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Emanuela Keller, Thorsten Steiner, Javier Fandino, Stefan Schwab and Werner Hacke

Object

Moderate hypothermia has been reported to be effective in the treatment of postischemic brain edema. The effect of hypothermia on cerebral hemodynamics is a matter of controversial discussion in literature. Clinical studies have yet to be performed in patients with ischemic stroke after induction of hypothermia.

Methods

Measurements during mild hypothermia (33–34°C) were made in six patients with severe ischemic stroke involving the middle cerebral artery territory. Hypothermia was induced as soon as possible and maintained for 48 to 72 hours. Cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) were estimated by a new double-indicator dilution method. Measurements of CBF were made during normothermia, immediately after induction of hypothermia, at the end of hypothermia, and after rewarming. A total of 19 measurements of CBF and jugular bulb O2 saturation were made. Immediately after induction of hypothermia, CBF decreased in all patients. During late hypothermia, CBF improved in patients who survived but remained diminished in the two patients who died. Reduced CMRO2 levels were observed during all phases of hypothermia in all but one case.

Conclusions

Preliminary oberservations indicate that moderate hypothermia seems to reduce CMRO2 Immediately after induction of hypothermia, CBF may decrease in all patients. During late hypothermia CBF seems to recover in patients with good outcome but remains diminished in patients who die. Serial bedside CBF measurements with the new double-indicator dilution technique may be useful to describe cerebral hemodynamic characteristics in patients with severe ischemic stroke during hypothermia.

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Javier Fandino, Yasuhiko Kaku, Bernhard Schuknecht, Anton Valavanis and Yasuhiro Yonekawa

Object. The purpose of the present study was to assess cerebral oxygenation patterns and brain lactate concentration changes before, during, and after intraarterial infusion of papaverine with or without balloon angioplasty in patients with symptomatic vasospasm.

Methods. A total of 23 vascular territories were successfully treated in 10 patients. In three patients balloon angioplasty was performed before the papaverine infusion. Continuous monitoring of jugular bulb vein oxygen saturation with a fiberoptic catheter and blood sampling allowed the assessment of the cerebral arteriovenous oxygen and lactate differences. A significant and rapid improvement in jugular bulb oxygen saturation was observed in all cases, with critical values reflecting an improvement in cerebral oxygenation after endovascular treatment of vasospasm (p = 0.005). Lactate concentration in the jugular bulb normalized within 4 hours in all patients who had evidence of brain lactic acidosis before superselective intraarterial infusion of papaverine. Recurrence of abnormal metabolic and oxygenation patterns were observed in one case in which an optimal hypertension and hypervolemic therapy could not be achieved after the procedure.

Conclusions. Improvement in cerebral oxygenation as well as prevention of cerebral lactic acidosis can be successfully achieved after intraarterial infusion of papaverine. Normalization of the oxygen supply after endovascular treatment has to be supported by optimal and well-monitored hypertension and hypervolemic hemodilution.

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Alexander Spiessberger, Deborah R. Vogt, Javier Fandino and Serge Marbacher

OBJECTIVE

Incidence rates of de novo aneurysm formation and recurrence after clip ligation remain controversial. In this meta-analysis, the authors provide data on pooled annual incidence rates and the association of patient characteristics with time to formation of de novo aneurysms and time to recurrence after clipping.

METHODS

A search of the literature up to June 15, 2016, on PubMed and a systematic review were performed. The association of age, aneurysm rupture status, aneurysm multiplicity, and anatomical location with time to recurrence or formation of de novo aneurysm was estimated using multivariable Cox proportional-hazards models. Kaplan-Meier estimates (event-free survival curves) are shown. Pooled annualized incidence rates of recurrent and de novo aneurysms were estimated using Poisson regression. Proportions of aneurysms and average follow-up times are displayed as bubble plots with LOESS smoothers weighted for study size.

RESULTS

Of the 7606 articles screened, 92 were included in the study. Case reports on 101 patients with recurrent aneurysms and 132 patients with de novo aneurysms were analyzed. Long-term follow-up studies on de novo aneurysm formation included 13,723 patients with 101,378 patient-years of follow-up; studies on aneurysm recurrence included 5922 patients with 31,055 patient-years of follow-up. Mean time to recurrence was 12.9 ± 6.6 years (mean ± standard deviation), and mean time to de novo formation was 9.3 ± 6.1 years. No association with sex, aneurysm location, and initial rupture could be shown. De novo aneurysms occurred later in patients with multiplicity of aneurysms at diagnosis (HR 0.63, p = 0.03) and in patients with increasing age (HR per 10 yrs 0.88, p = 0.06). Pooled annualized incidence rates were 0.35% for de novo aneurysms and 0.13% for recurrent aneurysms.

