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Oki Y, Sakakibara F, Uchida K, Kageyama H, Yasaka M, Toyoda K, Mori E, Hirano T, Hamasaki T, Yamagami H, Nagao T, Uchiyama S, Minematsu K, Yoshimura S. ASPECTS-Region-Dependent Functional Outcomes after Endovascular Therapy in Patients with Cardioembolic Stroke. J Stroke Cerebrovasc Dis 2021; 30:105814. [PMID: 33915390 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Cardioembolic stroke has a poor prognosis. We evaluated the region-dependent efficacy of endovascular therapy (EVT) based on diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS). METHODS This post-hoc analysis of the RELAXED study, which investigated the optimal timing of rivaroxaban to prevent nonvalvular atrial fibrillation (NVAF) recurrence in patients with acute ischemic stroke (AIS), included NVAF patients admitted with AIS or transient ischemic attack in the middle cerebral artery (MCA), with internal carotid artery (ICA), M1, or M2-MCA occlusion. Relationships between DWI-ASPECTS region and functional outcome (modified Rankin Scale [mRS]), mortality, recurrence, and hemorrhagic stroke were compared between patients with and without EVT, and adjusted odds ratios for age, pre-stroke mRS, National Institutes of Health Stroke Scale (NIHSS), ICA occlusion, infarct size, recombinant tissue plasminogen activator (rt-PA) use, and onset-to-hospitalization time were estimated. RESULTS EVT patients had significantly lower hemoglobin levels, higher median NIHSS scores, more lentiform nucleus infarcts, ICA or M1-MCA occlusions, treatment with rt-PA, and fewer M3, M5, or M6 infarcts and M2-MCA occlusions than no-EVT patients. EVT patients had shorter onset-to-hospitalization times and more frequent favorable functional outcomes (p=0.007). Mortality, recurrent ischemic stroke, and hemorrhagic infarction were similar in both groups. EVT was associated with significantly better functional outcomes among patients with insular ribbon (p=0.043) and M3 (p=0.0008) infarcts. M3 patients had significantly fewer rt-PA and EVT, and longer onset-to-hospitalization times. CONCLUSIONS An occlusion in the insular ribbon or M3 region was associated with favorable functional outcomes in patients treated with EVT after cardioembolic stroke.
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Affiliation(s)
- Yoshiharu Oki
- Department of Neurosurgery, Goushi Hospital, Amagasaki, Japan
| | | | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroto Kageyama
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Neuropsychiatry, United Graduate School of Child Development, Osaka University, Suita, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | | | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takehiko Nagao
- Department of Neurology, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
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Temporal Artery and Temporal Region Supplied by the Middle Cerebral Artery: An Anatomical Study. J Craniofac Surg 2021; 32:2873-2877. [PMID: 33710055 DOI: 10.1097/scs.0000000000007612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT This study was conducted to describe in detail the branching patterns of cortical branches from the middle cerebral artery supplying the feeding of the temporal region, to define the arterial structure of temporal artery (TA) and to determine the effect of this arterial supply to the temporal region. The arteries of brains (n = 22; 44 hemispheres) were prepared for dissection after filling them with colored latex. TA was defined, and its classification was described, specifying its relationship with other cortical branches. A new classification was defined related to TA terminology. TA was found in 95% of cadavers, and it originated as an early branch in 75% and from the inferior trunk in 24% of cadavers. TA was classified as Type 0: No TA, Type I: single branch providing two cortical branches, Type II: single branch providing three or more cortical branches and Type III: double TA. Type I-TA (45%) was the most common, and Type II-TA arterial diameter was significantly larger than that of other types. All cadavers showed the cortical branches of temporal region from middle cerebral artery, anterior TA , middle TA, posterior TA and temporooccipital artery, except temporopolar artery (81%). Temporopolar artery, anterior TA, and middle TA primarily originated from TA, an early branch, but posterior TA and temporooccipital artery primarily originated from the inferior trunk. Detailed knowledge about cortical branches together with TA and also this region's blood supply would enable increased prediction of complications, especially in cases with these region-related pathologies, and would make interventions safer.
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Sturiale CL, Rapisarda A, Marchese E, Puca A, Olivi A, Albanese A. Surgical Treatment of Middle Cerebral Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons. J Neurol Surg A Cent Eur Neurosurg 2021; 83:75-84. [PMID: 33641137 DOI: 10.1055/s-0040-1720996] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Clipping is still considered the treatment of choice for middle cerebral artery (MCA) aneurysms due to their angioarchitectural characteristics as they are often bifurcation dysplasias, needing a complex reconstruction rather than a simple exclusion. Thus, maintaining this surgical expertise is of paramount importance to train of young cerebrovascular surgeons. To balance for the increasingly limited experience due the worldwide general inclination toward the endovascular approaches, it is important to provide to the young neurosurgeons rules and operative nuances to guide this complex surgery. We describe the technical algorithm we use to teach our residents to approach ruptured and unruptured MCA aneurysms, which may help to develop a procedural memory useful to perform an effective and safe surgery. MATERIALS AND METHODS We reviewed our last 10 years' institutional experience of about 400 cases of ruptured and unruptured MCA aneurysms clipping, analyzing our technical refinements and the difficulties in residents and young neurosurgeons teaching, to establish fundamental key-points and design a didactic algorithm that includes operative instructions and safety rules. RESULTS We recognized seven pragmatic technical key points regarding craniotomy, sylvian fissure opening, basal cisternostomy, proximal vessel control, lenticulostriate arteries preservation, aneurysm neck microdissection, and clipping to use as a didactic algorithm for teaching residents, and as operative instructions for inexperienced neurosurgeons. CONCLUSION In the setting of clipping MCA aneurysms, respect for surgical rules is of paramount importance to perform an effective and safe procedure, ensure the best aneurysm exclusion, and preserve the flow in collaterals and perforators.
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Affiliation(s)
- Carmelo Lucio Sturiale
- Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia - Neurosurgery, Roma, Lazio, Italy
| | - Alessandro Rapisarda
- Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia - Neurosurgery, Roma, Lazio, Italy
| | - Enrico Marchese
- Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia - Neurosurgery, Roma, Lazio, Italy
| | - Alfredo Puca
- Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia - Neurosurgery, Roma, Lazio, Italy
| | - Alessandro Olivi
- Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia - Neurosurgery, Roma, Lazio, Italy
| | - Alessio Albanese
- Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia - Neurosurgery, Roma, Lazio, Italy
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Giampiccolo D, Parisi C, Meneghelli P, Tramontano V, Basaldella F, Pasetto M, Pinna G, Cattaneo L, Sala F. Long-term motor deficit in brain tumour surgery with preserved intra-operative motor-evoked potentials. Brain Commun 2021; 3:fcaa226. [PMID: 33615216 PMCID: PMC7884605 DOI: 10.1093/braincomms/fcaa226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/29/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Muscle motor-evoked potentials are commonly monitored during brain tumour surgery in motor areas, as these are assumed to reflect the integrity of descending motor pathways, including the corticospinal tract. However, while the loss of muscle motor-evoked potentials at the end of surgery is associated with long-term motor deficits (muscle motor-evoked potential-related deficits), there is increasing evidence that motor deficit can occur despite no change in muscle motor-evoked potentials (muscle motor-evoked potential-unrelated deficits), particularly after surgery of non-primary regions involved in motor control. In this study, we aimed to investigate the incidence of muscle motor-evoked potential-unrelated deficits and to identify the associated brain regions. We retrospectively reviewed 125 consecutive patients who underwent surgery for peri-Rolandic lesions using intra-operative neurophysiological monitoring. Intraoperative changes in muscle motor-evoked potentials were correlated with motor outcome, assessed by the Medical Research Council scale. We performed voxel–lesion–symptom mapping to identify which resected regions were associated with short- and long-term muscle motor-evoked potential-associated motor deficits. Muscle motor-evoked potentials reductions significantly predicted long-term motor deficits. However, in more than half of the patients who experienced long-term deficits (12/22 patients), no muscle motor-evoked potential reduction was reported during surgery. Lesion analysis showed that muscle motor-evoked potential-related long-term motor deficits were associated with direct or ischaemic damage to the corticospinal tract, whereas muscle motor-evoked potential-unrelated deficits occurred when supplementary motor areas were resected in conjunction with dorsal premotor regions and the anterior cingulate. Our results indicate that long-term motor deficits unrelated to the corticospinal tract can occur more often than currently reported. As these deficits cannot be predicted by muscle motor-evoked potentials, a combination of awake and/or novel asleep techniques other than muscle motor-evoked potentials monitoring should be implemented.
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Affiliation(s)
- Davide Giampiccolo
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Cristiano Parisi
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Pietro Meneghelli
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Vincenzo Tramontano
- Division of Neurology and Intraoperative Neurophysiology Unit, University Hospital, Verona, Italy
| | - Federica Basaldella
- Division of Neurology and Intraoperative Neurophysiology Unit, University Hospital, Verona, Italy
| | - Marco Pasetto
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Giampietro Pinna
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Luigi Cattaneo
- CIMEC-Center for Mind/Brain Sciences, University of Trento, Trento, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
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Marchi F, Bonasia S, Chiappini A, Reinert M, Robert T. Clinical and radiological outcomes in relation with the anatomical orientation of clipped middle cerebral artery bifurcation aneurysms. Clin Neurol Neurosurg 2021; 202:106491. [PMID: 33486156 DOI: 10.1016/j.clineuro.2021.106491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The middle cerebral artery (MCA) bifurcation represents the most frequent location for intracranial aneurysms. Often, the aneurysmal dome can hide the origin of perforating arteries from the M1 segment during the surgical clipping causing ischemic lesions and worse clinical outcome. The aim of this paper is to analyze the association between the orientation of the aneurysm sac and the clinical and radiological outcomes after surgical clipping. METHODS Data from 50 MCA bifurcation clipped aneurysms in 47 patients were collected retrospectively. Three different groups were identified according to the aneurysmal sac orientation: anterior-inferior, posterior and superior. A possible association between the aneurysmal sac projection and the outcome was searched through a univariable logistic regression analysis. RESULTS Statistical analysis showed significant correlation between the radiologic evidence of post-operative ischemia in the posterior group (p = 0.046, RR = 1.65) and an increased risk in the superior orientation group (p = 0.145, RR = 1.38). The anterior-inferior group was, instead, significantly associated with no evidence of radiologic ischemia (p = 0.0019, RR = 0.58). CONCLUSION The orientation of the aneurysmal dome and sac represents a fundamental feature to be considered during the surgical clipping of the MCA aneurysms. Indeed, its posterior and superior projection is associated with a higher incidence of radiologic ischemic lesions due to the origin of perforating arteries from M1 segment behind the aneurysmal sac. The anterior-inferior orientation, on the contrary, is associated with a lower risk.
