Practical application of intraoperative ultrasound imaging

Intraoperative real-time ultrasound imaging (US) was used in over 500 patients to investigate which of the previously considered applications are of practical use in everyday neurosurgery. During all intraoperative applications for a wide variety of pathological conditions, small deep-seated as well as subcortically located lesions were detected with accuracy; in many instances they could be approached through smaller surgical exposures. US guidance was accurate in 209 cases for the stereotactic introduction of needles or endoscopes into various lesions: thus burrhole evacuation was performed on 148 intracerebral haematomas; in 16 patients endoscopic biopsy and resection of ventricular tumours was performed as well as biopsies of 39 hemispheric brain tumours and aspiration of a brain abscess in 6 instances. Seventy six gliomas were investigated by US imaging; the frequently unclear boundary between tumour and surrounding oedema was not better visualized than with CT or MRI. Moreover, US imaging for the detection of residual tumour towards the end of operation was unreliable. Postoperative imaging through burrholes or other cranial defects was mostly of unacceptably low quality for therapeutic decision making.     

CT-guided stereotactic aspiration of brain abscesses

The effective treatment of intracranial abscess remains controversial. Progress in technology, linked with the development of neuronavigational systems, has made stereotactic aspiration and drainage of intracerebral abscesses effective and valid alternatives to traditional methods, namely, conservative medical treatment or open surgical excision. Between 1995 and 2002, 12 patients at our hospital underwent drainage of intracerebral abscesses under stereotactic guidance. Ten patients had solitary lesions and two had multiple abscesses. The appropriate antibiotic schemes were administered following culture of the aspirated material. The size of the abscess, the mass effect, and response to antibiotic treatment were followed up by repeated CT scans. All patients showed improvement and, at the end of treatment, returned to their previous activities. There were neither deaths nor any postoperative complication. A second aspiration was required in one patient due to recurrence of the abscess. The CT-guided stereotactic aspiration of brain abscesses helps achieve all treatment goals. It drains the contents of the abscess, reduces mass effect, and confirms diagnosis. It is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia.     

CT-guided stereotactic aspiration of brain abscesses

The effective treatment of intracranial abscess remains controversial. Progress in technology, linked with the development of neuronavigational systems, has made stereotactic aspiration and drainage of intracerebral abscesses effective and valid alternatives to traditional methods, namely, conservative medical treatment or open surgical excision. Between 1995 and 2002, 12 patients at our hospital underwent drainage of intracerebral abscesses under stereotactic guidance. Ten patients had solitary lesions and two had multiple abscesses. The appropriate antibiotic schemes were administered following culture of the aspirated material. The size of the abscess, the mass effect, and response to antibiotic treatment were followed up by repeated CT scans. All patients showed improvement and, at the end of treatment, returned to their previous activities. There were neither deaths nor any postoperative complication. A second aspiration was required in one patient due to recurrence of the abscess. The CT-guided stereotactic aspiration of brain abscesses helps achieve all treatment goals. It drains the contents of the abscess, reduces mass effect, and confirms diagnosis. It is minimally invasive, carries minimal morbidity and mortality, and can be performed on compromised patients under local anesthesia.     

Brain stem abscess managed with computed tomography-guided stereotactic aspiration

The importance of stereotactic aspiration to the successful management of three cases of brain stem abscess is discussed with special reference to the advantages offered over medical treatment alone. Stereotactic aspiration allows evacuation of pus, accurate bacteriological diagnosis, selection of an optimal antibiotic regimen, and instillation of antibiotics directly into the abscess cavity. In two of the three cases described here, the abscess reaccumulated after initial aspiration despite appropriate maximal medical therapy. A repeat aspiration was required before resolution occurred. We conclude that medical management alone is not adequate for some cases of brain stem abscess. There was no morbidity that could be attributed to the procedure, suggesting that the risk of stereotactic aspiration is probably quite low and is likely to be less than the risk of incorrect diagnosis, suboptimal choice of antibiotics, or progression of the lesion despite appropriate maximal medical therapy.     

