update

Falx Meningioma

Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain

Falx or falcine meningioma, as defined by Harvey Williams Cushing, is a intracranial meningioma arising from the falx cerebri and completely concealed by the overlying cortex 1).

Not involving the superior sagittal sinus.

Epidemiology

Falcine meningiomas account for 9% of all intracranial meningiomas.

Falcine meningioma tends to grow predominately into one cerebral hemisphere but is often bilateral, and in some patients the tumor grows into the inferior edge of the sagittal sinus.

The patients with falcine meningiomas with reference to gender had the following ratio of male:female of 1:2.1 and an average age of 55 years.

In the series of Pires de Aguiar et al 1:6 (men:women) relationship, and the mean age was 55.4 years old 2).

Classification

They can be divided into anterior, middle, and posterior types, depending on their origin in the falx 3).

The anterior type extends from the floor of the anterior cranial fossa to the coronal suture, the middle type from the coronal suture to the lambdoid suture, and the posterior type extends from the lambdoid suture to the torcular Herophili.

Falx meningioma of the anterior third

Falx meningioma of the middle third

Falcine meningioma of the posterior third.

Yasargil classified falcine meningiomas into outer and inner types. The former arise from the main body of the falx in the frontal (anterior or posterior), central parietal, or occipital regions, whereas inner falcine meningiomas arise in conjunction with the inferior sagittal sinus. 4).

Zuo et al classified FM into four types, according to tumour growth patterns on coronal MRI: Type I, hemispheroid-shaped tumours invaginating deeply into one hemisphere without shifting the falx (10 patients); Type II, olive-shaped tumours shifting the falx substantially to the contralateral side (six patients); Type IIIA, globular- or dumbbell-shaped tumours extending into both hemispheres, but to different extents (one patient); and Type IIIB, globular- or dumbbell-shaped tumours extending into both hemispheres to approximately equal extent (three patients). An ipsilateral interhemispheric approach was performed for Type I tumours, and a contralateral transfalcine approach for Type II. Type IIIA tumour was approached from the side where the smaller tumour was located. Type IIIB tumours were approached from the non-dominant hemisphere 5).

Das et al. proposed a new classification schema:

Thirty-five patients with FM (mean age, 50.03 years; male/female ratio, 16:19) were classified into unilateral conventional (type I; n = 17), unilateral high (type II; n = 9) and bilateral FM (type III; n = 9) based on the coronal magnetic resonance imaging findings. We excluded the primary parasagittal meningiomas from our analysis.

Type II and III tumors were more common in males (unlike the overall cohort), presented more often with seizures, and were associated with less favorable postoperative outcomes. Preoperative motor weakness was almost exclusively seen with the unilateral tumors (type I/II). Preexisting weakness (P = 0.02) was a strong predictor of the likelihood of postoperative motor power worsening, the major surgical complication in our series (n = 9; 25.7%). New-onset postoperative weakness (n = 2) recovered completely, whereas worsening of the preexisting weakness showed only a partial improvement (n = 6).

The proposed classification scheme characterizes FMs comprehensively. Bilaterality and parasagittal extensions in FMs affect their clinical presentation, increase surgical difficulty, and influence the surgical outcome adversely. Preexisting motor weakness portends a poor postoperative motor outcome 6).

see also cystic falx meningioma.

Clinical features

Symptoms can vary depending upon the location of these tumors along the falx.

Those located in the frontal section may impair higher levels of brain functioning such as reasoning and memory, while those located in the middle section would be more likely to cause leg weakness.

In the series of Chung et al. at presentation, symptom durations were found to vary widely. Twenty-one patients (30%) presented with headache, and eleven (16%) with unilateral motor weakness. Five (7%) patients had a chief complaint of a seizure history. Five (7%) patients presented with personality change and four (6%) were asymptomatic and their brain tumors were detected incidentally 7).

Diagnosis

MRI with and without gadolinium helps better to delineate the tumor in relation to the dural sinus, the tumor interface with the cerebral cortex, presence of significant blood supply, and presence of cysts or other intra-tumoral structures that will add to the complexity and malignant potential of the tumor. Good pre-operative evaluation of falcine meningiomas is also important when integrated with neuronavigation protocols to be utilized in the operating room. Furthermore, the junction between tumor and adjacent brain suggests the presence or absence of an accessible arachnoid plane and enables the surgeon to predict the potential degree of neurologic deficit that may follow surgical removal. Gadolinium-enhanced MRI allows demonstration of tumoral or adjancent dural enhancement. The radiological appearance affords a valid predictor of the degree of dural involvement in the region of the sinus and adjacent falx. This may suggest the presence of syncytium of meningeal cells spreading along the falx from the site of major dural attachment.

Multiplanar MRI is the current standard study for the preoperative evaluation of patients with falcine meningiomas. Coronal, sagittal, and axial T1-weighted gadolinium-enhanced sequences help define the anatomical locations, sizes, and medial hemisphere involvements of these tumors.

MR venography in vertex view can be useful for demonstrating nearby parasagittal draining veins, which must be protected 8) , but MRA alone seems to be inadequate in the lack of venous phase of cerebral vasculature around tumors.

Cerebral angiography

Cerebral angiography is necessary in patients with these meningiomas, and the pericallosal artery is often displaced and may actually be engulfed by the tumor. Arterial phase cerebral or MR angiograms should be studied to determine the relationship between tumor and ACA. Anterior falcine meningiomas are usually supplied by the ACA or by a tentorial branch of the ophthalmic artery. Venous phase cerebral angiography is important because it provides significant information about whether a tumor mass has invaded the sagittal sinus. Moreover, it provides information about the courses of many large drainers around a mass, which must be determined to identify trajectory to a falcine mass and to prevent postoperative venous infarction. It is also useful for determining sinus patency and for delineating the anatomical location of the major cortical draining vein. Signs of venous occlusion include the disappearance of a segment of the superior sagittal sinus (SSS), a delay in venous drainage in the area of obstruction, and failure of the cortical vein to reach the sinus.

Differential diagnosis

Falx meningioma differential diagnosis.

Treatment

see Falx meningioma treatment.

Complications

The falcine meningiomas may be present with bleeding as intraparenchymal hematomas, subdural hematomas and subarachnoid hemorrhage, causing a clinical finding of apoplexy in the patients.

Hemorrhages occurring in asymptomatic falcine meningiomas are known beforehand to have been described after the internal use of low-dose aspirin for prolonged period.

During falcine meningioma surgery, we must pay attention to cardiac monitoring due to the risk that the handling of falx and tentorium could provoke cardiac asystole. The mechanical stimulation of the falcine area may result in the hyperactivity of the trigeminal ganglion, thereby triggering TCR.

The dorsal region of the spinal trigeminal tract includes neurons from hypoglossal and vagus nerves, and projections have been seen between the vagus and trigeminal nuclei.

Recurrence

It has been reported that parasagittal meningioma and falx meningiomas recur more frequently than other intracranial meningiomas 9).

The rate of recurrence of falx meningiomas significantly increases in cases of non-radical resection of tumor. Aggressive surgical treatment obviously may present several hazards and may carry an increased risk of unsatisfactory outcome; however, the risk of recurrence is significantly decreased 10).

Abou Al-Shaar et al. have utilized brachytherapy as a salvage treatment in two patients with a unique implantation technique. Both patients had recurrence of WHO Grade II falcine meningiomas despite multiple prior surgical and RT treatments. Radioactive I-125 seeds were made into strands and sutured into a mesh implant, with 1 cm spacing, in a size appropriate to cover the cavity and region of susceptible falcine dura. Following resection the vicryl mesh was implanted and fixed to the margins of the falx. Implantation in this interhemispheric space provides good dose conformality with targeting of at-risk tissue and minimal radiation exposure to normal neural tissues. The patients are recurrence free 31 and 10 months after brachytherapy treatment. Brachytherapy was an effective salvage treatment for the recurrent aggressive falcine meningiomas in two patients 11).

Videos

Books

Parasagittal and falx meningiomas 1970 by P. C Gautier-Smith (Author)

Publisher: Appleton-Century-Crofts (1970) Language: English ISBN-10: 0407352406 ISBN-13: 978-0407352407

Case series

Falx meningioma case series.

Case reports

see Falx meningioma case reports

1)

Cushing H, Eisenhardt L. Their Classification, Regional Behavior, Life History, and Surgical End Results: The chiasmal syndrome, in Meningiomas. Suprasellar Meningiomas. 1938:224–49.
2) , 10)

Pires de Aguiar PH, Aires R, Maldaun MV, Tahara A, de Souza Filho AM, Zicarelli CA, Ramina R. Is sagittal sinus resection in falcine meningiomas a factor of bad surgical outcome? Surg Neurol Int. 2010 Oct 25;1:64. doi: 10.4103/2152-7806.71983. PubMed PMID: 21125007; PubMed Central PMCID: PMC2980903.
3)

Al-Mefty O, Becker DP, Lanman TH. Meningiomas. 1991. pp. 345–356.
4)

Yasargil MG. Microneurosurgery. Vol 4. 1996. Meningioma; pp. 134–165.
5)

Zuo FX, Wan JH, Li XJ, Qian HP, Meng XL. A proposed scheme for the classification and surgical planning of falcine meningioma treatment. J Clin Neurosci. 2012 Dec;19(12):1679-83. doi: 10.1016/j.jocn.2012.01.034. Epub 2012 Oct 6. PubMed PMID: 23047062.
6)

Das KK, Gosal JS, Sharma P, Mehrotra A, Bhaisora K, Sardhara J, Srivastava A, Jaiswal AK, Kumar R, Behari S. Falcine Meningiomas: Analysis of the Impact of Radiologic Tumor Extensions and Proposal of a Modified Preoperative Radiologic Classification Scheme. World Neurosurg. 2017 Aug;104:248-258. doi: 10.1016/j.wneu.2017.04.159. Epub 2017 May 3. PubMed PMID: 28478253.
7)

Chung SB, Kim CY, Park CK, Kim DG, Jung HW. Falx meningiomas: surgical results and lessons learned from 68 cases. J Korean Neurosurg Soc. 2007 Oct;42(4):276-80. doi: 10.3340/jkns.2007.42.4.276. Epub 2007 Oct 20. PubMed PMID: 19096556; PubMed Central PMCID: PMC2588203.
8)

Alvernia J, Sindou M. Preoperative neuroimaging findings as a predictor of surgical plane of cleavage : Prospective study of 100 consecutive cases of intracranial meningioma. J Neurosurg. 2004;100:422–430.
9)

Melamed S, Sahar A, Bellar AJ. The recurrence of intracranial meningiomas. Neurochirurgia. 1979;22:47–51.
11)

Abou Al-Shaar H, Almefty KK, Abolfotoh M, Arvold ND, Devlin PM, Reardon DA, Loeffler JS, Al-Mefty O. Brachytherapy in the treatment of recurrent aggressive falcine meningiomas. J Neurooncol. 2015 Aug 8. [Epub ahead of print] PubMed PMID: 26253325.