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Affiliation(s)
- Francesco Marchi
- Neurosurgery Department, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.
| | - Sara Bonasia
- Neurosurgery Department, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - Alessio Chiappini
- Neurosurgery Department, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland; Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Michael Reinert
- Neurosurgery Department, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland; Faculty of Medicine, University of the Southern Switzerland, Lugano, Switzerland; Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Thomas Robert
- Neurosurgery Department, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland; Faculty of Medicine, University of the Southern Switzerland, Lugano, Switzerland
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Isolan GR, Campero A, Ajler PM, Farina EM, Frigeri TM, Dini LI. El lóbulo de la ínsula: Parte 2 - anatomía microquirúrgica y correlación clínico-quirúrgica. Surg Neurol Int 2020. [DOI: 10.25259/sni_679_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El conocimiento profundo de la anatomía microquirúrgica del lóbulo de la ínsula es crucial para operar pacientes con tumores en esta región. El objetivo de la segunda parte de este estudio es correlacionar la anatomía microquirúrgica con casos ilustrativos retirados de nuestra casuística de 35 pacientes en los cuales fueron realizados 44 cirugías de tumores en relación con el lóbulo de la ínsula.
Métodos:
A lo largo de marzo de 2007 y agosto de 2014, 44 microcirugías fueron realizadas en 35 pacientes portadores de tumores insulares y los hallazgos de las cirugías y mapeo cerebral se correlacionaron con la anatomía microquirúrgica.
Resultados:
De una serie de 44 pacientes con tumores de la ínsula, la mayoría de los casos eran gliomas de bajo grado de malignidad (29 casos). El inicio de los síntomas en 34 pacientes fue epilepsia, siendo esta refractaria al tratamiento medicamentoso en 12 casos. El grado de resección fue subtotal o total en la mayoría de los casos de la serie. La mejoría en la calidad de vida (epilepsia, etc.) estuvo presente en más de la mitad de los pacientes. El dé cit neurológico permanente estuvo presente en tres pacientes.
Conclusión:
En los tumores insulares, es tan importante el conocimiento profundo de la anatomía, como el saber utilizar e interpretar en tiempo real las observaciones de la monitorización neuro siológica intraoperatoria.
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Affiliation(s)
- Gustavo Rassier Isolan
- Department of Surgery, The Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul, Brazil,
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padila, Country Las Yungas, Yerba Buena, Tucumán,
| | - Pablo Marcelo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Perón, Buenos Aires, Argentina,
| | - Edgar Manuel Farina
- Serviço de Neurocirurgia, Hospital Ministro Costa Cavalcanti Sanatório Le Blanc, Rua Joao Rouver, Foz do Iguaçu, Parana,
| | - Thomas More Frigeri
- Department of Neurosurgery, Pontifical Catholic University of Rio Grande do Sul, Luciana de Abreu, Porto Alegre,
| | - Leandro Infantini Dini
- Department of Neurosurgery, Center for Advanced Neurology and Neurosurgery, São Leopoldo, Rio Grande do Sul, Brazil
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The insular cortex as a vestibular area in relation to autonomic function. Clin Auton Res 2020; 31:179-185. [PMID: 33259005 DOI: 10.1007/s10286-020-00744-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/31/2020] [Indexed: 12/14/2022]
Abstract
The forebrain cerebral network including the insular cortex plays a crucial role in the regulation of the central autonomic nervous system in relation to emotional stress. Numerous studies have recently shown that the insular cortex also has roles as a vestibular area in addition to auditory function. In this review, we summarize the recent literature regarding the relationship between the insular cortex and vestibular function, and we describe our hypothesis that the insular cortex has a pivotal role in vestibular-cardiovascular integration.
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Aljafen BN. Insular epilepsy, an under-recognized seizure semiology. A review for general neurologist. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2020; 25:262-268. [PMID: 33130806 PMCID: PMC8015617 DOI: 10.17712/nsj.2020.4.20200063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Understanding seizure semiology is one of the most important and crucial steps in diagnosing a seizure disorder. Insular epilepsy may mimic other focal seizure semiologies, leading to misdiagnosis and failed epilepsy surgery. Insular seizures may begin as brief ictal symptoms, such as laryngeal discomfort and unpleasant throat sensations, and spread rapidly to the temporal or frontal regions, causing prominent ictal symptoms different to the initial insular ictal manifestation. Moreover, insular seizures are associated with complex epileptogenic networks and multiple connections. For this reason, accurate seizure semiology helps to lateralize and localize the seizure onset. The insular cortex is deep, and thus scalp electroencephalography is not always beneficial as the epileptic discharges will not be easily recorded, or they will be seen over other cortical regions like the temporal or frontal areas. Insular surgical resection is generally safe, but it requires extensive presurgical workup and surgical precautions in order to minimize mortality.
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Affiliation(s)
- Bandar N Aljafen
- College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail:
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Isolan GR, Campero A, Ajler P, Farina EM, Frigeri TM, Dini LI. Parte I: Anatomía microquirúrgica tridimensional de la ínsula. Surg Neurol Int 2020. [DOI: 10.25259/sni_557_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El lóbulo de la ínsula, o ínsula, se encuentra oculto en la super cie lateral del cerebro. La ínsula está localizada profundamente en el surco lateral o cisura silviana, recubierta por los opérculos frontal, parietal y temporal. Estudiar la compleja anatomía del lóbulo de la ínsula, una de las regiones de mayor complejidad quirúrgica del cerebro humano, y su correlación anatómica con casos quirúrgicos.
Métodos:
En la primera parte de este estudio presentamos los resultados de nuestras disecciones microquirúrgicas en fotografías 2 D y 3D; en la segunda parte de nuestro trabajo, la correlación anatómica con una serie de 44 cirugías en pacientes con tumores de la ínsula, principalmente gliomas, operados entre 2007 y 2014.
Resultados:
Extenso conjunto de bras subcorticales, incluyendo el fascículo uncinado, fronto-occipital inferior y el fascículo arcuato, conectan la ínsula a las regiones vecinas. Varias estructuras anatómicas responsables por dé cits neurológicos severos están íntimamente relacionadas con la cirugía de la ínsula, tales como lesiones de la arteria cerebral Media, cápsula interna, áreas del lenguaje en el hemisferio dominante y arterias lenticuloestriadas.
Conclusión:
El entrenamiento en laboratorio de neuroanatomía, estudio de material impreso en 3D, el conocimiento sobre neuro siología intra-operatoria y el uso de armamento neuroquirúrgico moderno son factores que in uencian en los resultados quirúrgicos.
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Affiliation(s)
- Gustavo Rassier Isolan
- Department of Surgery, Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul, Brazil,
| | - Alvaro Campero
- Department of Neurosurgery, Hospital Padilla, Country Las Yungas, Yerba Buena, Tucumuán, Argentina,
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Peron, Buenos Aires, Argentina,
| | - Edgar Manuel Farina
- Department of Serviço de Neurocirurgia, Hospital Ministro Costa Cavalcanti Sanatório Le Blanc, Foz do Iguacu, Paraná, Brazil,
| | - Thomas More Frigeri
- Department of Neurosurgery, Pontificical Catholic University of Rio Grande do Sul, Porto Alegre,
| | - Leandro Infantini Dini
- Department of Neurosurgery, Center for Advanced Neurology and Neurosurgery, São Leopoldo, Rio Grande do Sul, Brazil
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Bouthillier A, Weil AG, Martineau L, Létourneau-Guillon L, Nguyen DK. Operculoinsular cortectomy for refractory epilepsy. Part 2: Is it safe? J Neurosurg 2020; 133:960-970. [PMID: 31597116 DOI: 10.3171/2019.6.jns191126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Operculoinsular cortectomy (also termed operculoinsulectomy) is increasingly recognized as a therapeutic option for perisylvian refractory epilepsy. However, most neurosurgeons are reluctant to perform the technique because of previously experienced or feared neurological complications. The goal of this study was to quantify the incidence of basic neurological complications (loss of primary nonneuropsychological functions) associated with operculoinsular cortectomies for refractory epilepsy, and to identify factors predicting these complications. METHODS Clinical, imaging, and surgical data of all patients investigated and surgically treated by our team for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Patients with tumors and encephalitis were excluded. Logistic regression analysis was used for uni- and multivariate statistical analyses. RESULTS Forty-four operculoinsular cortectomies were performed in 43 patients. Although postoperative neurological deficits were frequent (54.5% of procedures), only 3 procedures were associated with a permanent significant neurological deficit. Out of the 3 permanent deficits, only 1 (2.3%; a sensorimotor hemisyndrome) was related to the technique of operculoinsular cortectomy (injury to a middle cerebral artery branch), while the other 2 (arm hypoesthesia and hemianopia) were attributed to cortical resection beyond the operculoinsular area. With multivariate analysis, a postoperative neurological deficit was associated with preoperative insular hypometabolism on PET scan. Postoperative motor deficit (29.6% of procedures) was correlated with fewer years of neurosurgical experience and frontal operculectomies, but not with corona radiata ischemic lesions. Ischemic lesions in the posterior two-thirds of the corona radiata (40.9% of procedures) were associated with parietal operculectomies, but not with posterior insulectomies. CONCLUSIONS Operculoinsular cortectomy for refractory epilepsy is a relatively safe therapeutic option but temporary neurological deficits after surgery are frequent. This study highlights the role of frontal/parietal opercula resections in postoperative complications. Corona radiata ischemic lesions are not clearly related to motor deficits. There were no obvious permanent neurological consequences of losing a part of an epileptic insula, including on the dominant side for language. A low complication rate can be achieved if the following conditions are met: 1) microsurgical technique is applied to spare cortical branches of the middle cerebral artery; 2) the resection of an opercula is done only if the opercula is part of the epileptic focus; and 3) the neurosurgeon involved has proper training and experience.
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Affiliation(s)
| | - Alexander G Weil
- 1Divisions of Neurosurgery
- 4Division of Neurosurgery, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
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Eichberg DG, Komotar RJ, Ivan ME. Commentary: Left Modified Orbitozygomatic Approach for Clipping of Multilobulated Middle Cerebral Artery Bifurcation Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 19:E387-E388. [PMID: 32678902 DOI: 10.1093/ons/opaa197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
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De Potter T, Yodfat O, Shinar G, Neta A, Reddy VY, Neuzil P, Veltkamp R, Connolly SJ. Permanent Bilateral Carotid Filters for Stroke Prevention in Atrial Fibrillation. Curr Cardiol Rep 2020; 22:144. [PMID: 32910288 PMCID: PMC7496024 DOI: 10.1007/s11886-020-01388-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purpose of Review A novel permanent carotid filter device for percutaneous implantation was developed for the purpose of stroke prevention. In this review, we cover rationale, existing preclinical and clinical data, and potential future directions for research using such a device. Recent Findings The Vine™ filter was assessed for safety in sheep and in 2 observational human studies, the completed CAPTURE 1 (n = 25) and the ongoing CAPTURE 2 (planned n = 100). CAPTURE 1 has shown high procedural and long-term implant safety. A control group was not available for comparison. Summary A mechanical filter for permanent stroke prevention can be implanted bilaterally in the common carotid artery safely and efficiently. A randomized trial is planned for 2021 (n = 3500, INTERCEPT) to demonstrate superiority of a filter + anticoagulation strategy over anticoagulation alone in patients at high risk for ischemic stroke.
