Clinoidal meningiomas

1990 ◽  
Vol 73 (6) ◽  
pp. 840-849 ◽  
Author(s):  
Ossama Al-Mefty
Keyword(s):  
Cerebral Vessels ◽  
Sinus Surgery ◽  
Morbidity Rate ◽  
Total Removal ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Group Iii ◽  
Group I ◽  
Subtotal Removal ◽  
Fine Print

✓ Anterior clinoidal meningiomas are frequently grouped with suprasellar or sphenoid ridge meningiomas, masking their notorious association with a high mortality and morbidity rate, failure of total removal, and recurrence. To avoid injury to encased cerebral vessels, most surgeons are content with subtotal removal. Without total removal, however, recurrence is expected. Recent advances in cranial-base exposure and cavernous sinus surgery have facilitated radical total removal. The author reports 24 cases operated on with vigorous attempts at total removal of the tumor with involved dura and bone. This experience has distinguished three groups (I, II, and III) which influence surgical difficulties, the success of total removal, and outcome. These subgroups relate to the presence of interfacing arachnoid membranes between the tumor and cerebral vessels. The presence or absence of arachnoid membranes depends on the origin of the tumor and its relation to the naked segment of carotid artery lying outside the carotid cistern. Total removal was impossible in the three patients in Group I, with postoperative death occurring in one patient and hemiplegia in another. Total removal was achieved in 18 of the 19 patients in Group II, with one death from pulmonary embolism. In the two patients in Group III, total removal without complications was easily achieved.

Surgical treatment of clival chordomas: the transsphenoidal approach revisited

1996 ◽  
Vol 85 (5) ◽  
pp. 784-792 ◽  
Author(s):  
Giulio Maira ◽  
Roberto Pallini ◽  
Carmelo Anile ◽  
Eduardo Fernandez ◽  
Fabrizio Salvinelli ◽  
...  
Keyword(s):  
Spinal Metastasis ◽  
Postoperative Radiotherapy ◽  
Primary Treatment ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Partial Removal ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Lower Clivus ◽  
Fine Print

✓ This is a report of 12 cases of clival chordomas that were surgically treated at the Catholic University Medical School, Rome, Italy, over a 7-year period. The study emphasizes the role of the transsphenoidal approach. The study group included seven men and five women whose ages ranged from 26 to 80 years (mean 49.8 years). Diplopia was the most common presenting symptom (eight cases). The tumor involved the upper and middle clivus in five cases, the middle clivus in five, and the lower clivus in two cases. One patient developed spinal metastasis. On histological examination, eight cases proved to be typical chordomas, three cases had a chondroid component, and one case of chordoma had atypical features. Immunohistological staining for vimentin and epithelial membrane antigen was positive in all cases. Follow-up periods ranged from 14 to 86 months (mean 40.2 months). The primary treatment consisted of surgery. Ten patients with chordomas of the upper and middle clivus underwent a total of 13 transsphenoidal procedures. Total tumor removal was achieved in seven cases, subtotal removal in two, and partial removal in one case. In the two cases of lower clival chordomas, total removal was accomplished in one and partial removal in the other. After total removal, no recurrence was noted at 14 to 86 months (mean 37.5 months). In the cases undergoing operation via a transsphenoidal approach, there was zero morbidity and one cerebrospinal fluid fistula that resolved without surgery. The tumor recurred in two patients after subtotal and partial removal, respectively. The authors opted to reoperate in cases of recurrence. Postoperative radiotherapy was administered in only two cases in which further surgery was not indicated because of medical reasons or because such a procedure was contrary to the patient's wishes. When mortality and morbidity rates of this group are compared to those of chordoma patients who were treated with extensive skull-base surgery, the results prompt a reappraisal of the transsphenoidal approach in the treatment of clival chordomas.

