Surgical resection of intrinsic insular tumors: complication avoidance

2001 ◽  
Vol 95 (4) ◽  
pp. 638-650 ◽  
Author(s):  
Frederick F. Lang ◽  
Nancy E. Olansen ◽  
Franco DeMonte ◽  
Ziya L. Gokaslan ◽  
Eric C. Holland ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Neurological Complications ◽  
Surgical Anatomy ◽  
Motor Dysfunction ◽  
Temporal Lobectomy ◽  
Content Type ◽  
Frontal Operculum ◽  
Fine Print

Object. Surgical resection of tumors located in the insular region is challenging for neurosurgeons, and few have published their surgical results. The authors report their experience with intrinsic tumors of the insula, with an emphasis on an objective determination of the extent of resection and neurological complications and on an analysis of the anatomical characteristics that can lead to suboptimal outcomes. Methods. Twenty-two patients who underwent surgical resection of intrinsic insular tumors were retrospectively identified. Eight tumors (36%) were purely insular, eight (36%) extended into the temporal pole, and six (27%) extended into the frontal operculum. A transsylvian surgical approach, combined with a frontal opercular resection or temporal lobectomy when necessary, was used in all cases. Five of 13 patients with tumors located in the dominant hemisphere underwent craniotomies while awake. The extent of tumor resection was determined using volumetric analyses. In 10 patients, more than 90% of the tumor was resected; in six patients, 75 to 90% was resected; and in six patients, less than 75% was resected. No patient died within 30 days after surgery. During the immediate postoperative period, the neurological conditions of 14 patients (64%) either improved or were unchanged, and in eight patients (36%) they worsened. Deficits included either motor or speech dysfunction. At the 3-month follow-up examination, only two patients (9%) displayed permanent deficits. Speech and motor dysfunction appeared to result most often from excessive opercular retraction and manipulation of the middle cerebral artery (MCA), interruption of the lateral lenticulostriate arteries (LLAs), interruption of the long perforating vessels of the second segment of the MCA (M2), or violation of the corona radiata at the superior aspect of the tumor. Specific methods used to avoid complications included widely splitting the sylvian fissure and identifying the bases of the periinsular sulci to define the superior and inferior resection planes, identifying early the most lateral LLA to define the medial resection plane, dissecting the MCA before tumor resection, removing the tumor subpially with preservation of all large perforating arteries arising from posterior M2 branches, and performing craniotomy with brain stimulation while the patient was awake. Conclusions. A good understanding of the surgical anatomy and an awareness of potential pitfalls can help reduce neurological complications and maximize surgical resection of insular tumors.

Current neurosurgical management and the impact of the extent of resection in the treatment of malignant gliomas of childhood: a report of the Children's Cancer Group Trial No. CCG-945

1998 ◽  
Vol 89 (1) ◽  
pp. 52-59 ◽  
Author(s):  
Jeffrey H. Wisoff ◽  
James M. Boyett ◽  
Mitchel S. Berger ◽  
Catherine Brant ◽  
Hao Li ◽  
...  
Keyword(s):  
Glioblastoma Multiforme ◽  
Posterior Fossa ◽  
Anaplastic Astrocytoma ◽  
Tumor Resection ◽  
Radical Resection ◽  
Extent Of Resection ◽  
Total Resection ◽  
Content Type ◽  
Cancer Group ◽  
Fine Print

