and 3 (33%) of 9 recurrent tumors were treated with GTR. There was no operative mortality, and 18 of 26 patients (69%) were alive at a mean follow-up of 8.9 years (median 9.3 years). Disease control was achieved in 21 (84%) of the 25 patients followed up for more than 6 months and was more successful in patients who underwent GTR (95%) than in those who underwent STR (50%, p = 0.03). New-onset diabetes insipidus (DI) occurred in 63.2% of patients (73% of patients had DI postoperatively). New or worsened deficits in visual acuity and visual fields occurred in 16% and 28%, respectively, of the 25 patients for whom postoperative visual data were available. Five patients (19%) experienced significant, permanent neurological deficits, and 5 (19%) had mild to moderate deficits. New or worsened hypothalamic disturbance occurred in 35% and 22% of patients, respectively, but obesity developed in only 15%. Conclusions In this retrospective series, radical resection of giant craniopharyngiomas in children was found to lead to excellent rates of disease control with acceptable or good functional outcomes but slightly higher rates of neurological complications compared with rates in patients with smaller tumors. Radical resection is less successful in recurrent tumors that reach very large sizes, especially previously irradiated tumors, with resultant diminished survival.

Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children

2010 ◽  
Vol 5 (1) ◽  
pp. 30-48 ◽  
Author(s):  
Robert E. Elliott ◽  
Kevin Hsieh ◽  
Tsivia Hochm ◽  
Ilana Belitskaya-Levy ◽  
Jessica Wisoff ◽  
...  
Keyword(s):  
Overall Survival ◽  
Radiation Therapy ◽  
Tumor Size ◽  
Progression Free Survival ◽  
Radical Resection ◽  
Primary Tumors ◽  
Free Survival ◽  
Recurrent Tumors ◽  
The Mean

Object Optimal treatment of primary and recurrent craniopharyngiomas remains controversial. Radical resection and limited resection plus radiation therapy yield similar rates of disease control and overall survival. The data are much less clear for recurrent tumors. The authors report their experience with radical resection of both primary and recurrent craniopharyngiomas in children and compare the outcomes between the 2 groups. Methods A retrospective analysis was performed in 86 children younger than 21 years of age who underwent a total of 103 operations for craniopharyngioma between 1986 and 2008; these were performed by the senior author. The goal was resection with curative intent in all patients. Two patients were lost to follow-up and were excluded from analysis. The mean age at the time of surgery was 9.6 years, and the mean follow-up was 9.0 years. Results All 57 children with primary tumors underwent gross-total resection (GTR). A GTR was achieved in significantly fewer children with recurrent tumors (18 [62%] of 29). There were 3 perioperative deaths (3%). Tumor recurred after GTR in 14 (20%) of 71 patients. Overall survival and progression-free survival were significantly better in patients with primary tumors at time of presentation to the authors' institution. There were no significant differences in the neurological, endocrinological, visual, or functional outcomes between patients with primary and those with recurrent tumors. Factors negatively affecting overall survival and progression-free survival include subtotal resection (recurrent tumors only), tumor size ≥ 5 cm, or presence of hydrocephalus or a ventriculoperitoneal shunt. Prior radiation therapy and increasing tumor size were both risk factors for incomplete resection at reoperation. Conclusions In the hands of surgeons with experience with craniopharyngiomas, the authors believe that radical resection at presentation offers the best chance of disease control and potential cure with acceptable morbidity. While GTR does not preclude recurrence and is more difficult to achieve in recurrent tumors, especially large and previously irradiated tumors, radical resection is still possible in patients with recurrent craniopharyngiomas with morbidity similar to that of primary tumors.