Middle cerebral artery M4 segment aneurysm

Middle cerebral artery M4 segment aneurysm

Middle cerebral artery aneurysms, are mainly found in the proximal and bifurcation tracts and only in the 1.1-1.7% of cases they are located in the M4 segment of the middle cerebral artery 1) 2) 3).

Etiology

Generally, these aneurysms are secondary to traumatic brain injury and inflammatory or infectious diseases and only rarely they have idiopathic origin 4).

At present, only nine cases of ruptured cortical middle cerebral artery aneurysms have been described in literature 5) 6) 7) 8) 9) 10).

The patients are all males, except the case of Ricci et al. 11). The average age of the reported patients is 40 years. The size of the aneurysms is between 1 mm and 10 mm and, in most cases, they are saccular intracranial aneurysms or fusiform morphology. In five patients, the aneurysms present infectious etiology. Usually, they occur with ICH, sometimes associated with subarachnoid hemorrhage (SAH).

Treatment

The endovascular treatment (EVT) has been performed in four cases, while the surgical treatment has been performed in three cases (two of trapping and one of clipping). In one patient, the infectious aneurysm has resolved spontaneously after antibiotic therapy. In all treatments performed, the patients have improved the neurologic symptoms and no residual aneurysms have been observed in the subsequent neuroradiology follow-up 12). Although surgery remains the main choice in the M4 aneurysms, because of the extremely distal location of them over the motor/somatosensory cortices, 13) Lv et al. 14) propose the use of the EVT in all types of the M4 aneurysms, especially after the surgery, when it is impossible to locate the small ruptured aneurysm.

The main difficulty of the surgery is the precise surgical localization of the small M4 aneurysms 15). An inaccurate localization of these vascular lesions may result in larger craniotomies and unnecessary arachnoid and pial dissections with possible resultant permanent neurological injuries 16).

In cases of aneurysms or arteriovenous malformations located at the sylvian point or at the posterior superior aspect of the insula, especially in dominant hemisphere, to reduce the dissection and open easily sylvian fissure, a logical path would follow the angular artery in the sylvian fissure cutting the arachnoid fibers and retracting only the tissues which are necessary to gain more exposure of the lesion 17).

Case reports

A case of a ruptured dissecting pseudoaneurysm in the distal Middle cerebral artery (distal M3/proximal M4) prefrontal division in an healthy young patient (<60 years) successfully treated with a Pipeline Embolization Device. The PED was chosen both as the only vessel sparing option in the young patient as well as for its potential as a vessel sacrifice tool if the pseudoaneurysm was felt to be incompletely treated, which in this case was not necessary-though would have leveraged the thrombogenicity of the device as a therapeutic advantage 18).

2017

A 53-year-old female was admitted with a sudden severe headache, nausea, vomiting, and a slight left hemiparesis. The computed tomography (CT) scan showed subarachnoid hemorrhage (SAH) in the left sylvian fissure and intracerebral hemorrhage (ICH) in the left posterior parietal area. The CT angiography (CTA) reconstructed with 3D imaging showed a small saccular aneurysm in the M4 segment in proximity of the angular area. A left parieto-temporal craniotomy was performed, the aneurysm was clipped and the ICH evacuated. The motor deficit was progressively recovered. At 3-month follow-up examination, the patient was asymptomatic and feeling well.

Surgery is the best choice for the treatment of ruptured M4 aneurysms with ICH in the opinion of Ricci et al., because it allows to evacuate the hematoma and to exclude the aneurysm from the intracranial circulation. In addition, we suggest both the use of the neuronavigation technique and of the indocyanine green videoangiography (ICGV) for the aneurismal surgery 19).

2007

A 41-year-old man presented with an infarction manifesting as left-sided weakness and dysarthria. Magnetic resonance angiography revealed a subacute stage infarction in the right MCA territory and complete occlusion of the right ICA. Angiography demonstrated aneurysmal dilatation of the M4 segment of the right MCA. Surgery was performed to prevent hemorrhage from the aneurysm. The aneurysm was proximally clipped guided by Navigation-CT angiography and flow to the distal MCA was restored by superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis 20).

2005

A 20-year-old man with an intracerebral haemorrhage due to a ruptured aneurysm, which arose from a penetrating artery of the distal middle cerebral artery (MCA; M4 segment). Excision of the aneurysm was successfully achieved via a right pterional approach. The follow-up angiogram demonstrated filling of the parent vessel and no residual aneurysm. This report illustrates the angiographical finding of a penetrating artery aneurysm of the distal MCA and summarizes the previous reports to discuss their pathological and clinical characteristics 21).

1) , 4) , 5) , 21)

Ahn JY, Han IB, Joo JY. Aneurysm in the penetrating artery of the distal middle cerebral artery presenting as intracerebral haemorrhage. Acta Neurochir (Wien). 2005 Dec;147(12):1287-90; discussion 1290. Epub 2005 Aug 29. PubMed PMID: 16133768.
2) , 8) , 14)

Lv N, Zhou Y, Yang P, Li Q, Zhao R, Fang Y, Xu Y, Hong B, Zhao W, Liu J, Huang Q. Endovascular treatment of distal middle cerebral artery aneurysms: Report of eight cases and literature review. Interv Neuroradiol. 2016 Feb;22(1):12-7. doi: 10.1177/1591019915617317. Epub 2015 Dec 3. Review. PubMed PMID: 26637241; PubMed Central PMCID: PMC4757379.
3)

Elsharkawy A, Lehečka M, Niemelä M, Billon-Grand R, Lehto H, Kivisaari R, Hernesniemi J. A new, more accurate classification of middle cerebral artery aneurysms: computed tomography angiographic study of 1,009 consecutive cases with 1,309 middle cerebral artery aneurysms. Neurosurgery. 2013 Jul;73(1):94-102; discussion 102. doi: 10.1227/01.neu.0000429842.61213.d5. PubMed PMID: 23615110.
6)

Horiuchi T, Tanaka Y, Takasawa H, Murata T, Yako T, Hongo K. Ruptured distal middle cerebral artery aneurysm. J Neurosurg. 2004;100:384–8.
7)

Lee SM, Park HS, Choi JH, Huh JT. Ruptured mycotic aneurysm of the distal middle cerebral artery manifesting as subacute subduralhematoma. J Cerebrovasc Endovasc Neurosurg. 2013;15:235–40.
9) , 13) , 15) , 16)

Raza SM, Papadimitriou K, Gandhi D, Radvany M, Olivi A, Huang J. Intra-arterial intraoperative computed tomography angiography guided navigation: a new technique for localization of vascular pathology. Neurosurgery. 2012 Dec;71(2 Suppl Operative):ons240-52; discussion ons252. doi: 10.1227/NEU.0b013e3182647a73. PubMed PMID: 22858682.
10) , 11) , 12) , 19)

Ricci A, Di Vitantonio H, De Paulis D, Del Maestro M, Raysi SD, Murrone D, Luzzi S, Galzio RJ. Cortical aneurysms of the middle cerebral artery: A review of the literature. Surg Neurol Int. 2017 Jun 13;8:117. doi: 10.4103/sni.sni_50_17. eCollection 2017. PubMed PMID: 28680736; PubMed Central PMCID: PMC5482160.
17)

Ausman JI, Diaz FG, Malik GM, Tomecek F. A new microsurgical approach to cerebrovascular lesions of the sylvian point: report of two cases. Surg Neurol. 1990 Jul;34(1):48-51. PubMed PMID: 2360163.
18)

Berwanger RP, Hoover MC, Scott JA, DeNardo AJ, Amuluru K, Payner TD, Kulwin CG, Sahlein DH. The Use of a Pipeline Embolization Device for Treatment of a Ruptured Dissecting Middle Cerebral Artery M3/M4 Aneurysm: Challenges and Technical Considerations. Neurointervention. 2022 Apr 7. doi: 10.5469/neuroint.2022.00045. Epub ahead of print. PMID: 35385900.
20)

Lee SH, Bang JS. Distal Middle Cerebral Artery M4 Aneurysm Surgery Using Navigation-CT Angiography. J Korean Neurosurg Soc. 2007 Dec;42(6):478-80. doi: 10.3340/jkns.2007.42.6.478. Epub 2007 Dec 20. PubMed PMID: 19096593; PubMed Central PMCID: PMC2588183.

Foramen ovale

Foramen ovale

Oval opening in the greater wing of sphenoid bone transmitting the mandibular nerve as its major content.

It serves as an important landmark for neurosurgeons in certain procedures as to gain access to trigeminal nerve.

Therefore, its topographic position in relation to adjacent bony landmarks provides useful tool during these procedures.

Morphometric analysis was carried out on 104 foramina ovalia of 52 dry human skulls from South India. Following dimensions of foramen ovale were measured: antero-posterior length, transverse width, distance (d(1)) from tubercle of root of zygoma to the centre of the foramen (CF) and distance (d(2)) from the midline of the base of the skull to CF. Results: The mean antero-posterior length was 7.0±2.17mm on right side and 6.8±1.40mm on left side, mean transverse width was 5.0±0.42mm and 4.70±0.91mm on right and left side respectively. Mean d(1) was 32.58±1.72mm on right side and 32.75±1.76mm on left side. Mean d(2) was 25.83±1.26mm on right side and 25.08±1.31mm on left side. Conclusion: Regional variations in the morphometric measures may be useful in neurosurgical procedures like administration of anaesthesia involving the mandibular nerve 1).