Effect of initially limited resuscitation in a combined model of fluid-percussion brain injury and severe uncontrolled hemorrhagic shock

2000 ◽  
Vol 93 (2) ◽  
pp. 305-314 ◽  
Author(s):  
Susan A. Stern ◽  
Brian J. Zink ◽  
Michelle Mertz ◽  
Xu Wang ◽  
Steven C. Dronen
Keyword(s):  
Brain Injury ◽  
Physiological Parameters ◽  
Content Type ◽  
Group Iii ◽  
Fluid Percussion ◽  
Group I ◽  
Group Ii ◽  
Goal Map ◽  
Uncontrolled Hemorrhage ◽  
Fine Print

Object. Studies of isolated uncontrolled hemorrhage have indicated that initial limited resuscitation improves survival. Limited resuscitation has not been studied in combined traumatic brain injury and uncontrolled hemorrhage. In this study the authors evaluated the effects of limited resuscitation on outcome in combined fluid-percussion injury (FPI) and uncontrolled hemorrhage.Methods. Twenty-four swine weighing 17 to 24 kg each underwent FPI (3 atm) and hemorrhage to a mean arterial pressure (MAP) of 30 mm Hg in the presence of a 4-mm aortic tear. Group I (nine animals) was initially resuscitated to a goal MAP of 60 mm Hg; Group II (nine animals) was resuscitated to a goal MAP of 80 mm Hg; and Group III (control; six animals) was not resuscitated. After 60 minutes, the aortic hemorrhage was controlled and the animals were resuscitated to baseline physiological parameters and observed for 150 minutes.Mortality rates were 11%, 50%, and 100% for Groups I, II, and III, respectively (Fisher's exact test; p = 0.002). The total hemorrhage volume was greater in Group II (69 ± 32 ml/kg), as compared with Group I (41 ± 18 ml/kg) and Group III (37 ± 3 ml/kg) according to analysis of variance (p < 0.05). In surviving animals, cerebral perfusion pressure, cerebral blood flow (CBF), cerebral venous O2 saturation (ScvO2), and cerebral metabolic rate of O2 did not differ among groups. Although CBF was approximately 50% of baseline during the period of limited resuscitation in Group I, ScvO2 remained greater than 60%, and arteriovenous O2 differences remained within normal limits.Conclusions. In this model of FPI and uncontrolled hemorrhage, early aggressive resuscitation, which is currently recommended, resulted in increased hemorrhage and failure to optimize cerebrovascular parameters. In addition, a 60-minute period of moderate hypotension (MAP = 60 mm Hg) was well tolerated and did not compromise cerebrovascular hemodynamics, as evidenced by physiological parameters that remained within the limits of cerebral autoregulation.

Expression of matrix metalloproteinases 2 and 9 in meningiomas associated with different degrees of brain invasiveness and edema

2001 ◽  
Vol 95 (5) ◽  
pp. 839-844 ◽  
Author(s):  
Ann-Christin Sandberg Nordqvist ◽  
Hubert Smurawa ◽  
Tiit Mathiesen
Keyword(s):  
Matrix Metalloproteinases ◽  
Clear Correlation ◽  
Consecutive Series ◽  
Tissue Samples ◽  
Content Type ◽  
Brain Invasion ◽  
Group Iii ◽  
Tumor Invasiveness ◽  
Group I ◽  
Fine Print

Object. Meningiomas display clinical characteristics that vary from very benign to clearly malignant with rapid invasive growth and metastasis. Benign meningiomas differ in their invasiveness and concomitant edema. This study was undertaken to analyze the expression of matrix metalloproteinases 2 and 9 (MMP-2 and MMP-9, respectively) in meningiomas associated with different degrees of brain invasion and edema. Methods. Tissue samples from 16 meningiomas were selected according to tumor invasiveness from a consecutive series of patients. Samples were analyzed for expression of both MMP-2 and MMP-9 by using in situ hybridization. The meningiomas consisted of three types: Group I, benign meningiomas that did not interfere with the arachnoid plane and exhibited no edema; Group II, benign meningiomas that invaded the arachnoid plane and caused edema; and Group III, aggressive and malignant meningiomas that caused edema and displayed brain invasion. In all 16 tumors analyzed, MMP-2 mRNA was identified. Levels of expression of MMP-2 mRNA were similar in all samples, and no correlation with increasing tumor invasiveness or associated edema could be detected. Expression of MMP-9 mRNA was identified in 14 of the 16 tumors, and a clear correlation with increasing tumor invasion into the brain was noted. Conclusions. Meningiomas express both MMP-2 and MMP-9. Tumor invasiveness, which ranged from minor with respect to the arachnoid membrane and progressed to frank brain invasion, correlated with the extent of MMP-9 expression. The findings indicate that MMP-9 expression and brain invasion are relevant mechanisms that must be interfered with in the treatment of aggressive and malignant meningiomas. No such correlation with MMP-2 was found.

