The purpose of this ongoing study is to compare the safety and efficacy of microsurgical clipping and endovascular coil embolization for the treatment of acutely ruptured cerebral aneurysms and to determine if one treatment is superior to the other by examining clinical and angiographic outcomes. The authors examined the null hypothesis that no difference exists between the 2 treatment modalities in the setting of subarachnoid hemorrhage (SAH). The current report is limited to the clinical results at 1 year after treatment.
The authors screened 725 patients with SAH, resulting in 500 eligible patients who were enrolled prospectively in the study after giving their informed consent. Patients were assigned in an alternating fashion to surgical aneurysm clipping or endovascular coil therapy. Intake evaluations and outcome measurements were collected by nurse practitioners independent of the treating surgeons. Ultimately, 238 patients were assigned to aneurysm clipping and 233 to coil embolization. The 2 treatment groups were well matched. There were no anatomical exclusions. Crossing over was allowed, but primary outcome analysis was based on the initial treatment modality assignment. Posttreatment care was standardized for both groups. Patient outcomes at 1 year were independently assessed using the modified Rankin Scale (mRS). A poor outcome was defined as an mRS score > 2 at 1 year. The primary outcome was based on the assigned group; that is, by intent to treat.
One year after treatment, 403 patients were available for evaluation. Of these, 358 patients had actually undergone treatment. The remainder either died before treatment or had no identifiable source of SAH. A poor outcome (mRS score > 2) was observed in 33.7% of the patients assigned to aneurysm clipping and in 23.2% of the patients assigned to coil embolization (OR 1.68, 95% CI 1.08-2.61; p = 0.02). Of treated patients assigned to the coil group, 124 (62.3%) of the 199 who were eligible for any treatment actually received endovascular coil embolization. Patients who crossed over from coil to clip treatment fared worse than patients assigned to coil embolization, but no worse than patients assigned to clip occlusion. No patient treated by coil embolization suffered a recurrent hemorrhage.
One year after treatment, a policy of intent to treat favoring coil embolization resulted in fewer poor outcomes than clip occlusion. Although most aneurysms assigned to the coil treatment group were treated by coil embolization, a substantial number crossed over to surgical clipping. Although a policy of intent to treat favoring coil embolization resulted in fewer poor outcomes at 1 year, it remains important that high-quality surgical clipping be available as an alternative treatment modality.
Endovascular treatment of a carotid cavernous fistula (CCF) via a transvenous approach is standard but, in rare cases, the standard approach is not feasible due to vessel occlusion or anomalies. In such cases it remains a challenge to find an alternative route for complete treatment.
A 42-year-old patient presented with a symptomatic CCF (Barrow type C). An endovascular approach to the CCF was not possible due to abnormal venous vessel architecture, so a combined surgical and interventional approach was undertaken. A custom-tailored craniotomy was first performed to access the major sylvian vein. After venotomy and insertion of a microcatheter, the CCF was completely occluded by coiling and embolization conventionally. The symptoms regressed and had almost completely disappeared at follow-up.
An individually tailored strategy with a combined surgical and endovascular approach enabled full treatment with minimal risk for the patient.
There is a subgroup of patients with Barrow Type D carotid-cavernous sinus fistulas (CCFs) who have progressive neurological deficits despite endovascular attempts at obliteration. To effectively arrest the progression of neurological deficits, especially visual loss, these patients require direct operative intervention. We have used a direct approach to such lesions, which comprehensively occludes all fistulous connections of the CCF.
We present a series of nine patients with Type D CCFs for which attempts at endovascular embolization failed and that, because of persistent symptoms, required surgical intervention. These lesions characteristically had extensive multiple external carotid artery feeders, often bilateral, in addition to the internal carotid artery feeders. The operative approach used was a combined extra- and intradural full exposure of the cavernous sinus and its contents, with identification and direct obliteration of all arterial input and selective ablation of the venous outflow from the cavernous sinus.
All nine patients experienced resolution of their symptoms, and complete ablation of the lesions, as demonstrated by postoperative angiography, was achieved. Transient diplopia and trigeminal hypesthesia was observed in all nine patients, which resolved by 6 months postoperatively. One patient suffered from a temporary hemiparesis and another from permanent hemiparesis. There were no deaths related to surgery in this series.
Patients with Type D CCFs who have persistent, progressive neurological deficits after failed endovascular attempts at obliteration may be treated by a direct surgical approach to ablate the fistulas. The pertinent anatomic concepts, indications for surgery, and operative techniques that are different from previously described methods are discussed.
We report 19 tibial fractures Types III B and C treated by free flaps. The fracture healed in 16 cases after 12 (3-54) months. In 3 cases a secondary amputation was carried out. Tibial malalignment or substantial shortening ensued in 1 case each. We conclude that coverage with free flaps, radical removal of dead bone, stable external fixation and transfer of vascularized bone may salvage the majority of Type III B and C tibial fracture with function superior to that after amputation.
Although craniofacial approaches to the midline skull base have been defined and surgical results have been published, clear descriptions of these complex approaches in a step-wise manner are lacking. The objective of this study is to demonstrate the surgical technique of craniofacial approaches based on Barrow classification (Levels I-III) and to study the microsurgical anatomy pertinent to these complex craniofacial approaches.