The aim of a study is to objectively describe the shape of the FO and its most likely shape variation. A total of 211 FO were evaluated by geometric morphometric analysis. A consensus shape is presented for the FO. No significant difference was found between the shapes of left- and right-sided FO. The most likely shape variation of the FO occurs as an inverse relationship between the anteromedial-posterolateral and anterolateral-posteromedial aspects of the foramen. The capacity to visualize the average FO shape and understand the most likely shape variance, as illustrated by Zdilla et al., will aid neurosurgeons in their approach to procedures requiring cannulation of the FO 2).

Anatomical variations can occasionally result in unexpected findings on physical examination. McDonough et al. from the Tulane Center for Clinical Neurosciences reported two cases of seemingly unique connections between maxillary nerve (V2, sensory) and mandibular nerve (V3, motor and sensory) branches parts of the trigeminal nerve. In these two cadaveric specimens, at the foramen ovale, small neural connections, confirmed with histology, were identified joining V2 to specifically, the motor root of V3 3).

Patent foramen ovale

see Patent foramen ovale.

Foramen ovale puncture

see Foramen ovale puncture.

1)

Patil J, Kumar N, K G MR, Ravindra S S, S N S, Nayak B S, Marpalli S, L S A. The foramen ovale morphometry of sphenoid bone in South Indian population. J Clin Diagn Res. 2013 Dec;7(12):2668-70. doi: 10.7860/JCDR/2013/7548.3727. Epub 2013 Dec 15. PubMed PMID: 24551606.
2)

Zdilla MJ, Fijalkowski KM. The Shape of the Foramen Ovale: A Visualization Aid for Cannulation Procedures. J Craniofac Surg. 2016 Dec 23. doi: 10.1097/SCS.0000000000003325. [Epub ahead of print] PubMed PMID: 28027173.
3)

McDonough S, Olewnik Ł, Iwanaga J, Dumont AS, Tubbs RS. Connection between V2 and V3 parts of the trigeminal nerve at the internal cranial base. Folia Morphol (Warsz). 2022 Apr 5. doi: 10.5603/FM.a2022.0031. Epub ahead of print. PMID: 35380015.

Unruptured intracranial aneurysm treatment score

Unruptured intracranial aneurysm treatment score

see also PHASES score.

The unruptured intracranial aneurysm treatment score (UIATS) was published in April 2015 as a multidisciplinary consensus regarding the treatment of unruptured intracranial aneurysms (UIA).

Etminan et al. endeavored to develop an unruptured intracranial aneurysm treatment score (UIATS) model that includes and quantifies key factors involved in clinical decision-making in the management of UIAs and to assess agreement for this model among specialists in Unruptured intracranial aneurysm (UIA) management and research.

An international multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 specialists was convened to develop and validate the UIATS model using a Delphi consensus. For internal (39-panel members involved in the identification of relevant features) and external validation (30 independent external reviewers), 30 selected UIA cases were used to analyze agreement with UIATS management recommendations based on a 5-point Likert scale (5 indicating strong agreement). Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (vr) (vr = 0 indicating excellent agreement and vr* = 1 indicating poor agreement).

The UIATS accounts for 29 key factors in UIA management. Agreement with UIATS (mean Likert scores) was 4.2 (95% confidence interval [CI] 4.1-4.3) per reviewer for both reviewer cohorts; agreement per case was 4.3 (95% CI 4.1-4.4) for panel members and 4.5 (95% CI 4.3-4.6) for external reviewers (p = 0.017). Mean Likert scores were 4.2 (95% CI 4.1-4.3) for interventional reviewers (n = 56) and 4.1 (95% CI 3.9-4.4) for noninterventional reviewers (n = 12) (p = 0.290). Overall IRA (vr*) for both cohorts was 0.026 (95% CI 0.019-0.033).

This novel UIA decision guidance study captures an excellent consensus among highly informed individuals on UIA management, irrespective of their underlying specialty. Clinicians can use the UIATS as a comprehensive mechanism for indicating how a large group of specialists might manage an individual patient with a UIA 1)   

The Unruptured Intracranial Aneurysm Treatment Score (UIATS) offers support for clinical decision making and has been shown to correlate with real-life decisions in clinical practice. However, there is no data concerning the correlation of patient Unruptured intracranial aneurysm outcome and UIATS. Patients presenting to the Department of Neurosurgery,University Hospital Leipzig, outpatient clinic between January 1st, 2014, and December 31st, 2017 were retrospectively analyzed. They recorded the Extended Glasgow Outcome Scale (GOS-E) for the longest possible follow-up, the choice of treatment, complications, and UIATS recommendation. They included 221 patients with 322 UIA. 124 (38.5 %) UIA were observed and 198 (61.5 %) were occluded, of which 62 (31.3 %) underwent open surgery and 136 (68.7 %) were treated endovascularly. Spearman’s rank correlation between the treatment choice and conclusive UIATS recommendation was 0.362 (p < 0.001). If UIATS was inconclusive, there were significantly more treatment-associated deteriorations (10/66 versus 7/132, p = 0.020). Otherwise, UIATS was not significantly associated with outcome. Therefore, the treatment choice for UIA remains an individual decision. However, inconclusive UIATS must trigger vigilance and may be a negative prognostic marker for complications 2).

A tertiary center with focus on vascular neurosurgery, aimed to investigate whether there treatment decision-making in patients with UIA has been in accordance with the published UIATS. A retrospective analysis of patients admitted to the center with UIA was performed. UIATS was applied to all identified UIA. Three decision groups were defined: (a) UIATS favoring treatment, (b) UIATS favoring observation, and © UIATS inconclusive. These results were then compared to our clinical decisions. Spearman’s rank-order correlation (ρ) was run to determine the relationship between the UIATS and our clinical decisions. Cases of discrepancies between UIATS and our clinical decisions were then examined for complications, defined as periprocedural adverse events in treated aneurysms, or aneurysm rupture in untreated aneurysms. Ninety-three patients with 147 UIA were included. A total of 118/147 (80.3%) UIA were treated. In 70/118 (59.3%), UIATS favored treatment, in 18/118 (15.3%), it was inconclusive, and in 30/118 (25.4%), it favored observation. A total of 29/147 (19.7%) UIA were not treated. In 15/29 (51.7%), UIATS favored observation, in 9/29 (31%), it favored treatment, and in 5/29 (17.2%), it was inconclusive (ρ = 0.366, p < 0.01). Discrepancies between UIATS and our clinical decisions did not correlate with complications (ρ = 0.034, p = 0.714). Our analysis shows that our more intuitive clinical decision-making has been in line with UIATS. Our treatment decisions did not correlate with an increased rate of complications 3).

The purpose of the study of Ravindra et al. was to compare the unruptured intracranial aneurysm treatment score (UIATS) recommendations with the real-world experience in a quaternary academic medical center with a high volume of patients with unruptured intracranial aneurysms (UIAs).

All patients with UIAs evaluated during a 3-year period were included. All factors included in the UIATS were abstracted, and patients were scored using the UIATS. Patients were categorized in a contingency table assessing UIATS recommendation versus real-world treatment decision. The authors calculated the percentage of misclassification, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve. RESULTS A total of 221 consecutive patients with UIAs met the inclusion criteria: 69 (31%) patients underwent treatment and 152 (69%) did not. Fifty-nine (27%) patients had a UIATS between -2 and 2, which does not offer a treatment recommendation, leaving 162 (73%) patients with a UIATS treatment recommendation. The UIATS was significantly associated with treatment (p < 0.001); however, the sensitivity, specificity, and percentage of misclassification were 49%, 80%, and 28%, respectively. Notably, 51% of patients for whom treatment would be recommended by the UIATS did not undergo treatment in the real-world cohort and 20% of patients for whom conservative management would be recommended by UIATS had intervention. The area under the ROC curve was 0.646.

Compared with the authors’ experience, the UIATS recommended overtreatment of UIAs. Although the UIATS could be used as a screening tool, individualized treatment recommendations based on consultation with a cerebrovascular specialist are necessary. Further validation with longitudinal data on rupture rates of UIAs is needed before widespread use 4).

1)

Etminan N, Brown RD Jr, Beseoglu K, Juvela S, Raymond J, Morita A, Torner JC, Derdeyn CP, Raabe A, Mocco J, Korja M, Abdulazim A, Amin-Hanjani S, Al-Shahi Salman R, Barrow DL, Bederson J, Bonafe A, Dumont AS, Fiorella DJ, Gruber A, Hankey GJ, Hasan DM, Hoh BL, Jabbour P, Kasuya H, Kelly ME, Kirkpatrick PJ, Knuckey N, Koivisto T, Krings T, Lawton MT, Marotta TR, Mayer SA, Mee E, Pereira VM, Molyneux A, Morgan MK, Mori K, Murayama Y, Nagahiro S, Nakayama N, Niemelä M, Ogilvy CS, Pierot L, Rabinstein AA, Roos YB, Rinne J, Rosenwasser RH, Ronkainen A, Schaller K, Seifert V, Solomon RA, Spears J, Steiger HJ, Vergouwen MD, Wanke I, Wermer MJ, Wong GK, Wong JH, Zipfel GJ, Connolly ES Jr, Steinmetz H, Lanzino G, Pasqualin A, Rüfenacht D, Vajkoczy P, McDougall C, Hänggi D, LeRoux P, Rinkel GJ, Macdonald RL. The unruptured intracranial aneurysm treatment score: a multidisciplinary consensus. Neurology. 2015 Sep 8;85(10):881-9. doi: 10.1212/WNL.0000000000001891. Epub 2015 Aug 14. PubMed PMID: 26276380; PubMed Central PMCID: PMC4560059.
2)

Wende T, Kasper J, Wilhemy F, Prasse G, Quäschling U, Haase A, Meixensberger J, Nestler U. Comparison of the unruptured intracranial aneurysm treatment score recommendations with clinical treatment results – A series of 322 aneurysms. J Clin Neurosci. 2022 Feb 9;98:104-108. doi: 10.1016/j.jocn.2022.01.038. Epub ahead of print. PMID: 35151060.
3)

Hernández-Durán S, Mielke D, Rohde V, Malinova V. The application of the unruptured intracranial aneurysm treatment score: a retrospective, single-center study. Neurosurg Rev. 2018 Feb 1. doi: 10.1007/s10143-018-0944-2. [Epub ahead of print] PubMed PMID: 29388120.
4)

Ravindra VM, de Havenon A, Gooldy TC, Scoville J, Guan J, Couldwell WT, Taussky P, MacDonald JD, Schmidt RH, Park MS. Validation of the unruptured intracranial aneurysm treatment score: comparison with real-world cerebrovascular practice. J Neurosurg. 2017 Oct 6:1-7. doi: 10.3171/2017.4.JNS17548. [Epub ahead of print] PubMed PMID: 28984518.