A case presenting brain abscess with multiple infectious aneurysms

We report a case presenting a brain abscess with multiple infectious aneurysms. A 59-year-old man was transferred to our hospital suffering from left hemiparesis. MRI demonstrated a huge mass in the right frontal lobe with marked brain edema in the surrounding area. Diffusion-weighted image revealed heterogenous intensity, which is not typical in cases of brain abscess. Surgical removal was planned, and preoperative angiography was performed. Angiography demonstrated aneurysms at the distal branch of both the right middle cerebral artery and the anterior cerebral artery. These aneurysms were surgically resected, and the abscess was totally removed. Postoperative course was uneventful. Left hemiparasis was resolved, and there was no ischemic lesion seen on postoperative MRI. In the treatment of brain abscess, stereotactic aspiration has recently been preferred to removal by craniotomy. We conclude that cerebral angiography might be necessary to evaluate cerebrovascular complications including infectious aneurysms, in cases presenting atypical findings in neuroimaging study.     

The role of magnetic resonance imaging mammography in the surgical management of the index breast cancer

HYPOTHESIS: Preoperative magnetic resonance imaging (MRI) mammography, after positive fine-needle aspiration (FNA) or stereotactic biopsy, may alter surgical management of the index breast cancer. DESIGN: Review of MRI mammograms compared with conventional mammograms and clinical examination. SETTING: Rural community hospital. PATIENTS: Consecutive cohort of 27 patients with breast cancer who underwent prebiopsy or preoperative MRI mammography. INTERVENTION: Surgical management of breast cancer. MAIN OUTCOME MEASURE: Change in surgical management prompted by findings on MRI mammography. RESULTS: Prebiopsy or preoperative MRI mammography changed surgical management in 13 (48%) of 27 patients with breast cancer by discovering multicentric cancers or more extensive cancer. Of the 27 patients, 9 with positive FNA biopsy results of palpable masses underwent preoperative MRI; in 6 of the 9, ipsilateral multicentric cancers or more extensive cancer was discovered that necessitated mastectomy rather than breast conservation. Eighteen of the 27 patients had category 4/5 mammograms. Ten of these patients had stereotactic biopsies followed by MRI; 4 of the 10 had changes on the MRIs that required mastectomy rather than breast conservation. Eight of the 27 patients had MRI before stereotactic biopsy; 3 of the 8 had MRI abnormalities that required mastectomy. One patient had contralateral, multicentric cancers not seen on conventional mammography, necessitating bilateral mastectomies. CONCLUSIONS: We recommend that patients who desire breast conservation undergo MRI mammography before biopsy of a category 4/5 mammogram or immediately after a positive FNA biopsy result of a palpable mass.     

脑立体定向内窥镜的研制及其临床应用

目的探讨经内窥镜切除脑肿瘤的可行性、适应证及优越性。方法自行设计生产一种工作道相对宽大、能在脑实质中进行操作的脑立体定向内窥镜,用来进行脑深部肿瘤切除手术和其它颅脑手术。临床试用３０例：颅内肿瘤１３例,颅内血肿１５例,脑脓肿１例,脑囊虫病１例。结果肿瘤全切除４例,次全及大部切除７例,活检２例。血肿全清除７例,大部清除８例。脑脓肿吸除１例,脑囊虫孤立病灶切除１例。全组术后无严重并发症。结论脑立体定向内窥镜切除脑深部肿瘤定位准确、损伤小,其适应证为边界清楚、血供不丰富的微小肿瘤。直视下迅速清除脑内血肿,能止血。内窥镜手术是神经外科的一种微侵袭性新技术     

Stereotactic aspiration of enlarged intracerebral hematoma caused by intraprocedural perforation of aneurysm during coil embolization

