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PubMed2007

Single-stage operation for a giant haemangiopericytoma following intracranial feeder embolization.

Meningeal haemangiopericytomas (HPC) are malignant intracranial neoplasms that commonly recur and metastasize. Large size at diagnosis, abundant intracranial feeders and the risk of intraoperative bleeding can make them difficult to completely remove in one operation. We report here a rare case of a giant HPC which was treated successfully using a one-stage operation following superselective intracranial feeder occlusion. A 30-year-old man presented with a left middle cranial fossa tumour extending to the left temporal lobe and cerebellar tentorium. Angiography revealed supply from a dilated left posterior temporal artery branching from the posterior cerebral artery. The tumour was totally removed in a single-stage excision after embolization of the intracranial major feeding artery. The present case suggests the usefulness of preoperative embolization for HPC, particularly of intracranial feeders, to achieve total resection safely in a single operation.

Adult↗
PubMed1991

PET scanning in partial epilepsy.

Many biologically active tracers are available for positron emission tomography (PET) investigations, but most studies of epilepsy have utilized 18F-fluorodeoxyglucose (FDG) to measure local cerebral metabolic rate for glucose. Over 70% of patients with medically refractory partial seizures demonstrate an interictal zone of hypometabolism corresponding to the epileptogenic region. This metabolic defect commonly involves the temporal lobe in patients with complex partial seizures of mesial temporal origin, and is encountered less consistently with seizures of extratemporal neocortical origin. Although false localization is less likely with FDG-PET than with EEG, the hypometabolic zone merely reflects a focal functional deficit and its epileptogenicity must still be demonstrated electrophysiologically. When hemispherectomy or large multilobar resections are planned in small children, FDG-PET also provides useful supporting evidence that the contralateral hemisphere is functioning normally. It is difficult to obtain FDG-PET scans and to interpret results during spontaneous partial seizures. Ictal scans can be more easily obtained with single photon emission computed tomography (SPECT), which may provide information for planning surgical resections.

Electroencephalography↗
PubMed1986

Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial base.

A multidisciplinary approach by the neurosurgeon, ENT surgeon, and plastic surgeon has been used in seven patients with extensive tumors involving the middle and posterior skull base. Wide resection of these tumors was accomplished, and the resultant defect of the cranial base was reconstructed using free rectus abdominis muscle flaps. The free muscle flap has been used to reconstruct defects in the posterior and lateral walls of the nasopharynx, obliterate the exposed paranasal sinuses, and cover tenuous dural repairs or dural grafts overlying the temporal lobe and posterior fossa to prevent cerebrospinal fluid leakage and ascending meningitis.

Abdominal Muscles↗
PubMed2002

Epilepsy surgery in tuberous sclerosis: multistage procedures with bilateral or multilobar foci.

Refractory seizures are common in patients with tuberous sclerosis and can contribute to developmental delay and behavioral problems. Surgical intervention can reduce the seizure burden in selected patients with tuberous sclerosis and refractory epilepsy, thereby improving cognitive function, behavior, and quality of life. However, the risks of surgery are usually considered unacceptable when the epileptogenic focus lies over dominant hemisphere eloquent cortex or is multilobar. Multistage invasive monitoring can provide detailed data regarding the location and number of ictal foci and functional extraoperative mapping can precisely delineate the boundaries of eloquent areas of the brain. If independent ictal onsets are demonstrated, a staged surgical approach can allow a more aggressive yet safe procedure in selected patients. A combination of staged resection and multiple subpial transections may provide an opportunity to treat epileptogenic foci located over eloquent cortex. Bilateral staged resections can be used when independent bihemispheric foci are present in patients with tuberous sclerosis. This article presents two cases, one of which (case 2) was previously reported, on successful multistage surgical treatment of epileptogenic foci located over an eloquent cortex or in both hemispheres in children with tuberous sclerosis. This case is represented since there is additional follow-up available and the prior report was to a neurosurgical audience. This multistage approach permitted resection of epileptogenic foci that would traditionally have been considered inoperable.

Child↗
PubMed2001

Management of neurocytomas: case report and review of the literature.