Magnetic resonance guided focused ultrasound thalamotomy for essential tremor

Magnetic resonance guided focused ultrasound thalamotomy for essential tremor

Magnetic resonance guided focused ultrasound is a minimally invasive surgical procedure for symptomatic treatment of Parkinson Disease. With this technology, the ventral intermediate nucleus, STN, and internal globus pallidus have been targeted for therapeutic cerebral ablation, while also minimizing the risk of hemorrhage and infection from more invasive neurosurgical procedures.

In a pilot study published in 2013, essential tremor improved in 15 patients treated with magnetic resonance guided focused ultrasound thalamotomy. 1).

Clinical trials have confirmed the efficacy of focused ultrasound (FUS) thalamotomy in essential tremor, but its effectiveness and safety for managing tremor-dominant Parkinson disease (TDPD) is unknown.

It might change the way that patients with essential tremor and potentially other disorders are treated 2).

Effectiveness

The post-treatment effectiveness was evaluated using the clinical rating scale for tremors. Thalamic MRgHIFU had substantial therapeutic effects on patients, based on MRgHIFU-mediated improvements in movement control and significant changes in brain mu rhythms. Ultrasonic thalamotomy may reduce hyper-excitable activity in the motor cortex, resulting in normalized behavioral activity after sonication treatment. Thus, non-invasive and spatially accurate MRgHIFU technology can serve as a potent therapeutic tool with broad clinical applications 3).

Safety

Magnetic resonance guided focused ultrasound (MRgFUS) for thalamotomy is a safe, effective and less-invasive surgical method for treating medication-refractory essential tremor (ET). However, several issues must be resolved before clinical application of MRgFUS, including optimal patient selection and management of patients during treatment 4).

Jung et al. found different MRI pattern evolution after MRgFUS for white matter and gray matter. Their results suggest that skull characteristics, such as low skull density, should be evaluated prior to MRgFUS to successfully achieve thermal rise 5).

Nursing management

In a large academic medical center in the mid-Atlantic region, the Department of Neurosurgery conducted a continued access study, recently approved by the Food and Drug Administration, to evaluate the effectiveness of transcranial FUS thalamotomy for the treatment of medication-refractory ET.

One patient’s experience will be introduced, including discussion of evidence-based treatment options for ET and information on the nursing management of the patient undergoing FUS thalamotomy 6).

Meta-analysis

A PubMed search was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if hand tremor scores (HTS), total Clinical Rating Scale for Tremor (CRST) scores, or Quality of Life in Essential Tremor Questionnaire (QUEST) scores at regular intervals following MRgFUS treatment for essential tremor were documented. Data analyses included a random effects model of meta-analysis and mixed-effects model of meta-regression. Twenty-one articles reporting HTS for 395 patients were included. Mean pre-operative HTS was 19.2 ± 5.0. Mean HTS at 3 months post-treatment was 7.4 ± 5.0 (61.5% improvement, p < 0.001). Treatment effect was mildly decreased at 36 months at 9.1 ± 5.4 (8.8% reduction). Meta-regression of time since treatment as a modifier of HTS revealed a downward trend in effect size, though this was not statistically significant (p = 0.208). Only 4 studies included follow-up ≥ 24 months. Thirteen included articles reported total CRST scores with standardized follow-up for 250 patients. Mean pre-operative total CRST score decreased by 46.2% at 3 months post-treatment (p < 0.001). Additionally, mean QUEST scores at 3 months post-treatment significantly improved compared to baseline (p < 0.001). HTS is significantly improved from baseline ≥ 24 months post-treatment and possibly ≥ 48 months post-treatment. There is a current paucity of long-term CRST and QUEST score reporting in the literature 7).

Prospective randomized clinical trials

In a double-blinded, prospective, sham-controlled randomized controlled trial of MR-guided focused ultrasound thalamotomy for treatment of tremor-dominant PD, 62% of treated patients demonstrated improvement in tremor scores from baseline to 3 months postoperatively, as compared to 22% in the sham group. There has been only one open-label trial of MR-guided focused ultrasound subthalamotomy for patients with PD, demonstrating improvements of 71% for rigidity, 36% for akinesia, and 77% for tremor 6 months after treatment. Among the two open-label trials of MR-guided focused ultrasound pallidotomy for patients with PD, dyskinesia and overall motor scores improved up to 52% and 45% at 6 months postoperatively. Although MR-guided focused ultrasound thalamotomy is now approved by the U.S. Food and Drug Administration for treatment of parkinsonian tremor, additional high-quality randomized controlled trials are warranted and are underway to determine the safety and efficacy of MR-guided focused ultrasound subthalamotomy and pallidotomy for treatment of the cardinal features of PD. These studies will be paramount to aid clinicians to determine the ideal ablative target for individual patients. Additional work will be required to assess the durability of MR-guided focused ultrasound lesions, ideal timing of MR-guided focused ultrasound ablation in the course of PD, and the safety of performing bilateral lesions 8).

Case series

see Magnetic resonance guided focused ultrasound thalamotomy for essential tremor case series.

Case reports

A 55-yr-old man with a history of right frontal craniotomy for resection of a colloid cyst underwent a left ventrointermedius nucleus thalamotomy through MRgFUS. The prior craniotomy flap was not excluded in the treatment plan; however, all bony defects and hardware were marked as “no-pass” regions. Clinical outcomes were collected at the 6-mo follow-up.

Transducer elements whose acoustic paths would have been altered by the craniotomy defect were turned off. Sonications reaching lesional temperatures of up to 56°C were successfully delivered. The procedure was well-tolerated, without any persistent intra-ablation or post-ablation adverse effects. The presence of a lesion was confirmed on MRI, which was associated with a significant reduction in the patient’s tremor that was sustained at the 6-mo follow-up.

This case demonstrates the safety and efficacy of MRgFUS thalamotomy in a patient with prior craniotomies and highlights our strategy for acoustic lesioning in this setting 9).

De Vloo et al. reported on an ET patient who underwent an Magnetic resonance guided focused ultrasound thalamotomy but experienced tremor recurrence. They expanded the MRgFUS-induced thalamic cavity using radiofrequency (RF), with good effect on the tremor but transient sensorimotor deficits and permanent ataxia. This is the first report of a patient undergoing RF thalamotomy after an unsuccessful MRgFUS thalamotomy. As they used microelectrode recording to guide the RF thalamotomy, they could also study for the first time the electrophysiological properties of previously sonicated thalamic neurons bordering the MRgFUS-induced cavity. These neurons displayed electrophysiological characteristics identical to those recorded from nonsonicated thalamic cells in ET patients. Hence, this findings support the widespread assumption that sonication below the necrotic threshold does not permanently alter neuronal function 10).

References

1)

Elias WJ, Huss D, Voss T, Loomba J, Khaled M, Zadicario E, Frysinger RC, Sperling SA, Wylie S, Monteith SJ, Druzgal J, Shah BB, Harrison M, Wintermark M. A pilot study of focused ultrasound thalamotomy for essential tremor. N Engl J Med. 2013 Aug 15;369(7):640-8. doi: 10.1056/NEJMoa1300962. PubMed PMID: 23944301.
2)

Lipsman N, Schwartz ML, Huang Y, Lee L, Sankar T, Chapman M, Hynynen K, Lozano AM. MR-guided focused ultrasound thalamotomy for essential tremor: a proof-of-concept study. Lancet Neurol. 2013 May;12(5):462-8. doi: 10.1016/S1474-4422(13)70048-6. Epub 2013 Mar 21. PubMed PMID: 23523144.
3)

Chang JW, Min BK, Kim BS, Chang WS, Lee YH. Neurophysiologic correlates of sonication treatment in patients with essential tremor. Ultrasound Med Biol. 2015 Jan;41(1):124-31. doi: 10.1016/j.ultrasmedbio.2014.08.008. Epub 2014 Oct 22. PubMed PMID: 25438838.
4)

Chang WS, Jung HH, Kweon EJ, Zadicario E, Rachmilevitch I, Chang JW. Unilateral magnetic resonance guided focused ultrasound thalamotomy for essential tremor: practices and clinicoradiological outcomes. J Neurol Neurosurg Psychiatry. 2015 Mar;86(3):257-64. doi: 10.1136/jnnp-2014-307642. Epub 2014 May 29. PubMed PMID: 24876191.
5)

Jung HH, Chang WS, Rachmilevitch I, Tlusty T, Zadicario E, Chang JW. Different magnetic resonance imaging patterns after transcranial magnetic resonance-guided focused ultrasound of the ventral intermediate nucleus of the thalamus and anterior limb of the internal capsule in patients with essential tremor or obsessive-compulsive disorder. J Neurosurg. 2015 Jan;122(1):162-8. doi: 10.3171/2014.8.JNS132603. PubMed PMID: 25343176.
6)