BACKGROUND: Instead of surgical intervention, endovascular treatment with GDC has become an important tool to treat intracranial aneurysm in recent years. However, intraoperative aneurysm rupture remains a devastating complication for physicians. Rapid and precise packing with coils and external ventricular drainage are advised. Stereotactic aspiration of an enlarged intracerebral hematoma caused by intraprocedural perforation of aneurysm has been rarely discussed as a method of dealing with this consequence. CASE DESCRIPTION: The authors describe a case of a 45-year-old man who presented with sudden onset of headache. A ruptured aneurysm of approximately 5.5 mm, arising from the proximal segment of superior sylvian M2 branch on the right middle cerebral artery, was diagnosed via intracranial angiography. During transarterial embolization, perforation of the aneurysm dome by coil and microcatheter was noted. Although the aneurysm was secured by rapid coiling, progressive weakness of left extremities related to enlarged intracranial hematoma was noted. The neurologic deficits improved successfully after stereotactic aspiration of hematoma. CONCLUSION: The role of stereotactic aspiration in the management of an enlarged hematoma due to intraprocedural perforation of aneurysm during coil embolization may have further implications, and it may be considered as an alternative treatment to open clot evacuation for intracranial hemorrhages with aneurysms.     

Breast abscess as a complication of human brucellosis

Breast abscess caused by human brucellosis is extremely rare. A 46-year-old woman received the diagnosis of brucellosis with positive serologic tests. Two weeks after the onset of symptoms, the case was complicated by vertebral (L5-S1) abscess which was treated by surgical drainage. One month after the diagnosis of brucellosis, the patient noticed a mass in her left breast. Breast palpation revealed a painless, mobile, round mass that was hypoechoic on ultrasound imaging. Purulent material was obtained by needle aspiration. Besides treatment of the breast abscess by needle aspiration, brucellosis was successfully controlled by prolonged antimicrobial treatment.     

Interventional MRI-guided stereotactic aspiration of acute/subacute intracerebral hematomas

Surgical interventions for hypertensive intracerebral hematomas are still controversial. Many believe only hyperacute intervention is of any real utility. The majority of present interventions require a formal craniotomy with standard neurosurgical techniques. There are, however, a few reports on CT-guided stereotactic aspiration of these hematomas with favorable results. We report 10 patients treated with frameless fiduciless stereotactic means using an intraoperative MRI scanner (GE 0.5 T Signa SP). These patients were initially diagnosed as having hypertensive intracerebral hematoma and operated on within 1-34 days after hemorrhage. The actual operating time averaged less than 120 min, including intraoperative imaging. Clot volumes ranged from 2.5 to 75 cm(3) with a mean of 31 cm(3). There were 2 thalamic hematomas and 8 basal gangliar hematomas. Three patients had intraventricular hematoma extension and all 3, as well as an additional patient, required extraventricular drainage. However, no patients required permanent posthemorrhage ventriculoperitoneal shunting. Aspiration was successful in all cases to 70-90% of clot removal. Two cases utilized intrahematoma t-PA infusion with subsequent 80-90% clot removal. There were no complications or rehemorrhages. All patients showed some form of improvement that included either improved blood pressure control, speech or cognitive abilities. We conclude that using an intraoperative MRI scanner to perform frameless, fiduciless stereotactic aspiration of acute/subacute intracerebral hematoma is a safe and potentially effective means of treating intracerebral hematomas.     

Successful treatment of brainstem abscess with stereotactic aspiration

BACKGROUND: Brainstem abscess is an uncommon condition associated with a high mortality. We report a case of brainstem abscess in a 51-year-old female with a pulmonary arteriovenous fistula that was cured after appropriate antibiotic therapy following stereotactic aspiration. The value of stereotactic aspiration in the management of brainstem abscess is documented with a review of the relevant literature. CASE REPORT: A 51-year-old female with a pulmonary arteriovenous fistula suffered fever, diplopia and weakness on the right side. Magnetic resonance (MR) imaging of the brain showed a large cystic mass with ring-like enhancement in the brainstem. A diagnosis of brainstem abscess as a complication of pulmonary arteriovenous fistula was made. MR imaging-guided stereotactic exploration was carried out via the suboccipital transcerebellar approach and the pathogen of the brainstem abscess was identified. The brainstem abscess was cured after treatment employing antibiotics to which the pathogen was sensitive. CONCLUSIONS: Stereotactic aspiration is an effective procedure for brainstem abscesses. This procedure is less invasive than open surgery and can be performed even in patients in poor general condition.     

