Radical removal of meningiomas involving the major dural sinuses remains controversial. In particular, whether the fragment invading the sinus must be resected and whether the venous system must be reconstructed continue to be issues of debate. In this paper the authors studied the effects, in terms of tumor recurrence rate as well as morbidity and mortality rates, of complete lesion removal including the invaded portion of the sinus and the consequences of restoring or not restoring the venous circulation.
The study consisted of 100 consecutive patients who had undergone surgery for meningiomas originating at the superior sagittal sinus in 92, the transverse sinus in five, and the confluence of sinuses in three. A simplified classification scheme based on the degree of sinus involvement was applied: Type I, lesion attachment to the outer surface of the sinus wall; Type II, tumor fragment inside the lateral recess; Type III, invasion of the ipsilateral wall; Type IV, invasion of the lateral wall and roof; and Types V and VI, complete sinus occlusion with or without one wall free, respectively. Lesions with Type I invasion were treated by peeling the outer layer of the sinus wall. In cases of sinus invasion Types II to VI, two strategies were used: a nonreconstructive (coagulation of the residual fragment or global resection) and a reconstructive one (suture, patch, or bypass). Gross-total tumor removal was achieved in 93% of cases, and sinus reconstruction was attempted in 45 (65%) of the 69 cases with wall and lumen invasion. The recurrence rate in the study overall was 4%, with a follow-up period from 3 to 23 years (mean 8 years). The mortality rate was 3%, all cases due to brain swelling after en bloc resection of a Type VI meningioma without venous restoration. Eight patients—seven of whom harbored a lesion in the middle third portion of the superior sagittal sinus—had permanent neurological aggravation, likely due to local venous infarction. Six of these patients had not undergone a venous repair procedure.
The relatively low recurrence rate in the present study (4%) favors attempts at complete tumor removal, including the portion invading the sinus. The subgroup of patients without venous reconstruction displayed statistically significant clinical deterioration after surgery compared with the other subgroups (p = 0.02). According to this result, venous flow restoration seems justified when not too risky.
Mikhail Chernov, Yoshihiro Muragaki, and Hiroshi Iseki
Mikhail Chernov, Yoshihiro Muragaki, and Hiroshi Iseki
Mikhail F. Chernov, Shuji Kamikawa, Fumitaka Yamane, Shoichiro Ishihara, and Tomokatsu Hori
Object. The purpose of this study was to evaluate an original neurofiberscope-guided strategy for the management of slit-ventricle syndrome that occurs after shunt placement.
Methods. Between 1995 and 2003 15 patients with slit-ventricle syndrome (mean age 14.2 years) underwent endoscopic third ventriculostomy (ETV) and shunt removal. During the initial surgical procedure a neurofiberscope with a small outer diameter was inserted along the shunt tube into the collapsed ventricle for endoscopically controlled removal of the ventricular catheter and evaluation of brain compliance. If the latter was sufficiently preserved, primary ETV and shunt removal were performed (four cases). If brain compliance seemed to be significantly reduced, endoscopically controlled replacement of the ventricular catheter and implantation of the Codman-Hakim programmable valve shunt device were performed (11 cases). In these patients, delayed ETV and shunt removal were performed later (mean period of 16.3 months).
No medical or surgical complications occurred in any case. Follow up ranged from 6 to 84 months (mean 31.1 months; median 22 months). All patients became shunt independent and 13 became symptom free. Overall, the size of the ventricles returned to normal in five cases, became slightly dilated in nine, and moderately dilated in one.
Conclusions. Neurofiberscope-guided treatment of slit-ventricle syndrome involving shunt removal and ETV appears to be beneficial; all patients in this series were symptom free and shunt independent at the end of follow up.
Benjamin Brokinkel, Johanna Sicking, Dorothee Cäcilia Spille, Katharina Hess, Werner Paulus, and Walter Stummer
Masahiro Izawa, Motohiro Hayashi, Mikhail Chernov, Koutarou Nakaya, Taku Ochiai, Noriko Murata, Yuichi Takasu, Osami Kubo, Tomokatsu Hori, and Kintomo Takakura
Object. The authors analyzed of the long-term complications that occur 2 or more years after gamma knife surgery (GKS) for intracranial arteriovenous malformations (AVMs).
Methods. Patients with previously untreated intracranial AVMs that were managed by GKS and followed for at least 2 years after treatment were selected for analysis (237 cases). Complete AVM obliteration was attained in 130 cases (54.9%), and incomplete obliteration in 107 cases (45.1%). Long-term complications were observed in 22 patients (9.3%). These complications included hemorrhage (eight cases), delayed cyst formation (eight cases), increase of seizure frequency (four cases), and middle cerebral artery stenosis and increased white matter signal intensity on T2-weighted magnetic resonance imaging (one case of each). The long-term complications were associated with larger nidus volume (p < 0.001) and a lobar location of the AVM (p < 0.01). Delayed hemorrhage was associated only with incomplete obliteration of the nidus (p < 0.05). Partial obliteration conveyed no benefit. Delayed cyst formation was associated with a higher maximal GKS dose (p < 0.001), larger nidus volume (p < 0.001), complete nidus obliteration (p < 0.01), and a lobar location of the AVM (p < 0.05).
Conclusions. Incomplete obliteration of the nidus is the most important factor associated with delayed hemorrhagic complications. Partial obliteration does not seem to reduce the risk of hemorrhage. Complete obliteration can be complicated by delayed cyst formation, especially if high maximal treatment doses have been administered.
Motohiro Hayashi, Mikhail Chernov, Masao Usukura, Kayoko Abe, Yuko Ono, Masahiro Izawa, Sadao Hori, Tomokatsu Hori, and Kintomo Takakura
The authors conducted a study to determine a way of overcoming the poor-quality demonstration of choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD) on conventional magnetic resonance (MR) imaging studies.
The poor MR imaging demonstration of CNV in patients with AMD makes the use of gamma knife surgery more difficult. This difficulty, however, can be overcome by use of a modified time-of-flight MR imaging sequence with Gd enhancement and coronal reconstruction.