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  • Author or Editor: Toshihiro Ishibashi x
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Tsutomu Ichinose, Takeo Goto, Kenichi Ishibashi, Toshihiro Takami and Kenji Ohata

Object

Because resection followed by timely stereotactic radiosurgery (SRS) is becoming a standard strategy for skull base meningiomas, the role of initial surgical tumor reduction in this combined treatment should be clarified.

Methods

This study examined 161 patients with benign skull base meningiomas surgically treated at Osaka City University between January 1985 and December 2005. The mean follow-up period was 95.3 months. Patients were categorized into 3 groups based on the operative period and into 4 groups based on tumor location. Maximal resection was performed as first therapy throughout all periods. In the early period (1985–1994), in the absence of SRS, total excision of the tumor was intentionally performed for surgical cure of the disease. In the mid and late periods (1995–2000 and 2001–2005), small parts of the tumor invading critical neurovascular structures were left untouched to obtain good functional results. Residual tumors with high proliferation potential (Ki 67 index > 4%) or with progressive tendencies were treated with SRS. The extent of initial tumor resection, recurrence rate, Karnofsky Performance Scale score, and complication rate were investigated in each group.

Results

The mean tumor equivalent diameter of residual tumors was 3.67 mm in the no-recurrence group and 11.7 mm in the recurrence group. The mean tumor resection rate (TRR) was 98.5% in the no-recurrence group and 90.1% in the recurrence group. A significant relationship was seen between postoperative tumor size, TRR, and recurrence rate (p < 0.001), but the recurrence rate showed no significant relationship with any other factors such as operative period (p = 0.48), tumor location (p = 0.76), or preoperative tumor size (p = 0.067). The mean TRR was maintained throughout all operative periods, but the complication rate was lowest and postoperative Karnofsky Performance Scale score was best in the late period (p < 0.001 each). Late-period results were as follows: mean TRR, 97.9%; mortality rate, 0%; and severe morbidity rate, 0%. Stereotactic radiosurgery procedures were added in 27 cases (16.8%) across all periods. Throughout all follow-up periods, 158 tumors were satisfactorily controlled by maximal possible excision alone or in combination with adequate SRS.

Conclusions

The combination of maximal possible resection and additional SRS improves functional outcomes in patients with skull base meningioma. A TRR greater than 97% in volume can be achieved with satisfactory functional preservation and will lead to excellent tumor control in combined treatment of skull base meningioma.

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Yuichi Murayama, Takayuki Saguchi, Toshihiro Ishibashi, Masaki Ebara, Hiroyuki Takao, Koreaki Irie, Satoshi Ikeuchi, Hisashi Onoue, Takeki Ogawa and Toshiaki Abe

Object

The purpose of this study was to evaluate initial experiences in a surgical operating room (OR) with a multi-purpose angiography unit, which offers integrated neurosurgical and radiological capabilities.

Methods

A specially designed biplane digital subtraction (DS) angiography system was installed in the neurosurgery OR. The new suite, which allows three-dimensional DS angiography with C-arm for computerized tomography and microsurgery capabilities, allows the neurosurgeon to perform a wide range of neurosurgical and endovascular procedures. Three hundred thirty-two procedures were performed in the endovascular OR between November 2003 and March 2005. Patients arriving in the emergency department were transferred to the endovascular OR without delay. The neurovascular team performed diagnostic angiography followed by endovascular interventional procedures or surgery.

Conclusions

The newly designed endovascular OR facilitates safe and systemic treatment of neurovascular disease.

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Koji Iihara, Kenichi Murao, Nobuyuki Sakai, Atsushi Shindo, Hideki Sakai, Toshio Higashi, Shuji Kogure, Jun C. Takahashi, Katsuhiko Hayashi, Toshihiro Ishibashi and Izumi Nagata

Object. To elucidate an optimal management strategy for unruptured paraclinoid aneurysms, the authors retrospectively reviewed their experience in the treatment of 100 patients who underwent 112 procedures for 111 paraclinoid aneurysms performed using direct surgery and/or endovascular treatment.

Methods. Between 1997 and 2002, 111 unruptured paraclinoid aneurysms categorized according to a modified al-Rodhan classification (Group Ia, 30 anterior wall lesions; Group Ib, 25 ventral paraclinoid lesions; Group II, 18 true ophthalmic artery lesions; Group III, 37 carotid cave lesions; and Group IV, one transitional lesion) were treated by direct surgery (35 lesions) and/or endovascular treatment (77 lesions) (one aneurysm was treated by both procedures). In lesions in Groups Ia, Ib, II, and III that were treated by endovascular treatment, complete aneurysm obliteration was achieved in 50, 65, 50, and 78%, respectively, and the combined transient and permanent morbidity rates due to cerebral embolic events were 20, 25, 20, and 13.9%, respectively. Overall, the transient morbidity rate after endovascular treatment was 14.3% and the permanent morbidity rate was 6.5%. Notably, permanent visual deficits caused by retinal embolism occurred after endovascular treatment in two patients with Group II aneurysms. Direct surgery was mainly performed in Groups Ia (20 lesions), Ib (five lesions), and II (eight lesions), with complete neck clip occlusion achieved in 80, 80, and 71.4%, respectively; the transient and permanent morbidity rates associated with aneurysms treated by surgery were 8.6 and 2.9%, respectively.

Conclusions. Endovascular therapy for superiorly projecting paraclinoid aneurysms (Groups Ia and II) is associated with lower rates of complete obliteration than direct surgery, and with rates of cerebral embolic events comparable to those of endovascular treatment in the other groups. Furthermore, endovascular treatment for Group II aneurysms entails additional risks of retinal embolism. Therefore, direct surgery is recommended for the treatment of paraclinoid aneurysms projecting superiorly. For other groups, especially for Group III, endovascular treatment is the acceptable first line of therapy.