Shaw KD, Johnston AS, Rush-Evans S, Prather S, Maynard K. Nursing Management of the Patient Undergoing Focused Ultrasound: A New Treatment Option for Essential Tremor. J Neurosci Nurs. 2017 Aug 16. doi: 10.1097/JNN.0000000000000301. [Epub ahead of print] PubMed PMID: 28817495.
7)

Miller WK, Becker KN, Caras AJ, Mansour TR, Mays MT, Rashid M, Schwalb J. Magnetic resonance-guided focused ultrasound treatment for essential tremor shows sustained efficacy: a meta-analysis. Neurosurg Rev. 2021 May 12. doi: 10.1007/s10143-021-01562-w. Epub ahead of print. PMID: 33978922.
8)

Moosa S, Martínez-Fernández R, Elias WJ, Del Alamo M, Eisenberg HM, Fishman PS. The role of high-intensity focused ultrasound as a symptomatic treatment for Parkinson’s disease. Mov Disord. 2019 Jul 10. doi: 10.1002/mds.27779. [Epub ahead of print] Review. PubMed PMID: 31291491.
9)

Wathen C, Yang AI, Hitti FL, Henry L, Chaibainou H, Baltuch GH. Feasibility of Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Essential Tremor in the Setting of Prior Craniotomy. Oper Neurosurg (Hagerstown). 2022 Feb 1;22(2):61-65. doi: 10.1227/ONS.0000000000000012. PMID: 35007218.
10)

De Vloo P, Milosevic L, Gramer RM, et al. Microelectrode Recording and Radiofrequency Thalamotomy following Focused Ultrasound Thalamotomy [published online ahead of print, 2020 Sep 16]. Stereotact Funct Neurosurg. 2020;1-4. doi:10.1159/000510109

Atypical meningioma

Atypical meningioma (AM)

Atypical meningioma (World health organization grade 2 meningioma) comprise a heterogeneous group of tumors, with histopathology delineated under the guidance of the WHO and a spectrum of clinical outcomes.

Epidemiology

Atypical Meningioma Epidemiology

Classification

Intracranial atypical meningiomas

Spinal atypical meningiomas.

Pathology

Atypical Meningioma Pathology.

Diagnosis

see Atypical meningioma diagnosis.

Differential Diagnosis

Atypical meningioma Differential Diagnosis

Treatment

see Atypical meningioma treatment.

Outcome

see Atypical meningioma outcome.

Case series

Atypical meningioma case series.

Case reports

Atypical meningioma case reports.

Chronic subdural hematoma recurrence

Chronic subdural hematoma recurrence

Epidemiology

In 2 large cohorts of US patients, approximately 5% to 10% of patients who underwent surgery for nontraumatic SDH were required to undergo repeated operation within 30 to 90 days. These results may inform the design of future prospective studies and trials and help practitioners calibrate their index of suspicion to ensure that patients are referred for timely surgical care 1).

Recurrence rates after chronic subdural hematoma (CSDH) evacuation with any of actual techniques twist drill craniostomy (TDC), burr hole craniostomy, craniotomy range from 5% to 30%. 2).

Grading

Oslo grading system.

Risk factors

Hyperdense hematoma components were the strongest prognostic factor of recurrence after surgery. Awareness of these findings allows for individual risk assessment and might prompt clinicians to tailor treatment measures 3).

In the series of Santos et al. it was possible to demonstrate an age-related protective factor, analyzed as a continuous variable, regarding the recurrence of the chronic subdural hematoma (CSDH), with a lower rate of recurrence the higher the age.

The results indicate that, among possible factors associated with recurrence, only age presented a protective factor with statistical significance. The fact that no significant difference between the patients submitted to trepanning or craniotomy was found favors the preferential use of burr-hole surgery as a procedure of choice due to its fast and less complex execution 4).

In the series of Han et al. independent risk factors for recurrence were as follows: age > 75 years (HR 1.72, 95% CI 1.03-2.88; p = 0.039), obesity (body mass index ≥ 25.0 kg/m2), and a bilateral operation 5).

Chon et al. shown that postoperative midline shifting (≥5 mm), diabetes mellitus, preoperative seizure, preoperative width of hematoma (≥20 mm), and anticoagulant therapy were independent predictors of the recurrence of chronic subdural hematoma.

According to internal architecture of hematoma, the rate of recurrence was significantly lower in the homogeneous and the trabecular type than the laminar and separated type 6).

The recurrence rate of chronic subdural hematoma cSDH seems to be related to the excessive neoangiogenesis in the parietal membrane, which is mediated via vascular endothelial growth factor (VEGF). This is found to be elevated in the hematoma fluid and is dependent on eicosanoid/prostaglandin and thromboxane synthesis via cyclooxygenase-2 (COX-2).

Anticoagulant therapy

see Chronic subdural hematoma and anticoagulant therapy.

Antiplatelet therapy

Antiplatelet therapy significantly influences the recurrence of CSDH 7).

Timing of Low-Dose Aspirin Discontinuation for chronic subdural hematoma

Timing of Low-Dose Aspirin Discontinuation for chronic subdural hematoma.

Pneumocephalus

Remaining pneumocephalus is seen as an approved factor of recurrence 8) 9).

Septation

Jack et al.found a 12% reoperation rate. CSDH septation (seen on computed tomogram scan) was found to be an independent risk factor for recurrence requiring reoperation (p=0.04). Larger post-operative subdural haematoma volume was also significantly associated with requiring a second drainage procedure (p<0.001). Independent risk factors of larger post-operative haematoma volume included septations within a CSDH (p<0.01), increased pre-operative haematoma volume (p<0.01), and a greater amount of parenchymal atrophy (p=0.04). A simple scoring system for quantifying recurrence risk was created and validated based on patient age (< or ≥80 years), haematoma volume (< or ≥160cc), and presence of septations within the subdural collection (yes or no).

Septations within CSDHs are associated with larger post-operative residual haematoma collections requiring repeat drainage. When septations are clearly visible within a CSDH, craniotomy might be more suitable as a primary procedure as it allows greater access to a septated subdural collection. The proposed scoring system combining haematoma volume, age, and presence of septations might be useful in identifying patients at higher risk for recurrence 10).

Membranectomy

Opening the internal hematoma membrane does not alter the rate of patients requiring revision surgery and the number of patients showing a marked residual hematoma six weeks after evacuation of a CSDH 11).

In the study of Lee et al, an extended surgical approach with partial membranectomy has no advantages regarding the rate of reoperation and the outcome. As initial treatment, burr-hole drainage with irrigation of the hematoma cavity and closed-system drainage is recommended. Extended craniotomy with membranectomy is now reserved for instances of acute rebleeding with solid hematoma 12).

Diabetes

Surgeons should consider informing patients with diabetes mellitus that this comorbidity is associated with an increased likelihood of recurrence

13) 14) 15).

Balser et al. report 11% recurrence, which included individuals who recurred as late as 3 years after initial diagnosis 16).

Close imaging follow-up is important for CSDH patients for recurrence prediction. Using quantitative CT volumetric analysis, strong evidence was provided that changes in the residual fluid volume during the ‘self-resolution’ period can be used as significantly radiological predictors of recurrence 17).

A structural equation model showed a significant association between increased antiinflammatory activity in hematoma fluid samples and a lower risk of recurrence, but this relationship was not statistically significant in venous blood samples. Moreover, these findings indicate that anti-inflammatory activities in the hematoma may play a role in the risk of a recurrence of CSDH 18).

Irrigation with artificial cerebrospinal fluid (ACF) decreased the rate of CSDH recurrence 19).

Drainage system

Little is known about the best type of drainage system and its relationship with recurrence. In a study, Takroni et al. compared the use of two drainage systems on the recurrence rate of CSDH. They retrospectively analyzed the charts of 180 CSDH patients treated with bedside twist drill craniostomy (TDC) and subdural drain insertion. Patients were divided into two groups: Group A (n=123) received our traditional drain (pediatric size nasogastric tube (NGT), while group B (n=49) had the external ventricular drain (EVD). Various demographic and radiological data were collected. Our main outcome was recurrence, defined as symptomatic re-accumulation of hematoma on the previously operated side within 3 months. Results 212 cases of subdural hematoma were treated in 172 patients. Majority of patients were male (78%) and had a history of previous head trauma (73%). 17 cases had recurrence, 11 in the NGT group drain and 6 in the EVD group. The use of antiplatelet or anticoagulation agents was associated with recurrence (P= 0.038 and 0.05, respectively). There was no difference between both groups in terms of recurrence [OR=1.42, 95% CI:0.49 to 4.08, P=0.573].

Chronic subdural hematoma is a common disease with a high rate of recurrence. Although using a drain postoperatively has shown to improve the incidence of recurrence, little remains known about the best type of drain to use. The analysis showed no difference in the recurrent rate between using the pediatric size NGT and the EVD catheter post TDC 20).

Treatment

There is no definite operative procedure for patients with intractable chronic subdural hematoma (CSDH).

Most recurrent hematomas are managed successfully with burr hole craniostomies with postoperative closed-system drainage. Refractory hematomas may be managed with a variety of techniques, including craniotomy or subdural-peritoneal shunt placement 21).

Although many studies have reported risk factors or treatments in efforts to prevent recurrence, those have focused on single recurrence, and little cumulative data is available to analyze refractory CSDH.

Matsumoto et al. defined refractory CSDH as ≥2 recurrences, then analyzed and compared clinical factors between patients with single recurrence and those with refractory CSDH in a cohort study, to clarify whether patients with refractory CSDH experience different or more risk factors than patients with single recurrence, and whether burr-hole irrigation with closed-system drainage reduces refractory CSDH.

Seventy-five patients had at least one recurrence, with single recurrence in 62 patients and ≥2 recurrences in 13 patients. In comparing clinical characteristics, patients with refractory CSDH were significantly younger (P=0.04) and showed shorter interval to first recurrence (P<0.001). Organized CSDH was also significantly associated with refractory CSDH (P=0.02). Multivariate logistic regression analysis identified first recurrence interval <1 month (OR 6.66, P<0.001) and age <71 years (OR 4.16, P<0.001) as independent risk factors for refractory CSDH. On the other hand, burr-hole irrigation with closed-system drainage did not reduce refractory CSDH.