Microsurgical resection of medullary cavernoma via the olivary zone by the retrosigmoid supracondylar approach

2019 ◽  
Vol 1 (2) ◽  
pp. V7
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Helmut Bertalanffy
Keyword(s):  
Cavernous Malformation ◽  
Cleavage Plane ◽  
Foramen Magnum ◽  
Senior Author ◽  
Neurological Deficits ◽  
Lateral Part ◽  
Sitting Position ◽  
Brainstem Cavernoma ◽  
Microsurgical Resection

Microsurgical resection of the medullary cavernoma is rare, comprising less than 15% of more than 250 surgeries of brainstem cavernoma performed by the senior author (H.B.).1 This video demonstrates a case of a cavernous malformation inside the lateral part of the medulla, which was surgically treated via the olivary zone by the retrosigmoid supracondylar approach in a half-sitting position. Osseous drilling of the lateral foramen magnum provided wide exposure of the cerebellomedullary cistern around the olive.2,3 The lesion was completely dissected at the appropriate cleavage plane from the normal parenchyma. The patient developed no new neurological deficits and had no recurrence during 3 years of follow-up after the operation.The video can be found here: https://youtu.be/7i7SccS5HmU.

scholarly journals Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes

2014 ◽  
Vol 14 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Matthew B. Potts ◽  
Sunil A. Sheth ◽  
Jonathan Louie ◽  
Matthew D. Smyth ◽  
Penny K. Sneed ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Target Volume ◽  
Neurological Deficits ◽  
Single Institution ◽  
Risks And Benefits ◽  
Scale Scores ◽  
Time Of Presentation

Object Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. Methods The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. Results A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm3 (range 0.09–62.3 cm3), and median prescription marginal dose used was 17.5 Gy (range 12–20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18–20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%–37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0–2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. Conclusions A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.

First clinical experience with the new Surpass Evolve flow diverter: technical and clinical considerations

2020 ◽  
Vol 12 (10) ◽  
pp. 974-980 ◽  
Author(s):  
Emanuele Orru ◽  
Henry Rice ◽  
Laetitia De Villiers ◽  
Jesse M Klostranec ◽  
Ajay K Wakhloo ◽  
...  
Keyword(s):  
Major Complication ◽  
Neurological Complications ◽  
Flow Diverter ◽  
Neurological Deficits ◽  
Mesh Density ◽  
Posterior Circulation Aneurysms ◽  
Acute Stent Thrombosis ◽  
Device Properties ◽  
Flow Diverters

ObjectiveTo describe the results in patients treated with the Surpass Evolve (SE) device, the new generation of Surpass flow diverters.MethodsTwenty-five consecutive patients (20 women, average age 58 years), with anterior or posterior circulation aneurysms treated with SEs in two early-user centers, were included. Device properties and related technical properties, imaging and clinical follow-up data, and intraprocedural, early (<30 days) and delayed (>30 days) neurological complications, further divided into minor (silent/non-permanent) and major (permanent) complications, were recorded and analyzed.ResultsTwenty-nine SEs were successfully implanted in all subjects to treat 26 aneurysms using an 0.027" microcatheter with an average of 1.2 stents per patient. No intraprocedural thromboembolic or hemorrhagic complications were seen. At clinical follow-up, 24/25 (96%) patients had a modified Rankin Score of 0–2. Mortality was 0%. Imaging follow-up, available in 22/25 (88%) patients (median follow-up time 4 months), showed a complete aneurysm occlusion in 13/23 (57%) imaged lesions. Minor, transitory neurological deficits were recorded in 5/25 (20%) patients. One (4%) major complication was seen in one patient (4%) with a left-sided hemispheric stroke on postprocedural day 4 due to an acute stent thrombosis.ConclusionsPreliminary experience in patients demonstrates a good performance of the SE. This newly designed implant maintains the engineering characteristics of Surpass flow diverters, including precise placement due to its lower foreshortening and a high mesh density, yet can be deployed through a significantly lower-profile delivery system.

SURGERY FOR CONVEXITY MENINGIOMAS

Neurosurgery ◽  
2008 ◽  
Vol 63 (3) ◽  
pp. 427-434 ◽  
Author(s):  
Andrew P. Morokoff ◽  
Jacob Zauberman ◽  
Peter M. Black
Keyword(s):  
Recurrence Rate ◽  
Malignant Tumors ◽  
Surgical Techniques ◽  
Senior Author ◽  
Neurological Deficits ◽  
Complication Rates ◽  
Recurrence Rates ◽  
Complete Excision ◽  
Image Guided

