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Ali Sajadi and Nicolas de Tribolet

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Luca Regli, Antoine Uske and Nicolas de Tribolet

Object. The goal of this study was to delineate the angioanatomical features that determine whether a patient with an unruptured middle cerebral artery (MCA) aneurysm is treated using endovascular coil placement or surgical clipping.

Methods. Thirty consecutive patients harboring 34 unruptured MCA aneurysms were evaluated. Patients with unruptured aneurysms are managed prospectively according to the following protocol: the primary treatment recommendation is endovascular packing with Guglielmi detachable coils (GDCs). Surgical clipping is recommended after failed attempts at coil placement or in the presence of angioanatomical features that contraindicate that type of endovascular therapy.

Of 34 unruptured MCA aneurysms, two (6%) were successfully embolized and 32 (94%) were clipped. Of these 32 surgically treated aneurysms, in 11 (34%) an attempt at GDC embolization had failed, whereas in 21 (66%) primary clipping was performed because of unfavorable angioanatomy. Of the 13 aneurysms treated endovascularly, two (15%) were successfully excluded, whereas GDC treatment failed in 11 (85%). An unfavorable dome/neck ratio (< 2) and an arterial branch originating at the aneurysm base were the reasons for embolization failure.

Conclusions. Careful evaluation of the angioanatomy of unruptured aneurysms allows selection of the most appropriate treatment. However, for unruptured MCA aneurysms, surgical clipping appears to be the most efficient treatment option. Series of unruptured aneurysms are ideal for comparing treatment results.

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Nicolas de Tribolet

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Pierre-Yves Dietrich and Nicolas de Tribolet

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Mitsuhiro Tada, Annie-Claire Diserens, Isabelle Desbaillets and Nicolas de Tribolet

✓ To elucidate which cytokine receptors may be expressed by human glioblastoma and normal astrocytic cells, the presence of messenger ribonucleic acid (RNA) for a number of cytokine receptors was examined in 16 glioblastoma cell lines and adult and fetal astrocytes. A complementary deoxyribonucleic acid copy of total RNA was synthesized and amplified with specific primers using the polymerase chain reaction method. The receptors studied were interleukin (IL)-1 receptor type I (IL-1RI) and type II (IL-1RII), p75 and p55 tumor necrosis factor (TNF) receptors (p75TNFR and p55TNFR), interferon (IFN)-α/β and -γ receptors (IFN-α/βR and IFN-γR), granulocyte-macrophage (GM) colony-stimulating factors receptor α subunit (GM-CSFR), G-CSF receptor (G-CSFR), M-CSF receptor (c-fms, M-CSFR), stem cell factor receptor (c-kit, SCFR), IL-6 receptor (IL-6R), and IL-8 receptor (IL-8R). Transcripts for IL-1RI, p55TNFR, IFN-α/βR, and IFN-γR were present in all cell lines. The presence of IL-1RII, p75TNFR, GM-CSFR, M-CSFR, SCFR, IL-6R, and IL-8R was identified in 13, eight, seven, eight, 14, three, and one cell lines, respectively. Normal astrocytes were positive for IL-1RI, p75TNFR, p55TNFR, IFN-α/βR, IFN-γR, M-CSFR, and SCFR, showing a similarity to glioblastoma cells. Expression of IL-1RII was observed in adult astrocytes but not in fetal astrocytes. Furthermore, gene expression was assessed in normal brain tissue and 11 glioblastoma tissue specimens. The normal brain tissue expressed IL-lRI, IL-1RII, IFN-α/βR, M-CSFR, and SCFR. Of the 11 glioblastoma tissue specimens, IL-1RI was positive in 11, IL-1RII in 10, p75TNFR in nine, p55TNFR in nine, IFN-α/βR in 10, IFN-γR in 10, GM-CSFR in two, G-CSFR in three, IL-8R in eight, and M-CSFR and SCFR in 11. These expressions were consistent with those in the cell lines, except for IL-8R. It is concluded that glioblastoma cells and normal astrocytes express a similar set of cytokine receptor genes in vitro and in vivo. Possible autocrine loops are suggested for IL-1α/IL-1RI, TNF-α/p55TNFR, IFN-β/IFN-α/βR, M-CSF/M-CSFR, and SCF/SCFR in glioblastomas.