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Affiliation(s)
- Tom De Potter
- Cardiovascular Center, OLV Hospital, Moorselbaan 164, B-9300 Aalst, Belgium
| | | | | | | | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Roland Veltkamp
- Department of Brain Science, Imperial College London, London, UK
- Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany
- Department of Neurology, University Heidelberg, Heidelberg, Germany
| | - Stuart J. Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario Canada
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Khatri R, Qureshi MA, Chaudhry MRA, Maud A, Vellipuram AR, Cruz-Flores S, Rodriguez GJ. The Angiographic Anatomy of the Sphenoidal Segment of the Middle Cerebral Artery and Its Relevance in Mechanical Thrombectomy. INTERVENTIONAL NEUROLOGY 2020; 8:231-241. [PMID: 32508905 DOI: 10.1159/000502545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 08/01/2019] [Indexed: 11/19/2022]
Abstract
Objective The middle cerebral artery (MCA) is the most commonly treated artery in mechanical thrombectomy stroke trials; however, there is no pragmatic agreement about the segmental anatomy and nomenclature utilized. It results in significant clinical-radiological dissociation and introduces bias in research trials. The purpose of the study is to review and compare angiographic anatomy with microsurgical anatomy literature of the MCA with emphasis on the discrepancy. Methodology Consecutive cerebral angiograms between January 2011 and March 2014 were retrospectively reviewed by endovascular surgical neuroradiologists. Information about the anatomy of the sphenoidal segment of the MCA classified as classic and non-classic pattern, the lenticulostriate artery takeoff pattern, and the course angulation of the sphenoidal segment were studied. Results A total of 500 patients, 886 cerebral angiograms, were reviewed. We found the classic pattern of the main trunk MCA bifurcation and a straight angulation course in less than half of the cases. The lenticulostriate arteries arose not only from the main trunk but also from its divisions in more than half of the cases. Conclusion It is important to corroborate our findings and to develop a pragmatic classification to accurately assess MCA occlusions from the radiological and clinical perspective.
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Affiliation(s)
- Rakesh Khatri
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | | | | | - Alberto Maud
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | | | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | - Gustavo Jose Rodriguez
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
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A Permanent Common Carotid Filter for Stroke Prevention in Atrial Fibrillation: Ex Vivo and In Vivo Pre-Clinical Testing. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1587-1593. [PMID: 32522397 DOI: 10.1016/j.carrev.2020.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE A novel, permanent, bilateral, common carotid artery (CCA) coil filter implant was designed to capture stroke-producing emboli in atrial fibrillation patients. Under ultrasound guidance, it is automatically deployed through a 24-guage needle and is retrievable up to 4 h post-procedure. We assessed the feasibility, safety, and effectiveness of the CCA filter in pre-clinical testing. METHODS In a pulsatile flow simulator, the filter's embolic capture efficiency and integrity of simulated (1.2 mm diameter nylon balls) and actual thromboemboli were tested. Implant insertion, retrieval, and chronic safety were tested in sheep by ultrasound and X-ray. At termination, the CCAs were explanted and examined by pathology, histopathology and scanning electron microscopy. The fate of captured emboli was evaluated in sheep 3 weeks after upstream injection of autologous thromboemboli. RESULTS In the flow simulator, 10 filters captured 29 of 29 (100%) 1.2 mm diameter nylon balls. In the thromboemboli integrity test, all captured thromboemboli (99 of 99) were adherent to the filter, without fragmentation. All sheep (n = 30/60 implants) underwent successful CCA filter implantation. During follow-ups at 4, 12, 13, 23, and 31 weeks (6 sheep/12 implants at each follow-up), there were no (0%) major bleeds, CCA damage/stenosis, implant migration, flow obstruction, or thrombi detected by ultrasound. Two organized microthrombi (<100 μm) were observed by histopathology at the puncture site. After 3 weeks, autologous captured thromboemboli (n = 10) either completely regressed (5 of 5) or did not progress (5 of 5). CONCLUSION These favorable pre-clinical results prompt clinical testing of the CCA filter in stroke prevention clinical trials.
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Hale AT, Sen S, Haider AS, Perkins FF, Clarke DF, Lee MR, Tomycz LD. Open Resection versus Laser Interstitial Thermal Therapy for the Treatment of Pediatric Insular Epilepsy. Neurosurgery 2020; 85:E730-E736. [PMID: 30888028 DOI: 10.1093/neuros/nyz094] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/28/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Various studies suggest that the insular cortex may play an underappreciated role in pediatric frontotemporal/parietal epilepsy. Here, we report on the postsurgical outcomes in 26 pediatric patients with confirmed insular involvement by depth electrode monitoring. OBJECTIVE To describe one of the largest series of pediatric patients with medically refractory epilepsy undergoing laser interstitial thermal therapy (LITT) or surgical resection of at least some portion of the insular cortex. METHODS Pediatric patients in whom invasive insular sampling confirmed insular involvement and who subsequently underwent a second stage surgery (LITT or open resection) were included. Complications and Engel Class outcomes at least 1 yr postsurgery were compiled as well as pathology results in the open surgical cases. RESULTS The average age in our cohort was 10.3 yr, 58% were male, and the average length of follow-up was 2.43 ± 0.20 (SEM) yr. A total of 14 patients underwent LITT, whereas 12 patients underwent open resection. Complications in patients undergoing either LITT or open resection were mostly minimal and generally transient. Forty-three percent of patients who underwent LITT were Engel Class I, compared to 50% of patients who underwent open insular resection. CONCLUSION Both surgical resection and LITT are valid management options in the treatment of medically refractory insular/opercular epilepsy in children. Although LITT may be a less invasive alternative to craniotomy, further studies are needed to determine its noninferiority in terms of complication rates and seizure freedom, especially in cases of cortical dysplasia that may involve extensive regions of the brain.
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Affiliation(s)
- Andrew T Hale
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sonali Sen
- Division of Child Neurology, Baylor College of Medicine, Houston, Texas
| | - Ali S Haider
- Department of Neurological Surgery, Texas A&M College of Medicine, Bryan, Texas
| | - Freedom F Perkins
- Department of Pediatric Neurology, Dell Children's Hospital, Austin, Texas
| | - Dave F Clarke
- Department of Pediatric Neurology, Texas Children's Hospital, Houston, Texas
| | - Mark R Lee
- Department of Neurological Surgery, Dell Children's Medical Center, Austin, Texas.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Luke D Tomycz
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
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Ghali MGZ. Preservation of the Lenticulostriate Arteries During Insular Glioma Resection. Asian J Neurosurg 2020; 15:16-21. [PMID: 32181167 PMCID: PMC7057893 DOI: 10.4103/ajns.ajns_146_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/15/2019] [Indexed: 11/21/2022] Open
Abstract
Insular gliomas represent 25% and 10% of low- and high-grade gliomas, respectively. Their resection proves challenging due to the intimate involvement of eloquent parenchyma and the lenticulostriate arteries (LSAs), limiting facility of achieving maximal safe resection. The majority of postoperative deficits following insular glioma resection is attributed to compromise of the LSAs. It is contemporaneously critical and challenging to preserve these vessels, given they are numerous and small, with an intraparenchymal course hidden from direct visualization during the operative intervention. A lesser degree of medially directed displacement of the LSAs predicts tumoral encasement of these vessels, which portends a decreased likelihood for achieving a gross total resection and increased probability of postoperative morbidity. Preservation of these vessels thus requires knowledge of their location during the entirety of the insular glioma resection and is facilitated by pre- and intra-operative imaging. Intraoperative real-time tracking, however, may prove rather challenging, especially with transcortical access. Conventional catheter digital subtraction angiography, computed tomographic angiography, magnetic resonance imaging and angiography, and three-dimensional ultrasound powered Doppler have proven effective modalities in assessing lenticulostriate position, and their use facilitates a greater extent of resection while minimizing the attendant morbidity consequent to LSA injury.
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67
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Min SH, Kim JT, Kang KW, Choi MJ, Yoon H, Shinohara Y, Lev MH, Saver JL, Cho KH. Acute insular infarction: Early outcomes of minor stroke with proximal artery occlusion. PLoS One 2020; 15:e0229836. [PMID: 32160209 PMCID: PMC7065779 DOI: 10.1371/journal.pone.0229836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE We hypothesized that admission insular infarcts could be associated with early neurological deterioration (END) in acute minor stroke with large vessel occlusion. METHODS Using acute and follow-up diffusion-weighted imaging (DWI), we assessed insular involvement including the percent insular ribbon infarction (PIRI) scores and follow-up lesion patterns in acute minor stroke (NIHSS ≤5) with MCA/ICA occlusion. Follow-up lesion patterns were classified as swelling, new lesions, or infarct growth. END was defined as any increase in the NIHSS score. RESULTS Among 166 patients (age: 66±12 y, 60.8% male), 82 (49.4%) had insular lesions on baseline DWI, and 64 (38.6%) had PIRI scores ≥2. On follow-up DWI, infarct growths, new lesions, and swelling were observed in 34.9%, 69.9%, and 29.5% of patients. Infarct growths were significantly more frequent in patients with insular infarcts (43.9%), especially those with a PIRI score of 2 (54.8%), than in patients without insular infarcts (p = 0.02). While END was not significantly different in patients with and without insular lesions, insular lesions were independently associated with infarct growths (OR 2.18, 95% CI 1.12-4.26, p = 0.02) and END due to infarct growth (OR 2.54, 95% CI 1.12-5.76, p = 0.03), particularly in those with PIRI scores ≥2. CONCLUSION In acute minor stroke with MCA/ICA occlusion, insular lesions on admission DWI, especially in patients with PIRI scores ≥2, were more likely to exhibit infarct growth and END due to infarct growth. This finding may help identify patients with higher risks of clinical worsening following acute minor stroke with large vessel occlusion.
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Affiliation(s)
- Seung-Hyun Min
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
- * E-mail:
| | - Kyung-Wook Kang
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Min-Ji Choi
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Hana Yoon
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
| | - Yuki Shinohara
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Michael H. Lev
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Gwanju, Korea
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68
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Li Z, Li G, Liu Z, Pan Y, Hou Z, Wu L, Huang Z, Zhang Y, Xie J. Transcortical approach for insular gliomas: a series of 253 patients. J Neurooncol 2020; 147:59-66. [PMID: 32006193 DOI: 10.1007/s11060-020-03390-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE The object of this study was to identify the distribution characteristics of insular gliomas and evaluate the efficiency of transcortical approach. METHODS Insular gliomas patients who underwent transcortical approach for the first time between March 2011 and July 2019 at our institute were analyzed. RESULTS A total of 253 primary insular gliomas patients were enrolled in the study. Of all patients, 176 patients (69.6%) underwent gross total resection, 61 patients (24.1%) underwent subtotal resection and 16 patients (6.3%) underwent partial resection. According to Berger-Sanai classification, the gross total resection rates of different types of insular gliomas were as follows: Zone I (90.1%), zone II (50.0%), zone III (40.0%), zone IV (89.5%), zone I + II (43.5%), zone I + IV (74.6%), zone II + III (44.4%), zone III + IV (41.7%), Giant (34.5%). According to our modified classification, the gross total resection rates were as follows: anterior type (84.9%), posterior type (45.8%), anterior-posterior type (42.9%), giant type (34.5%). After surgery, new limb motor deficit was observed in 28 patients (11.1%), and 5 patients (2.0%) were left long-term limb motor disability. New language impairment occurred in 23 patients (9.1%), and 3 patients (1.2%) were left long-term language disability. The patients were followed up for 1 to 89.2 months (average, 39.9 ± 20.3 months). At the end of follow-up, tumor progression occurred in 98 (38.7%) patients and 71 (28.1%) patients died of their disease. CONCLUSION This study demonstrated that the maximal safe resection of insular gliomas can be achieved by transcortical approach. Insular gliomas had the characteristic of forward distribution, anterior transcortical approach can provide enough surgical freedom for anterior type of insular gliomas. If anterior tumors can make route to the posterior parts, anterior transcortical approach was also applied to some anterior-posterior and giant types of insular gliomas without resection of excessive brain, which may reduce the incidence of neurological complications.