Successful treatment of a giant isolated cerebral mucormycotic (zygomycotic) abscess using endoscopic debridement: case report and therapeutic considerations

BACKGROUND: Cerebral mucormycosis without rhino-orbital or systemic involvement is an extremely rare condition mostly associated with parenteral drug abuse. CASE DESCRIPTION: We report the case of a 42-year-old woman who presented with hemiparesis of the left side and altered mental status. Neuroradiologic workup demonstrated an inflammatory lesion involving the right basal ganglia. Proton magnetic resonance spectroscopy demonstrated features consistent with a pyogenic abscess. Computed tomography-guided stereotactic biopsy led to the diagnosis of cerebral mucormycosis. Parenteral AMB-L treatment was conducted, but the patient worsened clinically, presenting with a complete hemiplegia, and cerebral magnetic resonance imaging (MRI) scans demonstrated a voluminous abscess formation. Then, under stereotactic guidance, a surgical endoscopic debridement of the abscess cavity associated with the placement of an Ommaya reservoir was performed. Systemic and intralesional treatment with AmB associated with an adjunctive immune therapy was conducted. At 3-year follow-up, the patient had recovered partially from her left hemiplegia, allowing her to walk without help, and cerebral MRI scans showed complete resorption of the abscess. CONCLUSION: Our good results suggest that surgical endoscopic debridement associated with intravenous and intracavitary antifungal therapy might be valuable in treating voluminous deep-seated mucormycotic lesions.     

Nocardia farcinica cerebral abscess: A systematic review of treatment strategies

PurposeNocardia farcinica is an opportunistic pathogen causing mainly pneumonia in immunocompromised patients, complicated in almost one-third of the cases by a thick-walled multiloculated cerebral abscess which induces significant morbidity and mortality. This review aims to assess the optimal treatment strategy for N. farcinica cerebral abscess.MethodsReport of a case. Medline database was used to conduct a systematic review from inception to January 2020 looking for English-language articles focused on N. farcinica cerebral abscess, in accordance with the PRISMA guidelines.ResultsThe research yielded 54 articles for a total of 58 patients. N. farcinica cerebral abscess displayed three different neuroimaging patterns: a single multiloculated abscess in half of the cases, multiple cerebral abscesses, or a small paraventricular abscess with meningitis. The patients who benefited from surgical excision of the abscess showed a trend towards a lower risk of surgical revision (8% versus 31%, P = 0.06) and a lower mortality rate (8% versus 23%, P = 0.18) than patients who benefited from needle aspiration. Twenty-two percent of the patients benefited from microbiological documentation from another site with a mortality rate of 23%.ConclusionUrgent multimodal MRI is necessary in face with clinical suspicion of cerebral nocardiosis. In case of single or multiple small cerebral abscesses, microbiological documentation can be obtained with puncture of pseudotumoral visceral lesions. In case of large or symptomatic cerebral abscess, an aggressive surgical excision seems a reliable option and can be preferred over needle aspiration. Long-term antibiotic therapy with cotrimoxazole is necessary thereafter.     

Nocardial brain abscess: diagnostic and therapeutic use of stereotactic aspiration

Three cases of nocardial brain abscess are presented. All three patients were receiving immunosuppressive therapy at the time of diagnosis. Two patients had cardiac transplantation and the third had periarteritis nodosa. The patients presented with generalized seizures or focal weakness. Accurate localization of the intracerebral mass lesion was obtained from computed tomography (CT) scans, but CT-guided stereotactic aspiration was required for diagnosis and treatment in every case. After Nocardia asteroides was seen on Gram's stain and subsequently identified by culture, appropriate antibiotic therapy was initiated. Both heart transplant patients survived in good neurological condition. We believe that stereotactic aspiration followed by prolonged antibiotic therapy may significantly improve the outcome of patients with nocardial brain abscess.     

