✓ An azygos pericallosal artery (APCA) aneurysm is a rare anomaly that is closely associated with saccular aneurysms. This is the earliest report to document de novo formation and rupture of an aneurysm at the bifurcation of an unpaired pericallosal trunk. The authors report the case of a woman who presented at the age of 52 years with subarachnoid hemorrhage (SAH) from the rupture of a newly formed APCA bifurcation aneurysm, 7 years after she had undergone surgery to clip a ruptured anterior cerebral artery aneurysm. De novo formation of aneurysms after SAH rarely occurs and certain risk factors like multiple and familial aneurysms, arterial hypertension, or smoking have been postulated. Late follow-up examination with angiography to detect de novo aneurysms should be considered in patients with this vascular anomaly after SAH.
Wolfgang Dietrich, Andrea Reinprecht, Andreas Gruber, and Thomas Czech
Christian Dorfer, Gregor Kasprian, Angelika Mühlebner, and Thomas Czech
Hypothalamic hamartomas are rare lesions for which different classification schemes have been proposed. The authors report on an exceptionally large solid-cystic hamartoma that led to hydrocephalus, precocious puberty, and intractable gelastic seizures. They discuss potential mechanisms of the development of hypothalamic hamartomas.
Growing blood clot mimicking an aneurysm on postoperative computerized tomography and magnetic resonance imaging studies
Case report and review of the literature
Alexander Bertalanffy, Wolfgang Dietrich, Martin Aichholzer, Karl Hittmair, and Thomas Czech
✓ The authors describe the case of a 15-year-old boy who underwent resection of a large left temporal tumor. During a normal postoperative course, computerized tomography (CT) scanning demonstrated a spherically hyperdense structure near the internal carotid artery, enlarging on a control CT scan. A suspected false aneurysm was confirmed on magnetic resonance imaging; angiographic studies were negative. The authors believed they were dealing with a thrombosed false aneurysm and they performed operative revision. Intraoperatively the “aneurysm” could be dissected off the internal carotid artery and no lesion of the arterial wall was obvious. Histological findings showed a fresh blood clot. This case demonstrates that a blood clot may mimic an aneurysm on CT and magnetic resonance studies, which has not been described earlier. The origin of the blood clot remains unclear.
Klaus Novak, Thomas Czech, Daniela Prayer, Wolfgang Dietrich, Wolfgang Serles, Stephan Lehr, and Christoph Baumgartner
Object. The concept of selective amygdalohippocampectomy is based on pathophysiological insights into the epileptogenicity of the hippocampal region and the definition of the clinical syndrome of mesial temporal lobe epilepsy (TLE). High-resolution magnetic resonance (MR) imaging allows correlation of the site of histologically conspicuous tissue with anatomical structure. The highly variable sulcal pattern of the basal temporal lobe, however, definitely complicates the morphometric analysis of histomorphologically defined subdivisions of the hippocampal region. The goal of this study was to define individual variations in the sulcal anatomy on the basis of preoperative MR images obtained in patients suffering from TLE.
Methods. The authors analyzed coronal MR images obtained in 50 patients for the presence of and intrinsic relationships among the rhinal, collateral, and occipitotemporal sulci. The surface relief of consecutive sections of 100 temporal lobes was graphically outlined and the resulting maps were used for visual analysis. The sulci were characterized by measurement of their depth, distance to the temporal horn, and laterality. The anatomical measurements and frequencies of sulcal patterns were assessed for statistical correlation with patients' histories and the lateralization of the seizure focus.
Conclusions. Statistical assessment shows that patient sex is a significant factor in sulcal patterns. Anatomical measurements are significantly decreased on the side of the seizure origin, which relates to loss of white matter, a known morphological abnormality associated with TLE. Magnetic resonance imaging allows for accurate preoperative knowledge of individual sulcal patterns and facilitates intraoperative orientation to anatomical landmarks.