Object. One hundred seventy-two children with high-grade astrocytomas were treated by members of the Children's Cancer Group in a prospective randomized trial designed to evaluate the role of two chemotherapy regimens. Seventy-six percent of the patients (131 children) in whom a diagnosis of either anaplastic astrocytoma or glioblastoma multiforme was confirmed by central pathological review are the subject of this report. Methods. Patients were stratified according to the extent of tumor resection (biopsy [< 10%], partial resection [10–50%], subtotal resection [51–90%], near-total resection [> 90%], and total resection) as determined by surgical observation and postoperative computerized tomography scanning. Information on contemporary neurosurgical management was obtained from the patient's operative records and standardized neurosurgical report forms. The vast majority of tumors were supratentorial: 63% (83 tumors) in the superficial cerebral hemisphere, 28% (37 tumors) in the deep or midline cerebrum, and only 8% (11 tumors) in the posterior fossa. A significant association was detected between the primary tumor site and the extent of resection (p < 0.0001). A radical resection (> 90%) was performed in 37% of the children: 49% of the tumors in the superficial hemisphere and 45% of tumors in the posterior fossa compared with 8% of midline tumors. Tumor location could also be used to predict the need for both temporary and permanent cerebrospinal fluid (CSF) diversion. Half of the deep tumors and 8% of the hemispheric astrocytomas ultimately required a permanent CSF shunt. Improvement in preoperative neurological deficits and level of consciousness was seen in 36% and 34% of the children, respectively. New or increased deficits were present in 14% of the children, with 6% experiencing a diminished sensorium after surgery. Postoperative nonneurological complications were rare: infection, hematoma, and CSF fistula each occurred in 1.7% of the children. Univariate and multivariate analyses demonstrated that radical tumor resection (> 90%) was the only therapeutic variable that significantly improved progression-free survival (PFS) rates. For all patients with malignant astrocytomas, the distributions of PFS rates were significantly different (p = 0.006) following radical resection compared with less extensive (< 90%) resection. The 5-year PFS rates were 35 ± 7% and 17 ± 4%, respectively. The differences in the distribution of PFS rate were significant for the subsets of patients with anaplastic astrocytoma (p = 0.055) and glioblastoma multiforme (p = 0.046). The 5-year PFS rates for anaplastic astrocytoma were 44 ± 11% and 22 ± 6% for cases in which the tumor was radically resected and less than radically resected, respectively; whereas the 5-year PFS rates for glioblastoma multiforme were 26 ± 9% and 4 ± 3% for cases in which the tumor was radically resected and less than radically resected, respectively. Conclusions. The demonstration of a survival advantage provided by radical resection should prompt neurosurgeons to treat malignant pediatric astrocytomas with aggressive surgical resection prior to initiation of radiotherapy or adjuvant chemotherapy.

Continuous somatosensory evoked potential monitoring during brain tumor resection

2002 ◽  
Vol 97 (3) ◽  
pp. 709-713 ◽  
Author(s):  
Gerald A. Grant ◽  
Donald Farrell ◽  
Daniel L. Silbergeld
Keyword(s):  
Brain Tumor ◽  
Functional Assessment ◽  
Evoked Potential ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Content Type ◽  
Case Examples ◽  
Brain Tumor Resection ◽  
Evoked Potential Monitoring ◽  
Fine Print

✓ The neurosurgical management of intrinsic brain tumors and brain metastases mandates maximum resection with preservation of functional cortex. There have been previous reports on the use of cortical somatosensory evoked potentials (SSEPs) for localization of functional cortex prior to resection. The identification of rolandic cortex with the use of intraoperative SSEP monitoring enables the neurosurgeon to tailor the surgery to achieve a greater extent of resection while minimizing the risk of morbidity. The use of continuous SSEP monitoring during resection to provide an ongoing functional assessment of somatosensory cortex has not been reported. This powerful technique is illustrated using four case examples.

Vestibular schwannoma management

1998 ◽  
Vol 89 (6) ◽  
pp. 949-955 ◽  
Author(s):  
Bruce E. Pollock ◽  
L. Dade Lunsford ◽  
Douglas Kondziolka ◽  
Raymond Sekula ◽  
Brian R. Subach ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Surgical Resection ◽  
Vestibular Schwannoma ◽  
Tumor Resection ◽  
Gamma Knife Radiosurgery ◽  
Gross Total Resection ◽  
Total Resection ◽  
Content Type ◽  
Tumor Enlargement ◽  
Fine Print

Object. The indications, operative findings, and outcomes of vestibular schwannoma microsurgery are controversial when it is performed after stereotactic radiosurgery. To address these issues, the authors reviewed the experience at two academic medical centers. Methods. During a 10-year interval, 452 patients with unilateral vestibular schwannomas underwent gamma knife radiosurgery. Thirteen patients (2.9%) underwent delayed microsurgery at a median of 27 months (range 7–72 months) after they had undergone radiosurgery. Six of the 13 patients had undergone one or more microsurgical procedures before they underwent radiosurgery. The indications for surgery were tumor enlargement with stable symptoms in five patients, tumor enlargement with new or increased symptoms in five patients, and increased symptoms without evidence of tumor growth in three patients. Gross-total resection was achieved in seven patients and near-gross-total resection in four patients. The surgery was described as more difficult than that typically performed for schwannoma in eight patients, no different in four patients, and easier in one patient. At the last follow-up evaluation, three patients had normal or near-normal facial function, three patients had moderate facial dysfunction, and seven had facial palsies. Three patients were incapable of caring for themselves, and one patient died of progression of a malignant triton tumor. Conclusions. Failed radiosurgery in cases of vestibular schwannoma was rare. No clear relationship was demonstrated between the use of radiosurgery and the subsequent ease or difficulty of delayed microsurgery. Because some patients have temporary enlargement of their tumor after radiosurgery, the need for surgical resection after radiosurgery should be reviewed with the neurosurgeon who performed the radiosurgery and should be delayed until sustained tumor growth is confirmed. A subtotal tumor resection should be considered for patients who require surgical resection of their tumor after vestibular schwannoma radiosurgery.