CT-guided stereotactic surgery of brain abscess

Seven patients with brain abscess underwent CT-guided stereotactic aspiration using Iseki's stereotactic apparatus. Three of them were under the age of fifteen and four were older than thirty. The lesions were single and round in four cases, multilobular in two and multiple in one patient. Operations were performed after systemic administration of antibiotics for more than two weeks and after capsule formation was confirmed on CTs. Preoperative volume of the abscesses was estimated from CTs. The target point chosen was the center of the ring of the largest diameter in the enhanced lesion. Abscess was aspirated under monitoring with intraoperative CT scan. No continuous drainage was performed and no antibiotics were given directly into the abscess cavity. In all cases the center of the abscess was punctured with a single trial. Average volume of the preoperative brain abscesses was 18.8ml. Aspirated volume at the time of the operation averaged 16.9ml and all the abscesses decreased to unmeasurable size on CTs. In five of seven patients abscesses were cured after a single aspiration, and in one case after the second operation. One case required extirpation of the lesion. During the follow-up period of four months to five and a half years six patients showed no recurrence. One patient died of unrelated cause four and a half years after the operation. No operative complication was noted. There was no operative morbidity or mortality. Using a CT guided stereotactic method, brain abscess is punctured so accurately, regardless of its location and size, that damage to the surrounding brain during operation can be minimized. Therefore it is highly possible to aspirate abscesses completely.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of real time ultrasonography in neurosurgery. Peroperative value in adults

The authors present their beginning experience in the use of a new technique applied to neurosurgery: that is real-time echography. A preliminary non operative experience has first been carried on. It concerned five adults who have been studied through surgical defects. Then, eight patients, were explored intra-operatively: concerning three cerebral abscesses, one intra-cerebral haematoma, two subcortical tumors and two biopsies. In these cases, the ultrasonographic study was performed through a 3 centimeters diameter craniotomy--in case of abscess or haematoma aspiration or of biopsy--or through a classic bone flap--in case of tumor extirpation. Echography allowed an easy study of intracerebral structures and lesions. Its permits to visualize subcortical neoplasms and thus to aim them with accuracy. In the treatment of brain abscess, real time echography gives the possibility of guiding and following the progression of the probe. It, also, allows to appreciate the reduction of the suppurated cavity and thus assures a more reliable efficacity. Such a procedure indeed facilitates brain tumor biopsy; but we think that such a technique should be used only if a classic stereotactic procedure is not considered as necessary and if the mass lesion is large enough (over 1.5 cm) and not too profondly seated.     

Stereotactic cyst wall disruption and aspiration of colloid cysts of the third ventricle.

BACKGROUND: Current strategies of surgical therapy for colloid cysts have been associated with low rates of initial success and high rates of morbidity, mortality and recurrence of cysts. Cyst recurrence following simple stereotactic aspiration has been hypothesized to be due to regrowth of the epithelium composing the cyst wall. METHODS: We propose a procedure involving stereotactic disruption of the colloid cyst wall with the removal of a portion of the cyst wall followed by aspiration of cyst contents as a surgical therapy for colloid cysts. RESULTS: This procedure was performed in 2 female and 3 male patients who were followed for an average of 49 months with all patients demonstrating immediate improvement of symptoms and resolution of the cyst verified with repeat computerized tomography (CT) scans. There was one incidence of recurrence in an asymptomatic patient at 75 months postoperatively. CONCLUSION: We propose that stereotactic partial cyst wall disruption and content aspiration may limit recurrence of colloid cysts, thus offering an advantage over simple stereotactic aspiration alone.     

Evaluation of computerized tomography-guided stereotactic evacuation of putaminal hematomas by somatosensory evoked potentials

