Letter to the Editor. Earlier radiosurgery is related to better outcome in trigeminal neuralgia
Alfio Spina, Nicola Boari, and Pietro Mortini
Letter to the Editor. Pain outcomes for trigeminal neuralgia
Luigi Albano, Lina Raffaella Barzaghi, and Pietro Mortini
Letter to the Editor. Pain outcomes for trigeminal neuralgia
Luigi Albano, Lina Raffaella Barzaghi, and Pietro Mortini
Fronto-orbitozygomatic approach: functional and cosmetic outcomes in a series of 169 patients
Nicola Boari, Alfio Spina, Lodoviga Giudice, Francesca Gorgoni, Michele Bailo, and Pietro Mortini
Advantages of the fronto-orbitozygomatic (FOZ) approach have been reported extensively in the literature; nevertheless, restoration of normal anatomy and the esthetic impact of surgery are increasingly important issues for patients and neurosurgeons. The aim of this study was to analyze functional and cosmetic outcomes in a series of 169 patients with different pathologies who underwent surgery in which the FOZ approach was used.
Between January 2000 and December 2014, 250 consecutive patients underwent surgery with an FOZ approach as the primary surgical treatment. Follow-up data were available for only 169 patients; 103 (60.9%) of these patients were female and 66 (39.1%) were male, and their ages ranged from 6 to 77 years (mean 46.9 years; SD 15.6 years). Mean follow-up time was 66 months (range 6–179 months; SD 49.5 months). Evaluation of clinical outcomes was performed with a focus on 4 main issues: surgical complications, functional outcome, cosmetic outcome, and patient satisfaction. The additional time needed to perform orbitotomy and orbital reconstruction was also evaluated.
The permanent postoperative complications included forehead hypesthesia (41.4%) and dysesthesia (15.3%), frontal muscle weakness (10.3%), exophthalmos (1.4%), enophthalmos (4.1%), diplopia (6.6%; 2% were related to surgical approach), and persistent periorbital and eyelid swelling (3%). Approximately 90% of the patients reported subjectively that surgery did not affect their quality of life or complained of only minor problems that did not influence their quality of life significantly. The mean time needed for orbitotomy and orbital reconstruction was approximately half an hour.
Comprehensive knowledge of the potential complications and overall clinical outcomes of the FOZ approach can be of great utility to neurosurgeons in balancing the well-known benefits of the approach with potential additional morbidities.
Results of volume-staged fractionated Gamma Knife radiosurgery for large complex arteriovenous malformations: obliteration rates and clinical outcomes of an evolving treatment paradigm
Alberto Franzin, Pietro Panni, Giorgio Spatola, Antonella del Vecchio, Alberto L. Gallotti, Carmen R. Gigliotti, Andrea Cavalli, Carmine A. Donofrio, and Pietro Mortini
There are few reported series regarding volume-staged Gamma Knife radiosurgery (GKRS) for the treatment of large, complex, cerebral arteriovenous malformations (AVMs). The object of this study was to report the results of using volume-staged Gamma Knife radiosurgery for patients affected by large and complex AVMs.
Data from 20 patients with large AVMs were prospectively included in the authors' AVM database between 2004 and 2012. A staging strategy was used when treating lesion volumes larger than 10 cm3. Hemorrhage and seizures were the presenting clinical feature for 6 (30%) and 8 (40%) patients, respectively. The median AVM volume was 15.9 cm3 (range 10.1–34.3 cm3). The mean interval between stages (± standard deviation) was 15 months (± 9 months). The median margin dose for each stage was 20 Gy (range 18–25 Gy).
Obliteration was confirmed in 8 (42%) patients after a mean follow-up of 45 months (range 19–87 months). A significant reduction (> 75%) of the original nidal volume was achieved in 4 (20%) patients. Engel Class I–II seizure status was reported by 75% of patients presenting with seizures (50% Engel Class I and 25% Engel Class II) after radiosurgery. After radiosurgery, 71.5% (5/7) of patients who had presented with a worsening neurological deficit reported a complete resolution or amelioration. None of the patients who presented acutely because of hemorrhage experienced a new bleeding episode during follow-up. One (5%) patient developed radionecrosis that caused sensorimotor hemisyndrome. Two (10%) patients sustained a bleeding episode after GKRS, although only 1 (5%) was symptomatic. High nidal flow rate and a time interval between stages of less than 11.7 months were factors significantly associated with AVM obliteration (p = 0.021 and p = 0.041, respectively). Patient age younger than 44 years was significantly associated with a greater than 75% reduction in AVM volume but not with AVM obliteration (p = 0.024).
