This report focuses on the surgical management of aggressive intracranial dural arteriovenous fistulae (d-AVFs), which are defined as fistulae with arterialized leptomeningeal veins (red veins). ...Particular attention is paid to the accurate identification of the venous drainage pattern and to the choice of the proper treatment strategy.
Thirty-four consecutive patients with aggressive intracranial d-AVFs were treated between 1994 and 1998. Angiographic studies allowed the identification of two main types of aggressive lesions, i.e., d-AVFs with sinus drainage and reflow into leptomeningeal veins (12 patients), which we designated sinus fistulae, and d-AVFs drained exclusively by leptomeningeal veins without sinus interposition (22 patients), which we designated nonsinus fistulae. All patients underwent surgical treatment, which consisted of resection of the fistulous sinus tract in 12 cases of sinus fistulae and interruption of the draining veins at their dural origin in 22 cases of nonsinus fistulae. Surgical preparation via multistage transarterial embolization was required in all 12 cases of sinus fistulae and in 4 of 22 cases of nonsinus fistulae.
The mortality rate was 0%, and there were no instances of lasting morbidity. Radioanatomic cures were achieved in all cases. There was no case of venous hypertension or venous infarction after resection of the affected sinus or interruption of the draining veins. No arteriovenous shunts recurred during the follow-up period.
Careful preoperative identification of the venous drainage pattern seems critical for planning of the correct surgical strategy to treat aggressive intracranial d-AVFs. If the fistula exhibits sinus drainage with reflow into leptomeningeal veins, surgical excision of the fistulous sinus segment represents a safe and definitive treatment option. In these cases, the affected sinus may be safely removed, provided that preoperative angiograms demonstrate participation of the sinus in drainage of the lesion, indicating that the sinus is nonfunctional. Conversely, if the fistula exhibits pure leptomeningeal drainage, the sinus does not participate in drainage of the lesion and cannot be excised. In these cases, the best treatment involves interruption of the draining veins at the point at which they exit the dural wall of the sinus. This simple easy treatment has been proven to be safe and highly effective in permanently eliminating arteriovenous shunts.
Objective: The aim of this study was to assess efficacy and toxicity of temozolomide given alone or in combination with thalidomide,
an anti-angiogenetic drug, in patients with newly diagnosed ...glioblastoma multiforme (GBM). Patients and Methods: 46 patients
with histologically proven GBM were eligible for inclusion. Twenty-three patients (15 males and 8 females) received temozolomide
on a conventional schedule; 23 patients (12 males and 11 females) received temozolomide on the same schedule and thalidomide
was dose-adjusted in each individual patient based on their tolerance. Results: The median survival time was 12 months for
temozolomide and 13 months for temozolomide + thalidomide. Conclusion: The administration of temozolomide in association with
thalidomide after radiotherapy (RT) does not offer an advantage over temozolomide alone in adults with newly diagnosed GBM.
The two therapeutic strategies produce similar results for survival, but the latter regimen shows a moderate increase in toxicity.
A 62-year-old woman developed dysphasia, signs of intracranial hypertension and seizures. An MRI scan evidenced extra-axial contrast enhancement in the absence of mass lesions. CSF analysis was ...negative for malignant cytology and viral or bacterial microbiology. In the absence of other evidence, considering the acute clinical onset and MRI picture, a viral encephalitis was suspected and antiviral therapy was started, however, with no effect. Death occurred three weeks after presentation because of acute brain swelling. Autopsy revealed leptomeningeal gliomatosis and diffuse parenchymal infiltration at the cerebellar and left temporal lobe. Primary leptomeningeal gliomatosis (PLMG) is a rare event. The reported case and the reviewed literature evidence that clinical signs at presentation are non-specific, CSF negative findings are common, the diagnosis is always delayed and the prognosis dismal.
The surgical treatment of intracerebral hemorrhage (ICH) is one of the most controversial areas of neurosurgery. Randomized trials are inconclusive due to the small number of patients enrolled or ...because performed in pre CT era. We analyze the 232 patients admitted to the Niguarda Hospital of Milano, Italy, for ICH during the period January 2001-December 2002. Sixty patients were operated: 29 had secondary haemorrhage, and 30 a primary one. The strategy followed in these patients is presented. The series suggests that indication to surgery is a complex process including several factors that have to be all considered in each patient.