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Keyvan Nicoucar, Shahan Momjian, John-Paul Vader and Nicolas de Tribolet

Object

The aim of this study was to assess the consequences of total removal of a large vestibular schwannoma on the patient’s symptoms and quality of life (QOL).

Methods

A questionnaire regarding preoperative and postoperative symptoms with measures of both daily and global QOL and a modified 36-Item Short Form Health Survey (SF-36) QOL instrument were sent to 103 patients who had undergone surgery via a retrosigmoid approach for total removal of a Grade III or IV vestibular schwannoma. In addition, 48 patients underwent follow-up clinical examinations to assess their conditions.

Seventy-two of the 103 patients completed and returned the questionnaire. Forty-six (64%) of the schwannomas were Grade IV and 26 (36%) were Grade III. The patients’ pre- and postoperative symptoms were similar to those reported in other studies. The patients’ perceptions of facial movement were likely to be worse than the clinicians’ estimation based on the House–Brackmann classification. All scores in the QOL categories were significantly reduced when compared with normative data. Patients with large vestibular schwannomas had lower scores in all SF-36 categories except pain compared with data from other studies. Psychological problems were the preponderant symptoms, and their presence was the most powerful predictive variable for global and daily QOL.

Conclusions

Surgery for a large vestibular schwannoma has a significant impact on the patient’s QOL. To improve QOL postoperatively, the patient should be prepared and well informed of the consequences of such a surgery on QOL. Clinicians must be aware that early involvement of a clinical psychologist may be very helpful.

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Yutaka Sawamura, Nicolas de Tribolet, Nobuaki Ishii and Hiroshi Abe

✓ Because intracranial germinomas are readily curable with radiation and chemotherapy or radiation therapy alone, the role of radical surgery has become debatable. This study assesses the optimum degree of surgical resection for intracranial germinomas.

Twenty-nine patients who underwent surgery for germinoma were retrospectively analyzed (male/female ratio 27:2, median age 18 years). Among these 29 patients there were 10 solitary pineal, seven solitary neurohypophyseal/hypothalamic, and 12 multifocal or disseminated tumors. Biopsy samples were obtained in 16 patients (stereotactically in eight, transsphenoidally in four, and via frontotemporal craniotomy in four). Partial resection was attained in five patients (via a frontotemporal approach in three and occipitotranstentorially in two). Gross-total resection was achieved via an occipitotranstentorial route in eight patients with pineal masses. After surgery, 10 patients were treated with radiotherapy alone, and 19 received radiation and chemotherapy; complete remission was achieved in all 29 patients. The overall tumor-free survival rate was 100% at a median follow-up period of 42 months. There was no significant difference in outcome related to the extent of surgical resection. Postoperative neurological improvement was seen in only two patients, whereas transient postoperative complications, mainly upgaze palsy, were observed in six. One patient experienced a slight hemiparesis, bringing the surgical morbidity rate to 3% (one of 29).

It is concluded that radical resection of intracranial germinomas offers no benefit over biopsy. The primary goal of surgery should be to obtain a sufficient volume of tumor tissue for histological examination. If there is strong evidence of germinoma on radiological studies, biopsy samples should be obtained. When a perioperative histological diagnosis of pure germinoma is made during craniotomy, no risk should be taken in continuing the resection.

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Philippe P. Maeder, Reto A. Meuli and Nicolas de Tribolet

✓ This study was undertaken to evaluate the capacity of three-dimensional (3-D) time-of-flight (TOF) magnetic resonance (MR) angiography with VoxelView (VV) 3-D volume rendering to detect and characterize intracranial aneurysms and to compare this rendering technique with that of maximum intensity projection (MIP).