The purpose of this report is to review the available literature on the presentation, pathology, and treatment of central nervous system (CNS) neurocytomas. A case report of an extraventricular neurocytoma is presented along with a comprehensive literature search of patients with a diagnosis of CNS neurocytoma. CNS neurocytomas are rare neoplasms, with fewer than 240 cases reported in the literature. The majority of neurocytomas are found in the ventricular system of the brain. Immunohistochemistry is frequently used to help distinguish this tumor from other CNS neoplasms. MIB-1 proliferation index is commonly used in an attempt to predict biologic behavior. Little is known about the management of patients with this tumor, because most reports are from the pathologic literature and contain sparse information regarding clinical management. Neurocytomas are rare CNS tumors with varied biologic behavior. MIB-1 index may help direct adjuvant therapy. An excellent prognosis can be expected if a gross total resection is achieved. Postoperative radiation therapy (RT) may be considered after subtotal resection. Otherwise, RT is an option for medically inoperable or recurrent disease.

Aged↗
PubMed1996

Early postoperative magnetic resonance imaging following nonneoplastic cortical resection.

Postcraniotomy residual tumor is often determined by magnetic resonance (MR) imaging. Magnetic resonance changes that occur in the postoperative setting must be defined to ensure both the optimum timing of postoperative image acquisition and the accurate assessment of images for residual tumor. Postoperative changes in nontumor parenchyma have previously been described for computerized tomography but not for MR imaging. In the present study, 11 patients without intracranial neoplastic disease (six females and five males with a median age of 36 years) submitted to MR imaging 17 to 28 hours after undergoing temporal lobectomies for epilepsy. Four of the operations were performed with the patients under general anesthesia and seven under local anesthesia. Postoperative MR images (T1-weighted, T1-weighted gadolinium enhanced, and T2-weighted) were reviewed. Extraaxial fluid, air, or blood was present in all cases. Enhancement of the resection bed parenchyma occurred in seven (64%) of 11 patients. In three of the remaining four patients, assessment of parenchymal enhancement was obscured by extraaxial fluid collections. Dural enhancement occurred adjacent to the resection site in all of the cases and remotely in 73%. Eight (73%) of 11 patients displayed enhancement of the pia-arachnoid of the ipsilateral cerebral convexity, two (18%) of the contralateral convexity, and four (36%) of the pia-arachnoid overlying the cerebellum. Contrary to previous reports, contrast enhancement of nonneoplastic human brain parenchyma can occur postoperatively within 17 hours. Benign parenchymal contrast enhancement is usually linear in appearance; nonneoplastic dural and leptomeningeal enhancement can occur both adjacent to and distant from the surgical site. Extraaxial fluid collections can hinder MR evaluation of the resection bed.

Adolescent↗
PubMed1976

Surgical and stereotactic attempts in intractable epilepsy.

The eras of surgical treatment of epilepsy, and experience with operations for epilepsy, especially those for temporal epilepsy, and stereotactic attempts based on depth multilead electrodes investigations and electro stimulation are described. Classical exposure and focus resection seems adequate whilst stereotaxy ought to be improved for the selective elimination of target structure activating the coded seizure pattern.

Brain↗
PubMed1993

The petrosal approach with hearing preservation.

Twenty-six patients with petroclival lesions were operated on via a petrosal approach designed to preserve hearing. The surgical pathology included 14 meningiomas, three chordomas, three epidermoid cysts, four vertebrobasilar aneurysms, and two pontine cavernous malformations. The approach allowed complete resection of 14 of 20 tumors and definitive treatment of all six vascular lesions. Complications included cerebrospinal fluid leakage in three patients, high-frequency sensorineural hearing loss in three, meningitis in one, and cranial nerve palsies (which were usually transient). This approach allows a wide exposure of the petroclival region with decreased operating distance. Cerebellar and temporal lobe retraction are minimized, dural sinus patency is maintained, and the inner ear structures are not sacrificed. The approach is suitable for neoplastic or vascular lesions involving the petroclival region, the ventral pons, or the basilar artery trunk. The surgical technique, indications, and neuro-otological considerations are discussed.

Adolescent↗
PubMed1995

[Dural AVF of the posterior fossa associated with sinus occlusion presenting as intracerebral hemorrhage: case report].