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Affiliation(s)
- Zhenye Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Gen Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhenxing Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zonggang Hou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhenxing Huang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jian Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
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69
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Shim R, Wen SW, Wanrooy BJ, Rank M, Thirugnanachandran T, Ho L, Sepehrizadeh T, de Veer M, Srikanth VK, Ma H, Phan TG, Sobey CG, Wong CHY. Stroke Severity, and Not Cerebral Infarct Location, Increases the Risk of Infection. Transl Stroke Res 2019; 11:387-401. [PMID: 31709500 DOI: 10.1007/s12975-019-00738-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/16/2022]
Abstract
Infection is a leading cause of death in patients with stroke; however, the impact of cerebral infarct size or location on infectious outcome is unclear. To examine the effect of infarct size on post-stroke infection, we utilised the intraluminal middle-cerebral artery occlusion (MCAO) mouse model of ischemic stroke and adjusted the duration of arterial occlusion. At 1 day following stroke onset, the proportion of mice with infection was significantly greater in mice that had larger infarct sizes. Additionally, the presence of lung infection in these mice with severe strokes extended past 2 days, suggestive of long-term immune impairment. At the acute phase, our data demonstrated an inverse relationship between infarct volume and the number of circulating leukocytes, indicating the elevated risk of infection in more severe stroke is associated with reduced cellularity in peripheral blood, owing predominately to markedly decreased lymphocyte numbers. In addition, the stroke-induced reduction of lymphocyte-to-neutrophil ratio was also evident in the lung of all post-stroke animals. To investigate the effect of infarct location on post-stroke infection, we additionally performed a photothrombotic (PT) model of stroke and using an innovative systematic approach of analysis, we found the location of cerebral infarct does not impact on the susceptibility of post-stroke infection, confirming the greater role of infarct volume over infarct location in the susceptibility to infection. Our experimental findings were validated in a clinical setting and reinforced that stroke severity, and not infarct location, influences the risk of infection after stroke.
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Affiliation(s)
- Raymond Shim
- Centre for Inflammatory Diseases, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, VIC, 3168, Australia
| | - Shu Wen Wen
- Centre for Inflammatory Diseases, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, VIC, 3168, Australia
| | - Brooke J Wanrooy
- Centre for Inflammatory Diseases, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, VIC, 3168, Australia
| | - Michelle Rank
- Department of Anatomy and Neuroscience, School of Biomedical Sciences, The University of Melbourne, Parkville, Victoria, Australia
- School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Tharani Thirugnanachandran
- Stroke and Ageing Research Group, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Luke Ho
- Centre for Inflammatory Diseases, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, VIC, 3168, Australia
- Department of Medicine (Academic Unit), Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Tara Sepehrizadeh
- Monash Biomedical Imaging, Monash University, Clayton, Victoria, Australia
| | - Michael de Veer
- Monash Biomedical Imaging, Monash University, Clayton, Victoria, Australia
| | - Velandai K Srikanth
- Department of Medicine (Academic Unit), Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Henry Ma
- Stroke and Ageing Research Group, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Thanh G Phan
- Stroke and Ageing Research Group, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Christopher G Sobey
- Department of Physiology, Anatomy and Microbiology, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Connie H Y Wong
- Centre for Inflammatory Diseases, Department of Medicine at Monash Health, School of Clinical Sciences, Monash Medical Centre, Monash University, Clayton, VIC, 3168, Australia.
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Purkayastha S, Williams B, Murphy M, Lyng S, Sabo T, Bell KR. Reduced heart rate variability and lower cerebral blood flow associated with poor cognition during recovery following concussion. Auton Neurosci 2019; 220:102548. [DOI: 10.1016/j.autneu.2019.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 03/12/2019] [Accepted: 04/27/2019] [Indexed: 11/24/2022]
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71
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Winder K, Linker RA, Seifert F, Wang R, Lee DH, Engelhorn T, Dörfler A, Fröhlich K, Hilz M. Cerebral lesion correlates of sympathetic cardiovascular activation in multiple sclerosis. Hum Brain Mapp 2019; 40:5083-5093. [PMID: 31403742 PMCID: PMC6865522 DOI: 10.1002/hbm.24759] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 12/19/2022] Open
Abstract
Cardiovascular autonomic dysfunction is common in multiple sclerosis (MS) and contributes significantly to disability. We hypothesized that cerebral MS‐lesions in specific areas of the central autonomic network might account for imbalance of the sympathetic and parasympathetic cardiovascular modulation. Therefore, we used voxel‐based lesion symptom mapping (VLSM) to determine associations between cardiovascular autonomic dysfunction and cerebral MS‐related lesion sites. In 74 MS‐patients (mean age 37.0 ± 10.5 years), we recorded electrocardiographic RR‐intervals and systolic and diastolic blood pressure. Using trigonometric regressive spectral analysis, we assessed low (0.04–0.15 Hz) and high (0.15–0.5 Hz) frequency RR‐interval‐and blood pressure‐oscillations and determined parasympathetically mediated RR‐interval–high‐frequency modulation, mainly sympathetically mediated RR‐interval–low‐frequency modulation, sympathetically mediated blood pressure‐low‐frequency modulation, and the ratios of sympathetic and parasympathetic RR‐interval‐modulation as an index of sympathetic‐parasympathetic balance. Cerebral MS‐lesions were analyzed on imaging scans. We performed a VLSM‐analysis correlating parameters of autonomic dysfunction with cerebral MS‐lesion sites. The VLSM‐analysis showed associations between increased RR‐interval low‐frequency/high‐frequency ratios and lesions most prominently in the left insular, hippocampal, and right frontal inferior opercular region, and a smaller lesion cluster in the right middle cerebellar peduncle. Increased blood pressure‐low‐frequency powers were associated with lesions primarily in the right posterior parietal white matter and again left insular region. Our data indicate associations between a shift of cardiovascular sympathetic‐parasympathetic balance toward increased sympathetic modulation and left insular and hippocampal lesions, areas of the central autonomic network. The VLSM‐analysis further distinguished between right inferior fronto‐opercular lesions disinhibiting cardiac sympathetic activation and right posterior parietal lesions increasing sympathetic blood pressure modulation.
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Affiliation(s)
- Klemens Winder
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ralf A Linker
- Department of Neurology, University Regensburg, Regensburg, Germany
| | - Frank Seifert
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - De-Hyung Lee
- Department of Neurology, University Regensburg, Regensburg, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Kilian Fröhlich
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Max Hilz
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
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72
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Raghu ALB, Parker T, van Wyk A, Green AL. Insula stroke: the weird and the worrisome. Postgrad Med J 2019; 95:497-504. [PMID: 31296791 DOI: 10.1136/postgradmedj-2019-136732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/10/2019] [Accepted: 06/23/2019] [Indexed: 01/10/2023]
Abstract
Infarction of the insula is a common scenario with large tissue-volume strokes in the middle cerebral artery territory. Considered to be part of the central autonomic network, infarction of this region is associated with autonomic disturbances, in particular cardiovascular dysregulation. Risk of aspiration following stroke is also associated with involvement of the insula, consistent with its purported participation in complex functions of the mouth and pharynx. Strokes restricted to the insula are rare and present with a broad range of symptoms that offer a window of insight into the diverse functionality of the insular cortex. Chemosensory, autonomic, vestibular, auditory, somatosensory, language and oropharyngeal functional deficits are all recognised, among others. Long-term sequelae are unknown but profound symptoms, such as hemiparesis, are usually transient. Understanding the patterns of dysfunction highlighted provides the basis for future strategies to optimise stroke management on the discovery of insula involvement.
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Affiliation(s)
| | - Tariq Parker
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - André van Wyk
- Acute Stroke Unit, Royal Berkshire Hospital, Reading, UK
| | - Alexander Laurence Green
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Dionisio S, Mayoglou L, Cho SM, Prime D, Flanigan PM, Lega B, Mosher J, Leahy R, Gonzalez-Martinez J, Nair D. Connectivity of the human insula: A cortico-cortical evoked potential (CCEP) study. Cortex 2019; 120:419-442. [PMID: 31442863 DOI: 10.1016/j.cortex.2019.05.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/02/2019] [Accepted: 05/22/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The human insula is increasingly being implicated as a multimodal functional network hub involved in a large variety of complex functions. Due to its inconspicuous location and highly vascular anatomy, it has historically been difficult to study. Cortico-cortical evoked potentials (CCEPs), utilize low frequency stimulation to map cerebral networks. They were used to study connections of the human insula. METHODS CCEP data was acquired from each sub-region of the dominant and non-dominant insula in 30 patients who underwent stereo-EEG. Connectivity strength to the various cortical regions was obtained via a measure of root mean square (RMS), calculated from each gyrus of the insula and ranked into weighted means. RESULTS The results of all cumulative CCEP responses for each individual gyrus were represented by circro plots. Forty-nine individual CCEP pairs were stimulated across all the gyri from the right and left insula. In brief, the left insula contributed more greatly to language areas. Sensory function, pain, saliency processing and vestibular function were more heavily implicated from the right insula. Connections to the primary auditory cortex arose from both insula regions. Both posterior insula regions showed significant contralateral connectivity. Ipsilateral mesial temporal connections were seen from both insula regions. In visual function, we further report the novel finding of a direct connection between the right posterior insula and left visual cortex. SIGNIFICANCE The insula is a major multi-modal network hub with the cerebral cortex having major roles in language, sensation, auditory, visual, limbic and vestibular functions as well as saliency processing. In temporal lobe epilepsy surgery failure, the insula may be implicated as an extra temporal cause, due to the strong mesial temporal connectivity findings.