Forty patients with a total of 53 intracranial aneurysms (10 giant and subgiant, 43 saccular) were consecutively admitted to University Hospital, Lausanne, Switzerland, and investigated with 3-D TOF MR angiography. Source images of the 43 saccular aneurysms were processed with both MIP and VV. The aneurysm detection rate of the two techniques and their ability to characterize features of an aneurysm, such as its neck and its relation to the parent vessel, were compared. Intraarterial digital subtraction angiography was used as the gold standard to which these techniques could be compared and evaluated.

Four aneurysms, less than 3 mm in size, were missed using MIP compared to three missed using VV. The representation of aneurysmal morphology using VV was superior to that found using conventional angiography in nine cases, equal in 16 cases, and inferior in seven cases. The representation of the aneurysm neck using VV was superior to MIP in 21 cases, equal in 17 cases, and inferior in one case; it was superior to that shown using conventional angiography in 10 cases, equal in 18 cases, and inferior in four cases.

Time-of-flight MR angiography in conjunction with both MIP and VV 3-D reconstruction was able to visualize all aneurysms that were larger than 3 mm. Compared to MIP, VV provides a better definition of the aneurysm neck and the morphology of saccular aneurysms, making VV valuable for use in a preoperative diagnostic workup.

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François Porchet, Anne Chollet-Bornand and Nicolas de Tribolet

Object. This study was undertaken to evaluate the long-term benefit in 202 patients who were surgically treated via a microsurgical far-lateral approach for foraminal or extraforaminal lumbar disc herniations.

Methods. All patients underwent surgery at the authors' institute since 1987 and represented 6.5% of all lumbar spinal disc surgeries. There were 67 women and 135 men who ranged in age from 19 to 78 years (mean age 58 years). All patients had unilateral leg pain due to lumbar disc herniations into or lateral to the lateral interpedicular compartment. One patient underwent surgery at the L1–2 level, nine at L2–3, 48 at L3–4, 86 at L4–5, and 58 at the L5—S1 level. The mean follow-up period was 50 months (range 12–120 months). Outcome was defined as excellent (no pain), good (some back pain), fair (moderate radiculopathy), and poor (unchanged or worse) based on Macnab classification. Overall, excellent and good results were achieved in 62 (31%) and 85 (42%) patients, respectively, and fair and poor results in 40 (20%) and 15 (7%) patients, respectively. Of 11 recurrent disc herniations, four presented in an extreme-lateral position, five in a paramedian location, and two on the contralateral side. There were three minor complications related to surgery, seven general complications, and no case of spinal instability.

Conclusions. The far-lateral approach is a safe, effective procedure that avoids the risk of secondary spinal instability.

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Siviero Agazzi, Luca Regli, Antoine Uske, Philippe Maeder and Nicolas de Tribolet

✓ Developmental venous anomalies (DVAs) are common congenital variations of normal venous drainage that are known for their benign natural history. Isolated cases of symptomatic DVAs with associated arteriovenous (AV) shunts have recently been reported. The present case, in which thrombosis occurred in a DVA involving an AV shunt, raises intriguing questions regarding the clinical characteristics of these lesions and can be used to argue in favor of considering such lesions to be arteriovenous malformations (AVMs).

A 39-year-old man presented with acute thrombosis in a complex system of anomalous hemispheric venous drainage, which included two distinct DVAs, one of which involved an AV shunt. The hemodynamic turbulences induced by a communication between shunted and normal venous outflows were the possible predisposing factor of the thrombosis. Follow-up angiographic and magnetic resonance images revealed complete recanalization of the thrombosed vessel and provided a thorough visualization of the particular angioarchitecture of the DVA.

Acute thrombosis within a DVA with an AV shunt has not been reported previously and, thus, this case can be added to other reports of complications that arise in this particular type of DVA. The authors hypothesize that the presence of an AV shunt in a DVA is a risk factor for aggressive clinical behavior of the anomaly, rendering those lesions prone to complications similar to AVMs.

Although no treatment can be offered, the presence of an AV shunt in a DVA warrants close follow-up observation because such lesions may represent a particular subtype of AVM and, therefore, may exhibit an aggressive clinical behavior.