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Sahin Hanalioglu, Omer Selcuk Sahin and Mehmet Erhan Turkoglu

This video demonstrates the resection of an anterolateral mesencephalic cavernous malformation (CM) through a transsylvian/transuncal approach. A 10-year-old girl presented with progressive headache and left-sided spastic hemiparesis. Neuroimaging revealed a 20-mm CM located in the right anterolateral midbrain/cerebral peduncle. After orbitozygomatic craniotomy and wide sylvian fissure opening, the oculomotor nerve was dissected and separated from the temporal lobe. Partial resection of the uncus allowed access to the CM through the oculomotor-tentorial triangle. The CM was excised in a piecemeal fashion. Postoperative imaging confirmed the gross-total resection. The patient had no additional neurological deficits postoperatively. Her left hemiparesis almost completely resolved at the 12-month follow-up.

The video can be found here: https://youtu.be/Jb_EaWbn5LU.

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Sahin Hanalioglu, Balkan Sahin, Omer Selcuk Sahin, Abdulbaki Kozan, Melih Ucer, Ulas Cikla, Steven L. Goodman and Mustafa K. Baskaya

OBJECTIVE

In daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7–10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date.

METHODS

The authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications.

RESULTS

A total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7–20.5, p = 0.005) and deep-extraaxial-benign (“skull base”) tumors (OR 3.6, 95% CI 1.3–9.7, p = 0.011) were found to be independent predictors of thromboembolic complications.

CONCLUSIONS

In this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.