Intracranial metastases surgery

Intracranial metastases surgery

see Intracranial metastases surgery indications.

Intracranial Metastases Surgical Technique.


Automated classification of brain metastases and healthy brain tissue is feasible using optical coherence tomography imaging, extracted texture features, and machine learning with principal component analysis (PCA) and support-vector machines (SVM). The established approach can prospectively provide the surgeon with additional information about the tissue, thus optimizing the extent of tumor resection and minimizing the risk of local recurrences 1).

Wolpert et al. defined risk profiles for the development of BM-related epilepsy and derived a score which might help to estimate the risk of post-operative seizures and identify individuals at risk who might benefit from primary prophylactic antiepileptic drug therapy 2).


1)

Möller J, Bartsch A, Lenz M, Tischoff I, Krug R, Welp H, Hofmann MR, Schmieder K, Miller D. Applying machine learning to optical coherence tomography images for automated tissue classification in brain metastases. Int J Comput Assist Radiol Surg. 2021 May 30. doi: 10.1007/s11548-021-02412-2. Epub ahead of print. PMID: 34053010.
2)

Wolpert F, Lareida A, Terziev R, Grossenbacher B, Neidert MC, Roth P, Poryazova R, Imbach L, Le Rhun E, Weller M. Risk factors for the development of epilepsy in patients with brain metastasis. Neuro Oncol. 2019 Sep 10. pii: noz172. doi: 10.1093/neuonc/noz172. [Epub ahead of print] PubMed PMID: 31498867.

Anterior transpetrosal approach

Anterior transpetrosal approach

see Anterior petrosectomy.

In 1985Takeshi Kawase from the Department of Neurosurgery, Keio University School of Medicine, Tokyo, and Ashikaga Red Cross Hospital, AshikagaJapan 1) published an anterior petrosal approach to expose the posterior cranial fossa and to minimize retraction of the temporal lobe for upper petroclival


Anterior subtemporal and transpetrous apex approaches let us some exposure of deep region, however they require an unacceptable temporal lobe retraction and provide an extremely narrow surgical corridor in cases of large tumors mainly located in the infratentorial space 2) 3).

This approach requires epidural subtemporal procedures to expose the petrous apex adequately. The petrous apex must be totally resected and the dura of the temporal lobe and posterior fossa is then cut to ligate the superior petrosal sinus and tentorium. In this procedure, the most important things are to preserve the internal carotid artery (C2 segment) and greater superficial petrosal nerve (GSPN). To identify the GSPN, facial nerve integrity monitor (Medtronic Inc, Dublin, Ireland) is very useful. In the extradural bone removal, Sonopet Ultrasonic Aspirator (Stryker Ltd, Portage, Michigan) is a very excellent surgical tool for avoiding the injury of the internal carotid artery. As demonstrated by Cavalcanti, ATPA is particularly useful for accessing lesions located in the upper ventral pons via the supratrigeminal zone because it provides a wide and shallow surgical field above the trigeminal nerve without requiring retraction of the cerebellum 4).


Several neurosurgeons still have difficulty with removing tumors through an anterior petrosal approach, because a complete understanding of the Kawase pyramid has not been achieved. Jung et al. hypothesized that if anterior petrosectomy is performed with a three-dimensional understanding of the Kawase pyramid, it would have a positive effect on the extent of tumor resection.

They performed a retrospective study of patients who underwent surgical treatment for meningioma through an anterior petrosal approach. Patients were divided into total resection and subtotal resection groups, and statistical differences between the two groups were analyzed. To identify factors predictive of complete tumor removal, univariable and multivariable logistic regression analyses were performed.

The width and height of the drilled internal acoustic canal (IAC) of the total resection group were significantly longer than those of the subtotal resection group (p=0.001, p=0.033). The operative angle of the total resection group was significantly larger than that of the subtotal resection group (p<0.001). Regression analyses showed only drilled IAC width to be predictive of complete tumor removal, increasing the likelihood thereof by 2.778-fold with an increase in drilled IAC width by 1 mm (p=0.023).

Insufficient petrosectomy during an anterior petrosal approach adversely affects the extent of tumor resection. Furthering a three-dimensional understanding of the Kawase pyramid could help complete tumor resection and better outcomes without causing damage to the surrounding organs 5).


see Anterior transpetrosal transtentorial approach.

see Anterior transpetrosal approach indications.

