Surgical resection of brainstem cavernous malformations (BCMs) is a high-risk procedure and can be challenging to the neurosurgeon. Lateral surgical routes are becoming increasingly used to approach ventrolaterally brainstem cavernoma. Surgical approach decision depends on the location of the cavernoma in the brainstem and a possible association with brainstem developmental venous anomalies (DVAs). DVA can affect the formation and clinical course of cavernous malformation (CM). CMs related to DVAs tend to have more aggressive behavior than isolated CM. In cases of DVAs associated with hemorrhage, CMs are most often the site of bleeding rather than DVAs themselves. In this case report, we present a 24-year-old woman with a pontomedullary CM and associated dorsally located DVA. BCM was operated through a far lateral suboccipital craniotomy. Brainstem entry point was at inferior olive with extension to the pontomedullary sulcus. This approach should be preferred as a safe surgical exposure to the central and paramedian pontomedullary cavernoma, especially in the cases with associated intraparenchymal brainstem DVA. Such surgical exposure allows preservation of the concomitant brainstem DVA.
Endovascular coil treatment is used as an alternative to clipping in cerebral aneurysms. The aim of this study was to compare endovascular treatment versus surgical clipping by cost-effectiveness аnd cost-utility analyses on the basis of the decision-tree modeling. The study included patients with cerebral aneurysms and was conducted from November 2010 to November 2011. Of 124 patients 90 underwent surgical clipping, whereas 34 were treated via coiling. The clinical outcome at 6 months according to Glasgow Outcome Scale (GOS) and cost of treatment were evaluated in both groups. Health conditioned quality of life for the first year was assessed in 106 patients using EuroQoL 5D5L. 91.2% of coiled patients and 81.1% of surgical treated patients were in GOS 4 and 5. The average cost for the patients undergoing endovascular treatment of aneurysms was 19856 BGL, while the average cost of surgical clipping was 11480 BGL. QALY was 0.844 for 27 coiled patients, and it was 0.737 for 79 surgical treated patients. There was no significant difference in clinical outcome at 6 months and in QALY for the first year after treatment. Patients with coiled cerebral aneurysms had higher procedure prices and costs of consumables than patients treated by clipping. В.Георгієва -хірург відділення нейрохірургії Університетської клініки «Софіамед» (м. Софія, Болгарія) Зл.Димитрова -доктор фарм. наук, професор факультету хімії та фармації Софійського університету ім. Св. Климента Охридського К.Петкова -канд. фарм. наук, доцент Пловдивського медичного університету
Dealing only with the ruptured paraclinoid aneurysm, without taking care of the underlying cerebral ischemia owing to concomitant extracranial ICA dissection, could be an insufficient approach for treatment. In the presented case of a giant ruptured paraclinoid aneurysm and coexistence of severe bilateral ICA dissecting stenosis, trapping with matching the bypass flow was the proper solution for managing simultaneously with the aneurysm and the cerebral ischemia from the left side. Anticoagulants and antiplatelets were applied safely to treat the right internal CAD.
Introduction: Spinal cord metastases represent a small proportion of intramedullary tumors. The occurrence of such lesion over the course of malignant disease is usually a predictor for shortened life expectancy and is often associated with severe neurological deficits. Treatment options include microsurgical excision, radio-, chemo- or palliative therapy. Despite these possibilities the optimal management of patients with intramedullary spinal cord metastases (ISCM) is difficult due to the wide variety of clinical situations and the lack of controlled studies on the results of different therapeutic options. Materials: We are presenting a case of a 68-year-old male with gradually increasing spinal neurological deficit – axial low back pain, numbness and muscle weakness in both legs and gait disturbance. Arterial hypertension was pointed as the only comorbidity of the patient. The MRI showed an intramedullary solitary lesion in the lumbar intumescence at the level of Th12 and L1 vertebra. Results: The patient underwent surgery and the tumor was totally excised. The symptoms improved dramatically. The histology evidence a metastasis from a lung adenocarcinoma. Six months later he presented with severe back pain, progression of the paresis and urinary retention. Tumour recurrence was detected by MRI. After careful decision making and taking into consideration the risk of permanent neurological deficit a reoperation was performed. The lesion was gross-totally removed with improvement in functions and no neurological deterioration registered in the postoperative period. Conclusion: It is possibly the symptoms from an intramedullary metastatic lesion to precede the detection of the primary tumour. The low frequency of occurrence and the absence of a manifested and diagnosed primary malignant process should not stop us thinking in the direction of metastasis. Surgical resection with function preservation is highly aimed. Operation and even reoperation in some cases is acceptable.
OBJECTIVE: The purpose of the present research was to evaluate the morphometric characteristics of ruptured and unruptured aneurysms in series of surgically treated patients with multiple intracranial aneurysms. According to the findings the differences between ruptured and unruptured aneurysms were analyzed in patients with subarachnoid hemorrhage and multiple intracranial aneurysms. METHODS: Sixty eight patients with 174 multiple aneurysms and clinical presentation of aneurismal subarachnoid hemorrhage were treated in two hospitals in Sofia, Bulgaria between 1991 and 2010. The ruptured aneurysm was identified from preoperative studies (head computed tomography, digital subtraction angiography, computed tomography angiography) and it was proved during the surgical procedure. The preoperative angiograms were used to perform measurements of morphometric characteristics of ruptured and unruptured cerebral aneurysms. We used univariable logistic regression analysis to obtain odds ratios. Cochran-Mantel-Haenszel test for dependence was performed to obtain adjusted odds ratio and P value for dependence. RESULTS: In 16 (23.53%) patients, the ruptured aneurysm was not the largest one. The calculated odds ratios with 95% confidence intervals revealed strong association with rupture for the aneurysm size ≥ 7.5 mm, aneurysm location at anterior communicating-anterior cerebral artery complex, irregular aneurysm shape and angle of inclination. The average value of the angle of inclination was 153.06° ± 21.16 for the ruptured aneurysms and 106.78° ± 29.50. After performing a test for dependence and adjustment for aneurysm size and location, size ratio, irregular shape, terminal aneurysm type and aneurysm inclination angle were strongly associated with aneurysm rupture. CONCLUSION: The only independent significant determinant for aneurysm rupture besides aneurysm size and location was aneurysm inclination angle (P < 0.05).
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