Insular gliomas with an MR imaging-defined tumor volume located lateral to the LSAs on stereotactic angiography displace the LSAs medially by expanding the insula, have well-demarcated tumor boundaries on MR images, and can be completely resected with minimal neurological morbidity. In contrast, insular tumors that appear to surround the LSAs do not displace these vessels medially, are poorly demarcated from normal brain parenchyma on MR images, and are associated with higher rates of neurological morbidity if aggressive resection is pursued. Preoperative identification of these anatomical growth patterns can be of value in planning resection.
Spinal dural arteriovenous fistulas (SDAVF) are a rare pathologic entity with a diverse and often misleading clinical presentation. While digital subtraction spinal angiography remains the gold standard, recent advances in noninvasive vascular imaging have improved the diagnosis of SDAVF. As this condition can result in permanent spinal cord injury, all patients require treatment, which consists of surgical or endovascular occlusion of the fistula. Failure to recognize and treat SDAVF in a timely fashion can result in irreversible neurologic disability, including myelopathy, lower extremity weakness and bowel, bladder and sexual dysfunction. This article reviews the clinical features, pathogenesis, radiographic features and current treatment strategies for these complex lesions.
MMA embolization could present a minimally invasive and low-risk initial treatment alternative to surgery for symptomatic chronic SDH when clinically appropriate.
Advances in diagnostic imaging modalities and improved access to specialty care have led directly to an increased diagnosis of both metastatic and primary brain tumors. As technology has improved, so has the ability to treat this larger patient population. Diffusion tensor imaging (DTI) has recently shown the potential to aid in histologic diagnosis as well as to identify local brain invasion outside of that readily identifiable by conventional MRI. Similar to DTI, functional MRI provides a noninvasive means of delineating tumor margin from eloquent cortex and aids in preoperative surgical planning. As the literature shows increasing support for the advantages of extensive resection in glioma patients, modalities that aid in this regard are displaying increased importance. Surgeons have recently demonstrated the utility of intraoperative MRI in increasing extent of resection in both low- and high-grade glioma patients. Intraoperative tumor fluorescence provided by the chemical compound 5-aminolevulinic acid assists surgeons in identifying the true tumor margin during resection of glial neoplasms consequently increasing extent of resection. Finally, laser interstitial thermal therapy is an emerging treatment modality allowing surgeons to treat small intracranial lesions with potentially decreased morbidity via this minimally invasive approach. The following review analyzes the recent literature in an effort to describe how these modalities can and should be used in the treatment of patients with intracranial pathology.
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