BACKGROUND AND OBJECTIVES: Endovascular treatment of cerebral aneurysms has tremendously advanced over the past decades. Nevertheless, aneurysm residual and recurrence remain challenges after embolization. The objective of this study was to elucidate the portion of embolized aneurysms requiring open surgery and evaluate whether newer endovascular treatments have changed the need for open surgery after failed embolization. METHODS: All 15 cerebrovascular centers in Austria and the Czech Republic provided overall aneurysm treatment frequency data and retrospectively reviewed consecutive cerebral aneurysms treated with open surgical treatment after failure of embolization from 2000 to 2022. All endovascular modalities were included. RESULTS: On average, 1362 aneurysms were treated annually in the 2 countries. The incidence increased from 0.006% in 2005 to 0.008% in 2020 in the overall population. Open surgery after failed endovascular intervention was necessary in 128 aneurysms (0.8%), a proportion that remained constant over time. Subarachnoid hemorrhage was the initial presentation in 70.3% of aneurysms. The most common location was the anterior communicating artery region (40.6%), followed by the middle cerebral artery (25.0%). The median diameter was 6 mm (2-32). Initial endovascular treatment included coiling (107 aneurysms), balloon-assist (10), stent-assist (4), intrasaccular device (3), flow diversion (2), and others (2). Complete occlusion after initial embolization was recorded in 40.6%. Seventy-one percent of aneurysms were operated within 3 years after embolization. In 7%, the indication for surgery was (re-)rupture and, in 88.3%, reperfusion. Device removal was performed in 16.4%. Symptomatic intraoperative and postoperative complications occurred in 10.2%. Complete aneurysm occlusion after open surgery was achieved in 94%. CONCLUSION: Open surgery remains a rare indication for cerebral aneurysms after failed endovascular embolization even in the age of novel endovascular technology, such as flow diverters and intrasaccular devices. Regardless, it is mostly performed for ruptured aneurysms initially treated with primary coiling that are in the anterior circulation.
- MeSH
- dospělí MeSH
- endovaskulární výkony * metody MeSH
- intrakraniální aneurysma * chirurgie epidemiologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mikrochirurgie metody MeSH
- neurochirurgické výkony metody MeSH
- neúspěšná terapie MeSH
- retrospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- terapeutická embolizace * metody MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- Geografické názvy
- Česká republika MeSH
- Rakousko MeSH
PURPOSE: Intracranial aneurysm (IA) rupture results in one of the most severe forms of stroke, with severe neurological sequelae. Inflammation appears to drive aneurysm formation and progression with macrophages playing a key role in this process. However, less is known about their involvement in aneurysm rupture. This study is aimed at demonstrating how relationship between the M1 (pro-inflammatory) and M2 (reparative) macrophage subtypes affect an aneurysm's structure resulting in its rupture. METHODS: Forty-one saccular aneurysm wall samples were collected during surgery including 13 ruptured and 28 unruptured aneurysm sacs. Structural changes were evaluated using histological staining. Macrophages in the aneurysm wall were quantified and defined as M1 and M2 using HLA-DR and CD163 antibodies. Aneurysm samples were divided into four groups according to the structural changes and the M2/1 ratio. Data were analyzed using the Mann-Whitney U test. RESULTS: This study has demonstrated an association between the severity of structural changes of an aneurysm with inflammatory cell infiltration within its wall and subsequent aneurysm rupture. More severe morphological changes and a significantly higher number of inflammatory cells were observed in ruptured IAs (p < 0.001). There was a prevalence of M2 macrophage subtypes within the wall of ruptured aneurysms (p < 0.001). A subgroup of unruptured IAs with morphological and inflammatory changes similar to ruptured IAs was observed. The common feature of this subgroup was the presence of an intraluminal thrombus. CONCLUSIONS: The degree of inflammatory cell infiltration associated with a shift in macrophage phenotype towards M2 macrophages could play an important role in structural changes of the aneurysm wall leading to its rupture.
Over the past 25 years the endovascular treatment of cerebral aneurysms has gained preference in some countries over the traditional surgical procedures. The review part of the article clearly demonstrates that the clinical results of both modalities are similar and the difference is seen only in technical effectivity. Surgical techniques fail far less frequently than the endovascular ones. Incompletely occluded or growing aneurysms after the endovascular approach expose the patient to the risk of rebleeding with all possible consequences. Markedly repeated procedures are much more common for endovascularly treated aneurysms, again with all the risks.In the authors institution over the past 20 years, a total of 2032 aneurysms were treated. In 1263 endovascularly managed aneurysms the regrowth or inclomplete initial occlusion necessitated 159 repeated propcedures (12.6%). In surgical group the total of 27 aneurysms needed retreatment (3.5%). The difference is statistically significant. In nine patients in endovascular group the rebleeding was the reason for repeated procedures. No rebleeding was seen in the surgical group.This fact, also shown in the review part of the article, is important in patients counseling. Given the similar clinical results of both modalities the patient should be advised on the necessity of repeated follow-ups and of possible technical failure and eventual repeated procedure which is more likely if endovascular procedure is chosen.