A 69-year-old man was admitted because of sudden onset of consciousness disturbance. Neurological examination on admission revealed slightly disturbed consciousness, sensory aphasia and right hemiparesis. CT scan disclosed a hematoma in the left posterior temporal lobe. Left carotid angiograms showed dural AVF of the transverse/sigmoid sinus fed mainly by the left occipital and posterior auricular arteries. On the angiograms the left sigmoid sinus was completely occluded. This was associated with retrograde venous flow into the cortical veins, the superior petrosal sinus and the contralateral traverse sinus. After stabilizing the condition, we totally resected the dural AVF including the left transverse sinus. The postoperative course was uneventful. Histopathological examination of the surgically resected specimen revealed that the dural A-V fistula per se existed in the sinus wall.

Aged↗
PubMed1991

[Pleomorphic xanthoastrocytoma. Apropos of 3 new cases. Review of the literature].

Three cases of pleomorphic xanthoastrocytomas (P.X.A.), a low grade leptomeningeal glioma are reported. Prominent histological features used for diagnosis were a cellular pleomorphism of G.F.A.P. positive cells, with intracytoplasmic lipidic vacuols. A reticulinic network and mononuclear cells infiltrates have been observed. A weak mitotic activity and lack of necrosis and of endothelial cells proliferation were significant additional features necessary for diagnosis. Our cases were observed during the surgical management of young patients with resistant epilepsy. Neuroradiological examinations showed a tumor superficially located within the temporal or the parietal lobe. This tumor could be calcified and/or cystic. Operative aspects showed a firm and non-encapsulated leptomeningeal tumor with possible various colors. Our patients were seizures-free after surgery even during the follow-up. From the currently reported cases clinical follow-up ranging for 1.5 to 3 years is not sufficient to predict a favorable carcinologic prognosis. P.X.A. is an uncommon tumor and less than 50 cases are reported throughout the literature. This tumor affecting young subjects mainly during the second decade is revealed in the majority of cases (3/4) by epileptic seizures, less frequently by a deficit or by an intracranial hypertension. The great majority of clinical events are observed before 20 years. The functional prognosis is rather good after surgery with a disappearance of epileptic fits in about 50% of the cases. Throughout the literature the prognosis of this tumor seems to be comparable to low-grade astrocytomas. Optimal management of P.X.A. seems to be primary surgical resection with later surgery for residual or recurrent tumor. The role of radiotherapy in the management of P.X.A. is at this time uncertain.

Adult↗
PubMed2005

Organization of receptive language-specific cortex before and after left temporal lobectomy.

OBJECTIVE: To examine brain activation associated with receptive language in patients with left temporal lobe epilepsy (TLE) before and after an anterior temporal lobectomy using magnetoencephalography (MEG), and to evaluate which patients were most likely to show a change in the lateralization and localization of the mechanisms supporting receptive language and if such changes were associated with neuropsychological function. METHODS: Twelve patients with left TLE underwent preoperative Wada testing, and pre- and postoperative neuropsychological testing and MEG language mapping. The anatomic location of receptive language-related activity sources observed with MEG was determined by coregistering MEG data with structural MRI scans. Language laterality indices were calculated based on the number of reproducible activity sources in each hemisphere. The proximity of language-specific activity sources to Wernicke's area was also examined. RESULTS: Although the small sample size precluded formal statistical analyses, patients with atypical (bilateral) hemispheric dominance preoperatively were more likely than patients with typical (left-hemisphere) dominance to show evidence of increased right hemisphere participation in language functions after surgery. Patients with left hemispheric dominance preoperatively were more likely to show intrahemispheric changes involving a slight inferior shift of the putative location of Wernicke's area. Patients with bilateral representation tended to perform worse on neuropsychological test measures obtained both pre- and postoperatively. CONCLUSION: Interhemispheric functional reorganization of language-specific areas may occur in patients undergoing left anterior temporal lobectomy. Intrahemispheric reorganization may take place even when the resection does not directly impinge upon Wernicke's area.

Amobarbital↗
PubMed1991

[Epilepsy surgery--advances in presurgical evaluations and operative techniques].