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Affiliation(s)
- Sasha Dionisio
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA; Epilepsy Centre, Mater Centre for Neurosciences, Brisbane, Australia.
| | - Lazarus Mayoglou
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA; Epilepsy Center, UPMC Hamot, Erie, PA, USA
| | - Sung-Min Cho
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - David Prime
- Epilepsy Centre, Mater Centre for Neurosciences, Brisbane, Australia; Griffith School of Electrical Engineering, Nathan Campus, QLD, Australia
| | - Patrick M Flanigan
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Bradley Lega
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA; Neurological Surgery, University of Texas-Southwestern, Dallas, TX, USA
| | - John Mosher
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Richard Leahy
- Signal and Image Processing Institute, University of Southern California, Los Angeles, CA, USA
| | | | - Dileep Nair
- Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
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Post-operative morbidity ensuing surgery for insular gliomas: a systematic review and meta-analysis. Neurosurg Rev 2019; 43:987-997. [DOI: 10.1007/s10143-019-01113-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/31/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
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Gunnal SA, Farooqui MS, Wabale RN. Study of Middle Cerebral Artery in Human Cadaveric Brain. Ann Indian Acad Neurol 2019; 22:187-194. [PMID: 31007431 PMCID: PMC6472224 DOI: 10.4103/0972-2327.144289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Middle cerebral artery (MCA) is the larger terminal branch of the internal carotid artery. It travels through the Sylvian fissure on the insula. Objective: MCA supplies a large area of distribution than the other two cerebral arteries. Though it is so, there are very few articles in the literature describing MCA. Aim of the present work is to study the MCA regarding its origin, course, termination, branching pattern, morphometry and symmetry. Materials and Methods: 340 MCAs from 170 formalin preserved brains were dissected. Morphology, morphometry and symmetry of MCAs, were studied in detail and well photographed. The data collected in the study was analyzed. Results: Accessory MCA was found in seven specimens (2.05%). Duplicated MCA was seen in three specimens (0.88%). Aneurysm was found in three specimens (0.88%). MCA with bifurcated, trifurcated, quadrifurcated and single trunk termination was seen in 220 (64.70%), 42 (12.35%), 8 (2.35%), and in 70 (20.58%) specimens respectively. Bifurcated pattern as upper prominent trunk (type A), lower prominent trunk (type B) and both equal prominent trunks (type C) were seen in 63 (28.63%), 129 (58.63%), and 28 (12.72%) specimens respectively. Asymmetry was seen in 102 specimens (60%). Mean length and diameter of the MCA was 25.5-27.8 mm and 3 mm respectively. Conclusion: Awareness of these anatomical variations in branching patterns is important in neurovascular procedures. As very few Anatomical studies on MCA are there in the literature, this type of research work should be done by a number of scientists from a different region of the world in large scale.
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A statistical atlas of cerebral arteries generated using multi-center MRA datasets from healthy subjects. Sci Data 2019; 6:29. [PMID: 30975990 PMCID: PMC6472360 DOI: 10.1038/s41597-019-0034-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 03/05/2019] [Indexed: 11/08/2022] Open
Abstract
Magnetic resonance angiography (MRA) can capture the variation of cerebral arteries with high spatial resolution. These measurements include valuable information about the morphology, geometry, and density of brain arteries, which may be useful to identify risk factors for cerebrovascular and neurological diseases at an early time point. However, this requires knowledge about the distribution and morphology of vessels in healthy subjects. The statistical arterial brain atlas described in this work is a free and public neuroimaging resource that can be used to identify vascular morphological changes. The atlas was generated based on 544 freely available multi-center MRA and T1-weighted MRI datasets. The arteries were automatically segmented in each MRA dataset and used for vessel radius quantification. The binary segmentation and vessel size information were non-linearly registered to the MNI brain atlas using the T1-weighted MRI datasets to construct atlases of artery occurrence probability, mean artery radius, and artery radius standard deviation. This public neuroimaging resource improves the understanding of the distribution and size of arteries in the healthy human brain.
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Lu VM, Goyal A, Quinones-Hinojosa A, Chaichana KL. Updated incidence of neurological deficits following insular glioma resection: A systematic review and meta-analysis. Clin Neurol Neurosurg 2019; 177:20-26. [DOI: 10.1016/j.clineuro.2018.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 12/14/2018] [Accepted: 12/16/2018] [Indexed: 12/16/2022]
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Hervey-Jumper SL, Berger MS. Insular glioma surgery: an evolution of thought and practice. J Neurosurg 2019; 130:9-16. [PMID: 30611160 DOI: 10.3171/2018.10.jns181519] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVEThe goal of this article is to review the history of surgery for low- and high-grade gliomas located within the insula with particular focus on microsurgical technique, anatomical considerations, survival, and postoperative morbidity.METHODSThe authors reviewed the literature for published reports focused on insular region anatomy, neurophysiology, surgical approaches, and outcomes for adults with World Health Organization grade II-IV gliomas.RESULTSWhile originally considered to pose too great a risk, insular glioma surgery can be performed safely due to the collective efforts of many individuals. Similar to resection of gliomas located within other cortical regions, maximal resection of gliomas within the insula offers patients greater survival time and superior seizure control for both newly diagnosed and recurrent tumors in this region. The identification and the preservation of M2 perforating and lateral lenticulostriate arteries are critical steps to preventing internal capsule stroke and hemiparesis. The transcortical approach and intraoperative mapping are useful tools to maximize safety.CONCLUSIONSThe insula's proximity to middle cerebral and lenticulostriate arteries, primary motor areas, and perisylvian language areas makes accessing and resecting gliomas in this region challenging. Maximal safe resection of insular gliomas not only is possible but also is associated with excellent outcomes and should be considered for all patients with low- and high-grade gliomas in this area.
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Loit MP, Rheault F, Gayat E, Poisson I, Froelich S, Zhi N, Velut S, Mandonnet E. Hotspots of small strokes in glioma surgery: an overlooked risk? Acta Neurochir (Wien) 2019; 161:91-98. [PMID: 30415385 DOI: 10.1007/s00701-018-3717-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/27/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Small deep infarcts constitute a well-known risk of motor and speech deficit in insulo-opercular glioma surgery. However, the risk of cognitive deterioration in relation to stroke occurrence in so-called silent areas is poorly known. In this paper, we propose to build a distribution map of small deep infarcts in glioma surgery, and to analyze patients' cognitive outcome in relation to stroke occurrence. METHODS We retrospectively studied a consecutive series of patients operated on for a diffuse glioma between June 2011and June 2017. Patients with lower-grade glioma were cognitively assessed, both before and 4 months after surgery. Areas of decreased apparent diffusion coefficient (ADC) on the immediate postoperative MRI were segmented. All images were registered in the MNI reference by ANTS algorithm, allowing to build a distribution map of the strokes. Stroke occurrence was correlated with the postoperative changes in semantic fluency score in the lower-grade glioma cohort. RESULTS One hundred fifteen patients were included. Areas of reduced ADC were observed in 27 out of 54 (50%) patients with a lower-grade glioma, and 25 out of 61 (41%) patients with a glioblastoma. Median volume was 1.6 cc. The distribution map revealed five clusters of deep strokes, corresponding respectively to callosal, prefrontal, insulo-opercular, parietal, and temporal tumor locations. No motor nor speech long-term deficits were caused by these strokes. Cognitive evaluations at 4 months showed that the presence of small infarcts correlated with a slight decrease of semantic fluency scores. CONCLUSION Deep small infarcts are commonly found after glioma surgery, but their actual impact in terms of patients' quality of life remains to be demonstrated. Further studies are needed to better evaluate the cognitive consequences-if any-for each of the described hotspots and to identify risk factors other than the surgery-induced damage of microvessels.
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Affiliation(s)
- Marie-Pierre Loit
- Université Paris 7 Diderot, Paris, France
- Department of Neurosurgery, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France
| | - François Rheault
- Department of Neurosurgery, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France
- Sherbrooke Connectivity Imaging Lab (SCIL), Computer Science Department, Université de Sherbrooke, Sherbrooke, Canada
| | - Etienne Gayat
- Université Paris 7 Diderot, Paris, France
- Department of Anesthesiology, Lariboisière Hospital, Paris, France
| | - Isabelle Poisson
- Department of Neurosurgery, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France
| | - Sébastien Froelich
- Université Paris 7 Diderot, Paris, France
- Department of Neurosurgery, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France
| | - Nanxi Zhi
- Université Paris 7 Diderot, Paris, France
- Department of Anesthesiology, Lariboisière Hospital, Paris, France
| | - Stéphane Velut
- Université François-Rabelais de Tours, Inserm, Imagerie et cerveau UMR U930, Tours, France
- Department of Neurosurgery, CHRU de Tours, Tours, France
| | - Emmanuel Mandonnet
- Université Paris 7 Diderot, Paris, France.
- Department of Neurosurgery, Lariboisière Hospital, 2 rue Ambroise Paré, 75010, Paris, France.
- Frontlab, INSERM, Institut du Cerveau et de la Moelle (ICM), Paris, France.
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Iwase T, Yoshida M, Hashizume Y, Yazawa I, Takahashi S, Ando T, Ikeda T, Nokura K. Intracranial vascular calcification with extensive white matter changes in an autopsy case of pseudopseudohypoparathyroidism. Neuropathology 2018; 39:39-46. [PMID: 30430658 DOI: 10.1111/neup.12518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 01/31/2023]
Abstract
We herein report an autopsy case of a 69-year-old man with pseudopseudohypoparathyroidism. The patient suffered from mental retardation and spastic tetraparesis and had all the features of Albright's hereditary osteodystrophy with a normal response to parathyroid hormone in the Ellsworth-Howard test. Computed tomography demonstrated symmetrical massive brain calcification involving the bilateral basal ganglia, thalami, dentate nuclei and cerebral gray/white matter junctions, which was consistent with Fahr's syndrome. Magnetic resonance imaging revealed extensive white matter changes sparing the corpus callosum. Severe ossification of the posterior longitudinal ligament of the cervical spine was also demonstrated. A neuropathological examination revealed massive intracranial calcification within the walls of the blood vessels and capillaries with numerous calcium deposits. The calcium deposits aligned along the capillaries, and deposits in the vessel wall at the initial stage were confined to the border between the tunica media and adventitia. The vascular calcification in the basal ganglia continuously spread over the surrounding white matter into the cortex. The area of vascular calcification in the white matter was very well correlated with the area of the attenuated myelin staining. Axonal loss, myelin sheath loss and gliosis were observed in the white matter with severe vascular calcification. We should recognize the continuous area of vascular calcification and its correlation with extensive white matter changes as possible causes of neuropsychiatric symptoms in pseudopseudohypoparathyroidism with Fahr's syndrome.