Meningiomas of the posterior petrous bone: functional outcome after microsurgery

2004 ◽  
Vol 100 (6) ◽  
pp. 1014-1024 ◽  
Author(s):  
Hischam Bassiouni ◽  
Anja Hunold ◽  
Siamak Asgari ◽  
Dietmar Stolke
Keyword(s):  
Mr Imaging ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Petrous Bone ◽  
Surgical Anatomy ◽  
Impaired Hearing ◽  
Imaging Data ◽  
Content Type ◽  
Hearing Function ◽  
Fine Print

Object. The aim of this study was to analyze a subgroup of patients harboring cerebellopontine angle meningiomas originating from the posterior petrous bone in regard to clinical presentation, surgical anatomy, complications, and long-term functional postoperative results. Methods. Data in a series of 51 patients with meningiomas of the posterior petrous bone who had undergone microsurgical treatment at the authors' institution between 1989 and 2002 were retrospectively reviewed. The patient population consisted of 46 women and five men with a mean age of 53 years (range 22–70 years). The main symptom on first admission was impaired hearing in 41%, dizziness in 20%, and tinnitus in 18% of the patients. Results of physical examination and audiological testing revealed hypacusis in 65% of patients, cerebellar ataxia in 31%, and impairment of the fifth cranial nerve in 26%. All patients underwent surgical treatment via a lateral suboccipital approach. Intraoperatively, the tumor was found to be attached to the postmeatal dura in 37%, the premeatal dura in 27.5%, the suprameatal dura in 19.6%, the inframeatal dura in 7.8%, and centered on the porus acusticus in 5.9% of cases. Tumor extension into the internal acoustic meatus was present in seven patients. Tumor resection was categorized as Grade I in 14 patients, Grade II in 29, Grade III in six, and Grade IV in two patients, according to the Simpson classification system. The site of displacement of the cranial nerves was predictable in up to 84% of patients, depending on the dural origin of the tumor as depicted on preoperative magnetic resonance (MR) imaging studies. Postoperatively, a new and permanent facial paresis was observed in five patients (9.8%). In 38 patients in whom both pre- and postoperative audiological data were available, hearing function deteriorated after surgery in 18.4% and improved in 7.9%. Clinical and MR imaging postsurgical data from a mean period of 5.8 years (range 13 months–13 years) were available in all patients. Forty-four patients (86%) resumed normal daily activity. Tumor recurrence was observed in two patients (3.9%), and both underwent a second surgery. Conclusions. Preoperative detailed analysis of MR imaging data gives the surgeon a clue about the dislocation of critical neurovascular structures, particularly the cranial nerves. Nonetheless, the exact relationship of the cranial nerves to the tumor (dislocation, adherence, infiltration, and splaying of nerves) can only be fully appreciated during surgery.

Neurocognitive efficiency following left temporal lobectomy: standard versus limited resection

1993 ◽  
Vol 79 (1) ◽  
pp. 76-83 ◽  
Author(s):  
Ronald L. Wolf ◽  
Robert J. Ivnik ◽  
Kathryn A. Hirschorn ◽  
Frank W. Sharbrough ◽  
Gregory D. Cascino ◽  
...  
Keyword(s):  
Extent Of Resection ◽  
Cognitive Change ◽  
Cognitive Outcome ◽  
Temporal Lobectomy ◽  
Seizure Onset ◽  
Content Type ◽  
Lateral Cortex ◽  
Intractable Seizures ◽  
Temporal Structures ◽  
Fine Print