Duraplasty with biosynthetic cellulose: an experimental study

1997 ◽  
Vol 86 (1) ◽  
pp. 143-150 ◽  
Author(s):  
Luis Renato Mello ◽  
Leonir T. Feltrin ◽  
Paulo T. Fontes Neto ◽  
Fernando A. P. Ferraz
Keyword(s):  
Dura Mater ◽  
Clinical Symptoms ◽  
Early Postoperative Period ◽  
Cellulose Membrane ◽  
Content Type ◽  
Group Iii ◽  
Temporal Fascia ◽  
Group I ◽  
Fine Print

✓ In the search for a new synthetic substitute for the dura mater, the authors conducted a research study using 32 mongrel dogs divided into three groups. Group I animals (21 dogs) underwent a right-sided parietooccipital craniotomy and substitution of two 1-cm pieces of dura mater by two different grafts: one piece of biosynthetic cellulose (50 µ thick) and one fragment of temporal fascia. The animals were observed for 30, 90, or 180 days. Group II animals (five dogs) underwent a somewhat larger craniotomy, removal of a 2-cm piece of dura mater, and lesioning of the cortex made by a thin sharp forceps, which caused bleeding that was controlled by application of a thin film of cellulose (10 µ thick). Duraplasty was performed using a 50-µ-thick cellulose membrane to complete the procedure and the animals were observed over a period of 270 days. Group III animals (six dogs) underwent smaller (1-cm diameter) bilateral parietal craniectomy, which included additional covering of the dura on the left side with 50-µ-thick cellulose and a suture of temporalis muscle. This group was observed for 40, 60, 80, or 120 days. Transient mild clinical symptoms were observed during the early postoperative period. At autopsy, macroscopic examination demonstrated good acceptance of the grafts with few and moderate extradural fibrosis, which caused adherence of the implants to the bone fragment. No adherence to the cortex was observed. Microscopic examination demonstrated absence of graft adherence to the cortical surface even when the cortex was injured. The cellulose was enveloped by two layers of connective tissue, the external layer being thicker than the internal one. Cellulose fibers increased in thickness over time until 30 days and then decreased in thickness until 270 days. This decrease in thickness between 30 to 270 days was statistically significant (p < 0.05). The physical properties of biosynthetic cellulose and the low cellular reaction to its implantation qualify this material as a dural substitute. Additional long-term studies must be undertaken to complete this report.

Evaluation of the healing process after dural reconstruction achieved using a free fascial graft

2002 ◽  
Vol 96 (2) ◽  
pp. 280-286 ◽  
Author(s):  
Eiji Tachibana ◽  
Kiyoshi Saito ◽  
Keizo Fukuta ◽  
Jun Yoshida
Keyword(s):  
Growth Factor ◽  
Subcutaneous Tissue ◽  
Healing Process ◽  
Fibrous Tissue ◽  
Dural Repair ◽  
Content Type ◽  
Group Iii ◽  
Group I ◽  
Silicone Sheet ◽  
Fine Print