Christian Dorfer, Georgi Minchev, Thomas Czech, Harald Stefanits, Martha Feucht, Ekaterina Pataraia, Christoph Baumgartner, Gernot Kronreif, and Stefan Wolfsberger
The authors' group recently published a novel technique for a navigation-guided frameless stereotactic approach for the placement of depth electrodes in epilepsy patients. To improve the accuracy of the trajectory and enhance the procedural workflow, the authors implemented the iSys1 miniature robotic device in the present study into this routine.
As a first step, a preclinical phantom study was performed using a human skull model, and the accuracy and timing between 5 electrodes implanted with the manual technique and 5 with the aid of the robot were compared. After this phantom study showed an increased accuracy with robot-assisted electrode placement and confirmed the robot's ability to maintain stability despite the rotational forces and the leverage effect from drilling and screwing, patients were enrolled and analyzed for robot-assisted depth electrode placement at the authors' institution from January 2014 to December 2015. All procedures were performed with the S7 Surgical Navigation System with Synergy Cranial software and the iSys1 miniature robotic device.
Ninety-three electrodes were implanted in 16 patients (median age 33 years, range 3–55 years; 9 females, 7 males). The authors saw a significant increase in accuracy compared with their manual technique, with a median deviation from the planned entry and target points of 1.3 mm (range 0.1–3.4 mm) and 1.5 mm (range 0.3–6.7 mm), respectively. For the last 5 patients (31 electrodes) of this series the authors modified their technique in placing a guide for implantation of depth electrodes (GIDE) on the bone and saw a significant further increase in the accuracy at the entry point to 1.18 ± 0.5 mm (mean ± SD) compared with 1.54 ± 0.8 mm for the first 11 patients (p = 0.021). The median length of the trajectories was 45.4 mm (range 19–102.6 mm). The mean duration of depth electrode placement from the start of trajectory alignment to fixation of the electrode was 15.7 minutes (range 8.5–26.6 minutes), which was significantly faster than with the manual technique. In 12 patients, depth electrode placement was combined with subdural electrode placement. The procedure was well tolerated in all patients. The authors did not encounter any case of hemorrhage or neurological deficit related to the electrode placement. In 1 patient with a psoriasis vulgaris, a superficial wound infection was encountered. Adequate physiological recordings were obtained from all electrodes. No additional electrodes had to be implanted because of misplacement.
The iSys1 robotic device is a versatile and easy to use tool for frameless implantation of depth electrodes for the treatment of epilepsy. It increased the accuracy of the authors' manual technique by 60% at the entry point and over 30% at the target. It further enhanced and expedited the authors' procedural workflow.
Andreas Gruber, Andrea Reinprecht, Harald Görzer, Peter Fridrich, Thomas Czech, Udo M. Illievich, and Bernd Richling
Object. This observational study is based on a consecutive series of 207 patients with aneurysmal subarachnoid hemorrhage who were treated within 7 days of their most recent bleed. The purpose of the study was to evaluate the effect of respiratory failure on neurological outcome.
Methods. Pulmonary function was assessed by determination of parameters describing pulmonary oxygen transport and exchange, by using composite scores for quantification of lung injury (lung injury score [LIS]) and mechanical ventilator settings (PIF score). Pulmonary function was related to the Hunt and Hess (H & H) grade assigned to the patient at hospital admission (p < 0.001). The pattern and time course of lung injury differed significantly between patients with H & H Grade I or II, Grade III, and Grade IV or V. Hunt and Hess grade, Fisher computerized tomography grade, intracranial pressure, cerebral perfusion pressure, LIS, ratio of PaO2 to the fraction of inspired oxygen (FiO2), and the ratio of the alveolar-minus-arterial oxygen tension difference (AaDO2) to FiO2 were related to neurological outcome (p < 0.001). The LIS on the day of maximum lung injury remained an independent predictor of outcome (p = 0.01) in a stepwise logistic regression analysis. The probability of poor neurological outcome significantly increased with both decreasing cerebral perfusion pressure and increasing severity of lung injury.