✓ Decreased memory and learning efficiency may follow left temporal lobectomy. Debate exists as to whether the acquired deficit is related to the size of the surgical resection. This study addresses this question by comparing changes in cognitive performance to the extent of resection of both mesial temporal structures and lateral cortex. The authors retrospectively reviewed 47 right-handed patients who underwent left temporal lobectomy for medically intractable seizures. To examine the effects of the extent of mesial resection, the patients were divided into two groups: those with resection at the anterior 1 to 2 cm of mesial structures versus those with resection greater than 2 cm. To examine the effects of the extent of lateral cortical resection, patients were again divided into two groups: those with lateral cortex resections of 4 cm or less versus those with resections greater than 4 cm. Statistical analyses showed no difference in cognitive outcome between the groups defined by the extent of mesial resection. Likewise, no difference in cognitive outcome was seen between the groups defined by the extent of lateral cortical resection. Associated data analyses did, however, reveal a negative correlation of cognitive change with patient age at seizure onset. These results showed that the neurocognitive consequences of extended mesial resections were similar to those of limited mesial resections, and that the neurocognitive consequences of extended lateral cortical resections were similar to those of limited lateral cortical resections. The risk of cognitive impairment depends more on age at seizure onset than on the extent of mesial or lateral resection.

scholarly journals Intraoperative infrared imaging of brain tumors

2004 ◽  
Vol 101 (6) ◽  
pp. 960-969 ◽  
Author(s):  
Alexander M. Gorbach ◽  
John D. Heiss ◽  
Leonid Kopylev ◽  
Edward H. Oldfield
Keyword(s):  
Blood Flow ◽  
Brain Tumor ◽  
Brain Tumors ◽  
Infrared Imaging ◽  
Tumor Resection ◽  
Temperature Gradients ◽  
Temporal Lobectomy ◽  
Neurological Deficits ◽  
Content Type ◽  
Fine Print

Object. Although clinical imaging defines the anatomical relationship between a brain tumor and the surrounding brain and neurological deficits indicate the neurophysiological consequences of the tumor, the effect of a brain tumor on vascular physiology is less clear. Methods. An infrared camera was used to measure the temperature of the cortical surface before, during, and after removal of a mass in 34 patients (primary brain tumor in 21 patients, brain metastases in 10 and falx meningioma, cavernous angioma, and radiation necrosis—astrocytosis in one patient each). To establish the magnitude of the effect on blood flow induced by the tumor, the images were compared with those from a group of six patients who underwent temporal lobectomy for epilepsy. In four cases a cerebral artery was temporarily occluded during the course of the surgery and infrared emissions from the cortex before and after occlusion were compared to establish the relationship of local temperature to regional blood flow. Discrete temperature gradients were associated with surgically verified lesions in all cases. Depending on the type of tumor, the cortex overlying the tumor was either colder or warmer than the surrounding cortex. Spatial reorganization of thermal gradients was observed after tumor resection. Temperature gradients of the cortex in patients with tumors exceeded those measured in the cortex of patients who underwent epilepsy surgery. Conclusions. Brain tumors induce changes in cerebral blood flow (CBF) in the cortex, which can be made visible by performing infrared imaging during cranial surgery. A reduction in CBF beyond the tumor margin improves after removal of the lesion.

A multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival

2001 ◽  
Vol 95 (2) ◽  
pp. 190-198 ◽  
Author(s):  
Michel Lacroix ◽  
Dima Abi-Said ◽  
Daryl R. Fourney ◽  
Ziya L. Gokaslan ◽  
Weiming Shi ◽  
...  
Keyword(s):  
Glioblastoma Multiforme ◽  
Mr Imaging ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Karnofsky Performance Scale ◽  
Content Type ◽  
Predictive Variables ◽  
Significant Survival ◽  
Performance Scale ◽  
Fine Print

Object. The extent of tumor resection that should be undertaken in patients with glioblastoma multiforme (GBM) remains controversial. The purpose of this study was to identify significant independent predictors of survival in these patients and to determine whether the extent of resection was associated with increased survival time. Methods. The authors retrospectively analyzed 416 consecutive patients with histologically proven GBM who underwent tumor resection at the authors' institution between June 1993 and June 1999. Volumetric data and other tumor characteristics identified on magnetic resonance (MR) imaging were collected prospectively. Conclusions. Five independent predictors of survival were identified: age, Karnofsky Performance Scale (KPS) score, extent of resection, and the degree of necrosis and enhancement on preoperative MR imaging studies. A significant survival advantage was associated with resection of 98% or more of the tumor volume (median survival 13 months, 95% confidence interval [CI] 11.4–14.6 months), compared with 8.8 months (95% CI 7.4–10.2 months; p < 0.0001) for resections of less than 98%. Using an outcome scale ranging from 0 to 5 based on age, KPS score, and tumor necrosis on MR imaging, we observed significantly longer survival in patients with lower scores (1–3) who underwent aggressive resections, and a trend toward slightly longer survival was found in patients with higher scores (4–5). Gross-total tumor resection is associated with longer survival in patients with GBM, especially when other predictive variables are favorable.