Endovascular techniques are still expanding in their capability by introducing novel technologies. Nevertheless, anterior communicating artery (ACoA) remains the region with high propensity for aneurysm (AN) re-growth after endovascular intervention. The purpose of this study is to highlight the ongoing importance for microsurgical treatment. The authors conducted a single-institution retrospective study of ACoA AN treatment between January 2000 and December 2016 maintaining "coil mainly" policy. The results are supplied with a systematic review of the literature. A total of n = 398 ACoA ANs were treated in n = 398 consecutive patients (207 females, 191 males). Microsurgical treatment was performed for 79 AN patients (54 ruptured, 25 unruptured), and 319 AN patients (250 ruptured, 69 unruptured) underwent coiling procedure. Treatment-related morbidity and mortality (MM) for unruptured ANs was 0% in the microsurgical and 1.5% in the endovascular group (p = 1.000). The percentage of patients with none or minor permanent deficits after subarachnoid hemorrhage was 74% in the microsurgical and 70% in the endovascular group (p = 0.693). The re-treatment rate was 3.8% in microsurgical group and 9.2% in endovascular group (p = 0.883). A literature review identified 39 studies concerning ACoA AN treatment. Clinical results of both modalities were comparable, with microsurgery being superior regarding radiological outcomes. This study demonstrates that both treatment techniques bring comparable clinical benefit to the patient. Microsurgery seemed superior regarding radiological outcomes. The decision about the treatment strategy should be made by a multi-disciplinary team consisting of specialists from both teams, bearing in mind the higher occlusion rate and longevity of the surgical treatment.
- MeSH
- arteria cerebri anterior chirurgie MeSH
- cévní protézy * MeSH
- dospělí MeSH
- endovaskulární výkony metody MeSH
- implantace prsní náhrady metody MeSH
- intrakraniální aneurysma chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- neurochirurgické výkony metody MeSH
- reoperace statistika a číselné údaje MeSH
- revaskularizace mozku MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- přehledy MeSH
V posledních letech se rozvinula metodika počítačového modelování toku tekutin v cerebrovaskulární problematice, především pak v oblasti intrakraniálních aneuryzmat. Cílem většiny studií je pochopit patofyziologii vzniku, růstu a ruptury mozkových výdutí a určit ty rizikové hemodynamické parametry, které k těmto procesům vedou. V naší práci shrnujeme současný stav počítačového modelování toku tekutin především z pohledu chirurgie mozkových aneuryzmat a zaměřujeme se na možný přínos pro klinickou praxi.
Computational fluid dynamics have developed in the area of cerebrovascular diseases in recent years, especially in the research of intracranial aneurysms. The goal of most studies is to understand the pathophysiology of the initiation, growth and rupture of brain aneurysms and determine those risk hemodynamic parameters that lead to such processes. In our paper, we summarize the current state of art computational fluid dynamics especially from a surgical point of view of intracranial aneurysms and we focus on its possible contribution in clinical practice.
Biopsie mozku je jednou z významných technik používaných k ověření ložiskového postižení mozku. Ve většině případů se v dnešní době provádí buď rámová nebo bezrámová stereotaktická biopsie. Otevřená biopsie z kraniotomie se provádí v případech nejasných nálezů při stereotaktické biopsii a nutnosti histologické verifikace ložiska nebo v případech, kdy je třeba odebrat mimo mozku i např. kortikální tepnu nebo tvrdou plenu. Rizika výkonu nejsou nulová. Proto je třeba vždy indikaci k biopsii mozku zvažovat v kontextu přínosu biopsie a změny léčebné strategie. Primární biopsie míchy se neprovádí.
Brain biopsy represents an important technique in the verification of focal brain processes. Nowadays, either framebased or frameless stereotactic biopsies are performed. Open biopsy from a craniotomy is reserved for cases of non-conclusive stereotactic biopsy that demand histological verification of the process which would change the treatment strategy or in case when there is a need for sample for histological examination, i.e. cortical vessel or dura mater. The risk of biopsy is not zero. Therefore, we should always consider the indication for biopsy. Primary biopsy of spinal cord is not indicated.
