Intentionally staged operation for large and high-flow cerebral arteriovenous malformation

Sterile Gelatin Film Reduces Cortical Injury Associated With Brain Tumor Re-Resection

BACKGROUND

Recurrent intracranial tumors frequently require re-resection. Dural adhesions to the cortex increase the morbidity and duration of these revision craniotomies.

OBJECTIVE

To describe the use of commercially available sterile gelatin film to prevent meningocerebral adhesions and decrease the rate of surgically induced ischemia from revision craniotomy.

METHODS

This retrospective cohort study examined patients with recurrent glioma, meningioma, and metastasis who underwent re-resection at least 30 d following their initial tumor resection. Cortical surface tissue ischemia after re-resection on diffusion-weighted magnetic resonance imaging was compared for patients with (gelatin film group) and without (nongelatin film group) a history of gelatin film placement at the conclusion of their initial tumor resection.

RESULTS

A total of 84 patients in the gelatin film group were compared to 86 patients in the nongelatin film group. Patient age, sex, tumor pathology, tumor volume, tumor eloquence, laterality of surgical approach, history of radiotherapy, and time interval between resections did not differ between groups. Radiographic evidence of cortical ischemia following reoperation was less prevalent in the gelatin film group (13.1% vs 32.6%; P < .01). In multivariate logistic regression analysis, no gelatin film (P < .01) and larger tumor size (P = .02) predicted cortical surface ischemia following revision craniotomy. Postoperative complications in the gelatin film and nongelatin film group otherwise did not differ.

CONCLUSION

Routine placement of commercially available sterile gelatin film on the cortex prior to dural closure is associated with decreased surgically induced tissue ischemia at the time of revision tumor craniotomy.

Staged Surgical Resection of Brain Arteriovenous Malformations

BACKGROUND

Staged treatment of brain arteriovenous malformations (AVMs) is sometimes necessary to minimize risks associated with sudden changes in cerebral hemodynamics. With the increasing availability and optimization of endovascular techniques, multiple surgical resections are rarely necessary, although, due to specific anatomic circumstances, some AVMs still require staged surgery. Here, we describe the largest reported series of staged surgical resections of brain AVMs.

METHODS

This is a retrospective review of surgically resected AVMs at a single institution from 1998-2018. Patients who underwent ≥2 resections within 1 year were reviewed. Only those in whom initial resection was terminated with intention for further resection were included in analysis.

RESULTS

Twenty patients underwent deliberately staged resection from 1998-2018. Average age at treatment was 36.2 years (SD 16.5 years). Eleven patients (55%) were female, and 12 (60%) had left-sided AVMs. Median Spetzler-Martin grade was 4 (interquartile range [IQR]: 3-4). Average AVM nidus diameter was 5.0 cm (SD 1.7 cm). Seven patients (35%) presented with AVM rupture, and 12 (60%) presented with focal neurologic deficits without hemorrhage. Seventeen patients (85%) underwent preoperative embolization, median number of embolizations was 3 (IQR: 2-4). Three patients (15%) underwent preoperative radiosurgery. Median number of days between surgeries was 28 (IQR: 8-41 days). Perioperative course was complicated by hemorrhage in 3 patients (15%); 1 required decompressive hemicraniectomy prior to the second stage of surgery. Good functional outcome (defined as modified Rankin Scale score ≤2) was achieved in 14 patients (70%).

CONCLUSIONS

Staged surgical resection of large and complex AVMs can be performed with good outcomes in carefully selected patients.

Staged Cranial Surgery for Intracranial Lesions: Historical Perspective

We follow the development of staged resection from its first description by Walter E. Dandy, one of the founding fathers of neurosurgery, in 1925 in which he removed a large vestibular schwannoma.This historical vignette cites neurosurgical case reports and literature to demonstrate the evolution of staged resection of intracranial lesions, from Dandy's initial use to its becoming a more viable and safe option for the treatment of meningiomas, vestibular schwannomas, and skull base lesions (among numerous other intracranial pathologies). We also discuss the current advancements and future perspectives of staged resection that may show promise in effectively treating a wide range of pathologies while simultaneously reducing morbidity rates-a warrant for further exploration of staged cranial surgery as an important tool in neurosurgery.

Decompressive craniectomy using gelatin film and future bone flap replacement

Object

Decompressive craniectomy plays an important role in the management of patients with traumatic brain injury (TBI) and stroke. Risks of decompressive craniectomy include those associated with cranioplasty, and may be related to adhesions that develop between the brain surface and overlying scalp and temporalis muscle. The authors report their institutional experience using a multilayered technique (collagen and gelatin film barriers) to facilitate safe and rapid cranioplasty following decompressive craniectomy.

Methods

The authors conducted a retrospective chart review of 62 consecutive adult and pediatric patients who underwent decompressive craniectomy and subsequent cranioplasty between December 2007 and January 2011. Diagnoses included TBI, ischemic stroke, intraparenchymal hemorrhage, or subarachnoid hemorrhage. A detailed review of clinical charts was performed, including anesthesia records and radiographic study results.

Results

The majority of patients underwent unilateral hemicraniectomy (n = 56), with indications for surgery including midline shift (n = 37) or elevated intracranial pressure (n = 25). Multilayered decompressive craniectomy was safe and easy to perform, and was associated with a low complication rate, minimal operative time, and limited blood loss.

Conclusions

Decompressive craniectomy repair using an absorbable gelatin film barrier facilitates subsequent cranioplasty by preventing adhesions between intracranial contents and the overlying galea aponeurotica and temporalis muscle fascia. This technique makes cranioplasty dissection faster and potentially safer, which may improve clinical outcomes. The indications for gelatin film should be expanded to include placement in the epidural space after craniectomy.