Computerized tomography (CT) guided stereotactic evacuation of intracerebral hematomas is effective and little invasive treatment at subacute or chronic stage. Somatosensory evoked potentials (SEPs) of 23 patients with putaminal hemorrhage whose stereotactic evacuations were performed from day 4 to day 24 are studied about surgical result and CT findings. As for SEP, N20 which is thought to be generated in the thalamus or in the primary parietal area receiving direct projections from the thalamus is used for comparison with functional recovery. Among 12 patients whose N20s before the evacuation showed normal, 9 had good recovery of their hemiplegia. Motor recovery tended to begin quickly after the evacuation and the evacuation of hematomas were thought to make better result than conservative treatment. CT findings of 9 patients with good recovery revealed that the hematomas didn't invade to the internal capsule or invaded to the posterior part of the posterior limb alone. Among 3 patients whose N20s before the evacuation were not distinct and those after the evacuation were normal, 2 had good recovery of their hemiplegia. As those hematomas were relatively large but located laterally, the internal capsule was seem to be not invaded but only compressed. Among 8 patients whose N20s were not distinct both before and after the evacuation, 7 could not get the recovery of their hemiplegia. CT findings of them revealed that the hematomas were large or invaded toward the internal capsule and thalamus. From this study N20s of SEPs are thought to be useful to the decision of indication and the prediction of the functional prognosis about stereotactic evacuation of putaminal hemorrhage.     

Management of brain stem abscess

The brain stem is an uncommon site of a brain abscess. Such lesions were invariably fatal before 1974, when the arrival of computed tomography and magnetic resonance imaging improved the prognosis. This new case with a good result shows the usefulness of early diagnosis, careful clinical and radiological monitoring and combined medical and surgical management. A child 2 1/2 years of age was admitted to the department of neurosurgery for diagnosis and treatment of a brain stem lesion. The clinical context and discovery of an intrabronchial foreign body, as well as neuroradiological investigations, suggested a diagnosis of brain stem abscess. Initial treatment with broad spectrum antibiotics with good cerebral penetration was associated with an increase in the size of the abscess and clinical worsening. Stereotactic aspiration of lesion was performed by a transpeduncular approach under CT guidance and general anaesthesia. Secondary thoracotomy enabled removal of an intrabronchial needle. After evacuation, in spite of failure to identify the organism, neurological deficit resolved rapidly and the lesion no longer appeared on CT. Management of a brain abscess always includes antibiotics. They must cover the organisms most often encountered in brain abscesses and have good cerebral penetration. Medical treatment seems to suffice for small abscesses. A brain stem abscess with rapid clinical signs, together with current neuroradiogical diagnostic techniques, enables early discovery of such abscesses when they are still small. Treatment of brain stem abscesses includes primary antibiotic therapy, then stereotaxic drainage when there is any diagnostic doubt, poor clinical tolerability or antibiotic resistance.     

Intraoperative imaging using a mobile computed tomography scanner.

OBJECTIVE: The radicality of tumour removal in patients suffering from glioma is discussed to be an important factor for longer survival times. Therefore intraoperative imaging modalities like magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound (US) are tested in many neurosurgical facilities for clinical use. In our department a mobile CT for intraoperative applications is used for this purpose since 1999. The handling and useful application of the mobile CT scanner as well as results without intraoperative imaging are discussed. MATERIAL AND METHODS: 470 CT scans with the mobile CT were accomplished, including 270 cases of neuronavigation planning, 76 cases of intraoperative scans, 48 cases of postoperative scans, 69 CT scans for stereotactic biopsy planning and control as well as 3 cases of emergency scanning in trauma patients and 4 spine applications. The results of the intraoperative CT scans are compared with those of the postoperative MRI scans. Additionally 87 patients with glioma were evaluated. These patients underwent surgery without intraoperative imaging. RESULTS: In 27 out of 43 patients with glioma residual tumour was detected with intraoperative CT. In 13 cases the surgery was resumed to complete resection, in 14 cases the operation was not continued due to close vicinity to eloquent areas or difficulties in image interpretation. In 44 cases the results of intraoperative CT and postoperative MRI were compared. In 6 cases the MRI demonstrated residual tumour in contrast to the results of the CT scans. In 3 cases the tumour removal could have been more complete (6.8 %). In 87 cases glioma surgery was performed without intraoperative CT. In 6 cases a more complete tumour removal could have been performed (6.9 %) according to the results of postoperative MRI. CONCLUSION: Intraoperative imaging with a mobile CT scanner is a good method for detection of residual tumour. The CT scanner can be integrated in an operative setting without problems. Although intraoperative imaging can be helpful in some selected cases, most of the neurosurgical procedures can be well performed with proper neuronavigation planning.