In 1886, Victor Horsley realized the possibility of surgical treatment of epilepsy, which had been suggested by John H. Jackson. However, it is only recently that surgery has been widely accepted as an important method of comprehensive management of epilepsies. In general, the presurgical evaluation is carried out in two phases: first phase of noninvasive studies (EEG and videomonitoring, brain imaging, psychometrics) and second phase using surgical techniques (videomonitoring with intracranial electrodes, angiography, Wada test, functional mapping). EEG-videomonitoring to record habitual seizures of patients contributed significantly. Although in about 25% of cases, phase 1 monitoring with scalp and sphenoid electrodes may be sufficient in determining surgical indication, depth electrode exploration is still necessary in the rest of cases. Among brain imaging tests, SPECT and PET showed better correlation with EEG abnormality, PET studies in ictal stage is the most reliable methods. The classical operative techniques, such as focal resection, temporal lobectomy and callosotomy are still in use. Application of microsurgical techniques enhanced the reliability of surgical outcome. The complex partial seizures of temporal origin are the most promising candidates for surgery. Careful presurgical evaluation may warrant more than a 90% postoperative improvement.

Epilepsy↗
PubMed2000

Statistical parametric mapping of regional glucose metabolism in mesial temporal lobe epilepsy.

We investigated statistical parametric mapping (SPM) use for positron emission tomography (PET) with [(18)F]fluorodeoxyglucose (FDG) data analysis in mesial temporal lobe epilepsy. The study involved 14 patients with temporal lobe epilepsy ultimately treated by anterior temporal lobectomy. Surgical outcome in terms of seizure control was favorable in 12 patients. Two different SPM approaches were designed to analyze each FDG-PET scan: a direct comparison with a control group (n = 27) and a search for significant interhemispheric asymmetry considering the asymmetry existing in the control group. Statistical inference was performed, first, without correction for multiple comparisons (making the hypothesis of temporal hypometabolism) and, second, after correction for multiple comparisons. Search for temporal interhemispheric asymmetry under the hypothesis of temporal hypometabolism was the most reliable SPM approach: hypometabolism was identified on the side chosen for resection in most cases (sensitivity, 71%; specificity, 100%) and was predictive of favorable postsurgical outcome in 90% of the patients. There was no false-positive result within the control group using this approach. After correction for multiple comparisons, SPM also identified in some patients temporal hypermetabolic areas as well as extratemporal cortical and subcortical hypometabolic areas on the side of resection but also on the contralateral side. In a further step, SPM was used for a group analysis of patients with favorable outcome after reversing scans when needed to set an identical lateralization in all patients. This analysis identified multiple ipsilateral temporal and extratemporal hypometabolic regions; when temporal metabolic changes were specifically assessed, the contralateral mesiotemporal region was found hypermetabolic, possibly as a manifestation of compensatory mechanisms in the presence of a unilateral epileptogenic lesion.

Adolescent↗
PubMed2005

[Surgical outcomes of different approaches for mesial temporal lobe gliomas].

OBJECTIVE: To analyze the surgical outcomes of different approaches for mesial temporal lobe gliomas. METHODS: Microsurgery was performed via trans-sylvian, trans-temporal, or subtemporal approaches on 62 patients with mesial temporal lobe gliomas, 33 with localized tumors within the mesial temporal structures (type A), 19 in anterior portion (type A1), and 14 extending to posterior portion (type A2); 19 patients with multicompartmental tumors involving the mesial temporal lobe, insular lobe, and posterior frontorbital gurus (type B); 14 patients with tumors involving the temporal pole and lateral areas of the temporal horn (type C); and 6 patients with tumors infiltrating the brain stem, basal nuclei and thalamus (type D). RESULTS: Trans-sylvian approach was performed in 25 cases of which total tumor removal was achieved in 14 cases, subtotal removal in 6 cases, and gross removal in 5 cases. Primary visual deficits worsened after surgery in 5 cases. Trans-temporal approach was used in 23 cases of which total tumor resection was achieved in 15 cases, subtotal resection in 5 cases, and gross resection in 3 cases. Primary visual deficits worsened after surgery in 5 cases. Four patients in which preoperative vision were good presented with visual deficits postoperatively. Subtemporal approach was used in 14 cases of which total tumor removal was achieved in 10 cases, and subtotal removal in 4 cases. All 14 patients did not develop worsened vision after surgery. CONCLUSION: Trans-sylvian and subtemporal approaches can reduce possible harm to parenchyma and optic radiation, whereas approaches to the temporal horn through the superior and middle temporal gyri will induce damage to parenchyma and optic radiation.