Object. This study was undertaken to investigate the healing process and to delineate factors important for the survival of free fascial grafts used for dural repair. Methods. A dural defect was created in guinea pigs and then reconstructed using either a free fascial graft or an expanded polytetrafluoroethylene (ePTFE) sheet. The fascial graft was covered directly by subcutaneous tissue (Group I) or by a silicone sheet to prevent tissue ingrowth from the subcutaneous tissue (Group II). The ePTFE sheet was covered with a silicone sheet (Group III). One or 2 weeks postoperatively, the strength of the dural repair was evaluated by determining the pressure at which cerebrospinal fluid (CSF) leaked through the wound margins. The dural repair was also histologically examined. In addition, using a rat model, specimens obtained from similar reconstruction sites were immunohistochemically stained with antibodies against basic fibroblast growth factor (bFGF), epidermal growth factor, or transforming growth factor—β. The pressures at which CSF leaked after 1 and 2 weeks, respectively, were 50 ± 14 mm Hg and 126 ± 20 mm Hg in Group I, 70 ± 16 mm Hg and 101 ± 38 mm Hg in Group II, and 0 mm Hg and 8 ± 8 mm Hg in Group III. Failure of repairs made in Group III occurred at significantly lower pressures when compared with Groups I and II. In Groups I and II, a thick fibrous tissue formed around the fascial graft. This tissue tightly adhered to adjacent dura mater. The fibrous tissue displayed a positive reaction for the presence of bFGF. In Group III, only a thin fibrous membrane surrounded the ePTFE sheet. Conclusions. Fascial grafts tolerated extraordinary intracranial pressures at 1 week postoperatively. Free fascial grafts can heal with durable fibrous tissue without the presence of a blood supply from an overlying vascularized flap.

Role of estrogen deficiency in the formation and progression of cerebral aneurysms. Part I: experimental study of the effect of oophorectomy in rats

2005 ◽  
Vol 103 (6) ◽  
pp. 1046-1051 ◽  
Author(s):  
Mohammad A. Jamous ◽  
Shinji Nagahiro ◽  
Keiko T. Kitazato ◽  
Junichiro Satomi ◽  
Koichi Satoh
Keyword(s):  
Cerebral Aneurysm ◽  
Cerebral Aneurysms ◽  
Bilateral Oophorectomy ◽  
Gelatinase Activity ◽  
Content Type ◽  
Group Iii ◽  
Group I ◽  
Group Ii ◽  
Fine Print

Object. Estrogen has been shown to play a central role in vascular biology. Although it may exert beneficial vascular effects, its role in the pathogenesis of cerebral aneurysms remains to be determined. To elucidate the role of hormones further, the authors examined the effects of bilateral oophorectomy on the formation and progression of cerebral aneurysms in rats. Methods. Forty-five female, 7-week-old Sprague—Dawley rats were divided into three equal groups. Group I consisted of intact rats (controls). To induce cerebral aneurysms, the animals in Groups II and III were subjected to ligation of the right common carotid and bilateral posterior renal arteries. One month later, the rats in Group II underwent bilateral oophorectomy. Three months after the experiment began all animals were killed and cerebral vascular corrosion casts were prepared and screened for cerebral aneurysms by using a scanning electron microscope. Plasma was used to determine the level of estradiol and the gelatinase activity. Hypertension developed in all rats except those in the control group. The estradiol level was significantly lower in Group II than in the other groups (p < 0.01). The incidence of cerebral aneurysm formation in Group II (60%) was three times higher than that in Group III (20%), and the mean size of aneurysms in Group II (76 ± 27 µm, mean ± standard deviation) was larger than that in Group III (28 ± 4.6 µm) (p < 0.05). No aneurysm developed in control animals (Group I), and there was no significant difference in plasma gelatinase activity among the three groups. Conclusions. The cerebral aneurysm model was highly reproducible in rats. Bilateral oophorectomy increased the susceptibility of rats to aneurysm formation, indicating that hormones play a role in the pathogenesis of cerebral aneurysms.

Microanatomical variations in the cerebellopontine angle associated with vestibular schwannomas (acoustic neuromas): a retrospective study of 1006 consecutive cases

2000 ◽  
Vol 92 (1) ◽  
pp. 70-78 ◽  
Author(s):  
Prakash Sampath ◽  
David Rini ◽  
Donlin M. Long
Keyword(s):  
Cranial Nerve ◽  
Anatomical Location ◽  
Eighth Cranial Nerve ◽  
Content Type ◽  
Middle Fossa Approach ◽  
Group Iii ◽  
Common Location ◽  
Group I ◽  
Cerebellar Artery ◽  
Fine Print