When patients with risk factors for refractory CSDH experience recurrence, alternative surgical procedures may be considered as the second surgery, because burr-hole irrigation with closed-system drainage did not reduce refractory CSDH 22).

Implantation of a reservoir 23) 24) 25).

Subdural-peritoneal shunt 26).

Middle meningeal artery embolization

Embolization of the MMA is effective for refractory CSDH or CSDH patients with a risk of recurrence, and is considered an effective therapeutic method to stop hematoma enlargement and promote resolution 27) 28) 29) 30) 31) 32).

A pilot study indicated that perioperative middle meningeal artery (MMA) embolization could be offered as the least invasive and most effectual means of treatment for resistant patients of CSDHs with 1 or more recurrences 33).

Chihara et al. have treated three cases of CSDH with MMA embolization to date, but there was a postoperative recurrence in one patient, which required a craniotomy for hematoma removal and capsulectomy. MMA embolization blocks the blood supply from the dura to the hematoma outer membrane in order to prevent recurrences of refractory CSDH. Histopathologic examination of the outer membrane of the hematoma excised during craniotomy showed foreign-body giant cells and neovascular proliferation associated with embolization. Because part of the hematoma was organized in this case, the CSDH did not resolve when the MMA was occluded, and the development of new collateral pathways in the hematoma outer membrane probably contributed to the recurrence. Therefore, in CSDH with some organized hematoma, MMA embolization may not be effective. Magnetic resonance imaging (MRI) should be performed in these patients before embolization 34).

Case series

see Chronic subdural hematoma recurrence case series.

Case reports

Chronic subdural hematoma recurrence case reports.

References

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Knopman J, Link TW, Navi BB, Murthy SB, Merkler AE, Kamel H. Rates of Repeated Operation for Isolated Subdural Hematoma Among Older Adults. JAMA Netw Open. 2018 Oct 5;1(6):e183737. doi: 10.1001/jamanetworkopen.2018.3737. PubMed PMID: 30646255.
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Escosa Baé M, Wessling H, Salca HC, de Las Heras Echeverría P. Use of twist-drill craniostomy with drain in evacuation of chronic subdural hematomas: independent predictors of recurrence. Acta Neurochir (Wien). 2011 May;153(5):1097-103. doi: 10.1007/s00701-010-0903-3. Epub 2010 Dec 31. PubMed PMID: 21193935.
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Miah IP, Tank Y, Rosendaal FR, Peul WC, Dammers R, Lingsma HF, den Hertog HM, Jellema K, van der Gaag NA; Dutch Chronic Subdural Hematoma Research Group. Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis. Neuroradiology. 2020 Oct 22. doi: 10.1007/s00234-020-02558-x. Epub ahead of print. Erratum in: Neuroradiology. 2020 Nov 5;: PMID: 33094383.
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Santos RGD, Xander PAW, Rodrigues LHDS, Costa GHFD, Veiga JCE, Aguiar GB. Analysis of predisposing factors for chronic subdural hematoma recurrence. Rev Assoc Med Bras (1992). 2019 Jul 22;65(6):834-838. doi: 10.1590/1806-9282.65.6.834. PubMed PMID: 31340313.
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Han MH, Ryu JI, Kim CH, Kim JM, Cheong JH, Yi HJ. Predictive factors for recurrence and clinical outcomes in patients with chronic subdural hematoma. J Neurosurg. 2017 Nov;127(5):1117-1125. doi: 10.3171/2016.8.JNS16867. Epub 2016 Dec 16. PubMed PMID: 27982768.
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Chon KH, Lee JM, Koh EJ, Choi HY. Independent predictors for recurrence of chronic subdural hematoma. Acta Neurochir (Wien). 2012 Sep;154(9):1541-8. doi: 10.1007/s00701-012-1399-9. Epub 2012 Jun 1. PubMed PMID: 22653496.
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Wada M, Yamakami I, Higuchi Y, Tanaka M, Suda S, Ono J, Saeki N. Influence of antiplatelet therapy on postoperative recurrence of chronic subdural hematoma: a multicenter retrospective study in 719 patients. Clin Neurol Neurosurg. 2014 May;120:49-54. doi: 10.1016/j.clineuro.2014.02.007. Epub 2014 Feb 24. PubMed PMID: 24731576.
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Mori K, Maeda M (2001) Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 41:371–381
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Stanišić M, Hald J, Rasmussen IA, Pripp AH, Ivanović J, Kolstad F, Sundseth J, Züchner M, Lindegaard KF (2013) Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients. Acta Neurochir 155:323–333
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Jack A, O’Kelly C, McDougall C, Max Findlay J. Predicting Recurrence after Chronic Subdural Haematoma Drainage. Can J Neurol Sci. 2015 Jan 5:1-6. [Epub ahead of print] PubMed PMID: 25557536.
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Unterhofer C, Freyschlag CF, Thomé C, Ortler M. Opening the Internal Hematoma Membrane does not Alter the Recurrence Rate of Chronic Subdural Hematomas – A Prospective Randomized Trial. World Neurosurg. 2016 May 2. pii: S1878-8750(16)30210-8. doi: 10.1016/j.wneu.2016.04.081. [Epub ahead of print] PubMed PMID: 27150644.
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Lee JY, Ebel H, Ernestus RI, Klug N. Various surgical treatments of chronic subdural hematoma and outcome in 172 patients: is membranectomy necessary? Surg Neurol. 2004 Jun;61(6):523-7; discussion 527-8. PubMed PMID: 15165784.
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Matsumoto K, Akagi K, Abekura M, Ryujin H, Ohkawa M, Iwasa N, Akiyama C. Recurrence factors for chronic subdural hematomas after burr-hole craniostomy and closed system drainage. Neurol Res. 1999 Apr;21(3):277-80. PubMed PMID: 10319336.
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Yamamoto H, Hirashima Y, Hamada H, Hayashi N, Origasa H, Endo S. Independent predictors of recurrence of chronic subdural hematoma: results of multivariate analysis performed using a logistic regression model. J Neurosurg. 2003 Jun;98(6):1217-21. PubMed PMID: 12816267.
15)

Pang CH, Lee SE, Kim CH, Kim JE, Kang HS, Park CK, Paek SH, Kim CH, Jahng TA, Kim JW, Kim YH, Kim DG, Chung CK, Jung HW, Yoo H. Acute intracranial bleeding and recurrence after bur hole craniostomy for chronic subdural hematoma. J Neurosurg. 2015 Jul;123(1):65-74. doi: 10.3171/2014.12.JNS141189. Epub 2015 Feb 13. PubMed PMID: 25679282.
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Balser D, Rodgers SD, Johnson B, Shi C, Tabak E, Samadani U. Evolving management of symptomatic chronic subdural hematoma: experience of a single institution and review of the literature. Neurol Res. 2013 Apr;35(3):233-42. doi: 10.1179/1743132813Y.0000000166. Review. PubMed PMID: 23485050.
17)

Xu FF, Chen JH, Leung GK, Hao SY, Xu L, Hou ZG, Mao X, Shi GZ, Li JS, Liu BY. Quantitative computer tomography analysis of post-operative subdural fluid volume predicts recurrence of chronic subdural haematoma. Brain Inj. 2014;28(8):1121-6. doi: 10.3109/02699052.2014.910702. Epub 2014 May 6. PubMed PMID: 24801643.
18)

Pripp AH, Stanišić M. The Correlation between Pro- and Anti-Inflammatory Cytokines in Chronic Subdural Hematoma Patients Assessed with Factor Analysis. PLoS One. 2014 Feb 27;9(2):e90149. doi: 10.1371/journal.pone.0090149. eCollection 2014. PubMed PMID: 24587250.
19)

Adachi A, Higuchi Y, Fujikawa A, Machida T, Sueyoshi S, Harigaya K, Ono J, Saeki N. Risk factors in chronic subdural hematoma: comparison of irrigation with artificial cerebrospinal fluid and normal saline in a cohort analysis. PLoS One. 2014 Aug 4;9(8):e103703. doi: 10.1371/journal.pone.0103703. eCollection 2014. PubMed PMID: 25089621; PubMed Central PMCID: PMC4121178.
20)

Takroni R, Zagzoog N, Patel N, Martyniuk A, Farrokhyar F, Singh S, Trivedi A, Alotaibi M, Algird A. Comparison of two drainage systems on chronic subdural hematoma (CSDH) recurrence. J Neurol Surg A Cent Eur Neurosurg. 2021 Nov 16. doi: 10.1055/a-1698-6212. Epub ahead of print. PMID: 34784622.
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Desai VR, Scranton RA, Britz GW. Management of Recurrent Subdural Hematomas. Neurosurg Clin N Am. 2017 Apr;28(2):279-286. doi: 10.1016/j.nec.2016.11.010. Epub 2017 Jan 4. Review. PubMed PMID: 28325462.
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Matsumoto H, Hanayama H, Okada T, Sakurai Y, Minami H, Masuda A, Tominaga S, Miyaji K, Yamaura I, Yoshida Y, Yoshida K. Clinical investigation of refractory chronic subdural hematoma: a comparison of clinical factors between single and repeated recurrences. World Neurosurg. 2017 Aug 24. pii: S1878-8750(17)31402-X. doi: 10.1016/j.wneu.2017.08.101. [Epub ahead of print] PubMed PMID: 28844917.
23)

Sato M, Iwatsuki K, Akiyama C, Masana Y, Yoshimine T, Hayakawa T. [Use of Ommaya CSF reservoir for refractory chronic subdural hematoma]. No Shinkei Geka. 1999 Apr;27(4):323-8. Japanese. PubMed PMID: 10347846.
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Sato M, Iwatsuki K, Akiyama C, Kumura E, Yoshimine T. Implantation of a reservoir for refractory chronic subdural hematoma. Neurosurgery. 2001 Jun;48(6):1297-301. PubMed PMID: 11383733.
25)

