Neurosurgey in Chandigarh: November 2012

Saturday 10 November 2012

Neurosurgery in Chandigarh, Neurosurgery

LARGE 12 x 10 CENTEMETERS MENINGIOMA (BRAIN TUMOUR)OPERATED AT IVY HOSPITAL BY DR VINEET SAGGAR

CASE

A 50 year old female presented to us in emergency with complaints of episodes of seizures and headache for past few days . MRI brain done at a private institution revealed large olfactory grove meningioma measuring approximately 10 x 12 centimeters in size. Tumor was successfully removed by Dr Vineet Saggar after eight hours of marathon surgery and patient was discharged after few days without any neurological deficit.

Pre Operative MRI of the Patient showing large tumour

Post operative MRI showing complete tumor removal

Meningiomas account for 15% of intracranial tumors and 90 percent of meningiomas are intracranial. They commonly occur in the fourth through sixth decades of life. They are more common in females and are rare in children

A meningioma is a tumor of the meninges – membranes that line the skull and enclose the brain. Meningiomas may arise from any location where meninges exist (eg, nasal cavity, paranasal sinuses, middle ear, mediastinum) and are generally thought to be slow-growing and benign. A meningioma can vary in size from a few millimeters to many centimeters in diameter.

Olfactory groove meningiomas grow along the nerves that run between the brain and the nose, the nerves allow you to smell. They can become large without causing significant neurologic deficits or evidence of increased intracranial pressure. Loss of smell can often be the only symptom. Changes in mental status are seldom striking until the tumor has reached a large size. Once the tumor becomes large it impinges on the optic nerves and chiasm resulting in visual loss.

Olfactory groove meningioma. (A) Incision and bone flap used for bifrontal craniootomy. (B) The mucosa of the frontal sinus has been removed, and the sinus is packed with bacitracin-soaked getfoam and covered with a flap of peiicranial tissue sewn to the dura. (C) The anterior sagittal sinus is ligated. (D) The blood supply coming in through the midline base of the skull is being occluded and an internal decompression of the tumor done. (E) The capsule of the tumor is being reflected into the area of internal tumor decompression and the attachments to the surrounding brain divided. Minimal retraction is placed on the surrounding brain. The major trunk of the anterior cerebral artery is dissected off the tumor (arrow) but a branch going into the capsule is coagulated and divided. (F) The posterior inferior capsule is dissected off the arachnoid over the region of the optic nerve and internal carotid artery (arrows). (G) The dural attachment has been excised. The bone usually does not need to be removed. The area is covered with a graft of perieranial tissue and gelfoam. MRI clearly defines the extent of the tumor, the edema in the surrounding brain, the relationship of the optic nerves and anterior cerebral arteries, and any extension into the ethmoid sinus . Angiography is rarely needed. In our experience, there has been no indication for preoperative embolization.

The indications for surgical treatment have been the presence of neurological symptoms, which may include a change in mental function, headache, disturbance in vision, or a seizure disorder, an asymptomatic patient with edema in the adjacent brain areas, or MRI findings that the meningioma is near the optic nerves. Radiation therapy is not recommended as a primary treatment and would be used only to treat recurrence following radical subtotal removal.

Rarely does the patient report loss of sense of smell as a symptom, although it is usually documented on examination. However, if olfaction is still present the patient should be warned about the loss of this function, since acute loss may be quite bothersome.

For patients with large tumors, we prefer a bifrontal craniotomy. . This approach is associated with the smallest amount of retraction on the frontal lobes, gives direct access to all sides of the tumor, and allows one to decompress the tumor while working along the base of the skull to interrupt the blood supply. For smaller tumors, a right subfrontal approach coming laterally over the orbital roof may be used.