Conclusions. The overall mortality rate was 22.2% (46 of 207 patients). Subarachnoid hemorrhage and its neurological sequelae accounted for the principal mortality in this series. Medical (nonneurological and nontreatment-related) complications accounted for 37% of all deaths. Systemic inflammatory response syndrome with associated multiple organ dysfunction syndrome was the leading cause of death from medical complications. The authors conclude that respiratory failure is related to neurological outcome, although it is not commonly the primary cause of death from medical complications.
Stefan Wolfsberger, Ahmed Ba-Ssalamah, Katja Pinker, Vladimír Mlynárik, Thomas Czech, Engelbert Knosp, and Siegfried Trattnig
The aim of this study was to determine the value of high-field magnetic resonance (MR) imaging for diagnosis and surgery of sellar lesions.
High-field MR images were obtained using a 3-tesla unit with emphasis on sellar and parasellar structures in 21 patients preoperatively to delineate endo-, supra-, and parasellar anatomical structures. Special attention was given to the medial border of the cavernous sinus and possible invasion of a sellar tumor therein, and to assessing the application of high-resolution images during intraoperative neuronavigation. The 3-tesla MR images were compared with the standard MR images already obtained and with intraoperative findings.
Anatomical structures were studied in all 42 cavernous sinuses; in 32 of them comparisons with intraoperative findings were possible. The medial cavernous sinus border was rated intact in 53% on standard MR images, in 72% on 3-tesla MR images, and in 81% intraoperatively. With a positive correlation to surgical findings on 84% of 3-tesla MR images compared with 59% of standard MR images, a sensitivity of 83% compared with 67%, and a specificity of 84% compared with 58% (p = 0.016, McNemar test), 3-tesla MR imaging was superior for predicting tumor invasion through the medial cavernous sinus border. Although no difference was noted in delineation of the medial, superior, and inferior compartments, there was a better delineation of the lateral cavernous sinus compartment with 3-tesla MR imaging. This compartment was clearly visible on 40 sides (95%) on 3-tesla MR images compared with 34 sides (81%) on standard MR images. Identification of the cavernous sinus segments of the third, fourth, fifth (V1 and V2), and sixth cranial nerves was improved using high-resolution 3-tesla imaging compared with standard MR imaging. A mean of four cranial nerves was found as hypo-intense spots (range two–five spots) on 3-tesla MR imaging compared with a mean of three (range zero–four spots) on standard MR imaging. After addition of contrast agents, the anterior pituitary gland was found to be highly intense on 78% of T1-weighted three-dimensional magnetization-prepared rapid acquisition gradient-echo (MPRAGE) 3-tesla MR images compared with 73% of standard T1-weighted MR images. The optochiasmatic system displayed increased intensity on pre-contrast T1-weighted MPRAGE 3-tesla compared with standard T1-weighted MR images; it was hyperintense on 76% of 3-tesla compared with 15% of standard MR images, which was helpful for its delineation from suprasellar pituitary and tumor structures. Intraoperative navigation guided by fusion of 3-tesla MR images and computerized tomography (CT) scans was performed in seven patients. Whereas CT scanning was used during the transsphenoidal approach to depict the nasal bone structures, 3-tesla MR imaging was particularly useful for the visualization of parasellar tumor extension during microsurgical and/or endoscopic resection.
Due to its higher resolution, 3-tesla MR imaging was found to be superior to standard MR imaging for the delineation of parasellar anatomy and tumor infiltration of the cavernous sinus, and this modality provided improved imaging for intraoperative navigation.
Christian Dorfer, Arthur Hosmann, Julia Vendl, Irene Steiner, Irene Slavc, Johannes Gojo, Gregor Kasprian, and Thomas Czech
CSF dynamics after transcallosal resection of intraventricular lesions can be altered, and the need for shunt implantation complicates the management of these patients. Because the pathophysiological mechanism and contributing factors are poorly understood and the incidence has largely not been described, the authors conducted a study to elucidate these factors.
