Suboccipital decompressive craniectomy due to space-occupying cerebellar infarction

All patients treated with suboccipital decompressive craniectomy (SDC) due to space-occupying cerebellar infarction between January 2009 and October 2015 in the Rigshospitalet, were included in the study. Data was retrospectively collected from patient records, CT/MRI scans and surgical protocols. Long-term functional outcome was determined by the modified Rankin Scale (mRS) and mRS ≥ 4 was defined as unfavorable outcome.

Twenty-two patients (16 male, 6 female) were included in the study. Median age was 53 years. Nine patients were treated with external ventricular drainage as an initial treatment attempt prior to SDC. Median time from symptom onset (stroke ictus) to initiation of the SDC surgery was 48 h (IQR 28-99 hours) and median GCS before SDC was 8 (IQR 5-10). At follow up, median mRS was 3 (IQR 2-6). Outcome was favorable (mRS 0-3) in 12 patients and unfavorable in 10 (3 with major disability, 7 dead). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome.

In this small study, functional long-term outcome in patients with space-occupying cerebellar infarction treated by SDC was acceptable and comparable to previously published results (favorable outcome in 54% of patients). Brainstem infarction and bilateral cerebellar infarction were associated with unfavorable outcome 1).1) Lindeskog D, Lilja-Cyron A, Kelsen J, Juhler M. Long-term functional outcome after decompressive suboccipital craniectomy for space-occupying cerebellar infarction. Clin Neurol Neurosurg. 2018 Dec 1;176:47-52. doi: 10.1016/j.clineuro.2018.11.023. [Epub ahead of print] PubMed PMID: 30522035.

Unruptured intracranial aneurysm treatment decision

For a treatment decision of unruptured intracranial aneurysmphysicians and patients need to weigh the risk of treatment against the risk of hemorrhagic stroke caused by aneurysm rupture.

In a study of Detmer et al. Image segmentation data and patient information obtained from two patient cohorts including 203 patients with 249 aneurysms were used for patient-specific computational fluid dynamics simulations and subsequent evaluation of the statistical model in terms of accuracydiscrimination, and goodness of fit. The model’s performance was further compared to a similarity-based approach for rupture assessment by identifying aneurysms in the training cohort that were similar in terms of intracranial aneurysm hemodynamics and shape compared to a given aneurysm from the external cohorts.

When applied to the external data, the model achieved a good discrimination and goodness of fit (area under the receiver operating characteristic curve AUC = 0.82), which was only slightly reduced compared to the optimism-corrected AUC in the training population (AUC = 0.84). The accuracy metrics indicated a small decrease in accuracy compared to the training data (misclassification error of 0.24 vs. 0.21). The model’s prediction accuracy was improved when combined with the similarity approach (misclassification error of 0.14).

The model’s performance measures indicated a good generalizability for data acquired at different clinical institutions. Combining the model-based and similarity-based approach could further improve the assessment and interpretation of new cases, demonstrating its potential use for clinical unruptured intracranial aneurysm rupture risk assessment 1).

Scores

see also Unruptured intracranial aneurysm treatment score.

Unruptured intracranial aneurysm repair is the most commonly performed procedure for the prevention of hemorrhagic stroke. Despite efforts to regionalize care in high-volume centers, overall results have improved little 2).

The management of small unruptured incidentally discovered intracranial aneurysms (SUIAs) is still controversial.

Despite large trials supporting the management of small asymptomatic aneurysms, most neurosurgeons internationally chooses to treat them with surgery or endovascular means. Since clinicians use a number of factors beyond the maximum diameter when considering treatment options, future trials should consider these factors in their design 3).

Once a decision has been made to treat an intact aneurysm, the best treatment remains uncertain. Both surgical and endovascular management strategies are commonly performed for these lesions.

No one knows how best to manage these patients (an estimated 2—5% of the adult population), but with the increasing accessibility of non-invasive imaging, physicians are increasingly faced with the dilemma of what to do 4).

One stance maintains that the only acceptable rationale for a preventive treatment is randomised evidence that therapy does more good than harm. Thus, a randomised trial showing better outcomes for treated patients compared with conservatively managed patients would be necessary to justify invasive treatment of UIAs. However, this trial has not yet been successfully completed.

Posterior circulation in surgery, large aneurysms (>15 mm) in EVT, and stent- or balloon-assisted procedures in EVT were associated with the occurrence of complications. Poor clinical outcome (mRS of 3-6) was 0.8 % at hospital discharge.1) Detmer FJ, Fajardo-Jiménez D, Mut F, Juchler N, Hirsch S, Pereira VM, Bijlenga P, Cebral JR. External validation of cerebral aneurysm rupture probability model with data from two patient cohorts. Acta Neurochir (Wien). 2018 Dec;160(12):2425-2434. doi: 10.1007/s00701-018-3712-8. Epub 2018 Oct 30. PubMed PMID: 30374656.2) Zacharia BE, Bruce SS, Carpenter AM, Hickman ZL, Vaughan KA, Richards C, Gold WE, Lu J, Appelboom G, Solomon RA, Connolly ES. Variability in outcome after elective cerebral aneurysm repair in high-volume academic medical centers. Stroke. 2014 May;45(5):1447-52. doi: 10.1161/STROKEAHA.113.004412. Epub 2014 Mar 25. PubMed PMID: 24668204.3) Alshafai N, Falenchuk O, Cusimano MD. Practises and controversies in the management of asymptomatic aneurysms: Results of an international survey. Br J Neurosurg. 2015 Nov 5:1-7. [Epub ahead of print] PubMed PMID: 26540183.4) Raymond J, Darsaut TE, Molyneux AJ. A trial on unruptured intracranial aneurysms (the TEAM trial): results, lessons from a failure and the necessity for clinical care trials. Trials 2011; 12: 64.

Long-term outcome in intraspinal dermoid and epidermoid tumors

The purpose of the study of Wang et al. from the Peking Union Medical College Hospital, was to review the progression free survival (PFS), overall survival (OS), and long-term outcome in a consecutive series of 57 patients with intraspinal dermoid and epidermoid tumors.

A total of 57 patients who underwent surgery at the Peking Union Medical College Hospital between 2002 and 2010 were reviewed. Patients outcome were determined using the Japanese Orthopaedic Association scale (JOA) and the McCormick score.

The follow-up data were 100% complete and the median follow-up time was 9.2 years. Gross total resection was performed in 21 patients (36.84%) and subtotal resection in 36 patients (63.16%). The PFS and OS at 8 years were 78.95% and 100% respectively. A good outcome was observed in 56.14% of patients based on the JOA and McCormick score. The univariate analysis showed that a tumor size of more than 4 cm, subtotal resection and sphincter disturbances were the influencing factors of poor outcome.

The gold standard treatment for intraspinal tumors is gross total resection, but the operation needs to protect the remaining nerve function as much as possible and follow-up should be focused on patients with a high risk of poor outcome 1).Edit1) Wang X, Gao J, Wang T, Li Z, Li Y. Intraspinal dermoid and epidermoid cysts: Long-term outcome and risk factors. J Spinal Cord Med. 2018 Dec 5:1-6. doi: 10.1080/10790268.2018.1553008. [Epub ahead of print] PubMed PMID: 30517826.

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