Intracerebral hemorrhage following endovascular embolization of brain arteriovenous malformation with a combination of Onyx and n-butyl cyanoacrylate: a case report

We report a 29-year-old female patient who developed intracerebral hemorrhage 16 h after endovascular embolization of a brain arteriovenous malformation with a combination of liquid embolic agents of Onyx and n-butyl cyanoacrylate. After emergent craniectomy with evacuation of the hematoma, the patient recovered consciousness with mild expressive aphasia. The possible etiology of postembolization brain hemorrhage was discussed, and the literature was reviewed.

Pathophysiology of overactive bladder

Overactive bladder (OAB) is a common disorder that negatively affects the quality of life of our patients and carries a large socioeconomic burden. According to the International Continence Society, it is characterized as urinary urgency, with or without urge incontinence, usually, with frequency and nocturia in the absence of causative infection. The pathophysiology of this disease entity varies between neurogenic, myogenic, or idiopathic factors. This paper provides a review of the contemporary theories behind the pathophysiology of OAB.

Parkinson disease and comorbid cerebrovascular disease

Optimal management of chronic diseases not only requires tackling of the primary disease processes, but also necessitates timely recognition and treatment of comorbid conditions. In this article, we illustrate this two-pronged approach for two common age-related disorders: Parkinson disease (PD) and cerebrovascular disease (CVD). We first discuss the pathophysiological mechanisms that could provide a link between PD and CVD. Patients with PD have a series of risk factors that could promote development of CVD, but also have several protective factors. We then review the available clinical, radiological and neuropathological evidence to support an association between these two conditions. We conclude by discussing the potential implications for clinical practice, highlighting how comorbid CVD could alter the clinical presentation of PD and reviewing the possibilities for prevention and secondary prophylaxis. Additional research will be needed to fully evaluate the prevalence and clinical relevance of comorbid CVD in PD. Pending further evidence, we recommend that cerebral neuroimaging should be considered if patients with initially uncomplicated PD develop-either acutely or chronically-prominent and/or treatment-resistant gait impairment, postural instability, depression, cognitive decline, or urinary incontinence. Finding comorbid CVD in such patients could have prognostic implications, and could necessitate treatment to arrest further progression of CVD.

Overactive bladder in Parkinson's disease: alteration of brainstem raphe detected by transcranial sonography

Urinary dysfunction is very common in idiopathic Parkinson's disease (PD) and manifests primarily with symptoms of overactive bladder (OAB). Affection of central serotonergic systems has been suggested to play a role in OAB. The objective of this study was to evaluate whether in PD patients with OAB symptoms a specific alteration of the brainstem raphe (BR), which contains serotonergic neurons, can be detected with transcranial sonography (TCS). Of 116 PD patients enrolled, 19 had PD-related OAB symptoms (OAB+) unlike remaining 97 patients (OAB-). Patients were examined by a sonographer blinded to the clinical data. Reduced echogenicity of BR was found in 12 (63%) OAB+ patients but only in 18 (19%) of 93 assessable OAB- patients (Mann-Whitney U-test, P < 0.001). In OAB+ patients, lower raphe echogenicity score was associated with longer duration of OAB symptoms (anova, P = 0.033). Other TCS findings such as echogenicity of substantia nigra, thalami, lenticular and caudate nuclei, and widths of third and lateral ventricles did not differ between OAB+ and OAB- patients. TCS findings suggest a pathogenetic role of BR in OAB related to PD. Alterations may reflect disturbance of its central serotonergic system.

Pharmacotherapy of Parkinson’s disease in Germany

Treatment standards or guidelines have been developed for most features of Parkinson's disease (PD). However, data on the actual treatment that is put into practice are scarce. In 2000, a nationwide survey on the topic of sudden onset of sleep (SOS) in PD was initiated among the members of the German patient support group (deutsche Parkinson-Vereinigung, dPV). A part of this mailed questionnaire survey covering the antiparkinsonian and concomitant medication of the participants is presented here. This study analyses data sets from more than 6,500 PD patients. The mean dopaminergic dose was equivalent to 599 +/- 387 mg levodopa/die. The most frequently administered drugs were levodopa (94.2 %), dopamine agonists (DA) (71.7 %), amantadine (40.1 %), selegiline (27.6 %), entacapone (20.4 %), budipine (12.3 %), and anticholinergics (11.8 %). Costs of pharmacotherapy were estimated to be approximately <euro> 399 million/year in Germany. PD drug therapy in general strongly depended on age, disease duration, and the level of care. The treatment guidelines were apparently not consistently followed underlining the need for their continuous propagation throughout the medical community. In addition our data suggest that non-motor symptoms in PD are not adequately treated and that concomitant sedative medication contributes to the occurrence of SOS.

Mechanisms of Disease: central nervous system involvement in overactive bladder syndrome

The pathophysiology of overactive bladder syndrome (OABS) and detrusor overactivity (DO) is complex and involves both peripheral and central nervous system (CNS) factors. Central in OABS is urgency, the pathophysiology of which is unknown. Increased afferent activity, decreased capacity to process afferent information, decreased suprapontine inhibition, and increased sensitivity to contraction-mediating transmitters are all potential causes of DO and OABS. Because both urgency and initiation of the micturition reflex depend on afferent input from the lower urinary tract, it seems logical that in the search for new therapies for DO/OABS, afferent functions and central control of afferent functions are targets of interest. Voiding and storage reflexes involve several transmitters and transmitter systems that could be targets for the development of drugs that control DO/OABS. Perturbations of these systems are found in CNS disorders associated with DO/OAB, such as stroke, Parkinson's disease, spinal cord injury and multiple sclerosis. This short overview focuses on the afferent pathways and on how the transmitter systems that control micturition can be perturbed by disease to give rise to DO/OABS.