CONCLUSIONS

Despite low reported annual incidence rates, the cumulative risk of 9.6%–22% for aneurysm recurrence or de novo formation 20 years after clip ligation warrants lifelong follow-up. Screening at 5, 10, and 20 years would detect 30.8% (95% CI 23.3%–37.6%), 64.2% (95% CI 55.9%–70.9%), and 95.9% (95% CI 90.9%–97.9%) of de novo aneurysms. Screening for recurrent aneurysms at 10, 15, and 20 years would detect 36.6% (95% CI 26.5%–45.4%), 65.3% (95% CI 54.7%–73.5%), and 95.1% (95% CI 85.8%–96.6%) of lesions.

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Sven Berkmann, Javier Fandino, Sascha Zosso, Hanspeter E. Killer, Luca Remonda and Hans Landolt

Object

Sellar lesions with suprasellar extension may cause loss of visual acuity and visual field damage due to compression of the optic chiasm. Using intraoperative MR (iMR) imaging to detect symptomatic lesion remnants adjacent to the optic chiasm (that may be resected in the same procedure) may positively affect the functional outcome of patients with these lesions. The aim of this study was to evaluate the correlation between visual improvement and optic nerve decompression detected by iMR imaging in patients undergoing transsphenoidal resection of pituitary lesions.

Methods

A total of 32 patients (23 men and 9 women) who underwent transsphenoidal resection of sellar lesions causing visual impairment were included in this study. Tumor volume ranged from 0.9 cm3 to 55.7 cm3 (mean 9.8 ± 11.7 cm3). Preoperative assessment showed visual field damage in 31 patients (97%) and loss of visual acuity in 28 patients (88%). The latency period between the appearance of symptoms and transsphenoidal decompression was 14.9 ± 19.5 weeks.

Results

Intraoperative MR imaging was performed after the resection was believed to be complete, or if further tumor removal was not safely possible due to changed conditions in the surgical field. Complete resection was detected on these initial scans in 17 patients (53%). Partial resection was achieved in 9 patients (28%) and tumor debulking in 6 (19%). Additional resection was possible in 8 (53%) of these 15 patients. Four (50%) of these 8 cases had suprasellar remnants and the optic chiasm was subsequently decompressed. In 5 cases optimal decompression of the optic chiasm was not possible. On early follow-up within 1 month after surgery, overall improvement of visual field damage was observed in 27 patients (87%). In 23 patients (74%), the Goldmann perimetry demonstrated complete recovery. Improvement of visual acuity was noted in 24 patients (86%). Eighteen patients (64%) regained full visual acuity. Identification of a decompressed optic chiasm on iMR imaging was significantly correlated with visual field improvement (p = 0.0007; positive predictive value 0.96, 95% CI 0.81–0.99) and relief of visual acuity deficits (p = 0.0002; positive predictive value 0.96, 95% CI 0.79–0.99). Two patients needed transcranial procedures for symptomatic tumor remnants detected on iMR imaging.

Conclusions

Intraoperative MR imaging findings correlate with prognosis of visual deficits after transsphenoidal decompression of the anterior optic pathways. The use of iMR imaging may prevent revision surgery for unexpected symptomatic remnants.

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Robert H. Andres, Thilo Graupner, Christian B. Bärlocher, Arthur Augsburger and Javier Fandino

The authors describe a modification of the medial branch kryorhizotomy technique for the treatment of lumbar facet joint syndrome using a fluoroscopy-based laser-guided method. A total of 32 patients suffering from lumbar facet joint syndrome confirmed by positive medial nerve block underwent conventional or laser-guided kryorhizotomy. The procedural time (20.6 ± 1.0 vs 16.3 ± 0.9 minutes, p < 0.01), fluoroscopy time (54.1 ± 3.5 vs 28.2 ± 2.4 seconds, p < 0.01), radiation dose (407.5 ± 32.0 vs 224.1 ± 20.3 cGy/cm2, p < 0.01), and patient discomfort during the procedure (7.1 ± 0.4 vs 5.2 ± 0.4 on the visual analog scale, p < 0.01) were significantly reduced in the laser-guided group. There was a tendency for a better positioning accuracy when the laser guidance method was used (3.0 ± 0.3 vs 2.2 ± 0.3 mm of deviation from the target points, p > 0.05). No difference in the outcome was observed between the 2 groups of patients (visual analog scale score 3.5 ± 0.2 vs 3.3 ± 0.3, p > 0.05). This improved minimally invasive surgical technique offers advantages to conventional fluoroscopy-based kryorhizotomy.