In order to identify prognostic factors of survival, twelve elements of disease and treatment have been evaluated for a population of 49 patients with diffuse low-grade astrocytoma treated with ...surgical resection and radiotherapy. The survival values were inversely correlated with age and major residual portion. On the other hand, KPS, lobar site, grade II Daumas-Duport lesions, protoplasmatic variant, early epilepsy, hyperfractionated radiotherapy and extent of exeresis were prognostic factors correlated with survival. Tumor extent and radiation total dose were not correlated in a meaningful way. Only KPS was statistically significant when compared to all the prognostic factors. We believe that patient selection according to age, lesion site and histological features are not sufficient to generate a homogeneous tumoral population. The most appropriate therapy for treating low-grade astrocytomas is still an open subject. However, recent studies have shown that the prognostic value of a group of factors is useful to plan controlled studies that compare differentiated treatment protocols.
Tirilazad mesylate, a nonglucocorticoid 21-aminosteroid, has been shown in experimental models to reduce vasospasm following subarachnoid hemorrhage (SAH) and to reduce infarct size from focal ...cerebral ischemia. To test whether treatment with tirilazad would reduce ischemic symptoms from vasospasm and improve overall outcome in patients with ruptured aneurysms, a prospective randomized, double-blind, vehicle-controlled trial was conducted at 41 neurosurgical centers in Europe, Australia, and New Zealand. One thousand twenty-three patients were randomly assigned to receive 0.6, 2, or 6 mg/kg per day of intravenously administered tirilazad or a placebo containing the citrate vehicle. All patients were also treated with intravenously administered nimodipine. Patients receiving 6 mg/kg per day of tirilazad had reduced mortality (p = 0.01) and a greater frequency of good recovery on the Glasgow Outcome Scale 3 months after SAH (p = 0.01) than similar patients treated with vehicle. There was a reduction in symptomatic vasospasm in the group that received 6 mg/kg per day tirilazad; however, the difference was not statistically significant (p = 0.048). The benefits of treatment with tirilazad were predominantly shown in men rather than in women. There were no material differences between the outcomes in the groups treated with 0.6 and 2 mg/kg tirilazad per day and the group treated with vehicle. Tirilazad was well tolerated at all three dose levels. These observations suggest that tirilazad mesylate, at a dosage of 6 mg/kg per day, is safe and improves overall outcome in patients (especially in men) who have experienced an aneurysmal SAH.
Intracranial dural arteriovenous fistulas (AVFs) have been recognized as acquired lesions that can behave aggressively depending on the pattern of venous drainage. Based on the type of venous ...drainage, they can be classified as fistulas drained only by venous sinuses, those drained by venous sinuses with retrograde flow in arterialized leptomeningeal veins, and fistulas drained solely by arterialized leptomeningeal veins. Serious symptoms, including hemorrhage and focal deficit, are related to the presence of arterialized leptomeningeal veins. In this paper, the authors report a consecutive series treated between 1988 and 1993 of 20 cases of intracranial dural AVFs with "pure leptomeningeal drainage." All patients underwent surgical interruption of the leptomeningeal draining veins. Based on the arterial supply, nine patients were managed by direct surgery, whereas 11 patients were prepared for surgery by means of preoperative arterial embolization. Radioanatomical cure of the fistula and good neurological recovery were achieved in 18 cases. Complete obliteration of the fistula was documented angiographically in two cases, but fatal hemorrhage occurred, probably due to partial thrombosis of the venous drainage. Based on this experience, the authors believe that surgical interruption of the draining veins is the best treatment option for intracranial dural AVFs. However, surgical results may be affected by the extension of postoperative thrombosis, which in turn may be related to the degree of preoperative venous engorgement.
Aneurysms of the vertebro-basilar junction area have been considered the most difficult to be surgically treated because of their deep location, the proximity of the brain stem and the cranial ...nerves. However, at present, new endovascular techniques and new transbasal surgical approaches offer valuable management strategies. This paper concerns six consecutive patients whom we managed either endovascularly or surgically during a period of eighteen months. Direct surgical treatment was offered to two young patients with relatively small aneurysms in good neurological condition, whereas the other four patients initially underwent an endovascular attempt at aneurysm obliteration using the Guglielmi detachable coil system. Unfortunately, interventional neuroradiology failed in three cases, and surgery had to be re-considered. Accordingly, a total of five patients underwent surgical clipping through the combination of a transmastoid retrolabyrinthine approach with the suboccipital lateral approach. This combination of approaches provided a good control of both vertebral arteries and basilar artery, and allowed the aneurysm to be correctly clipped in all cases. Good long-term results were achieved in all cases but one. Based on this preliminary experience, we would stress the importance of multidisciplinary approach with a treatment calibrated for each single case. Furthermore, if surgery is to be performed, the combination of transmastoid-retrolabyrinthine and suboccipital lateral approaches provides a wide exposure of the whole vertebro-basilar junction area and allows good access to the lesion.