Object. Great advances in neuroimaging, intraoperative cranial nerve monitoring, and microsurgical technique have shifted the focus of acoustic neuroma surgery from prolonging life to preserving cranial nerve function in patients. An appreciation of the vascular and cranial nerve microanatomy and the intimate relationship between neurovascular structures and the tumor is essential to achieve optimum results. In this paper the authors analyze the microanatomical variations in location of the facial and cochlear nerves in the cerebellopontine angle (CPA) associated with acoustic neuromas and, additionally, describe the frequency of involvement of surrounding neural and vascular structures with acoustic tumors of varying size. The authors base these findings on their experience with 1006 consecutive patients who underwent surgery via a retrosigmoid or translabyrinthine approach.Methods. Between July 1969 and January 1998, the senior author (D.M.L.) performed surgery in 1022 patients for acoustic neuroma: 705 (69%) via the retrosigmoid (suboccipital); 301 (29%) via the translabyrinthine; and 16 (2%) via the middle fossa approach. Patients undergoing the middle fossa approach were excluded from the study. The remaining 1006 patients were subdivided into three groups based on tumor size: Group I tumors (609 patients [61%]) were smaller than 2.5 cm; Group II tumors (244 patients [24%]) were between 2.5 and 4 cm; and Group III tumors (153 patients [15%]) were larger than 4 cm. The senior author's operative notes were analyzed for each patient. Relevant cranial nerve and vascular “involvement” as well as anatomical location with respect to the tumor in the CPA were noted. “Involvement” was defined as adherence between neurovascular structure and tumor (or capsule), for which surgical dissection was required to free the structure. Seventh and eighth cranial nerve involvement was divided into anterior, posterior, and polar (around the upper or lower pole) locations. Anterior and posterior locations were further subdivided into upper, middle, or lower thirds of the tumor.The most common location of the seventh cranial nerve (facial) was the anterior middle third of the tumor for all groups, although a significant number were found on the anterior superior portion. The posterior location was exceedingly rare (< 1%). Interestingly, patients with smaller tumors (Group I) had an incidence (3.4%) of the seventh cranial nerve passing through the tumor itself, equal to that of patients with larger tumors. The most common location of the eighth cranial nerve complex was the anterior inferior portion of the tumor. Not surprisingly, larger tumors (Group III) had a higher incidence of involvement of fourth cranial nerve (41%), fifth cranial nerve (100%), ninth—11th cranial nerve complex (99%), and 12th cranial nerve (31%), as well as superior cerebellar artery (79%), anterior inferior cerebellar artery (AICA) trunk (91.5%), AICA branches (100%), posterior inferior cerebellar artery (PICA) trunk (59.5%), PICA branches (79%), and the vertebral artery (VA) (93.5%). A small number of patients in Group III also had AICA (3.3%), PICA (3.3%), or VA (1.3%) vessels within the tumor itself.Conclusions. In this study, the authors show the great variation in anatomical location and involvement of neurovascular structures in the CPA. With this knowledge, they present certain technical lessons that may be useful in preserving nerve function during surgery and, in doing so, hope to provide neurosurgeons and neurootologists with valuable information that may help to achieve optimum outcomes in patients.

Intracranial teratoma in early infancy

1973 ◽  
Vol 38 (3) ◽  
pp. 265-268 ◽  
Author(s):  
Akiba Takaku ◽  
Reizo Mita ◽  
Jiro Suzuki
Keyword(s):  
Early Infancy ◽  
Total Removal ◽  
Content Type ◽  
Intracranial Teratoma ◽  
Subtotal Removal ◽  
Fine Print

✓ Three cases of large supratentorial teratomas in patients under 1 year old are reported. One 320-gm tumor was successfully totally removed; one patient died without surgery 7 days after birth, and one died 10 days after subtotal removal. The symptoms and diagnosis of intracranial teratomas in infancy are discussed. Treatment by total removal is recommended.