The key considerations in the operation include:

1. Dividing the attachments along the skull base to interrupt the blood supply

2. Doing an extensive internal decompression of the tumor.

3. Retracting the tumor capsule into the area of decompression to keep traction on the frontal lobes to a minimum.

4. Carefully separating the tumor from attachments to the optic nerves and anterior cerebral arteries. The major branches of the anterior cerebral arteries are usually separated from the tumor by a rim of cerebral tissue or arachnoid but in large meningiomas these arteries can be involved with the tumor capsule. Frontopolar and small branches of the anterior cerebral arteries may be adherent to the posterior or superior tumor capsule and can be taken with the tumor .

5. Excising the dural attachment and when present the hyperostotic bone, with care taken to avoid entering the ethmoid sinus unless it is known that tumor extends into that area.

Covering the region of the dural attachment with a graft of pericranial tissue and gelfoam.

Dr. Vineet Saggar (MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
http://www.neurosurgeoninchandigarh.com
http://neurosergeonhead.blogspot.in
http://www.facebook.com/neuro.surgeon.7186

http://www.linkedin.com/pub/dr-vineet/56/2a9/863

https://twitter.com/drvineetsaggar

http://www.slideshare.net/neurosergeonhead

Thursday 8 November 2012

Neurosurgery in chandigarh, Neurosurgery, Isolated Cervical Intradural Schwannoma With Intramedullary Extension

Isolated Cervical Intradural Schwannoma With Intramedullary Extension

INTRODUCTION

Schwannomas are mostly intradural extramedullary tumors originating from the Schwann cells. They correspond to 30% of spinal tumors and are generally associated with neurofibromatosis types 1 and 2(1). Because the Schwann cell are normally not found within the parenchyma of the brain and the spinal cord it these lesions are rare in this location Intramedullary lesions represent 0.3% of all medullary tumors and 1.1% of spinal schwannomas(2). Most of these intramedullary tumors are confined to parenchyma of brain and spinal cord without extramedullary extension and are diagnosed on histopathology. We at our institution describe a rare intraoperative finding in which a case of suspected intradural extramedullaryschwannoma had an intra medullary extension.

CASE REPORT

A 22year female presented in our hospital with complaints of pain neck radiating to occipital region of 2 yrs duration. She had stiffness and gradually progressive weakness all four limbs left more than right for past 6 months. There was no family history of Von Recklinghausen's disease. Neurological examination revealed spastic quadriparesis, prominent in the left extremities. Posterior column sensations were lost in all four limbs. Deep tendon reflexes were exaggerated in all four limbs. A positive Hoffman s and Babinsky signs and sign were present bilaterally. Gait was broad-based due to spasticity. Difficulty in urination was present .MRI of cervical spine was done at some other institute revealed a large well defined homogenously enhancing intradural extramedullary mass at C1-2 level on left side markedly compressing the cord, there was associated cord edema at adjacent cervical levels(fig.1&2). A provisional diagnosis of schwannoma or neurofibroma was kept since there was no dural tail or broad based attachment of tumor to dura.

Patient was advised surgical removal of tumour . Tumor was approached via midline incision in neck and C-1 to C-3 laminectomy was done. Dura was opened under microscope and tumor was found on left side and whole of the tumor was intra arachnoidal. To our surprise though tumor was mainly extra medullary on left side ,it had an intra-medullary extension. Extramedullary component was completely removed followed by intatumoral decompression of intra medullary part.Capsule of intramedullary component was densely adherent to spinal cord and small amount of tumor tissue had to be left behind to avoid post operative neurological deficit(fig.4). Duraplasty was done. In the postoperative period the power of the patient improved gradually and by the end of the first week she could walk without support and at the end of one month power in all four limbs was 5/5 , though spasticity remained in all four limbs. Her gait remain broad based and there is clumsiness while walking.

DISCUSSION

Intramedullary schwannomas are rare tumors . The first surgical description of a spinal tumor was made in 1888 by Sir Victor Horsley(3). In 1907 Von Eiselberg published the successful resection of an intramedullary neurofibrosarcoma. First intramedullary schwannoma was reported by Kernohanin1952 though Penfield had already described an intramedullary lesion with schwannoma characteristics in 1932(4).