A study of Shibao et al., included 126 patients treated via the ATPA. The bridging vein (BV) and the tentorial sinus (TenS) located in the operative fields were analyzed. Furthermore, in the preoperative evaluation, the cross-sectional shapes of the intradural vein and the interdural sinus were analyzed by curved planar reconstruction (CPR), and the flattening rate was calculated. Flattening rate = (a-b)/a = 1-b/a (a: long radius, b: short radius).

Seventeen BVs and 18 TenS were identified. The bridging site was divided into two groups: tentorial and middle fossa. The middle fossa group was divided into three subgroups: cavernous sinus, middle fossa dural sinus, and middle fossa dural adherence. Five isolated TenS were sacrificed and no venous complications were observed. The mean flattening rate was 0.13 in the intradural vein and 0.51 in the interdural sinus, respectively (P = 0.0003).

They showed classification of the BV, and preservation of the BV and TenS during the ATPA. Furthermore, they found that the interdural sinus was significantly flatter than the intradural veins. Measuring the flattening rate by CPR may be useful to identify BVs preoperatively 6).


1)

Kawase T, Toya S, Shiobara R, Mine T. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg. 1985 Dec;63(6):857-61. PubMed PMID: 4056899.
2)

Bambakidis NC, Gonzalez LF, Amin‐Hanjani S, et al: Combined skull base approaches to the posterior fossa. Technical note. Neurosurg Focus 19:E8, 2005
3)

Yang J, Ma SC, Fang T, et al: Subtemporal transpetrosal apex approach: study on its use in large and giant petroclival meningiomas. Chin Med J (Engl) 124:49‐55, 2011
4)

Yokoyama K, Kawanishi M, Sugie A, Yamada M, Tanaka H, Ito Y, Yamshita M. Microsurgical Resection of a Ventral Pontine Cavernoma via Supratrigeminal Zone by Anterior Transpetrosal Approach: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2018 Jul 19. doi: 10.1093/ons/opy177. [Epub ahead of print] PubMed PMID: 30032310.
5)

Jung IH, Yoo J, Roh TH, Park HH, Hong CK. Importance of sufficient petrosectomy in an anterior petrosal approach relightening of the Kawase pyramid. World Neurosurg. 2021 May 15:S1878-8750(21)00712-9. doi: 10.1016/j.wneu.2021.05.017. Epub ahead of print. PMID: 34004357.
6)

Shibao S, Toda M, Fujiwara H, Jinzaki M, Yoshida K. Bridging vein and tentorial sinus in the subtemporal corridor during the anterior transpetrosal approach. Acta Neurochir (Wien). 2019 Feb 23. doi: 10.1007/s00701-019-03857-w. [Epub ahead of print] PubMed PMID: 30798482.

Delirium

Delirium

Delirium, or acute confusional state, is an organically-caused decline from a previously attained baseline level of cognitive function. It is typified by fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-wake cycle, and psychotic features such as hallucinations and delusions.

With Cocaine initial CNS stimulation that first manifests as a sense of well-being and euphoria. Sometimes dysphoric agitation results, occasionally with delirium.


Thallium: may produce tremors, leg pains, paresthesias in the hands and feet, polyneuritis in the LE, psychosisdeliriumseizures, encephalopathy.


Hypercalcemia

Delirium tremens.

see Postoperative Delirium.

see Alcohol withdrawal seizures.

Early neutrophil-to-lymphocyte ratio (NLR) elevation may also predict delayed-onset delirium, potentially implicating systemic inflammation as a contributory delirium mechanism 1).