Unruptured paraclinoid aneurysms: a management strategy

2003 ◽  
Vol 99 (2) ◽  
pp. 241-247 ◽  
Author(s):  
Koji Iihara ◽  
Kenichi Murao ◽  
Nobuyuki Sakai ◽  
Atsushi Shindo ◽  
Hideki Sakai ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Management Strategy ◽  
Morbidity Rate ◽  
Content Type ◽  
Group Iii ◽  
Paraclinoid Aneurysms ◽  
Permanent Morbidity ◽  
Group Ii ◽  
Retinal Embolism ◽  
Fine Print

Object. To elucidate an optimal management strategy for unruptured paraclinoid aneurysms, the authors retrospectively reviewed their experience in the treatment of 100 patients who underwent 112 procedures for 111 paraclinoid aneurysms performed using direct surgery and/or endovascular treatment. Methods. Between 1997 and 2002, 111 unruptured paraclinoid aneurysms categorized according to a modified al-Rodhan classification (Group Ia, 30 anterior wall lesions; Group Ib, 25 ventral paraclinoid lesions; Group II, 18 true ophthalmic artery lesions; Group III, 37 carotid cave lesions; and Group IV, one transitional lesion) were treated by direct surgery (35 lesions) and/or endovascular treatment (77 lesions) (one aneurysm was treated by both procedures). In lesions in Groups Ia, Ib, II, and III that were treated by endovascular treatment, complete aneurysm obliteration was achieved in 50, 65, 50, and 78%, respectively, and the combined transient and permanent morbidity rates due to cerebral embolic events were 20, 25, 20, and 13.9%, respectively. Overall, the transient morbidity rate after endovascular treatment was 14.3% and the permanent morbidity rate was 6.5%. Notably, permanent visual deficits caused by retinal embolism occurred after endovascular treatment in two patients with Group II aneurysms. Direct surgery was mainly performed in Groups Ia (20 lesions), Ib (five lesions), and II (eight lesions), with complete neck clip occlusion achieved in 80, 80, and 71.4%, respectively; the transient and permanent morbidity rates associated with aneurysms treated by surgery were 8.6 and 2.9%, respectively. Conclusions. Endovascular therapy for superiorly projecting paraclinoid aneurysms (Groups Ia and II) is associated with lower rates of complete obliteration than direct surgery, and with rates of cerebral embolic events comparable to those of endovascular treatment in the other groups. Furthermore, endovascular treatment for Group II aneurysms entails additional risks of retinal embolism. Therefore, direct surgery is recommended for the treatment of paraclinoid aneurysms projecting superiorly. For other groups, especially for Group III, endovascular treatment is the acceptable first line of therapy.

Spinal neurological complications of achondroplasia

1980 ◽  
Vol 52 (4) ◽  
pp. 463-472 ◽  
Author(s):  
David F. Morgan ◽  
Ronald F. Young
Keyword(s):  
Early Recognition ◽  
Neurological Complications ◽  
Foramen Magnum ◽  
Operative Procedures ◽  
Content Type ◽  
Group Iii ◽  
Group I ◽  
Upper Cervical ◽  
Tomographic Analysis ◽  
Fine Print

✓ Spinal neurological complications caused the admission of 17 patients with achondroplasia to the UCLA affiliated hospitals between 1955 and 1979. These patients constituted 41% of all achondroplastic patients admitted during that period. The spinal stenotic syndromes could be divided into three groups: Group I: thoracolumbar stenosis (10 patients); Group II: foramen magnum and upper cervical stenosis (five patients); and Group III: generalized spinal stenosis (two patients). Eleven patients underwent a total of 18 decompressive operative procedures for treatment of paraparesis, quadriparesis, sensory deficits, and sphincter dysfunction. Excellent results were obtained with patients in Group I and II, 77% of whom were ambulatory and continent postoperatively. Two patients in Group III fared less well, showing steady neurological deterioration despite multiple operative procedures. The spectrum of spinal neurological manifestations secondary to achondroplasia is reviewed. Problems with conventional radiological studies and the potential role of computerized tomographic analysis of such patients are discussed. Recommendations for surgical technique are made. Early recognition, prompt clinical evaluation, and safe and accurate radiological analysis of spinal neurological complications of achondroplasia will allow appropriate decompressive surgical procedures to be performed. Excellent results may be anticipated in the reversal and prevention of neurological deficit secondary to achondroplasia with such an approach.

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