We found 52 cases in the literature, in addition to our case. Of these cases only three have been reported as having both intramedullary and extramedullary component . Gorman etal., have reported the extramedullary component to be an exophytic extension of the intramedullary tumor from the enlarged spinal cord(5).

Mean age at presentation of these lesions is 40-years . They are usually single lesions affecting the cervical spinal cord (63%), the thoracic spinal cord (26%) and the lumbar spinal cord (11%). They have a slow growth pattern and because of this the average interval between first symptoms and diagnosis is 28.2 months (from six months to 20 years)(6). The most described clinical manifestation is the pyramidal syndrome followed by sensitivity complaints and sphincter dysfunction(6).

The absence of schwann cells within the brain and spinal cord in normal individuals has raised speculation as to the pathogenesis of these tumors(7.8,9,10). Hypoteses have discussed the possibility that these tumors arise from proliferation of schwann cells in the perivascular plexuses within the central nervous system(7,10,11,12) . Alternatively, the disordered migration of the neural crest elements at the moment of neural tube closure during the fourth week of embryogenesis may result in these tumors. But the most acceptable theory was reported by Rusell and Rubenstein in 1971. According to them, these tumors emerge from the transformation of neuroectodermal pial cells into Schwann cells, leading to a possible fast neoplastic growth of Schwann cells located in a “critical area” in the dorsal roots.(9,10,11,13)

Most of the cases described in the literature are primarily intramedullary in nature .Our case is one of the four cases described till date which had both intra as well as extramedullary component. The other three cases had small exophytic but a large intra medullary component(5,14) but our case had smaller intramedullary component. In all the cases intramedullary component was diagnosed to be present preoperatively but in our case intramedullary component was not suspected preoperatively but was found intraoperatively only . However we retrospectively analyzed the radiology in our case there were few subtle hints on radiology which suggested possible intramedullary extension.On T-2 wighted coronal sequences though tumour appeared to be well defined and separated from cord there was a lot of edema in the cervical cord suggesting an intraparenchymal involvement(fig.3) . On searching literature we found out that this sign had been described by Colosimo etal in two of their cases in 2003. They suggested that MR imaging evidence of a small- or medium-sized well-marginated intramedullary spinal cord tumor in a patient in whom no syringomyelia is present but in whom moderate edema with marked Galodinium enhancement can be seen should be considered in the differential diagnosis of intramedullary spinal cord schwannoma(15). Thus marked cord edema in the presence of intradural extramedullary mass should be considered as an indication of intramedullary extension . In cases in which an associated thickened Gd-enhancing spinal nerve root is seen the diagnosis of schwannoma should be assumed.

CONCLUSIONS

Schwannomas are usually benign, well delineated and posteriorly located tumors, and are eminently suited for surgical excision. In the literature it is reported that the use of ultrasonic aspirator and surgical microscope facilitate the removal of intramedullary tumors with minimal damage to adjacent cord substance. Gross total resection is the goal but sometimes this cannot be accomplished due to the infiltrative characteristic of the tumor.MRI can be used to predict intramedullary extension, if it shows no syringomyelia but moderate cord edema. In cases in which an associated thickened Gd-enhancing spinal nerve root is seen the diagnosis of schwannoma should be assumed .

FIGURES AND LEGENDS

Fig-1

Saggital post contrast image showing large IDEM at C-1 and C-2 levels

FIG-2

Post contrast Axial image showing Large intradural IDEM with enhancing left Nerve Root

FIG-3 Coronal T-2 weighted image showing large IDEM with lot of associated edema in cervical cord below the lesion. This edema can suggest intra medullary extension of tumors and can be differentiated from syringomyelia on post contrast scans where it will not enhance but syrinx cavity will show contrast uptake.

FIG-4.