Delirium is an acute disorder affecting up to 80% of intensive care unit (ICU) patients. It is associated with a 10-fold increase in cognitive impairment, triples the rate of in-hospital mortality, and costs $164 billion annually. Delirium acutely affects attention and global cognitive function with fluctuating symptoms caused by underlying organic etiologies. Early detection is crucial because the longer a patient experiences delirium the worse it becomes and the harder it is to treat. Currently, identification is through intermittent clinical assessment using standardized tools, like the Confusion Assessment Method for ICU. Such tools work well in clinical research but do not translate well into clinical practice because they are subjective, intermittent and have low sensitivity. As such, healthcare providers using these tools fail to recognize delirium symptoms as much as 80% of the time. Delirium-related biochemical derangement leads to electrical changes in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. However, continuous EEG monitoring is not feasible due to cost and need for skilled interpretation. Studies using limited-lead EEG show large differences between patients with and without delirium while discriminating delirium from other causes. The Ceribell is a limited-lead device that analyzes EEG. If it is capable of detecting delirium, it would provide an objective physiological monitor to identify delirium before symptom onset. This pilot study was designed to explore relationships between Ceribell and delirium status. Completion of this study will provide a foundation for further research regarding delirium status using the Ceribell data 2).

Unlike dementia, delirium has an acute onset, motor signs (tremormyoclonusasterixis), slurred speech, altered consciousness (hyperalert/agitated or lethargic, or fluctuations), hallucinations may be florid. EEG shows pronounced diffuse slowing.


Delirium itself is not a disease, but rather a clinical syndrome (a set of symptoms). It may result from an underlying disease, from drugs administered during treatment of that disease in a critical phase, withdrawal from drugs, from a new problem with mentation, or from varying combinations of two or more of these factors. It is a corollary of the criteria that a diagnosis of delirium usually cannot be made without a previous assessment, or knowledge, of the affected person’s baseline level of cognitive function. In other words, a mentally disabled person who is suffering from this will be operating at their own baseline level of mental ability and would be expected to appear delirious without a baseline mental functional status against which to compare.


Hut SC, Dijkstra-Kersten SM, Numan T, Henriquez NR, Teunissen NW, van den Boogaard M, Leijten FS, Slooter AJ. EEG and clinical assessment in delirium and acute encephalopathy. Psychiatry Clin Neurosci. 2021 May 16. doi: 10.1111/pcn.13225. Epub ahead of print. PMID: 33993579.

Delirium vs. dementia (critical distinction). Delirium AKA acute confusional state. Distinct from dementia; however, patients with dementia are at increased risk of developing delirium.

A primary disorder of attention that subsequently affects all other aspects of cognition.

Often represents life-threatening illness, e.g.hypoxiasepsisuremic encephalopathyelectrolyte abnormality, drug intoxication, MI. 50% of patients die within 2 yrs of this diagnosis.

Unlike dementia, delirium has acute onset, motor signs (tremormyoclonusasterixis), slurred speech, altered consciousness (hyperalert/agitated or lethargic, or fluctuations), hallucinations may be florid. EEG shows pronounced diffuse slowing.


Status epilepticus.

Delirium during critical illness is associated with nearly a 3-fold increased risk of death the following day for patients in the hospital but is not associated withmortality after hospital discharge. This finding appears primarily driven by the hypoactive motoric subtype. The independent relationship between delirium and mortality occurs early during critical illness but does not persist after hospital discharge 3)


1)

Reznik ME, Kalagara R, Moody S, Drake J, Margolis SA, Cizginer S, Mahta A, Rao SS, Stretz C, Wendell LC, Thompson BB, Asaad WF, Furie KL, Jones RN, Daiello LA. Common biomarkers of physiologic stress and associations with delirium in patients with intracerebral hemorrhage. J Crit Care. 2021 Mar 23;64:62-67. doi: 10.1016/j.jcrc.2021.03.009. Epub ahead of print. PMID: 33794468.
2)

Mulkey MA, Hardin SR, Munro CL, Everhart DE, Kim S, Schoemann AM, Olson DM. Methods of identifying delirium: A research protocol. Res Nurs Health. 2019 May 30. doi: 10.1002/nur.21953. [Epub ahead of print] PubMed PMID: 31148216.
3)

Hughes CG, Hayhurst CJ, Pandharipande PP, Shotwell MS, Feng X, Wilson JE, Brummel NE, Girard TD, Jackson JC, Ely EW, Patel MB. Association of Delirium during Critical Illness With Mortality: Multicenter Prospective Cohort Study. Anesth Analg. 2021 Apr 30. doi: 10.1213/ANE.0000000000005544. Epub ahead of print. PMID: 33929361.
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