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Lorenz Ertl, Hartmut Brückmann, Mathias Kunz, Alexander Crispin, and Gunther Fesl

OBJECTIVE

Sinus-preserving (SP) embolization techniques augment endovascular treatment options for intracranial lateral dural arteriovenous fistulas (DAVFs). The authors aimed to perform a retrospective comparison of their primary success rates, complication rates, and long-term follow-up with those of sinus-occluding (SO) treatment variants in the collective of low- and intermediate-grade lateral DAVFs (Cognard Types I–IIb).

METHODS

Clinical symptoms, complication rates, and Cognard grading prior to and after endovascular DAVF treatment using different technical approaches was retrospectively analyzed in 36 patients with lateral DAVF Cognard Types I–IIb. The long-term success rate was determined by a standardized questionnaire.

RESULTS

The SO approaches offered a higher rate of definitive fistula occlusion (93% SO vs 71% SP) but were accompanied by a significantly higher complication rate (33% or 20% SO vs 0% SP). The patients interviewed reported very high satisfaction with their health in long-term follow-up in both groups.

CONCLUSIONS

A higher rate of definitive fistula occlusion in the SO group was attained at the price of a significantly higher complication rate. The SP approaches offered a good primary success rate in combination with a very low complication rate. Despite some limitations of the data (e.g., a small sample size) the authors thus recommend an SP variant as the primary therapeutic option for the endovascular treatment of low- and intermediate-grade DAVFs. The SO approaches should be restricted to cases in which SP treatment does not achieve a downgrading to no worse than Cognard Type IIa.

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Mathias Kunz, Philipp Karschnia, Ingo Borggraefe, Soheyl Noachtar, Joerg-Christian Tonn, and Christian Vollmar

OBJECTIVE

Reoperation may be an option for select patients with unsatisfactory seizure control after their first epilepsy surgery. The aim of this study was to describe the seizure-free outcome and safety of repeated epilepsy surgery in our tertiary referral center.

METHODS

Thirty-eight patients with focal refractory epilepsy, who underwent repeated epilepsy surgeries and had a minimum follow-up time of 12 months after reoperation, were included. Systematic reevaluation, including comprehensive neuroimaging and noninvasive (n = 38) and invasive (n = 25, 66%) video-electroencephalography monitoring, was performed. Multimodal 3D resection maps were created for individual patients to allow personalized reoperation.

RESULTS

The median time between the first operation and reoperation was 74 months (range 5–324 months). The median age at reoperation was 34 years (range 1–74 years), and the median follow-up was 38 months (range 13–142 months). Repeat MRI after the first epilepsy surgery showed an epileptogenic lesion in 24 patients (63%). The reoperation was temporal in 18 patients (47%), extratemporal in 9 (24%), and multilobar in 11 (29%). The reoperation was left hemispheric in 24 patients (63%), close to eloquent cortex in 19 (50%), and distant from the initial resection in 8 (21%). Following reoperation, 27 patients (71%) became seizure free (Engel class I), while 11 (29%) continued to have seizures. There were trends toward better outcome in temporal lobe epilepsy and for unilobar resections adjacent to the initial surgery, but there was no difference between MRI lesional and nonlesional patients. In all subgroups, Engel class I outcome was at least 50%. Perioperative complications occurred in 4 patients (11%), with no fatalities.

CONCLUSIONS

Reoperation for refractory focal epilepsy is an effective and safe option in patients with persistent or recurrent seizures after initial epilepsy surgery. A thorough presurgical reevaluation is essential for favorable outcome.

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Nicole A. Terpolilli, Walter Rachinger, Mathias Kunz, Niklas Thon, Wilhelm H. Flatz, Jörg-Christian Tonn, and Christian Schichor

OBJECT

Treatment of skull base lesions is complex and usually requires a multidisciplinary approach. In meningioma, which is the most common tumor entity in this region, resection is considered to be the most important therapeutic step to avoid tumor recurrence. However, resection of skull base lesions with orbital or optic nerve involvement poses a challenge due to their anatomical structure and their proximity to eloquent areas. Therefore the main goal of surgery should be to achieve the maximum extent of resection while preserving neurological function. In the postoperative course, medical and radiotherapeutic strategies may then be successfully used to treat possible tumor residues. Methods to safely improve the extent of resection in skull base lesions therefore are desirable. The current study reports the authors’ experience with the use of intraoperative CT (iCT) combined with neuronavigation with regard to feasibility and possible benefits of the method.

METHODS

Those patients with tumorous lesions in relationship to the orbit, sphenoid wing, or cavernous sinus who were surgically treated between October 2008 and December 2013 using iCT-based neuronavigation and in whom an intraoperative scan was obtained for control of resection were included. In all cases a second iCT scan was performed under sterile conditions after completion of navigation-guided microsurgical tumor resection. The surgical strategy was adapted accordingly; if necessary, resection was continued.

RESULTS

Twenty-three patients (19 with WHO Grade I meningioma and 4 with other lesions) were included. The most common clinical symptoms were loss of visual acuity and exophthalmus. Intraoperative control of resection by iCT was successfully obtained in all cases. Intraoperative imaging changed the surgical approach in more than half (52.2%) of these patients, either because iCT demonstrated unexpected residual tumor masses or because the second scan revealed additional tumor tissue that was not detected in the first scan due to overlay by osseous tumor parts; in these cases resection was continued. In the remaining cases resection was concluded as planned because iCT verified the surgeon’s microscopic estimation of tumor resection status. Postoperative visual outcome was favorable in more than 80% of patients.

CONCLUSIONS

Intraoperative CT allows control of resection in case of uncertainty and can help to improve the extent of maximal safe resection, especially in case of osseous tumor parts and masses within the orbit.

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Mathias Kunz, Gernot Schulte-Altedorneburg, Eberhard Uhl, Robert Schmid-Elsaesser, Karsten Schöller, and Stefan Zausinger

Object

Endoscopic third ventriculostomy is the treatment of choice in patients with obstructive hydrocephalus caused by aqueductal stenosis. The authors examined the clinical course and results of surgical treatment for obstructive hydrocephalus with pre- and postoperative refined constructive interference in steady-state (CISS) MR imaging.

Methods

Forty patients with obstructive hydrocephalus underwent pre- and postoperative 3D-CISS imaging and clinical evaluation. Radiological findings were correlated with intraoperative observations of the thickness and transparency of the floor of the third ventricle and the patient's postoperative clinical course.

Results

Three-dimensional CISS MR imaging provides precise visualization of the basilar/posterior cerebral artery, its distance to the clivus, the diameter of the foramen of Monro, and the extension of and thickness of the floor of the third ventricle. In 71% of patients a flow void was detectable postoperatively on the ventriculostomy. In this group 81.5% had strong and 14.8% moderate clinical benefit, and 3.7% required secondary shunt placement. In the remaining 29% of the patients without a visible flow void, strong improvement was seen in 54.5%, moderate improvement in 18.2%, and stoma failure occurred in 27.3% (p = 0.094). Radiological measurements of the thickness of the third ventricle floor correlated with intraoperative findings (r = 0.35, p = 0.029). Comparison of outcomes showed a statistically significant tendency for a better outcome in patients with thin and easily perforated third ventricle floors (p = 0.04).

Conclusions

Endoscopic ventriculostomy in patients with obstructive hydrocephalus is safe and mostly successful, and 3D-CISS MR imaging seems to be a valuable diagnostic method for precisely identifying the anatomy of relevant structures. Furthermore, 3D-CISS MR imaging allows judgment of the thickness of the third ventricle floor and display of the ventriculostomy/flow void, which are predictive for intraoperative course and clinical outcome.