Postoperative Contrast enhanced saggital image showing small remnant of tumor capsule left behind after surgery

Dr. Vineet Saggar (MCh)

Neuro Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71

+91-9855990990
http://neurosergeonhead.blogspot.in/
http://www.facebook.com/neuro.surgeon.7186

Neurosurgery in Chandigarh, Neurosurgery, Best neurosurgery in Chandigarh

Management of Spontaneous Intracerebral Haematomas - a Neurosurgeons Perspective by DR. vineet saggar Consultant neurosurgeon (Brain & Spine Specialist) ivy hospital Chandigarh mohali

Spontaneous intracerebral hemorrhage (ICH) accounts for 9% to 25% of all strokes and has devastating consequences.

More than 50% of patients die, and half of the survivors are left severely disabled.

Death at 1 year varies by different location: 51% for deep, 57% for lobar, 42% for cerebellar and 65% for brain stem hemorrhages

CAUSES OF SPONTANEOUS ICH

Depending on the underlying cause of hemorrhage, ICH may be classified as

Primary when it originates from the spontaneous rupture of small arterioles damaged by chronic hypertension or cerebral amyloid angiopathy, representing at least 85% of all cases

secondary when associated with

vascular malformations,

Bleeding related to an ischemic stroke,

tumors,

abnormal coagulation or vasculitis

Pathophysiology

Intracerebral haemorrhage due to chronic hypertension accounts for about one-half of the cases.

The underlying pathology is haemodynamic injury to perforating arteries, 100—400 urn in diameter, which arise directly from much larger trunks to enter the brain at right angles and are end arteries.

Whereas the cortical vessels are protected by a thicker smooth muscle layer in the media, a series of bifurcations and collateral vessels, the perforating arteries are subjected directly to changes in blood pressure.

The arteries in question include the lenticulostriate arteries, the thalamoperforating arteries the paramedian branches of the basilar artery and the superior and anterior inferior cerebellar arteries.

The pathological lesions may take the form of hyalinosis, lipohyalinosis or focal necrosis and Charcot-Bouchard/miliary aneurysm formation

Locations of hypertensive ICH are as follows:

65% in the basal ganglia,

15% in the subcortical white matter,

10% cerebellar

10% pontine

MANAGEMENT

It is important to determine the underlying aetiology rapidly. A history of hypertension, drug abuse and anticoagulant treatment is important.

If a history of hypertension is not available, it may be difficult in the acute state in a patient with high blood pressure to decide whether it is due to previously undetected hypertension or secondary to raised intracranial pressure (ICP) with a Cushing response.

Signs of end organ damage (brain, retina, heart and kidneys) can help differentiate the two.

DIAGNOSTIC MODALITIES

CT is the investigation of choice

Advantages

CT scan evaluates the size and location of the hematoma,

Extension into ventricular system

Degree of surrounding edema,

Anatomical disruption (Class I, Level of Evidence A).

Hematoma volume may be easily calculated from CT scan images by use of the following formula

ABC÷2

a derived formula from the calculation of the volume of the sphere.

Right Basal Ganglia Haematoma With Intraventricular Extension in a Hypertensive

Role of Surgery : When to operate

1. A spectrum of ICH patients are alert with subtle neurological signs and small (< 2 cm) haematomas Surgery not indicated

2. Indications for surgery between 1 and 3 are controversial The following patients are more likely to be operated upon (i) clot volumes between 20-80 ml,(2)superficial lobar haemorrhages, and (3) worsening conscious level/neurological deficit

3. Large haemorrhage with significant neuronal destruction and poor neurological status (GCS < 5)Surgery not indicated.

Most neurosurgeons would operate on patients with a deteriorating conscious level and a worsening neurological deficit

In addition, lobar/superficial haematomas 20—80 ml in volume are more likely to be operated upon

Cerebellar haemorrhage greater than 3—4 cm should be operated upon, especially when there is concomitant clinical deterioration or hydrocephalus3

Stich 1 Trial

The need to gain robust evidence to support clinical decision making led to the initiation of the Surgical Trial in Intracerebral Haemorrhage (STICH) funded by the MRC and the Stroke Association in 1998.