The authors retrospectively reviewed data from patients who had been operated on at their institution via a transcallosal approach between March 2002 and December 2016. They evaluated the need for a shunt implantation up to 3 months after surgery by assessing clinical variables. These variables were age at surgery, the need for perioperative external CSF drainage, histology of the lesion, and the following radiological parameters: pre- and postoperative Evans index, maximal postoperative extension of subdural effusions (SDEs) measured on axial images, and maximal interhemispheric fissure (IHF) width measured on coronal images assessed at 4 different points in time (preoperatively, day 1, days 2–4, and days 4–8 after surgery). To identify potential risk factors, univariate and multivariate regression models were constructed. Receiver operating characteristic (ROC) curves for significant predictors, as well as the area under the curve (AUC), were calculated.
Seventy-four patients (40 female and 34 male) were identified; their median age at surgery was 17.6 years (range 4 months to 76 years). Shunt implantation was necessary in 13 patients (ventriculoperitoneal [VP] shunt, n = 7; subdural peritoneal [SDP] shunt, n = 6) after a median interval of 24 days (range 10 days to 3 months). Univariate logistic regression models revealed a significant effect of IHF width on days 4–8 (OR 1.31, 95% CI 1.03–1.66; p = 0.027), extension of SDE on days 2–4 (OR 1.33, 95% CI 1.11–1 0.60; p = 0.003), and age (OR 0.932, 95% CI 0.88–0.99; p = 0.02). In the multiple regression model, the effect of the independent variable extension of the SDE remained significant. ROC curves for the predictors IHF width on days 4–8 and extension of SDE on days 2–4 revealed an AUC equal to 0.732 and 0.752, respectively. Before shunt implantation, the ventricles were smaller compared to the preoperative size in 9 of the 13 patients (SDP shunt, n = 5; VP shunt, n = 4).
The rate of shunt-dependent hydrocephalus 3 months after surgery in this heterogeneous group of patients was 17.6% (95% CI 9.7%–28.2%). The authors identified as predictive factors the variables extension of the convexity space, IHF 1 week after surgery, and younger age.
Andreas Gruber, Karl Roessler, Apostolos Georgopoulos, Albert Mißbichler, Raphael Bonelli, Bernd Richling, Gerhard Bavinzski, and Thomas Czech
Whereas the removal of subarachnoid blood is possible during early-stage aneurysm surgery, this cannot be achieved in aneurysms treated by endovascular means. The levels of potential spasmogens in the cerebrospinal fluid (CSF) in patients receiving endovascular treatment might therefore be higher, with the potential for more severe post–subarachnoid hemorrhage (SAH) vasospasm.
Serum and CSF concentrations of big endothelin (ET)–1 were serially measured in patients with SAH receiving one of the following treatments: 1) early (within 72 hours of SAH) aneurysm surgical treatment (15 patients), 2) early endovascular treatment (17 patients), or 3) no intervention in the acute phase (12 patients). In patients suffering delayed infarctions higher levels of big ET–1 CSF were demonstrated than in those without infarctions (p = 0.01). In patients in whom surgery was performed in the acute phase lower big ET–1 CSF concentrations were demonstrated than in those who received embolization treatment or no treatment (p = 0.02). Subgroup analysis demonstrated that in patients receiving early endovascular treatment, higher big ET–1 CSF concentrations were revealed than in those undergoing early aneurysm surgery; this was true for patients with (microsurgery-treated, 1.84 ± 0.83 pg/ml; and embolization-treated 2.19 & plusmn; 0.54 pg/ml) and without (microsurgery-treated 1.76 & plusmn; 0.61 pg/ml; and embolization-treated 2.01 ± 0.48 pg/ml) delayed infarctions.