According to the results of this study, volume-staged GKRS is an effective and safe treatment strategy for large, complex, cerebral AVMs for which microsurgery or endovascular approaches could carry substantially higher risks to the patient. Radiation doses up to 20 Gy can be safely administered. The time interval between stages should be shorter than 11.7 months to increase the chance of obliteration. High nidal flow and a patient age younger than 44 years were factors associated with nidus obliteration and significant nidus reduction, respectively.
Gamma Knife radiosurgery for cluster-tic syndrome unresponsive to medical treatment: illustrative case
Lina R. Barzaghi, Edoardo Pompeo, Luigi Albano, Antonella Del Vecchio, and Pietro Mortini
Cluster-tic syndrome is a disorder characterized by the coexistence of symptoms related to both cluster headache and trigeminal neuralgia. Etiopathogenesis is not yet well defined. Medical treatment, including drugs for both cluster headache and trigeminal neuralgia, is the first therapeutic choice, whereas more invasive treatments are indicated in the case of pharmacological therapy failure or in the presence of drug side effects. To date, no randomized and/or large cohort trials describing Gamma Knife radiosurgery (GKRS) for cluster-tic syndrome are available, probably due to the syndrome’s rarity.
The authors describe the case of a 76-year-old woman with refractory cluster-tic syndrome who underwent GKRS with double target (the retrogasserian portion of the trigeminal nerve and the sphenopalatine ganglion). The Numerical Rating Scale (NRS) of pain and the Barrow Neurological Institute (BNI) pain intensity score before treatment were 7 (up to 10 during paroxysmal pain attacks) and V, respectively. At last follow-up, 24 months after GKRS, the patient had discontinued her pain medications and NRS and BNI pain scores were 1 and I, respectively. No trigeminal sensory disorders were reported.
The present case shows that GKRS, in selected cases, could be an effective treatment in patients with refractory cluster-tic syndrome.
Quantification of clival and paraclival exposure in the Le Fort I transmaxillary transpterygoid approach: a microanatomical study
Nicola Boari, Fabio Roberti, Federico Biglioli, Anthony J. Caputy, and Pietro Mortini
The authors describe a modified Le Fort I maxillotomy with medial and posterior antrectomy and removal of the pterygoid plates, aimed at improving the lateral surgical exposure during open transmaxillary surgery for pathological conditions involving the clivus. A cadaveric microanatomical study was conducted to compare the planimetric exposures allowed by the transmaxillary transpterygoid (TMTP) approach and the standard Le Fort I maxillotomy (STM).
Six cadaveric specimens that had been fixed with glutaraldehyde and injected with latex were dissected to obtain morphometric measurements after both TMTP and STM approaches. The anatomical areas exposed by the surgical approaches were calculated using ImageJ 1.37a software.
As expected, the TMTP approach allowed for a greater surgical exposure, with an incremental area exposed ranging from 4.9 to 7.6 cm2 (mean ± standard deviation 6.4 ± 1.2 cm2, 95% CI 5.4–7.4 cm2). The amount of additional anatomical area visualized, as recorded as a percentage increase after the TMTP approach when compared with the STM approach, ranged from 83 to 109% (mean 99%).
The lateral surgical exposure allowed by the STM approach is limited by the pterygoid plates. The TMTP approach significantly improves the exposure of the anatomical regions lateral to the clivus, allowing access to the pterygopalatine and medial infratemporal fossae. In comparison with the STM, the TMTP approach allows for a surgical exposure that is nearly double. The authors conclude that the TMTP approach provides a significant improvement in the surgical exposure of the lateral paraclival areas, when compared with the STM approach.
Presurgical treatment with somatostatin analogs in patients with acromegaly: effects on the remission and complication rates
Marco Losa, Pietro Mortini, Laura Urbaz, Paolo Ribotto, Tristana Castrignanò, and Massimo Giovanelli
The question of whether preoperative therapy with somatostatin analogs can improve surgical outcome in acromegaly has not been definitively answered. In this paper, the authors report the effects of preoperative treatment with somatostatin analogs in a large sample of patients with acromegaly.