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Affiliation(s)
- Tamaki Iwase
- Department of Neurology, Nagoya City Koseiin Medical Welfare Center, Aichi, Japan
| | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan
| | - Yoshio Hashizume
- Institute for Neuropathology, Fukushimura Hospital, Aichi, Japan
| | - Ikuru Yazawa
- Laboratory of Research Resources, Research Institute, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Seishiro Takahashi
- Department of Experimental Pathology and Tumor Biology, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Takashi Ando
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan.,Department of Neurology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshimasa Ikeda
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan.,Department of Neurology and Neuroscience, Nagoya City University, Graduate School of Medical Sciences, Aichi, Japan
| | - Kazuya Nokura
- Department of Neurology, Ban Buntane Hotokukai Hospital, School of Medicine, Fujita Health University, Aichi, Japan
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Ribas EC, Yağmurlu K, de Oliveira E, Ribas GC, Rhoton A. Microsurgical anatomy of the central core of the brain. J Neurosurg 2018; 129:752-769. [DOI: 10.3171/2017.5.jns162897] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe purpose of this study was to describe in detail the cortical and subcortical anatomy of the central core of the brain, defining its limits, with particular attention to the topography and relationships of the thalamus, basal ganglia, and related white matter pathways and vessels.METHODSThe authors studied 19 cerebral hemispheres. The vascular systems of all of the specimens were injected with colored silicone, and the specimens were then frozen for at least 1 month to facilitate identification of individual fiber tracts. The dissections were performed in a stepwise manner, locating each gray matter nucleus and white matter pathway at different depths inside the central core. The course of fiber pathways was also noted in relation to the insular limiting sulci.RESULTSThe insular surface is the most superficial aspect of the central core and is divided by a central sulcus into an anterior portion, usually containing 3 short gyri, and a posterior portion, with 2 long gyri. It is bounded by the anterior limiting sulcus, the superior limiting sulcus, and the inferior limiting sulcus. The extreme capsule is directly underneath the insular surface and is composed of short association fibers that extend toward all the opercula. The claustrum lies deep to the extreme capsule, and the external capsule is found medial to it. Three fiber pathways contribute to form both the extreme and external capsules, and they lie in a sequential anteroposterior disposition: the uncinate fascicle, the inferior fronto-occipital fascicle, and claustrocortical fibers. The putamen and the globus pallidus are between the external capsule, laterally, and the internal capsule, medially. The internal capsule is present medial to almost all insular limiting sulci and most of the insular surface, but not to their most anteroinferior portions. This anteroinferior portion of the central core has a more complex anatomy and is distinguished in this paper as the “anterior perforated substance region.” The caudate nucleus and thalamus lie medial to the internal capsule, as the most medial structures of the central core. While the anterior half of the central core is related to the head of the caudate nucleus, the posterior half is related to the thalamus, and hence to each associated portion of the internal capsule between these structures and the insular surface. The central core stands on top of the brainstem. The brainstem and central core are connected by several white matter pathways and are not separated from each other by any natural division. The authors propose a subdivision of the central core into quadrants and describe each in detail. The functional importance of each structure is highlighted, and surgical approaches are suggested for each quadrant of the central core.CONCLUSIONSAs a general rule, the internal capsule and its vascularization should be seen as a parasagittal barrier with great functional importance. This is of particular importance in choosing surgical approaches within this region.
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Affiliation(s)
- Eduardo Carvalhal Ribas
- 1Department of Neurosurgery, University of Florida, Gainesville, Florida
- 3Hospital Israelita Albert Einstein; and
| | - Kaan Yağmurlu
- 1Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Evandro de Oliveira
- 4Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
- 5Institute of Neurological Sciences, São Paulo, São Paulo, Brazil; and
| | - Guilherme Carvalhal Ribas
- 3Hospital Israelita Albert Einstein; and
- 6Department of Surgery, University of São Paulo Medical School
| | - Albert Rhoton
- 1Department of Neurosurgery, University of Florida, Gainesville, Florida
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Abstract
Focal epilepsy originating from the insular cortex is rare. One reason is the small amount of cortical tissue compared with other lobes of the brain. However, the incidence of insular epilepsy might be underestimated because of diagnostic difficulties. The semiology and the surface EEG are often not meaningful or even misleading, and elaborated imaging might be necessary. The close connections of the insular cortex with other potentially epileptogenic areas, such as the temporal lobe or frontal/central cortex, is increasingly recognized as possible reason for failure of epilepsy surgery for temporal or extratemporal seizures. Therefore, some centers consider invasive EEG recording of the insular cortex not only in case of insular epilepsy but also in other focal epilepsies with nonconclusive results from the presurgical work-up. The surgical approach to and resection of insular cortex is challenging because of its deep location and proximity to highly eloquent brain structures. Over the last decades, technical adjuncts like navigation tools, electrophysiological monitoring and intraoperative imaging have improved the outcome after surgery. Nevertheless, there is still a considerable rate of postoperative transient or permanent deficits, in some cases as unavoidable and calculated deficits. In most of the recent series, seizure outcome was favorable and comparable with extratemporal epilepsy surgery or even better. Up to now, the data volume concerning long-term follow-up is limited. This review focusses on the surgical challenges of resections to treat insular epilepsy, on prognostic factors concerning seizure outcome, on postoperative deficits and complications. Moreover, less invasive surgical techniques to treat epilepsy in this highly eloquent area are summarized.
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van der Thiel M, Rodriguez C, Giannakopoulos P, Burke MX, Lebel RM, Gninenko N, Van De Ville D, Haller S. Brain Perfusion Measurements Using Multidelay Arterial Spin-Labeling Are Systematically Biased by the Number of Delays. AJNR Am J Neuroradiol 2018; 39:1432-1438. [PMID: 29976831 DOI: 10.3174/ajnr.a5717] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Multidelay arterial spin-labeling is a promising emerging method in clinical practice. The effect of imaging parameters in multidelay arterial spin-labeling on estimated cerebral blood flow measurements remains unknown. We directly compared 3-delay versus 7-delay sequences, assessing the difference in the estimated transit time and blood flow. MATERIALS AND METHODS This study included 87 cognitively healthy controls (78.7 ± 3.8 years of age; 49 women). We assessed delay and transit time-uncorrected and transit time-corrected CBF maps. Data analysis included voxelwise permutation-based between-sequence comparisons of 3-delay versus 7-delay, within-sequence comparison of transit time-uncorrected versus transit time-corrected maps, and average CBF calculations in regions that have been shown to differ. RESULTS The 7-delay sequence estimated a higher CBF value than the 3-delay for the transit time-uncorrected and transit time-corrected maps in regions corresponding to the watershed areas (transit time-uncorrected = 27.62 ± 12.23 versus 24.58 ± 11.70 mL/min/100 g, Cohen's d = 0.25; transit time-corrected = 33.48 ± 14.92 versus 30.16 ± 14.32 mL/min/100 g, Cohen's d = 0.23). In the peripheral regions of the brain, the estimated delay was found to be longer for the 3-delay sequence (1.52408 ± 0.25236 seconds versus 1.47755 ± 0.24242 seconds, Cohen's d = 0.19), while the inverse was found in the center of the brain (1.39388 ± 0.22056 seconds versus 1.42565 ± 0.21872 seconds, Cohen's d = 0.14). Moreover, 7-delay had lower hemispheric asymmetry. CONCLUSIONS The results of this study support the necessity of standardizing acquisition parameters in multidelay arterial spin-labeling and identifying basic parameters as a confounding factor in CBF quantification studies. Our findings conclude that multidelay arterial spin-labeling sequences with a high number of delays estimate higher CBF values than those with a lower number of delays.
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Affiliation(s)
- M van der Thiel
- From the Faculty of Medicine of the University of Geneva (M.v.d.T., P.G., N.G., D.v.d.V., S.H.), Geneva, Switzerland
- Institute of Bioengineering (M.v.d.T., N.G., D.v.d.V.), School of Engineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - C Rodriguez
- Division of Institutional Measures (C.R., P.G.), Medical Direction, University Hospitals of Geneva, Geneva, Switzerland
| | - P Giannakopoulos
- From the Faculty of Medicine of the University of Geneva (M.v.d.T., P.G., N.G., D.v.d.V., S.H.), Geneva, Switzerland
- Division of Institutional Measures (C.R., P.G.), Medical Direction, University Hospitals of Geneva, Geneva, Switzerland
| | - M X Burke
- GE Healthcare (M.X.B., M.L.), Little Chalfont, UK
| | - R Marc Lebel
- GE Healthcare (M.X.B., M.L.), Little Chalfont, UK
| | - N Gninenko
- From the Faculty of Medicine of the University of Geneva (M.v.d.T., P.G., N.G., D.v.d.V., S.H.), Geneva, Switzerland
- Institute of Bioengineering (M.v.d.T., N.G., D.v.d.V.), School of Engineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - D Van De Ville
- From the Faculty of Medicine of the University of Geneva (M.v.d.T., P.G., N.G., D.v.d.V., S.H.), Geneva, Switzerland
- Institute of Bioengineering (M.v.d.T., N.G., D.v.d.V.), School of Engineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - S Haller
- From the Faculty of Medicine of the University of Geneva (M.v.d.T., P.G., N.G., D.v.d.V., S.H.), Geneva, Switzerland
- Affidea Centre de Diagnostic Radiologique de Carouge (S.H.), Geneva, Switzerland
- Department of Surgical Sciences and Radiology (S.H.), Uppsala University, Uppsala, Sweden
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Bouthillier A, Nguyen DK. Epilepsy Surgeries Requiring an Operculoinsular Cortectomy: Operative Technique and Results. Neurosurgery 2018; 81:602-612. [PMID: 28419327 DOI: 10.1093/neuros/nyx080] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 02/04/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Epilepsy surgeries requiring an operculoinsulectomy pose significant difficulties because the perisylvian area is highly vascular, deep, and functional. OBJECTIVE To report the operative technique and results of epilepsy surgeries requiring an operculoinsular cortectomy at our institution. METHODS The data of all consecutive patients who had undergone an epilepsy surgery requiring an operculoinsular cortectomy with a minimum follow-up of 1 yr were reviewed. Tumor and vascular malformation cases were excluded. Surgical techniques are described based on findings during surgery. RESULTS Twenty-five patients underwent an epilepsy surgery requiring an operculoinsular cortectomy: mean age at surgery was 35 y (9-51), mean duration of epilepsy was 19 y (5-36), 14 were female, and mean duration of follow-up was 4.7 y (1-16). Magnetic resonance imaging of the operculoinsular area was normal or revealed questionable nonspecific findings in 72% of cases. Investigation with intracranial EEG electrodes was done in 17 patients. Surgery was performed on the dominant side for language in 7 patients. An opercular resection was performed in all but 2 patients who only had an insulectomy. Engel class I seizure control was achieved in 80% of patients. Postoperative neurological deficits (paresis, dysphasia, alteration of taste, smell, hearing, pain, and thermal perceptions) were frequent (75%) but always transient except for 1 patient with persistent mild alteration of thermal and pain perception. CONCLUSION Surgical treatment of operculoinsular epilepsy is effective in achieving seizure control and is associated with an acceptable long-term complication rate.
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Affiliation(s)
- Alain Bouthillier
- Division of Neurosurgery, Hôpital Notre-Dame (CHUM), Université de Montréal, Quebec, Canada
| | - Dang Khoa Nguyen
- Division of Neurology, Hôpital Notre-Dame (CHUM), Université de Montréal, Quebec, Canada
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Corrivetti F, Froelich S, Mandonnet E. Endoscopic Approach of the Insula Through the Anterior Middle Temporal Gyrus: A Feasibility Study in the Laboratory. Oper Neurosurg (Hagerstown) 2018; 14:441-448. [PMID: 28973523 DOI: 10.1093/ons/opx128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 07/06/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Insular glioma surgery still represents a challenge. Nonetheless, advances in microsurgical anatomy and brain mapping techniques have allowed an increase in the extent of resection with acceptable morbidity rates. Transsylvian and transcortical approaches constitute the main surgical corridors, the latter providing considerable advantages and a high degree of reliability. Nevertheless, both surgical corridors yield remarkable difficulties in reaching the most posterior insular region. OBJECTIVE To study the feasibility of an endoscopic transtemporal approach in brain specimens, with the aim to provide a suitable access for posterior insular region. METHODS Four postmortem human hemispheres, embalmed using Klingler's technique, were dissected by means of a 30° rigid endoscope. The specimens underwent magnetic resonance imaging scans and, using the neuronavigation system, we were able to design a safe cortical window and an optimized endoscopic trajectory for the posterior insular dissection. RESULTS Insular dissection was led subpially through a small 2-cm cortical access, located in the anterior part of the middle temporal gyrus. During the posterior insula dissection, the endoscope allowed for optimized surgical view all along the long gyri, up to the posterior insular point. Anterior insular dissection was accomplished with more difficulties, as the endoscopic trajectory was not aligned to the axis of the short gyri. CONCLUSION This new surgical approach provides a favorable transcortical access to reach the most posterior insular portion. It seems to be a promising tool, in combination with intraoperative functional brain mapping, to further improve extent of resection rates in insular glioma surgery.