Ten adult cadaveric heads perfused with colored silicone and 24 dry human skulls were used to study the microsurgical anatomy and to demonstrate craniofacial approaches in a step-wise manner. In addition to cadaveric studies, case illustrations of anterior skull base meningiomas were presented to demonstrate the clinical application of the first 3 (Levels I-III) approaches.
Cadaveric head dissection was performed in 10 heads using craniofacial approaches. Ethmoid and sphenoid sinuses, cribriform plate, orbit, planum sphenoidale, clivus, sellar, and parasellar regions were shown at Levels I, II, and III. In 24 human dry skulls (48 sides), a supraorbital notch (85.4%) was observed more frequently than the supraorbital foramen (14.6%). The mean distance between the supraorbital foramen notch to the midline was 21.9 mm on the right side and 21.8 mm on the left. By accepting the middle point of the nasofrontal suture as a landmark, the mean distances to the anterior ethmoidal foramen from the middle point of this suture were 32 mm on the right side and 34 mm on the left. The mean distance between the anterior and posterior ethmoidal foramina was 12.3 mm on both sides; the mean distance between the posterior ethmoidal foramen and distal opening of the optic canal was 7.1 mm on the right side and 7.3 mm on the left.
Barrow classification is a simple and stepwise system to better understand the surgical anatomy and refine the techniques in performing these complex craniofacial approaches. On the other hand, thorough anatomical knowledge of the midline skull base and variations of the neurovascular structures is crucial to perform successful craniofacial approaches.
Dural arteriovenous fistulas (DAVFs) are complex disorders, some of them with aggressive clinical behaviour. During past decades their treatment strategy has changed due to increased knowledge of their pathophysiology and natural history, and advances in treatment modalities. In asymptomatic cases or cases with mild symptoms in the absence of cortical venous drainage (CVD) no treatment is necessarily required, whereas aggressive DAVFs should be treated promptly by endovascular or microsurgical means.In our series of 323 patients with 333 fistulas, treated in two neurosurgical units in Finland since 1944, there were 265 true DAVFs and 68 Barrow type A caroticocavernous fistulas. Among the DAVFs there was a slight female predominance, 140 women (55%) and 115 men (45%), and the majority of the cases were located in the area of transverse and sigmoid sinuses. Mode of treatment in the early series was proximal ligation of feeding artery, and later craniotomy, endovascular treatment and radiosurgery, or combination of these treatments, with total occlusion rate being 53%.
Cerebral vascular malformations remain among the most difficult neurosurgical entities to treat. We report a retrospective study of the outcome in 95 consecutive patients with angiographically revealed arteriovenous malformations (AVMs). Fifty-four patients underwent microsurgical total AVM removal (group I). Forty-one patients who refused open surgery (group II) were managed either by endovascular embolisation (16 cases), radiosurgery (three) or followed up with medical treatment for their symptoms. In the first group pretreatment with the non-selective beta-blocker propranolol before surgery, the current neuronavigation techniques, intraoperative embolisation and AVM nidus colouring in high flow AVM were used for total microsurgical excision of the lesions. All AVM patients but one survived microsurgery. The mortality rate was 1.8% for group I. Six patients with grade IV-V AVM developed new temporal neurological symptoms following surgery. Four of them recovered completely in 3-6 weeks; two patients remained with mild persistent monoparesis and with homonymous hemianopsia postoperatively. In ten of 13 epileptic patients surgery produced a cure. No patient re-bled following surgery. No postoperative normal perfusion pressure breakthrough occurred. In the second group ten patients (24%) developed intracerebral haemorrhages, six of ten patients demonstrated progressive seizures. The mortality rate in group II totalled 17% over 6 years. Microsurgical management approaches must consider preoperative correction of impaired cerebral autoregulation, neuronavigation for preoperative planning and intraoperative orientation, intraoperative embolisation and dying of the nidus for large high-flow AVMs.
Lesions of the pineal region are histopathologically heterogeneous but often accompanied with severe progression of clinical signs. Surgical treatment remains challenging because of the close vicinity of the deep venous system and the mesencephalo-diencephalic structures in this region. We present the surgical approaches and techniques in a consecutive series of 119 patients treated by the senior author (J.H.) between 1980 and 2007 at 2 different neurosurgical university centers in Kuopio and Helsinki, Finland.
Of the included patients, 107 (90%) presented with pineal region tumors and 12 (10%) with vascular malformations. The ITSC route was used for removal of the lesion in 111 (93%) patients and the OIH approach in 8 (7%) patients. All except one patient were operated on in a sitting position.
We reviewed all clinical data and radiographic images and analyzed all surgical videos. The pineal lesions were removed completely in most cases (88%). There was no surgical mortality. Twenty-two (18%) of the patients had complications in the postoperative period; these included 1 epidural hematoma, 9 transient Parinaud syndrome, 2 meningitis, 3 wound infections, 2 transient memory disturbances, 2 mild hemiparesis, 1 CSF fistula, and 2 cranial nerves palsies (IV and VI). During a 3.5-year follow-up, 12 patients with malignant lesions died; all patients with benign tumors survived.
The ITSC route is a safe and effective surgical approach, associated with low morbidity, complete lesion removal, and definitive histopathologic diagnosis. Considering risk vs benefit, we therefore believe that the surgical treatment can be offered in most cases as the first treatment option for pineal tumors.
[Microsurgical vascular anastomosis between the superficial temporary artery and branches of the median cerebral artery. A preliminary evaluation of the results and operative technic from Danish material].