Among patients with SAH who received treatment during the acute phase, those undergoing early aneurysm surgery were shown to have lower big ET–1 CSF levels than those receiving embolization and no treatment (that is, the nonsurgical treatment groups). The clinical significance of this finding remains to be established in future clinical trials, because in the present study the trend toward lower levels of big ET–1 CSF in the microsurgically treated group was not paralleled by a lower delayed stroke rate or an improvement in neurological outcome.
Barbara Kiesel, Mario Mischkulnig, Adelheid Woehrer, Mauricio Martinez-Moreno, Matthias Millesi, Ammar Mallouhi, Thomas Czech, Matthias Preusser, Johannes A. Hainfellner, Stefan Wolfsberger, Engelbert Knosp, and Georg Widhalm
Glioblastoma (GBM) is characterized by distinct intratumoral histopathological heterogeneity with regard to variable tumor morphology, cell proliferation, and microvascularity. Maximum resection of a GBM results in an improved prognosis and thus represents the aim of surgery in the majority of cases. Fluorescence-guided surgery using 5-aminolevulinic acid (5-ALA) is currently widely applied for improved intraoperative tumor visualization in patients with a GBM. Three intratumoral fluorescence levels (i.e., strong, vague, or no fluorescence) can usually be distinguished during surgery. So far, however, their exact histopathological correlates and their surgical relevance have not been clarified sufficiently. Thus, the aim of this study was to systematically analyze tissue samples from newly diagnosed GBMs with different fluorescence levels according to relevant histopathological parameters.
This prospective study recruited patients who underwent 5-ALA fluorescence-guided resection of a newly diagnosed radiologically suspected GBM. Each patient received 5-ALA approximately 3 hours before surgery, and a modified neurosurgical microscope was applied for intraoperative visualization of 5-ALA–induced fluorescence. During surgery, tissue samples with strong, vague, or no fluorescence were collected. For each sample, the presence of tumor tissue, quality of tissue (compact, infiltrative, or no tumor), histopathological criteria of malignancy (cell density, nuclear pleomorphism, mitotic activity, and presence of microvascular proliferation/necrosis), proliferation rate (MIB-1 labeling index [LI]), and microvessel density (using CD34 staining) were investigated.
Altogether, 77 patients with a newly diagnosed, histopathologically confirmed GBM were included, and 131 samples with strong fluorescence, 69 samples with vague fluorescence, and 67 samples with no fluorescence were collected. Tumor tissue was detected in all 131 (100%) of the samples with strong fluorescence and in 65 (94%) of the 69 samples with vague fluorescence. However, mostly infiltrative tumor tissue was still found in 33 (49%) of 67 samples despite their lack of fluorescence. Strong fluorescence corresponded to compact tumors in 109 (83%) of 131 samples, whereas vague fluorescence was consistent with infiltrative tumors in 44 (64%) of 69 samples. In terms of the histopathological criteria of malignancy, a significant positive correlation of all analyzed parameters comprising cell density, nuclear pleomorphism, mitotic activity, microvascular proliferation, and necrosis with the 3 fluorescence levels was observed (p < 0.001). Furthermore, the proliferation rate significantly and positively correlated with strong (MIB-1 LI 28.3%), vague (MIB-1 LI 16.7%), and no (MIB-1 LI 8.8%) fluorescence (p < 0.001). Last, a significantly higher microvessel density was detected in samples with strong fluorescence (CD34 125.5 vessels/0.25 mm2) than in those with vague (CD34 82.8 vessels/0.25 mm2) or no (CD34 68.6 vessels/0.25 mm2) fluorescence (p < 0.001).
Strong and vague 5-ALA–induced fluorescence enables visualization of intratumoral areas with specific histopathological features and thus supports neurosurgeons in improving the extent of resection in patients with a newly diagnosed GBM. Despite the lack of fluorescence, tumor tissue was still observed in approximately half of the cases. To overcome this current limitation, the promising approach of complementary spectroscopic measurement of fluorescence should be investigated further.