- Klíčová slova
- mozková biopsie, rámová biopsie, bezrámová biopsie,
- MeSH
- biopsie * metody MeSH
- chirurgie s pomocí počítače MeSH
- jehlová biopsie metody MeSH
- lidé MeSH
- nádory mozku * diagnóza patologie MeSH
- nemoci mozku diagnóza patologie MeSH
- neuronavigace MeSH
- stereotaktické techniky * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- práce podpořená grantem MeSH
BACKGROUND: The proportion of women among neurosurgeons appears to be growing worldwide with time. Official data concerning the current situation across Europe have not yet been published. Thus, there are still concerns about gender inequality. The European Women in Neurosurgery Project 2016 was designed to recognize the current situation across Europe. METHODS: The office holders of the national neurosurgical societies of 39 countries forming the European Association of Neurosurgical Societies were contacted to provide data stating the proportion of women in neurosurgery. Obtained data were supplied with the results of an online survey. RESULTS: The response rate of national office holders was 90%. The number of reported neurosurgeons was 12,985, and overall proportion of women represented was 12%. Two hundred thirty-seven responses to online questionnaire were taken into account. The overall proportion of female respondents was 30%. There was no intergender variability in responses regarding amount of working time per week, exposure to surgeries, or administrative work. Male respondents reported dedicating significantly more time to scientific work and feeling more confident dictating own career direction. Female respondents reported being less often married, having fewer children, a stronger perception of gender significance level, and a higher appreciation of personal qualities. CONCLUSIONS: Neurosurgery is a challenging field of medicine. The results of our survey did not imply an overall feeling of gender inequality among European respondents, although women believe that the gender issue to be more important than men do and that they have to sacrifice more of their personal lives.
- MeSH
- dospělí MeSH
- lékařky statistika a číselné údaje MeSH
- lidé středního věku MeSH
- lidé MeSH
- manželský stav statistika a číselné údaje MeSH
- neurochirurgie pracovní síly MeSH
- neurochirurgové statistika a číselné údaje MeSH
- postoj zdravotnického personálu * MeSH
- rozložení podle pohlaví MeSH
- sexismus statistika a číselné údaje MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Evropa epidemiologie MeSH
INTRODUCTION: Frameless stereotactic brain biopsy systems are widely used today. VarioGuide (VG) is a relatively novel frameless system. Its accuracy was studied in a laboratory setting but has not yet been studied in the clinical setting. The purpose of this study was to determine its accuracy and diagnostic yield and to compare this with frame-based (FB) stereotaxy. MATERIAL AND METHODS: Overall, 53 patients (33 males and 20 females, 60 ± 15 years old) were enrolled into this prospective, randomized, single-center study. Twenty-six patients were randomized into the FB group and 27 patients into the VG group. Real trajectory was pointed on intraoperative magnetic resonance. The distance of the targets and angle deviation between the planned and real trajectories were computed. The overall discomfort of the patient was subjectively assessed by the visual analog scale score. RESULTS: The median lesion volume was 5 mL (interquartile range [IQR]: 2-16 mL) (FB) and 16 mL (IQR: 2-27 mL) (VG), P = 0.133. The mean distance of the targets was 2.7 ± 1.1 mm (FB) and 2.9 ± 1.3 mm (VG), P = 0.456. Mean angle deviation was 2.6 ± 1.3 deg (FB) and 3.5 ± 2.1 deg (VG), P = 0.074. Diagnostic yield was 93% (25/27) in VG and 96% (25/26) in FB, P = 1.000. Mean operating time was 47 ± 26 minutes (FB) and 59 ± 31 minutes (VG), P = 0.140. One minor bleeding was encountered in the VG group. Overall patient discomfort was significantly higher in the FB group (visual analog scale score 2.5 ± 2.1 vs. 1.2 ± 0.6, P = 0,004). CONCLUSIONS: The VG system proved to be comparable in terms of the trajectory accuracy, rate of complications and diagnostic yield compared with the "gold standard" represented by the traditional FB stereotaxy for patients undergoing brain biopsy. VG is also better accepted by patients.