STICH was a prospective randomised trial to compare

Early surgery

with

Initial conservative treatment

in with spontaneous supratentorial intracerebral haemorrhage.

A parallel group-trial design was used

Early surgery combined haematoma evacuation (within 24 hours of randomisation)

with

best medical treatment.

Initial conservative treatment used best medical treatment although delayed evacuation was allowed if it became necessary. Analysis was on an intention-to-treat basis.

Primary Outcome Measure: 8 point Glasgow Outcome Scale sent as a postal questionnaire to patients at 6 months follow-up. From this a dichotomised prognosis-based outcome measure was used

Results: This trial was the largest to date and successfully recruited 1033 patients from 87 centres around the world. Patients were randomised to early surgery (503) or initial conservative treatment (530). Of 468 patients randomised to early surgery 26% had a favourable outcome compared to 24% of the 496 randomised to initial conservative treatment (95% CI 0.66-1.19, p=0.414). (Outcome data was unavailable for 69 patients).

Interpretation: STICH suggested a small non-significant advantage for surgery

Although the STICH has rightfully dampened the enthusiasm of neurosurgeons for performing surgery, it must be remembered that the trial was based on the principle of clinical equipoise and patients who the local investigator felt would most likely benefit from emergency surgery were not enrolled into the study.

In a post hoc analysis of the STICH it was found that the subgroup of patients with superficial hematomas and no IVH had better outcomes in the surgical arm

Where do we go from STICH 1 TRIAL

PATIENTS IN WHOM SURGERY WAS DIRECTLY INDICATED SUCH AS LARGE LOBAR HAEMATOMAS OR CEREBELLAR HAEMATOMAS WERTE NOT INCLUDED IN STUDY- THESE WERE THE PATIENTS WHO BENEFIT MOST FROM SURGERY AND HENCE WOULD HAVE INCREASED % OF FAVOURABLE OUT IN SURGICAL ARM

2 ALSO PATIENTS WHO DETERIORATED ON MEDICAL TREAT MENT WERE AGAIN OPERATED AND THEIR OUT COME WAS NOT INCLUDED IN DATA FOR MEDICAL M/M THERE BY IMPROVING OUT COME IN MEDICAL T/T GROUP

BECAUSE THESE ARE THE PATIENTS WHO HAVE POORER OUTCOMES.

STICH-2

Disease/condition/study domain Spontaneous intracerebral haemorrhage confined to the lobar region

Participants - inclusion criteria

Evidence of a spontaneous lobar ICH on Computed Tomography (CT) scan (within 1 cm of the cortical surface)

Patient within 48 hours of ictus

The 'clinical uncertainty principle' is used: only patients for whom the responsible neurosurgeon is uncertain about the benefits of either treatment are eligible. These include patients with a haematoma volume of between 10 and 100 ml and a best motor score on the Glasgow Coma Score (GCS) of five or six together with some eye opening

Participants - exclusion criteria

1 Clear evidence that the haemorrhage is due to an aneurysm or angiographically proven arteriovenous malformation

2. Intraventricular haemorrhage of any sort

3. ICH secondary to tumour or trauma

4. Basal ganglia, thalamic, or brainstem haemorrhage or extension of a lobar haemorrhage into any of these regions

5. Severe pre-existing physical or mental disability or severe co-morbidity which might interfere with assessment of outcome

6. If surgery cannot be performed within 12 hours

Current practice favours surgical intervention in the following situations:

superficial haemorrhage, >10 ml in volume

Clot volume between 20-80 ml; with worsening neurological status; and relatively young patients;

(v) Haemorrhage causing midline shift/raised ICP; and (vi) Cerebellar haematomas >3 cm or causing hydrocephalus.

Dr. Vineet Saggar (MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
http://www.neurosurgeoninchandigarh.com
http://neurosergeonhead.blogspot.in
http://www.facebook.com/neuro.surgeon.7186

http://www.linkedin.com/pub/dr-vineet/56/2a9/863

https://twitter.com/drvineetsaggar

http://www.slideshare.net/neurosergeonhead