Laumer R. Implantation of a reservoir for refractory chronic subdural hematoma. Neurosurgery. 2002 Mar;50(3):672. PubMed PMID: 11841742.
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Misra M, Salazar JL, Bloom DM. Subdural-peritoneal shunt: treatment for bilateral chronic subdural hematoma. Surg Neurol. 1996 Oct;46(4):378-83. PubMed PMID: 8876720.
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Mandai S, Sakurai M, Matsumoto Y. Middle meningeal artery embolization for refractory chronic subdural hematoma. Case report. J Neurosurg. 2000 Oct;93(4):686-8. PubMed PMID: 11014549.
28)

Takahashi K, Muraoka K, Sugiura T, Maeda Y, Mandai S, Gohda Y, Kawauchi M, Matsumoto Y. [Middle meningeal artery embolization for refractory chronic subdural hematoma: 3 case reports]. No Shinkei Geka. 2002 May;30(5):535-9. Japanese. PubMed PMID: 11993178.
29)

Hirai S, Ono J, Odaki M, Serizawa T, Nagano O. Embolization of the Middle Meningeal Artery for Refractory Chronic Subdural Haematoma. Usefulness for Patients under Anticoagulant Therapy. Interv Neuroradiol. 2004 Dec 24;10 Suppl 2:101-4. Epub 2008 May 15. PubMed PMID: 20587257; PubMed Central PMCID: PMC3522210.
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Tsukamoto Y, Oishi M, Shinbo J, Fujii Y. Transarterial embolisation for refractory bilateral chronic subdural hematomas in a case with dentatorubral-pallidoluysian atrophy. Acta Neurochir (Wien). 2011 May;153(5):1145-7. doi: 10.1007/s00701-010-0891-3. Epub 2010 Dec 2. PubMed PMID: 21125409.
31)

Mino M, Nishimura S, Hori E, Kohama M, Yonezawa S, Midorikawa H, Kaimori M, Tanaka T, Nishijima M. Efficacy of middle meningeal artery embolization in the treatment of refractory chronic subdural hematoma. Surg Neurol Int. 2010 Dec 13;1:78. doi: 10.4103/2152-7806.73801. PubMed PMID: 21206540; PubMed Central PMCID: PMC3011107.
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Hashimoto T, Ohashi T, Watanabe D, Koyama S, Namatame H, Izawa H, Haraoka R, Okada H, Ichimasu N, Akimoto J, Haraoka J. Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas. Surg Neurol Int. 2013 Aug 19;4:104. doi: 10.4103/2152-7806.116679. eCollection 2013. PubMed PMID: 24032079; PubMed Central PMCID: PMC3766342.
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Kim E. Embolization Therapy for Refractory Hemorrhage in Patients with Chronic Subdural Hematomas. World Neurosurg. 2017 May;101:520-527. doi: 10.1016/j.wneu.2017.02.070. Epub 2017 Feb 27. PubMed PMID: 28249828.
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Chihara H, Imamura H, Ogura T, Adachi H, Imai Y, Sakai N. Recurrence of a Refractory Chronic Subdural Hematoma after Middle Meningeal Artery Embolization That Required Craniotomy. NMC Case Rep J. 2014 May 9;1(1):1-5. doi: 10.2176/nmccrj.2013-0343. eCollection 2014 Oct. PubMed PMID: 28663942; PubMed Central PMCID: PMC5364934.

Idiopathic normal pressure hydrocephalus

Idiopathic normal pressure hydrocephalus

Definition

Idiopathic Normal Pressure Hydrocephalus Definition.

History

see Idiopathic normal pressure hydrocephalus history.

Epidemiology

Idiopathic Normal Pressure Hydrocephalus Epidemiology.

Classification

Idiopathic Normal Pressure Hydrocephalus Classification.

Idiopathic Normal Pressure Hydrocephalus Natural History

Idiopathic Normal Pressure Hydrocephalus Natural History

Etiology

Idiopathic Normal Pressure Hydrocephalus Etiology.

Pathogenesis

see Idiopathic normal pressure hydrocephalus Pathogenesis.

Pathophysiology

see Idiopathic normal pressure hydrocephalus pathophysiology.

Clinical Features

see Idiopathic normal pressure hydrocephalus clinical features.

Scales

see Idiopathic normal pressure hydrocephalus scales

Diagnosis

see Idiopathic normal pressure hydrocephalus diagnosis

Differential diagnosis

see Idiopathic normal pressure hydrocephalus differential diagnosis.

Treatment

see Idiopathic normal pressure hydrocephalus treatment.

Outcome

see Idiopathic normal pressure hydrocephalus outcome.

Case series

see Idiopathic normal pressure hydrocephalus case series.

Case reports

see Idiopathic normal pressure hydrocephalus case reports.

Experimental animal model

see Idiopathic normal pressure hydrocephalus experimental animal model.

Microvascular decompression for trigeminal neuralgia

Microvascular decompression for trigeminal neuralgia

Microvascular decompression is a first-line neurosurgical approach for classical trigeminal neuralgia with neurovascular conflict, but can show clinical relapse despite proper decompression. Second-line destructive techniques like radiofrequency thermocoagulation have become reluctantly used due to their potential for irreversible side effects. Subcutaneous peripheral nerve field stimulation (sPNFS) is a minimally invasive neuromodulatory technique which has been shown to be effective for chronic localised pain conditions.

The most frequently used surgical management of trigeminal neuralgia is Microvascular decompression (MVD), followed closely by stereotactic radiosurgery (SRS). Percutaneous stereotactic rhizotomy (PSR) , despite being the most cost-effective, is by far the least utilized treatment modality 1).

Microvascular decompression (MVD) via lateral suboccipital approach is the standard surgical intervention for trigeminal neuralgia treatment.

Teflon™ and Ivalon® are two materials used in MVD for TN. It is an effective treatment with long-term symptom relief and recurrence rates of 1-5% each year. Ivalon® has been used less than Teflon™ though is associated with similar success rates and similar complication rates 2)

Although microvascular decompression (MVD) is the most effective long-term operative treatment for TN, its use in older patient populations has been debated due to its invasive nature. The symptoms and surgical findings presented in a cohort for young-onset TN are similar to those reported in elderly adults. MVD appears to be a safe and effective treatment for young patients with TN 3).

see Microvascular decompression for trigeminal neuralgia and multiple sclerosis

see Awake Microvascular Decompression for Trigeminal Neuralgia.

Endoscope assisted microvascular decompression for trigeminal neuralgia

see also Endoscope assisted microvascular decompression for trigeminal neuralgia.

Compared with the standard microscope-assisted techniques, the 3D exoscopic endoscope-assisted MVD offers an improved visualisation without compromising the field of view within and outside the surgical field 4).

Fully endoscopic microvascular decompression for trigeminal neuralgia via keyhole approach

97 patients with primary trigeminal neuralgia (PTN) underwent fully endoscopic microvascular decompression (MVD) via keyhole approach in Capital Medical University Affiliated Beijing Shijitan Hospital from December 2014 to February 2019 was collected. During fully endoscopic MVD in PTN via keyhole approach, performer use natural clearance without grinding except developed rock bone crest or excessive retraction of the brain tissue, visually and panoramically observe and evaluate the CPA area, accurately identify the responsible vessels, to avoid the omission of responsible vessels or insufficient decompression. And the use of preplaced technology, bridging technology and submersible technology, ensure the efficacy of surgery and reduce the surgical side injuries. Barrow Neurological Institute Pain Intensity Score was used to evaluate the efficacy and identify the recurrence. The surgical efficacy was analyzed. The offending vessels were identified under endoscope in 96 cases. Among them, arterial compression was found in 77 cases, venous compression in 6 cases, and both arterial and venous compression in 13 cases. About the pain outcomes, 87 cases had immediate and complete relief of pain, 5 cases had almost relief of pain, 4 cases had partial relief of pain, and still needed medication control, but the dose was lower than that before operation, and 1 case had no obvious relief of pain. About complications, there were 4 cases of temporary facial numbness, 1 case of temporary hearing loss, both of them recovered after symptomatic treatment. There was no cerebral infarction or hemorrhage, intracranial or incision infection. All cases were followed up for 3.0-38.0 months with a median period of(22.4±2.2) months. During the follow-up periods, postoperative recurrence occurred in 3 cases. Fully endoscopic MVD for PTN through keyhole approach, provides panoramic view to avoid omission of offending vessels and reduce complications, seemed to be a safe and effective surgical method 5).

Systematic Review and Meta-Analysis

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMed, Cochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors.

Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom after MVD with a mean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effects models included (1) disease duration ≤5 yr (OR = 2.06, 95% CI = 1.08-3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67).

Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict a more favorable outcome. These results may improve patient selection and provider expectations 6).

Technique

Microvascular decompression for trigeminal neuralgia technique.

Outcome

Microvascular decompression for trigeminal neuralgia outcome.

Complications

Microvascular decompression for trigeminal neuralgia complications

Case series

Microvascular decompression for trigeminal neuralgia case series.

References

1)

Sivakanthan S, Van Gompel JJ, Alikhani P, van Loveren H, Chen R, Agazzi S. Surgical management of trigeminal neuralgia: use and cost-effectiveness from an analysis of the medicare claims database. Neurosurgery. 2014 Sep;75(3):220-6. doi: 10.1227/NEU.0000000000000430. PubMed PMID: 24871139.
2)

Pressman E, Jha RT, Zavadskiy G, Kumar JI, van Loveren H, van Gompel JJ, Agazzi S. Teflon™ or Ivalon®: a scoping review of implants used in microvascular decompression for trigeminal neuralgia. Neurosurg Rev. 2019 Nov 30. doi: 10.1007/s10143-019-01187-0. [Epub ahead of print] Review. PubMed PMID: 31786660.
3)

Yu F, Yin J. Young-onset trigeminal neuralgia: a clinical study and literature review. Acta Neurochir (Wien). 2021 Apr 17. doi: 10.1007/s00701-021-04848-6. Epub ahead of print. PMID: 33864143.
4)

Li Ching Ng A, Di Ieva A. How I do it: 3D exoscopic endoscope-assisted microvascular decompression. Acta Neurochir (Wien). 2019 May 29. doi: 10.1007/s00701-019-03954-w. [Epub ahead of print] PubMed PMID: 31144166.
5)

Peng WC, Guan F, Hu ZQ, Huang H, Dai B, Zhu GT, Mao BB, Xiao ZY, Zhang BL, Liang X. [Efficacy analysis of fully endoscopic microvascular decompression in primary trigeminal neuralgia via keyhole approach]. Zhonghua Yi Xue Za Zhi. 2021 Mar 30;101(12):856-860. Chinese. doi: 10.3760/cma.j.cn112137-20200630-02002. PMID: 33789367.
6)

Holste K, Chan AY, Rolston JD, Englot DJ. Pain Outcomes Following Microvascular Decompression for Drug-Resistant Trigeminal Neuralgia: A Systematic Review and Meta-Analysis. Neurosurgery. 2020 Feb 1;86(2):182-190. doi: 10.1093/neuros/nyz075. PubMed PMID: 30892607.