ABSTRACT OBJECTIVE Meningiomas that occur over the convexity of the brain are the most common meningiomas, but little has been published about their contemporary management. We aimed to analyze a large series of convexity meningiomas with respect to surgical technique, complication rates, and pathological factors leading to recurrence. METHODS We retrospectively reviewed 163 cases of convexity meningiomas operated on in our institution by the senior author (PMB) between 1986 and 2005. The median follow-up time was 2.3 years (range, 1–13 yr). RESULTS Convexity tumors represented 22% of all meningiomas operated on. There was a female:male ratio of 2.7:1. Median age was 57 years (range, 20–89 yr). Image-guided surgery was used on all cases in the last 5 years. The 30-day mortality rate was 0%. The incidence of new neurological deficits was 1.7%, and the overall complication rate was 9.4%. The pathology of the tumors was benign in 144 (88.3%), atypical in 16 (9.8%), and anaplastic/malignant in 3 (1.8%). In six of the cases designated “benign,” there were borderline atypical features. The 5-year recurrence rate for benign meningiomas was 1.8%, atypical meningiomas 27.2%, and anaplastic meningiomas 50%. The two cases of benign tumor recurrences involved tumors with borderline atypia and high MIB-1 indices. The borderline atypical cases had a 5-year recurrence-free survival rate of only 55.9%, more closely approximating that of tumors designated “atypical.” CONCLUSION Convexity meningiomas can be safely removed using modern image-guided minimally invasive surgical techniques with a very low operative mortality. Benign convexity meningiomas having a Simpson Grade I complete excision have a very low recurrence rate. The recurrence rates of atypical and malignant tumors are significantly higher, and borderline atypical tumors should be considered to behave more like atypical rather than benign lesions. Longer-term follow-up data are needed to more accurately determine the recurrence rates of benign meningiomas.

Occipitocervical Fixation

Neurosurgery ◽  
2016 ◽  
Vol 79 (4) ◽  
pp. 549-560 ◽  
Author(s):  
Eduardo Martinez-del-Campo ◽  
Jay D. Turner ◽  
Samuel Kalb ◽  
Leonardo Rangel-Castilla ◽  
Luis Perez-Orribo ◽  
...  
Keyword(s):  
Case Series ◽  
Median Number ◽  
Senior Author ◽  
Neurological Deficits ◽  
Neurological Injury ◽  
Long Term Results ◽  
Occipitocervical Fixation ◽  
Surgical Fixation

Abstract BACKGROUND Occipitocervical junction instability can lead to serious neurological injury or death. Open surgical fixation is often necessary to provide definitive stabilization. However, long-term results are limited to small case series. OBJECTIVE To review the causes of occipitocervical instability, discuss the indications for surgical intervention, and evaluate long-term surgical outcomes after occipitocervical fixation. METHODS The charts of all patients undergoing posterior surgical fixation of the occipitocervical junction by the senior author were retrospectively reviewed. A total of 120 consecutive patients were identified for analysis. Patient demographic characteristics, occipitocervical junction pathology, surgical indications, and clinical and radiographic outcomes are reported. RESULTS The study population consisted of 64 male and 56 female patients with a mean age of 39.9 years (range, 7 months to 88 years). Trauma was the most common cause of instability, occurring in 56 patients (47%). Ninety patients (75%) were treated with screw/rod constructs; wiring was used in 30 patients (25%). The median number of fixated segments was 5 (O-C4). Structural bone grafts were implanted in all patients (100%). Preoperative neurological deficits were present in 83 patients (69%); 91% of those patients improved with surgery. Mean follow-up was 35.1 ± 27.4 months (range, 0-123 months). Two patients died, and 10 were lost to follow-up before the end of the 6-month follow-up period. Fusion was confirmed in 107 patients (89.1%). The overall complication rate was 10%, including 3 patients with vertebral artery injuries and 2 patients who required revision surgery. CONCLUSION Occipitocervical fixation is a durable treatment option with acceptable morbidity for patients with occipitocervical instability.