Adolescent↗
PubMed1995

Surgical management of middle cerebral artery aneurysms: experience with transsylvian and superior temporal gyrus approaches.

BACKGROUND: Middle cerebral artery (MCA) aneurysms are typically approached surgically using one of three basic techniques. The sylvian fissure can be opened in one of two ways; either from medial to lateral or from lateral to medial. Alternatively, an incision in the superior temporal gyrus with subpial resection can be used to expose the MCA branches and aneurysm neck. METHODS: We reviewed 65 middle cerebral aneurysms in 62 patients operated on over a 5-year interval where a choice of operative approach was made based on preoperative evaluation of available radiological studies. RESULTS: The superior temporal gyrus was used when intraparenchymal hematoma was present in the temporal lobe or when the length of the middle cerebral artery trunk was long (average length 2.44 +/- 0.41 SE cm). This approach was used in 20 operations on 22 aneurysms. The sylvian fissure approach was used in cases where the middle cerebral artery main trunk was short (1.32 +/- 0.41 SE cm) or the direction of the aneurysm was favorable. This approach was used in 38 operations. In 4 operations (5 aneurysms) we combined the two approaches to remove clot, obtain adequate exposure, and secure control of the proximal MCA. CONCLUSIONS: In most cases of MCA aneurysms the decision as to which surgical approach to use is made preoperatively depending on the presence of intraparenchymal clot, size of aneurysm, direction of aneurysm, and length of the proximal middle cerebral artery.

Cerebral Aqueduct↗
PubMed2000

High F-18 FDG uptake in a low-grade supratentorial ganglioma: a positron emission tomography case report.

PURPOSE: Positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (F-18 FDG) is used for the noninvasive monitoring and grading of primary brain tumors. Here the FDG uptake is positively correlated with the malignant extent of the lesion and thereby negatively correlated with patient survival. Little is known about the FDG PET features of primary brain tumors in children, such as mixed neuronal-glial tumors. METHODS: The authors describe a 13-year-old boy who had partial complex seizures since early childhood caused by a brain tumor in the left temporal lobe. RESULTS: Magnetic resonance and computed tomographic examinations yielded uncharacteristic results: mixed density, marked calcifications, little contrast enhancement, a nearly absent mass effect, and no edema. The FDG PET scan revealed a large hypermetabolic tumor, with a tumor: contralateral gray matter FDG uptake ratio of 1.45. In contrast to this intense hypermetabolism, the pathologic analysis after gross total resection revealed a low-grade ganglioglioma (WHO grade 1), which is usually associated with an excellent prognosis. CONCLUSIONS: Mixed neuronal-glial tumors such as gangliogliomas must be considered in making differential diagnoses by judging hypermetabolic FDG PET scans in young patients with brain tumors in the presence of uncharacteristic imaging features.

Adolescent↗
PubMed2002

Reorganization of cortical language areas in patients with aphasia: a functional MRI study.

The purpose of this study is to delineate the pattern of reorganization of cortical language areas using functional magnetic resonance imaging (fMRI) after rehabilitation therapy in patients with aphasia. Six right-handed aphasic patients were investigated. Causes of aphasia were intracerebral hemorrhages of the left basal ganglia in 3 patients, cerebral infarction of the left MCA in 2, and surgical resection of the frontotemporal lobes to control intractable epilepsy in 1. An auditory sentence completion task was used to activate brain language areas during the fMRI. Three patients with left frontal lesions showed activation in the right inferior frontal lobes while performing language tasks, whereas the other 3, whose lesions located at subcortical areas, showed activation in the bilateral frontal and temporal lobes. Our results demonstrated the differences in interhemispheric reorganization of the language network depending on the location of the lesion in aphasic patients. While the patients with subcortical lesion showed tendency of bilateral frontal activation, those with cortical lesion showed activation of the right frontal lobe.

Adult↗