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87
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Perry MS, Donahue DJ, Malik SI, Keator CG, Hernandez A, Reddy RK, Perkins FF, Lee MR, Clarke DF. Magnetic resonance imaging-guided laser interstitial thermal therapy as treatment for intractable insular epilepsy in children. J Neurosurg Pediatr 2017; 20:575-582. [PMID: 29027866 DOI: 10.3171/2017.6.peds17158] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Seizure onset within the insula is increasingly recognized as a cause of intractable epilepsy. Surgery within the insula is difficult, with considerable risks, given the rich vascular supply and location near critical cortex. MRI-guided laser interstitial thermal therapy (LiTT) provides an attractive treatment option for insular epilepsy, allowing direct ablation of abnormal tissue while sparing nearby normal cortex. Herein, the authors describe their experience using this technique in a large cohort of children undergoing treatment of intractable localization-related epilepsy of insular onset. METHODS The combined epilepsy surgery database of Cook Children's Medical Center and Dell Children's Hospital was queried for all cases of insular onset epilepsy treated with LiTT. Patients without at least 6 months of follow-up data and cases preoperatively designated as palliative were excluded. Patient demographics, presurgical evaluation, surgical plan, and outcome were collected from patient charts and described. RESULTS Twenty patients (mean age 12.8 years, range 6.1-18.6 years) underwent a total of 24 LiTT procedures; 70% of these patients had normal findings on MRI. Patients underwent a mean follow-up of 20.4 months after their last surgery (range 7-39 months), with 10 (50%) in Engel Class I, 1 (5%) in Engel Class II, 5 (25%) in Engel Class III, and 4 (20%) in Engel Class IV at last follow-up. Patients were discharged within 24 hours of the procedure in 15 (63%) cases, in 48 hours in 6 (24%) cases, and in more than 48 hours in the remaining cases. Adverse functional effects were experienced following 7 (29%) of the procedures: mild hemiparesis after 6 procedures (all patients experienced complete resolution or had minimal residual dysfunction by 6 months), and expressive language dysfunction after 1 procedure (resolved by 3 months). CONCLUSIONS To their knowledge, the authors present the largest cohort of pediatric patients undergoing insular surgery for treatment of intractable epilepsy. The patient outcomes suggest that LiTT can successfully treat intractable seizures originating within the insula and offers an attractive alternative to open resection. This is the first description of LiTT applied to insular epilepsy and represents one of only a few series describing the use of LiTT in children. The results indicate that seizure reduction after LiTT compares favorably to that after conventional open surgical techniques.
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Affiliation(s)
- M Scott Perry
- 1Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth
| | - David J Donahue
- 1Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth
| | - Saleem I Malik
- 1Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth
| | - Cynthia G Keator
- 1Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth
| | - Angel Hernandez
- 1Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth
| | - Rohit K Reddy
- 2Comprehensive Epilepsy Program, Dell Children's Hospital, Austin; and
| | - Freedom F Perkins
- 2Comprehensive Epilepsy Program, Dell Children's Hospital, Austin; and
| | - Mark R Lee
- 2Comprehensive Epilepsy Program, Dell Children's Hospital, Austin; and.,4Surgery and Perioperative Services, Dell Medical School, University of Texas, Austin, Texas
| | - Dave F Clarke
- 2Comprehensive Epilepsy Program, Dell Children's Hospital, Austin; and.,Departments of3Pediatrics and
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Ischemic White Matter Lesions Associated With Medullary Arteries: Classification of MRI Findings Based on the Anatomic Arterial Distributions. AJR Am J Roentgenol 2017; 209:W160-W168. [DOI: 10.2214/ajr.16.17231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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89
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Yaşargil MG, Krisht AF, Türe U, Al-Mefty O, Yaşargil DC. Microsurgery of Insular Gliomas: Part I—Surgical Anatomy of the Sylvian Cistern. ACTA ACUST UNITED AC 2017. [DOI: 10.1097/01.cne.0000522111.96155.e8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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90
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Laoprasert P, Ojemann JG, Handler MH. Insular epilepsy surgery. Epilepsia 2017; 58 Suppl 1:35-45. [PMID: 28386920 DOI: 10.1111/epi.13682] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 11/29/2022]
Abstract
Since it was originally described nearly 70 years ago, insular epilepsy has been increasingly recognized and may explain failures after apparently well-planned operations. We review the history of awareness of the phenomenon, techniques for its assessment, and its surgical management. Insular epilepsy can mimic features of frontal, parietal, or temporal seizures. It should be considered when a combination of somatosensory, visceral, and motor symptoms is observed early in a seizure. Extraoperative intracranial recordings are required to accurately diagnose insular seizures. Stereo-electroencephalography (EEG) or craniotomy with implantation of surface and depth electrodes have been used successfully to identify insular onset of seizures. Surgical resection of an insular focus may be performed with good success and acceptable risk.
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Affiliation(s)
- Pramote Laoprasert
- Division of Neurology, Department of Pediatrics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Jeffrey G Ojemann
- Department of Neurosurgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Michael H Handler
- Department of Neurosurgery, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado, U.S.A
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91
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Ikegaya N, Takahashi A, Kaido T, Kaneko Y, Iwasaki M, Kawahara N, Otsuki T. Surgical strategy to avoid ischemic complications of the pyramidal tract in resective epilepsy surgery of the insula: technical case report. J Neurosurg 2017; 128:1173-1177. [PMID: 28598277 DOI: 10.3171/2017.1.jns161278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical treatment of the insula is notorious for its high probability of motor complications, particularly when resecting the superoposterior part. Ischemic damage to the pyramidal tract in the corona radiata has been regarded as the cause of these complications, resulting from occlusion of the perforating arteries to the pyramidal tract through the insular cortex. The authors describe a strategy in which a small piece of gray matter is spared at the bottom of the periinsular sulcus, where the perforating arteries pass en route to the pyramidal tract, in order to avoid these complications. This method was successfully applied in 3 patients harboring focal cortical dysplasia in the posterior insula and frontoparietal operculum surrounding the periinsular sulcus. None of the patients developed permanent postoperative motor deficits, and seizure control was achieved in all 3 cases. The method described in this paper can be adopted for functional preservation of the pyramidal tract in the corona radiata when resecting epileptogenic pathologies involving insular and opercular regions.
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Affiliation(s)
- Naoki Ikegaya
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira.,2Department of Neurosurgery, Yokohama City University, Yokohama; and
| | - Akio Takahashi
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Takanobu Kaido
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Yuu Kaneko
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Masaki Iwasaki
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Nobutaka Kawahara
- 2Department of Neurosurgery, Yokohama City University, Yokohama; and
| | - Taisuke Otsuki
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira.,3Epilepsy Hospital Bethel Japan, Iwanuma, Japan
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92
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Murrone D, Maduri R, Afif A, Chirchiglia D, Pelissou-Guyotat I, Guyotat J, Signorelli F. Insular gliomas: a surgical reappraisal based on a systematic review of the literature. J Neurosurg Sci 2017; 63:566-580. [PMID: 28548479 DOI: 10.23736/s0390-5616.17.04045-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Insular gliomas are heterogeneous lesions whose management presents multiple challenges for their tendency to affect young patients in good neurological and cognitive conditions, their deep anatomic location and proximity with critical functional and vascular structures. The appropriate management of insular gliomas requires a multidisciplinary evidence-centred teamwork grounded on the best anatomic, neurophysiological and oncological knowledge. The present study provides a reappraisal of the management of insular gliomas based on a systematic review of the literature with the aim of guiding clinicians in the management of such tumors. EVIDENCE ACQUISITION A systematic review of the literature from the Medline, Embase and Cochrane Central databases was performed. From 2006 to 2016, all articles meeting specific inclusion criteria were included. EVIDENCE SYNTHESIS The present work summarizes the most relevant evidence about insular gliomas management. The anatomy and physiology of the insula, the new WHO 2016 classification and clinico-radiological presentation of insular gliomas are reviewed. Surgical pearls of insular gliomas resection as well as oncologic and functional outcomes after insular gliomas treatment are discussed. CONCLUSIONS Management of insular gliomas remains challenging despite improvement in surgical and oncological techniques. However, the literature review supports a growing evidence that recent developments in the multidisciplinary care account for constant improvements of survival and quality of life.
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Affiliation(s)
- Domenico Murrone
- Service of Neurosurgery, "Di Venere" Hospital of Bari, Bari, Italy
| | - Rodolfo Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Afif Afif
- Service of Neurosurgery A, "Pierre Wertheimer" Neurological Neurosurgical Hospital of Lyon, Lyon, France
| | - Domenico Chirchiglia
- Department of Medical Sciences, "Magna Græcia" University of Catanzaro, Catanzaro, Italy
| | - Isabelle Pelissou-Guyotat
- Service of Neurosurgery A, "Pierre Wertheimer" Neurological Neurosurgical Hospital of Lyon, Lyon, France
| | - Jacques Guyotat
- Service of Neurosurgery A, "Pierre Wertheimer" Neurological Neurosurgical Hospital of Lyon, Lyon, France
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs "Aldo Moro" University, Bari, Italy -
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93
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Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes. World Neurosurg 2017; 102:301-312. [PMID: 28323182 DOI: 10.1016/j.wneu.2017.03.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical and radiologic outcomes after neurosurgical treatment of large and giant aneurysms of the middle cerebral artery (MCA). In addition, we aimed to identify risk factors for unfavorable outcomes. METHODS This retrospective study included 105 patients with 106 large or giant MCA aneurysms treated with neurosurgical methods, including microsurgery and endovascular treatment, over a 15-year period. RESULTS The mean aneurysm size was 15.3 ± 7.1 mm. Ten (9.4%) were giant aneurysms. The MCA bifurcation was the most common aneurysm site, followed by the MCA trunk and distal MCA. Aneurysm clipping was the most common treatment method, followed by clipping or trapping with bypass surgery and endovascular treatment. However, acute cerebral infarction was the most common complication (16.0%), poor outcomes (modified Rankin Scale score, 3-6) developed in 12.3% of aneurysms after treatment, and 6.6% of treated aneurysms needed retreatment. Multivariate analysis showed that independent risk factors for acute cerebral infarction after treatment were aneurysms located on the MCA trunk and 2 or more underlying diseases. Initial presentation with subarachnoid hemorrhage and complications during treatment were independent risk factors for poor outcomes. In addition, endosaccular coiling was an independent risk factor for retreatment. CONCLUSIONS Neurosurgical management should be considered a priority for large and giant MCA aneurysms because of the high rupture rate and clinical symptoms. However, treatment outcomes remain unsatisfactory. Therefore, tailored management with consideration of risk factors for unfavorable outcomes should be implemented.