Successful surgical treatment of craniopharyngioma in very young children

2009 ◽  
Vol 3 (5) ◽  
pp. 397-406 ◽  
Author(s):  
Robert E. Elliott ◽  
Jeffrey H. Wisoff
Keyword(s):  
Surgical Treatment ◽  
Young Children ◽  
Disease Control ◽  
Gamma Knife ◽  
Radical Resection ◽  
Cranial Irradiation ◽  
Senior Author ◽  
Gamma Knife Surgery ◽  
Limited Surgery ◽  
Fractionated Radiation Therapy

Object Given the potential morbidity of cranial irradiation in young children, the risk-benefit analysis of limited surgery plus irradiation versus radical resection may favor the latter strategy. The purpose of this study was to assess the oncological, endocrinological, and functional outcomes of patients 5 years of age and younger who underwent radical resection of craniopharyngiomas. Methods Between 1991 and 2008, 19 children age ≤ 5 years were diagnosed with a craniopharyngioma and underwent radical resection by the senior author (J.H.W.). Data were retrospectively collected on these 19 patients (11 males, 8 females; mean age 3.2 years) to assess the efficacy and impact of surgical treatment. Results Eighteen (95%) of 19 patients underwent gross-total resection (GTR) confirmed by intraoperative inspection and postoperative imaging. There was no operative death and 18 of (95%) 19 patients were alive at a mean follow-up of 9.4 years (median 8.3 years). Six patients (31%) had a total of 7 tumor recurrences treated by repeat GTR in 5 patients and Gamma knife surgery in 1 patient. No patient required conventional, fractionated radiation therapy. Disease control was achieved surgically in 17 (89.5%) patients and with surgery and Gamma knife surgery in 1 patient, yielding an overall rate of disease control of 95% without the use of conventional radiotherapy. New-onset diabetes insipidus occurred in 50% of patients. Vision worsened in 1 patient, and there was no long-term neurological morbidity. Conclusions In this retrospective series, children aged ≤ 5 years with craniopharyngiomas can have excellent outcomes with minimal morbidity after radical resection by an experienced surgeon. Disease control in this population can be successfully achieved with GTR alone in the majority of cases, avoiding the detrimental effects of radiotherapy in this vulnerable population.

scholarly journals Resection of brainstem cavernous malformation via perifacial zone through retrosigmoid supracondylar approach

2019 ◽  
Vol 1 (1) ◽  
pp. V16 ◽  
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Helmut Bertalanffy
Keyword(s):  
Cavernous Malformation ◽  
Senior Author ◽  
Neurological Deficits ◽  
Cavernous Malformations ◽  
Inferior Surface ◽  
Complete Surgical Resection ◽  
Brainstem Cavernoma ◽  
Dissection Techniques ◽  
Pontomedullary Junction

Hemorrhagic brainstem cavernous malformations carry a high risk of progressive neurological deficits owing to recurrent hemorrhages and hence require complete surgical resection while minimizing damage to the dense concentration of nuclei and fibers inside the brainstem. To access lesions inside the lower pons, the senior author (H.B.) has preferred to approach the lesions via the “perifacial zone” through the pontomedullary sulcus from the inferior surface of the pontine bulge for more than 20 years.1,2 This video demonstrates a case of a cavernous malformation inside the lower pons, which was surgically treated via the pontomedullary junction through the retrosigmoid supracondylar approach in a half-sitting position. The lesion was completely removed in piecemeal fashion through a tiny incision on the sulcus, which did not cause any new neurological deficits. The modified Rankin Scale improved from 4 before the surgery to 1, and the patient had no recurrence during the 2 years of follow-up. The advantage of this access and the dissection techniques for this challenging lesion are introduced, based on our experience with more than 230 surgeries of brainstem cavernoma.The video can be found here: https://youtu.be/0H_XqkQgQ9I.

scholarly journals Management and outcomes of pituitary apoplexy

2015 ◽  
Vol 122 (6) ◽  
pp. 1450-1457 ◽  
Author(s):  
Tarun D. Singh ◽  
Navid Valizadeh ◽  
Fredric B. Meyer ◽  
John L. D. Atkinson ◽  
Dana Erickson ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Functional Outcomes ◽  
Pituitary Apoplexy ◽  
Histopathological Examination ◽  
Visual Fields ◽  
Visual Field Defects ◽  
Ocular Motility ◽  
Cranial Nerve Palsies