- MeSH
- biopsie přístrojové vybavení MeSH
- design vybavení MeSH
- diferenciální diagnóza MeSH
- dospělí MeSH
- interpretace obrazu počítačem přístrojové vybavení MeSH
- kohortové studie MeSH
- lidé středního věku MeSH
- lidé MeSH
- magnetická rezonanční tomografie přístrojové vybavení MeSH
- mozek patologie MeSH
- nádory mozku patologie sekundární chirurgie MeSH
- neuronavigace přístrojové vybavení MeSH
- odchylka pozorovatele MeSH
- počítačová rentgenová tomografie MeSH
- senioři MeSH
- senzitivita a specificita MeSH
- zobrazování trojrozměrné MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
Úvod: Stereotaktická biopsie je standardní, rutinně využívaný výkon v diagnostice mozkových lézí. Bioptické ověření histologického charakteru patologie je nutnost pro další vedení terapie u otevřeně nepřístupných patologií. V naší práci hodnotíme pětileté výsledky užívání bezrámového stereotaktického systému Varioguide. Soubor a metodika: Mezi lety 2010 a 2014 jsme bioptovali 97 pacientů, 54 mužů a 43 žen. Průměrný věk byl 61 ? 14 let. Stereobiopsie byly prováděny na základě MR navigace, trajektorie byly plánovány na pracovní stanici IPlan. Sledovány byly pooperační komplikace a diagnostický výtěžek v závislosti na objemu ložiska. Výsledky: V souboru 97 nemocných bylo provedeno celkem 101 biopsií. U čtyř nemocných bylo tedy nutné biopsii opakovat. Medián objemu ložiska byl 18,8 cm3, IQR (mezikvartilové rozpětí) 4,6–32 cm3. Objem pod 1 cm3 mělo 10 ložisek. U osmi pacientů nebyla ve vzorku zastižena patologická tkáň. Z 10 ložisek pod 1 cm3 byly bez známek patologie vzorky u tří případů, významně častěji než u ložisek nad 1 cm3 (p = 0,031). Krvácivá komplikace se vyskytla u osmi pacientů. Symptomatické krvácení bylo zaznamenáno ve čtyřech případech. Závažná morbidita a mortalita v naší sestavě dosáhla tedy 4 %. V den operace byl nízkomolekulární heparin podáván v terapeutické dávce 10 pacientům, u tří došlo ke krvácivé komplikaci (p = 0,031). Závěry: Bezrámová stereobiopsie systémem Varioguide je bezpečná metoda odběru vzorku při mozkové biopsii. Diagnostický výtěžek dosažený touto metodou je až 92 %. Jediný identifikovaný prediktor výtěžnosti biopsie je objem ložiska nad 1 cm3. Podávání nízkomolekulárního heparinu v antikoagulační dávce v den operace se zdá být spojeno s vyšším výskytem krvácivých komplikací.
Introduction: Stereotactic brain biopsy is a routine procedure used to evaluate brain pathologies. Knowledge of histological diagnosis is crucial for further management in the majority of cases. In this paper we present our 5-year experience with Varioguide frameless stereotactic system. Material and methods: Between 2010 and 2014, we treated 97 patients, 54 males and 43 females. Mean age was 61 ? 14 years. Stereobiopsies were performed using trajectories planned on IPlan application based on MRI navigation sequences. Primary outcome was diagnostic yield and rate of severe haemorrhagic complications. Results: We performed two procedures in four patients, thus we performed 101 procedures together. Median volume of lesion was 18.8 cm3, IQR (interquartile range) 4.6–32 cm3. Lesion volume below 1 cm3 was found in 10 cases. The biopsy was non-diagnostic in eight patients. Out of the 10 less than 1 cm3 lesions, biopsy was non-diagnostic in three cases, significantly more frequently than in larger lesions (p = 0.031). A haemorrhagic complication was encountered in eight cases, bleeding was symptomatic in four. Severe morbidity and mortality was thus 4%. On the day of surgery, a therapeutic dose of LMWH was administered in 10 cases, three of these suffered from post-op haemorrhage (p = 0.031). Conclusions: Frameless stereobiopsy using Varioguide system is a safe and effective system for brain biopsies. Diagnostic yield was 92%. The only identified predictor of diagnostic yield was lesion volume above 1 cm3. A therapeutic dose of LMWH on the day of surgery seems to be linked to higher incidence of haemorrhagic complications.
- Klíčová slova
- bezrámová stereotaxe, diagnostický výtěžek, MR navigace, mozková biopsie,
- MeSH
- biopsie * metody přístrojové vybavení MeSH
- chirurgie s pomocí počítače MeSH
- design vybavení MeSH
- heparin nízkomolekulární škodlivé účinky MeSH
- intrakraniální krvácení etiologie komplikace MeSH
- Karnofského skóre MeSH
- lidé středního věku MeSH
- lidé MeSH
- magnetická rezonanční tomografie MeSH
- mozek patologie MeSH
- nádory mozku diagnóza patologie MeSH
- nemoci mozku * diagnóza patologie MeSH
- neuronavigace metody přístrojové vybavení MeSH
- pooperační komplikace MeSH
- retrospektivní studie MeSH
- senioři MeSH
- stereotaktické techniky * přístrojové vybavení MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- hodnotící studie MeSH
- práce podpořená grantem MeSH