Between 1990 and 2003, 399 consecutive patients with acromegaly underwent surgery at the Istituto Scientifico San Raffaele. Thirty-three patients who had previously undergone surgery or radiation treatment, 48 patients treated with somatostatin analogs for fewer than 3 months, and patients who had stopped therapy for too long a time before surgery were excluded from the study. One hundred forty-three patients who had received somatostatin analogs prior to surgery (Group 1) were randomly matched to 143 patients who had never been treated with somatostatin analogs (Group 2). Matching criteria were tumor size and invasiveness into the cavernous sinus. Before surgery, Group 1 patients showed reduction of growth hormone levels to less than 50% of baseline in 64% of cases, but insulin-like growth factor–I was normalized in only 19.5%. Surgical remission occurred in 81 Group 1 patients (56.6%) and in 91 Group 2 patients (63.6%; p = 0.28). No significant difference in the remission rate was observed when cases were analyzed according to tumor size or invasiveness. Logistic regression analysis confirmed that pretreatment with somatostatin analogs was not associated with surgical outcome. Surgical morbidity was mild and similar in Group 1 and Group 2 patients (7 and 5.6%, respectively; p = 0.81). Surgical remission and complication rates in patients with acromegaly who received treatment with somatostatin analogs prior to surgery were not significantly different from those of matched patients who did not receive these agents.
At present, the routine use of presurgical therapy with somatostatin analogs for patients with acromegaly cannot be recommended.
Radiosurgery and the prevention of regrowth of incompletely removed nonfunctioning pituitary adenomas
Piero Picozzi, Marco Losa, Pietro Mortini, Micol Angela Valle, Alberto Franzin, Luca Attuati, Camillo Ferrari da Passano, and Massimo Giovanelli
Object. The authors studied the efficacy of gamma knife radiosurgery (GKS) in the prevention of regrowth of nonfunctioning pituitary adenomas (NPA).
Methods. One hundred nineteen patients were included in this study and were divided into two groups. All patients had undergone surgery in our department and recurrent or residual adenoma was demonstrated on postoperative MR imaging. Group A consisted of 68 patients who were followed without additional treatment. Group B was composed of 51 patients who received GKS within 1 year after microsurgery. There was no significant demographic difference between the two groups. In Group B the mean margin dose was 16.5 ± 0.3 Gy (range 13–21 Gy). Fifty one and one tenth percent of patients in Group A were recurrence free at 5 years and 89.8% in Group B (p < 0.001). In Group B patients, tumor volume decreased from a baseline value of 2.4 ± 0.2 cm3 to 1.6 ± 0.2 cm3 at last follow up (p < 0.001).
Conclusions. The results of this study suggest that GKS is effective in controlling growth of residual NPA for at least 5 years following initial maximal surgical debulking compared with no radiation therapy. Thus, GKS is recommended after microsurgery when visible tumor can be detected on imaging studies.
Masseteric–facial nerve neurorrhaphy: results of a case series
Federico Biglioli, Valeria Colombo, Dimitri Rabbiosi, Filippo Tarabbia, Federica Giovanditto, Alessandro Lozza, Silvia Cupello, and Pietro Mortini
Facial palsy is a well-known functional and esthetic problem that bothers most patients and affects their social relationships. When the time between the onset of paralysis and patient presentation is less than 18 months and the proximal stump of the injured facial nerve is not available, another nerve must be anastomosed to the facial nerve to reactivate its function. The masseteric nerve has recently gained popularity over the classic hypoglossus nerve as a new motor source because of its lower associated morbidity rate and the relative ease with which the patient can activate it. The aim of this work was to evaluate the effectiveness of masseteric–facial nerve neurorrhaphy for early facial reanimation.
Thirty-four consecutive patients (21 females, 13 males) with early unilateral facial paralysis underwent masseteric–facial nerve neurorrhaphy in which an interpositional nerve graft of the great auricular or sural nerve was placed. The time between the onset of paralysis and surgery ranged from 2 to 18 months (mean 13.3 months). Electromyography revealed mimetic muscle fibrillations in all the patients. Before surgery, all patients had House-Brackmann Grade VI facial nerve dysfunction. Twelve months after the onset of postoperative facial nerve reactivation, each patient underwent a clinical examination using the modified House-Brackmann grading scale as a guide.
Overall, 91.2% of the patients experienced facial nerve function reactivation. Facial recovery began within 2–12 months (mean 6.3 months) with the restoration of facial symmetry at rest. According to the modified House-Brackmann grading scale, 5.9% of the patients had Grade I function, 61.8% Grade II, 20.6% Grade III, 2.9% Grade V, and 8.8% Grade VI. The morbidity rate was low; none of the patients could feel the loss of masseteric nerve function. There were only a few complications, including 1 case of postoperative bleeding (2.9%) and 2 local infections (5.9%), and a few patients complained about partial loss of sensitivity of the earlobe or a small area of the ankle and foot, depending on whether great auricular or sural nerves were harvested.
The surgical technique described here seems to be efficient for the early treatment of facial paralysis and results in very little morbidity.