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REVIEWER COMMENTS

Intraoperative validation of functional magnetic resonance imaging and cortical reorganization patterns in patients with brain tumors involving the primary motor cortex

Javier Fandino, Spyros S. Kollias, Heinz Gregor Wieser, Anton Valavanis and Yasuhiro Yonekawa

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Javier Fandino, Spyros S. Kollias, Heinz G. Wieser, Anton Valavanis and Yasuhiro Yonekawa

Object. The purpose of the present study was to compare the results of functional magnetic resonance (fMR) imaging with those of intraoperative cortical stimulation in patients who harbored tumors close to or involving the primary motor area and to assess the usefulness of fMR imaging in the objective evaluation of motor function as part of the surgical strategy in the treatment of these patients.

Methods. A total of 11 consecutive patients, whose tumors were close to or involving the central region, underwent presurgical blood oxygen level—dependent fMR imaging while performing a motor paradigm that required them to clench and spread their hands contra- and ipsilateral to the tumor. Statistical cross-correlation functional maps covering the primary and secondary motor cortical areas were generated and overlaid onto high-resolution anatomical MR images. Intraoperative electrical cortical stimulation was performed to validate the presurgical fMR imaging findings. In nine (82%) of 11 patients, the anatomical fMR imaging localization of motor areas could be verified by intraoperative electrical cortical stimulation. In seven patients two or more activation sites were demonstrated on fMR imaging, which were considered a consequence of reorganization phenomena of the motor cortex: contralateral primary motor area (nine patients), contralateral premotor area (four patients), ipsilateral primary motor area (two patients), and ipsilateral premotor area (four patients).

Conclusions. Functional MR imaging can be used to perform objective evaluation of motor function and surgical planning in patients who harbor lesions near or involving the primary motor cortex. Correlation between fMR imaging findings and the results of direct electrical brain stimulation is high, although not 100%. Based on their study, the authors believe that cortical reorganization patterns of motor areas might explain the differences in motor function and the diversity of postoperative motor function among patients with central tumors.

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Javier Fandino, Adrian M. Siegel, R. Hubert Laeng and M. Gazi Yaºargil

The authors describe a patient who survived 26 years after resection of a right temporal glioblastoma multiforme (GBM) without signs of tumor recurrence. Preoperative emergency angiography demonstrated a hypovascular mass localized in the right temporal lobe with right-to-left shift of the vascular structures. At surgery, the tumor had cystic and solid components localized in the lateral occipitotemporal gyrus, reaching the posterolateral wall of the inferior horn of the right lateral ventricle and extending to the trigone and posterior horn. The initial pathological diagnosis of a GBM was reviewed and confirmed throughout the follow-up period. Twenty-six years after surgery and subsequent radiosurgery, the patient underwent resection of a medulloblastoma localized in the right cerebellum as well as stereotactic biopsy sampling of tissue at the original GBM site. Neither radiological nor histological evidence of recurrence of the GBM could be documented. The intraoperative, histological, and radiological findings are described.

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Javier Fandino, Spyros S. Kollias, Heinz Gregor Wieser, Anton Valavanis and Yasuhiro Yonekawa

The purpose of the present study was to compare the results of functional magnetic resonance (fMR) imaging with those of intraoperative cortical stimulation in patients who harbored tumors close to or involving the primary motor area and to assess the usefulness of fMR imaging in the objective evaluation of motor function as part of the surgical strategy in the treatment of these patients.

A total of 11 consecutive patients, whose tumors were near to or involving the central region, underwent presurgical blood oxygen level-dependent fMR imaging while performing a motor paradigm that required the patients to clench and spread their hands contra- and ipsilateral to the tumor. Statistical cross-correlation functional maps covering the primary and secondary motor cortical areas were generated and overlaid onto high-resolution anatomical MR images. Intraoperative electrical cortical stimulation was performed to validate the presurgical fMR imaging findings. In nine (82%) of 11 patients, the anatomical fMR imaging localization of motor areas could be verified by intraoperative electrical cortical stimulation. In seven patients two or more activation sites were demonstrated on fMR imaging, which were considered a consequence of reorganization phenomena of the motor cortex: contralateral primary motor area (nine sites), contralateral premotor area (four sites), ipsilateral primary motor area (two sites), and ipsilateral premotor area (four sites).

Functional MR imaging can be used to perform objective evaluation of motor function and surgical planning in patients who harbor lesions near or involving the primary motor cortex. Correlation between fMR imaging findings and the results of direct electrical brain stimulation is high, although not 100%. Based on their study, the authors believe that cortical reorganization patterns of motor areas might explain the differences in motor function and the diversity of postoperative motor function among patients with central tumors.