OBJECT This study was undertaken to analyze the predisposing factors, clinical presentation, therapeutic management, and clinical recovery in patients with pituitary apoplexy, with an emphasis on the long-term visual, endocrine, and functional outcomes. METHODS The authors performed a retrospective analysis of consecutive cases involving patients treated at Mayo Clinic between 1992 and 2013. Patients were included in the study only if they had 1) abrupt onset of severe headache or visual disturbance in the presence of a pituitary adenoma and 2) radiological or surgical confirmation of a pituitary mass. The primary endpoints of analysis were the visual (ocular motility, visual fields, and visual acuity), endocrine, and functional outcomes (using the modified Rankin Scale). RESULTS Eighty-seven patients were identified (57 males and 30 females, mean age 50.9 years, range 15–91 years). Twenty-two patients (25.3%) had a known pituitary adenoma. Hypertension was the most common associated factor (39%). Headache was the most frequent presenting symptom (89.7%), followed by visual abnormalities (47.1%). Cranial nerve palsies were present in 39% and visual field defects in 34.1%. MRI detected hemorrhage in 89% patients, as compared with 42% detected by CT scan. Sixty-one patients (70.1%) underwent surgery during acute hospitalization (median time from apoplexy 5 days, IQR 3–10 days), 8 (9.2%) had delayed surgery, and 18 (20.7%) were treated conservatively. Histopathological examination revealed adenoma with pure necrosis in 18 (30%), pure hemorrhage in 4 (6.7%), and both in 6 (10%) patients. Four patients died during hospitalization. The average duration of follow-up was 44.2 ± 43.8 months. All survivors were independent and had complete resolution or substantial improvement in eye movements and visual fields at the last follow-up. Many patients needed long-term hormonal replacement with levothyroxine (62.7%) and cortisol (60%). Daily desmopressin was needed in 23% of all surgical patients at 3 months (versus none of the medically treated) and this requirement decreased slightly over time. Regrowth of pituitary adenoma was seen in 7 patients (8.6%). There were no statistically significant differences in any of the outcome measures across the treatment groups. CONCLUSIONS The outcome of most patients with pituitary apoplexy is excellent. Selected patients can be managed conservatively, and patients with severe neuro-ophthalmological deficits treated with early surgery can achieve an excellent recovery.

Fusiform dilation of the carotid artery following radical resection of pediatric craniopharyngiomas: natural history and management

2010 ◽  
Vol 28 (4) ◽  
pp. E14 ◽  
Author(s):  
Robert E. Elliott ◽  
Jeffrey H. Wisoff
Keyword(s):  
Carotid Artery ◽  
Natural History ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Radical Resection ◽  
Total Resection ◽  
Primary Tumors ◽  
The Mean ◽  
Supraclinoid Internal Carotid Artery

Object Fusiform dilation of the supraclinoid internal carotid artery (FDCA) is a reported occurrence following surgery for suprasellar tumors, in particular craniopharyngiomas. We report our experience of the incidence and natural history of FDCA following aggressive surgical resection of craniopharyngiomas in children. Methods Between 1986 and 2006, 86 patients under the age of 21 underwent radical resection of craniopharyngiomas at our institution. Ten cases with < 1 year of follow-up imaging (6), perioperative death (3), or nonsuprasellar tumors (1) were excluded. Data were retrospectively collected on the remaining 76 patients (43 male, 33 female; mean age 9.5 years; mean tumor size 3.3 cm) to determine the risk factors for and the rate and clinical significance of FDCA. Results Fifty patients had primary tumors and 26 patients received treatment before referral to our center. Sixty-six children (87%) had gross-total resection. At a mean follow-up time of 9.9 years, FDCA had developed in 7 patients (9.2%), all of whom had primary tumors and gross-total resection. The mean time to onset of FDCA was 6.8 months (range 3–11 months) with stabilization occurring at mean of 17.7 months (range 9–29.5 months). The mean size of the aneurysms was 9.1 mm (range 7.1–12 mm). After arrest, no lesions showed continued growth on serial imaging or produced symptoms or required treatment. There were no significant differences in age, sex, tumor size, pre- or retrochiasmatic location, extent of resection, or surgical approach (p > 0.05) between patients with and without FDCA. Conclusions Fusiform dilation of the supraclinoid internal carotid artery occurred in almost 10% of children following radical resection of craniopharyngiomas. In agreement with other reports, the authors concluded that FDCA probably occurs as a result of surgical manipulation of the supraclinoid carotid artery and should be managed conservatively because very few patients exhibit continued symptoms or experience growth or rupture of the lesion.

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