Mesial temporal lobe epilepsy

Mesial temporal lobe epilepsy

Temporal lobe epilepsy (TLE) is a chronic neurological condition characterized by recurrent seizures (epilepsy) which originate in the temporal lobe of the brain with progressive neurological disabilities, including cognitive deficit, anxiety and depression.

The seizures involve sensory changes, for example smelling an unusual odour that is not there, and disturbance of memory.

Epidemiology

Mesial temporal lobe epilepsy with hippocampal sclerosis (mTLE-HS) is the most common type of focal epilepsy.

Etiology

see Temporal lobe epilepsy etiology.

Pathophysiology

In order to understand the pathophysiology of temporal lobe epilepsy (TLE), and thus to develop new pharmacological treatments, in vivo animal models that present features similar to those seen in TLE patients have been developed during the last four decades. Some of these models are based on the systemic administration of chemoconvulsants to induce an initial precipitating injury (status epilepticus) that is followed by the appearance of recurrent seizures originating from limbic structures.

Kainic acid and pilocarpine models, have been widely employed in basic epilepsy research. Their behavioral, electroencephalographic and neuropathologic features and response of these models to antiepileptic drugs and the impact they might have in developing new treatments are explained in the work of Lévesque et al. 1).

The transition to the ictal stage is accompanied by increasing global synchronization and a more ordered spectral content of the signals, indicated by lower spectral entropy. The interictal connectivity imbalance (lower ipsilateral connectivity) is sustained during the seizure, irrespective of any appreciable imbalance in the spectral entropy of the mesial recordings 2).

Clinical features

Recurrent seizures (epilepsy) which originate in the temporal lobe of the brain with progressive neurological disabilities, including cognitive deficit, anxiety and depression.

The seizures involve sensory changes, for example smelling an unusual odour that is not there, and disturbance of memory.

Olfactory function was significantly impaired in patients with MTLE compared with healthy controls in all domains, namely threshold, discrimination, and identification. In addition, the olfactory bulb volume was smaller in patients with olfactory dysfunction 3).

Earlier tachycardia for seizures originating from the right versus left hemisphere in a patient with bilateral mesial temporal lobe epilepsy 4).

A strong association of this ailment has been established with psychiatric comorbidities, primarily mood and anxiety disorders. The side of epileptogenic may contribute to depressive and anxiety symptoms; thus, in a study, Radaelli et al. performed a systematic review to evaluate the prevalence of depression in TLE in surgical patients. The literature search was performed using PubMed/Medline, Web of Science, and PsycNet to gather data from inception until January 2019. The search strategy was related to TLE, depressive disorder, and anxiety. After reading full texts, 14 articles meeting the inclusion criteria were screened. The main method utilized for psychiatric diagnosis was Diagnostic and Statistical Manual of Structured Clinical Interview for DSM Disorders. However, most studies failed to perform the neuropsychological evaluation. For those with lateralization of epilepsy, focus mostly occurred in the left hemisphere. For individual depressive diagnosis, 9 studies were evaluated, and 5 for anxiety. Therefore, from the data analyzed in both situations, no diagnosis was representative in preoperative and postoperative cases. In order to estimate the efficacy of surgery in the psychiatry episodes and its relation to seizure control, the risk of depression and anxiety symptoms in epileptic patients need to be determined before surgical procedures. Rigorous preoperative and postoperative evaluation is essential for psychiatry conditions in patients with refractory epilepsy candidates for surgery 5).

Diagnosis

A pilot study demonstrates that seizures in mesial temporal and temporal-plus epilepsies (i.e., temporoperisylvian) can be detected reliably in the anterior thalamic nucleus (ATN). Further studies are needed to validate these findings 6).

Fractional anisotropy asymmetry (FAA) values can be potentially used to identify the seizures of origin of TLE and to help understand the relationship between fiber tracts with the side of seizure origin of TLE 7).

The area of predominant perifocal 18F positron emission tomography hypometabolism and reduced [11C]flumazenil (11C-FMZ) -binding on PET scans is currently considered to contain the epileptogenic zone and corresponds anatomically to the area localizing epileptogenicity in patients with temporal lobe epilepsy (TLE).

Differential diagnosis

Mesial temporal lobe epilepsy differential diagnosis.

Complications

Drug resistant epilepsy is a major clinical challenge affecting about 30% of temporal lobe epilepsy (TLE) patients.

The reasons for failure of surgical treatment for mesial temporal lobe epilepsy (MTLE) associated with hippocampal sclerosis (HS) remain unclear.

Treatment

Mesial temporal lobe epilepsy treatment.

Outcome

Temporal lobe epilepsy (TLE) is considered to be the most common form of epilepsy, and it has been seen that most patients are refractory to antiepileptic drugs.

After surgery for intractable mesiotemporal lobe epilepsy (mTLE) seizures recur in 30-40%. One predictor for seizure recurrence is the distribution of seizure onset and interictal epileptiform discharges (IED).

Preoperative bilateral ictal foci are a negative predictor for seizure outcome. Contrarily, IED exceeding the affected temporal lobe in the ipsilateral hemisphere or even bilateral IED had favorable seizure outcome if seizure onset is strictly limited to the affected temporal lobe. Reoperation for seizure persistence constitutes a promising therapeutic option 8).

The extent of pre-surgical perifocal PET abnormalities, the extent of their resection, and the extent of non-resected abnormalities were not useful predictors of individual freedom from seizures in patients with TLE 9).

Case series

see Mesial temporal lobe epilepsy case series.

References

1)

Lévesque M, Avoli M, Bernard C. Animal Models of temporal Lobe Epilepsy Following Systemic Chemoconvulsant Administration. J Neurosci Methods. 2015 Mar 10. pii: S0165-0270(15)00091-6. doi: 10.1016/j.jneumeth.2015.03.009. [Epub ahead of print] PubMed PMID: 25769270.
2)

Vega-Zelaya L, Pastor J, de Sola RG, Ortega GJ. Disrupted Ipsilateral Network Connectivity in Temporal Lobe Epilepsy. PLoS One. 2015 Oct 21;10(10):e0140859. doi: 10.1371/journal.pone.0140859. eCollection 2015. PubMed PMID: 26489091.
3)

Türk BG, Metin B, Tekeli H, Sayman ÖA, Kızılkılıç O, Uzan M, Özkara Ç. Evaluation of olfactory and gustatory changes in patients with mesial temporal lobe epilepsy. Seizure. 2020 Jan 7;75:110-114. doi: 10.1016/j.seizure.2020.01.001. [Epub ahead of print] PubMed PMID: 31945715.
4)

Yanai K, Shimada S, Kunii N, Takasago M, Takabatake K, Saito N. Earlier tachycardia for seizures originating from the right versus left hemisphere in a patient with bilateral mesial temporal lobe epilepsy [published online ahead of print, 2020 Jun 25]. Clin Neurophysiol. 2020;131(9):2168-2170. doi:10.1016/j.clinph.2020.06.011
5)

Radaelli G, Majolo F, Leal-Conceição E, de Souza Santos F, Escobar V, Zanirati GG, Portuguez MW, Scorza FA, da Costa JC. Left Hemisphere Lateralization of Epileptic Focus Can Be More Frequent in Temporal Lobe Epilepsy Surgical Patients with No Consensus Associated with Depression Lateralization. Dev Neurosci. 2021 Mar 31:1-8. doi: 10.1159/000513537. Epub ahead of print. PMID: 33789300.
6)

Pizarro D, Ilyas A, Toth E, Romeo A, Riley KO, Esteller R, Vlachos I, Pati S. Automated detection of mesial temporal and temporoperisylvian seizures in the anterior thalamic nucleus. Epilepsy Res. 2018 Jul 23;146:17-20. doi: 10.1016/j.eplepsyres.2018.07.014. [Epub ahead of print] PubMed PMID: 30055392.
7)

Li H, Xue Z, Dulay MF Jr, Verma A, Karmonik C, Grossman RG, Wong ST. Fractional anisotropy asymmetry and the side of seizure origin for partial onset-temporal lobe epilepsy. Comput Med Imaging Graph. 2014 Jul 2. pii: S0895-6111(14)00102-5. doi: 10.1016/j.compmedimag.2014.06.009. [Epub ahead of print] PubMed PMID: 25037096.
8)

Schmeiser B, Zentner J, Steinhoff BJ, Brandt A, Schulze-Bonhage A, Kogias E, Hammen T. The role of presurgical EEG parameters and of reoperation for seizure outcome in temporal lobe epilepsy. Seizure. 2017 Sep 6;51:174-179. doi: 10.1016/j.seizure.2017.08.015. [Epub ahead of print] PubMed PMID: 28888215.
9)

Stanišić M, Coello C, Ivanović J, Egge A, Danfors T, Hald J, Heminghyt E, Mikkelsen MM, Krossnes BK, Pripp AH, Larsson PG. Seizure outcomes in relation to the extent of resection of the perifocal fluorodeoxyglucose and flumazenil PET abnormalities in anteromedial temporal lobectomy. Acta Neurochir (Wien). 2015 Sep 8. [Epub ahead of print] PubMed PMID: 26350516.