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Bhogal P, AlMatter M, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. Flow Diversion for the Treatment of MCA Bifurcation Aneurysms-A Single Centre Experience. Front Neurol 2017; 8:20. [PMID: 28210239 PMCID: PMC5288345 DOI: 10.3389/fneur.2017.00020] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Intracranial aneurysms located at the bifurcation of the middle cerebral artery (MCA) can often be challenging for the neurointerventionalist. We aimed to evaluate the efficacy and safety of flow diverting stents (FDS) in the treatment of these aneurysms. Materials and methods We retrospectively reviewed our prospectively maintained database to collect information for all patients with unruptured saccular bifurcation MCA aneurysms treated with FDS between January 2010 and January 2016. In addition to demographic data, we recorded the location, aneurysm characteristics, previous treatments, number and type of FDS, complications, and clinical and angiographic follow-up. Results Our search identified 13 patients (7 males) with an average age of 61.7 years (47–74 years). All patients had a single bifurcation aneurysm of the MCA, and none of the aneurysms were acutely ruptured. The average fundus size of the saccular aneurysms was 3 mm (range 1.5–10 mm). Follow-up studies were available for 12 patients. Based on the most recent follow-up angiograms, six aneurysms (50%) were totally occluded; five aneurysms (41.7%) showed only a small remnant; and one aneurysm (8.3%) remained unchanged. One patient suffered from an ischemic stroke with resultant permanent hemiparesis (mRS 3). In another case, there was an in-stent thrombosis during the intervention, which resolved upon intra-arterial infusion of Eptifibatide (mRS 0). There were no intra-operative vessel or aneurysm ruptures and no mortalities. Angiography of the covered MCA branches showed no change in the caliber or flow of the vessel in six (50%), a reduction in caliber in five (41.7%), and a complete occlusion in one (8.3%). All caliber changes and occlusions of the vessels were asymptomatic. Conclusion In our series, 91.7% of treated MCA bifurcation aneurysms were either completely occluded or showed only a small remnant with a good safety profile. Flow diversion of MCA bifurcation aneurysms should be considered as an alternative treatment strategy when microsurgical clipping or alternative endovascular treatment options are not feasible.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiologic Clinic, Klinikum Stuttgart , Stuttgart , Germany
| | | | | | | | - Hans Henkes
- Neuroradiologic Clinic, Klinikum Stuttgart, Stuttgart, Germany; Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
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95
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Joo SP, Kim TS. The Clinical Importance of Perforator Preservation in Intracranial Aneurysm Surgery: An Overview with a Review of the Literature. Chonnam Med J 2017; 53:47-55. [PMID: 28184338 PMCID: PMC5299129 DOI: 10.4068/cmj.2017.53.1.47] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/16/2016] [Accepted: 08/16/2016] [Indexed: 12/29/2022] Open
Abstract
Clipping for intracranial aneurysms is done to achieve complete occlusion of the aneurysm without a remnant sac. Despite modern advancements of neurosurgical techniques, morbidity related to the clipping of intracranial aneurysms still exists. Clip occlusion of a parent artery or small hidden perforators commonly leads to permanent neurological deficits, and is a serious and unwanted complication. Thus, preserving blood flow in the branches and perforators of a parent artery is very important for successful surgery without postoperative morbidity and mortality. The aim of this review article is to discuss the consequences of perforator injury and how to avoid this phenomenon in aneurysm surgeries using intraoperative monitoring devices.
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Affiliation(s)
- Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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96
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Abstract
Neurocardiology refers to the interplay between the nervous system and the cardiovascular system. Stress-related cardiomyopathy exemplifies the brain-heart connection and occurs in several conditions with acute brain injury that share oversympathetic activation. The brain's influences on the heart can include elevated cardiac markers, arrhythmias, repolarization abnormalities on electrocardiogram, myocardial necrosis, and autonomic dysfunction. The neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage represents one end of the spectrum, and is associated with an explosive rise in intracranial pressure that results in excess catecholamine state and possibly CBN. A brain-heart link is more known to cardiologists than neurologists. This chapter provides some insight into the pathophysiology of these pathologic neurocardiac states and their most appropriate management relevant to neurologists.
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Affiliation(s)
- N D Osteraas
- Section of Cerebrovascular Diseases, Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - V H Lee
- Section of Cerebrovascular Diseases, Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA.
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97
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Bhogal P, Martinez R, Gansladt O, Bäzner H, Henkes H, Aguilar M. Management of Unruptured Saccular Aneurysms of the M1 Segment with Flow Diversion : A Single Centre Experience. Clin Neuroradiol 2016; 28:209-216. [PMID: 27942770 DOI: 10.1007/s00062-016-0553-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/21/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The optimal strategy for the treatment of M1 segment aneurysms has not yet been determined as both standard microneurosurgical and endovascular techniques can pose challenges. We sought to determine the efficacy of flow diverting stents to treat small, unruptured aneurysms of the M1 segment. METHODS We retrospectively reviewed our database of prospectively collected information for all patients treated with flow diversion for an unruptured saccular aneurysm of the middle cerebral artery (MCA) between February 2009 and February 2016. The relationship to early cortical branches, aneurysm fundus size, number and type of flow diverting stent (FDS), complications and follow-up data were recorded. RESULTS In total 15 patients were identified that matched our inclusion criteria (11 female and 4 male). The average age of the patients was 58.3 years (range 14-76 years). All patients had a single aneurysm affecting the M1 segment of the MCA, 10 (66.6%) of which were related to early cortical branches and 10 aneurysms were located on the left (66.6%). The average aneurysm fundus size was 3 mm (range 2-9 mm) and 13 patients had follow-up angiographic studies. In total, 8 aneurysms were completely excluded, and 6 remained incompletely occluded (3 modified Raymond-Roy classification [mRRC] II and 3 mRRC IIIa). One patient suffered a stroke and another patient had an iatrogenic vessel dissection that was not flow limiting. CONCLUSION Flow diversion can be used to treat small, unruptured aneurysms of the M1 segment of the MCA and even though side vessel occlusion can occur clinically relevant infarction occurs infrequently.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
| | - Rosa Martinez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - Oliver Gansladt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Marta Aguilar
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
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98
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Mandonnet E, Martino J, Sarubbo S, Corrivetti F, Bouazza S, Bresson D, Duffau H, Froelich S. Neuronavigated Fiber Dissection with Pial Preservation: Laboratory Model to Simulate Opercular Approaches to Insular Tumors. World Neurosurg 2016; 98:239-242. [PMID: 27765721 DOI: 10.1016/j.wneu.2016.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Advances in the oncologic and functional results of insular surgery have been reported recently. Such successes have been made possible by the advent of the transopercular approach under awake monitoring and by improved anatomic and functional knowledge of white matter pathways surrounding the insula. Nonetheless, given the rarity of insular tumors, it is difficult to get familiar with the complex 3-dimensional anatomy of the different neuronal and vascular structures encountered during a transopercular insular resection. We thus propose to develop a laboratory model allowing to train transopercular approaches of the insula. METHODS Two hemispheres prepared with Klinger's technique were dissected under light microscope, preserving all pial membranes. The different steps of the dissection were video recorded. RESULTS Preservation of pial membranes enabled us to simulate subpial resection, both during operculum removal and during insular cortex resection. The medial wall of the resection was defined by the inferior-fronto-occipital fasciculus, protecting from the lenticulostriate arteries. CONCLUSION In this paper, we show that Klinger dissection with preservation of pial membranes provides a realistic model of insular surgery, allowing surgeons to learn and train on this highly specialized surgery.
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Affiliation(s)
- Emmanuel Mandonnet
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France; University Paris 7, Paris, France; IMNC UMR8165, Orsay, France.
| | - Juan Martino
- Department of Neurological Surgery, Hospital Universitario Marques de Valdecilla and Fundacion Instituto de Investigacion Marques de Valdecilla (IDIVAL), Trento APSS, Italy
| | - Silvio Sarubbo
- Department of Neurosciences, Division of Neurosurgery, Structural and Functional Connectivity Lab Project, 'S. Chiara' Hospital, Trento APSS, Italy; Structural and Functional Connectivity Lab Project, Division of Neurosurgery, 'S. Chiara' Hospital, Trento APSS, Italy
| | - Francesco Corrivetti
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France; Department of Neurosurgery, University of Rome Tor Vergata, Rome, Italy
| | | | - Damien Bresson
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier Medical University Center, Montpellier, France; Institute of Neuroscience of Montpellier, INSERM U1051, Montpellier, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France; University Paris 7, Paris, France; Laboratory of Experimental Neurosurgery, Paris, France
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99
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Payabvash S, Taleb S, Benson JC, McKinney AM. Acute Ischemic Stroke Infarct Topology: Association with Lesion Volume and Severity of Symptoms at Admission and Discharge. AJNR Am J Neuroradiol 2016; 38:58-63. [PMID: 27758775 DOI: 10.3174/ajnr.a4970] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/22/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Acute stroke presentation and outcome depend on both ischemic infarct volume and location. We aimed to determine the association between acute ischemic infarct topology and lesion volume and stroke severity at presentation and discharge. MATERIALS AND METHODS Patients with acute ischemic stroke who underwent MR imaging within 24 hours of symptom onset or last seen well were included. Infarcts were segmented and coregistered on the Montreal Neurological Institute-152 brain map. Voxel-based analyses were performed to determine the distribution of infarct lesions associated with larger volumes, higher NIHSS scores at admission and discharge, and greater NIHSS/volume ratios. RESULTS A total of 238 patients were included. Ischemic infarcts involving the bilateral lentiform nuclei, insular ribbons, middle corona radiata, and right precentral gyrus were associated with larger infarct volumes (average, 76.7 ± 125.6 mL versus 16.4 ± 24.0 mL, P < .001) and higher admission NIHSS scores. Meanwhile, brain stem and thalami infarctions were associated with higher admission NIHSS/volume ratios. The discharge NIHSS scores were available in 218 patients, in whom voxel-based analysis demonstrated that ischemic infarcts of the bilateral posterior insular ribbons, middle corona radiata, and right precentral gyrus were associated with more severe symptoms at discharge, whereas ischemic lesions of the brain stem, bilateral thalami, and, to a lesser extent, the middle corona radiata were associated with higher ratios of discharge NIHSS score/infarct volume. CONCLUSIONS Acute ischemic infarcts of the insulae, lentiform nuclei, and middle corona radiata tend to have larger volumes, more severe presentations, and worse outcomes, whereas brain stem and thalamic infarcts have greater symptom severity relative to smaller lesion volumes.
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Affiliation(s)
- S Payabvash
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - S Taleb
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - J C Benson
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - A M McKinney
- From the Department of Radiology, University of Minnesota, Minneapolis, Minnesota.
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100
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Wang CC, Wen WL, Feng ZZ, Xu Y, Hong B, Liu JM, Huang QH. Endovascular Treatment of 48 Early Branch Aneurysms of the Middle Cerebral Artery. World Neurosurg 2016; 94:131-136. [DOI: 10.1016/j.wneu.2016.06.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/26/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
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