Monstrous, crablike hypertrophy of the cerebellar vermis and its relationship with Lhermitte—Duclos disease

1996 ◽  
Vol 85 (1) ◽  
pp. 157-162 ◽  
Author(s):  
Guillermo A. de León ◽  
John A. Grant ◽  
Crystal F. Darling
Keyword(s):  
Surgical Resection ◽  
Basic Structure ◽  
Cerebellar Vermis ◽  
Biological Behavior ◽  
Content Type ◽  
Neuroepithelial Cells ◽  
Poorly Differentiated ◽  
New Interpretation ◽  
Fine Print

✓ The case of an infant with a peculiar tumorous malformation of the cerebellum is described. The tumor apparently developed as an exophytic, hypertrophic sprout of the inferior vermis. It had a monstrous appearance resembling a crab, with a metameric body and multiple pairs of limbs attached to the folia of both cerebellar hemispheres. Histologically, the lesion was formed by poorly differentiated neuroepithelial cells without any evidence of organization into nuclei, cortex, or fascicles. Clinically, the tumor behaved in an indolent manner and did not regrow after subtotal surgical resection. Because of its gross appearance and its biological behavior, this unusual hamartoblastomatous growth is readily distinguished from medulloblastoma. The morphology of the cerebellum in Lhermitte—Duclos disease is reviewed, and a new interpretation of its basic structure is proposed. This and other known types of cerebellar hypertrophy are different from the malformation in the present case.

A proposed grading system for arteriovenous malformations

1986 ◽  
Vol 65 (4) ◽  
pp. 476-483 ◽  
Author(s):  
Robert F. Spetzler ◽  
Neil A. Martin
Keyword(s):  
Venous Drainage ◽  
Neurological Complications ◽  
Management Decision ◽  
Grading System ◽  
Content Type ◽  
Treatment Techniques ◽  
Clinical Series ◽  
Management Decision Making ◽  
Eloquent Cortex ◽  
Fine Print

✓ An important factor in making a recommendation for treatment of a patient with arteriovenous malformation (AVM) is to estimate the risk of surgery for that patient. A simple, broadly applicable grading system that is designed to predict the risk of morbidity and mortality attending the operative treatment of specific AVM's is proposed. The lesion is graded on the basis of size, pattern of venous drainage, and neurological eloquence of adjacent brain. All AVM's fall into one of six grades. Grade I malformations are small, superficial, and located in non-eloquent cortex; Grade V lesions are large, deep, and situated in neurologically critical areas; and Grade VI lesions are essentially inoperable AVM's. Retrospective application of this grading scheme to a series of surgically excised AVM's has demonstrated its correlation with the incidence of postoperative neurological complications. The application of a standardized grading scheme will enable a comparison of results between various clinical series and between different treatment techniques, and will assist in the process of management decision-making.

Intraoperative angiography in the resection of arteriovenous malformations

1994 ◽  
Vol 80 (1) ◽  
pp. 73-78 ◽  
Author(s):  
Shigetaka Anegawa ◽  
Takashi Hayashi ◽  
Ryuichiro Torigoe ◽  
Katsuhiko Harada ◽  
Shun-ichi Kihara
Keyword(s):  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Three Dimensional ◽  
Initial Operation ◽  
Total Resection ◽  
Intraoperative Angiography ◽  
Content Type ◽  
Fine Print

✓ Surgical resection of 13 operatively obscure arteriovenous malformations (AVM's) was accomplished with the assistance of intraoperative angiography, which was performed stereographically to provide three-dimensional orientation and was repeated until total resection of the AVM was confirmed. All films obtained were subtracted to improve clarity. The method presented here may be useful for the resection of all types of AVM. Only two patients had residual AVM after the initial operation. No complications attributable to angiography were noted.

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