1.19 Il Cervello e Chirurgia Cranica 1951-2000

 

 

 1944. CLIP EMOSTATICHE SECONDO CUSHING.

 

Questa strumentazione era sul tavolo della strumentista dall’apertura alla chiusura delle craniotomie per prendere le clip emostatiche dalla rastrelliera (in basso a sinistra) dove erano state riposte e pronte per essere riprese con la pinza posaclip ed usate per fare emostasi chiudendo piccole arterie soprattutto quelle ai bordi della dura madre.  Vedi Uffreduzzi in Trattato di Tecnica Operatoria, pg 357).

Le clip erano preparate prima degli interventi mediante l’uso di una piattina di argento larga 1 mm e sottile 0,5 mm  che veniva inserita lateralmente alla apertura della pinza fino a battuta. Quindi la pinza veniva serrata e la piattina d’argento veniva tranciata a misura e modellata a V capovolto. Le clip venivano conservate  nella rastrelliera e sterilizzate in modo che fossero sempre pronte per l’uso.

Venivano usare per chiudere piccoli vasi, soprattutto quelli meningei che non si volevano coagulare con l’elettrobisturi.

 

 

1956.  STEREOTASSICO DI COOPER.

 

In alto, l’apparecchio Stereotassico di Cooper per infiltrazione del . Sotto a sinistra due immagini schematiche (frontale e laterale) di una pneumoencefalografia che mostra la presunta posizione del globus pallidus come targhet per il controllo del tremore parkinsoniano. A destra il casco in posizione sul cranio e la cannula per infiltrare il globus pallidus.

CANNULA PER CHEMOPALLIDECTOMIA DI COOPER

Mediante la cannula per chemopallidectomia di Cooper venivano iniettati cc 0,5-0,75 di una soluzione di cellodin all’8% in etanolo che essendo più viscoso dell’etanolo puro rende la neurolisi più lenta ed afficace.

Da Saint Barnabas Symposium on Surgical Therapy of extrapyramidal Disorders, Irving S. Cooper and Associates, from neurosurgical services of St. Barnabas Hospital and The New York University-Bellevue Medical Center, N.Y., 1956.

 

 

MARTELLETTI PER RIFLESSI OSTEOTENDINEI

 

 

 

 

PINZE OSSIVORE

 

Ossivora di Olivecrona

 

Ossivora GENTILE FRANCE

Ossivora di Laksell STILLE

Ossivora semplice

Tagliateca GENTILE FRANCE con accessori di spessore diverso.

Tagliateca

 

 

 

CANNULE PER ASPIRAZIONE LIQUIDI

 

Le cannule per l’aspirazione del liquido di lavaggio introdotte da Cuhing sono state usate in neurochirurgia per rimuovere il sangue dopo aver lavato il campo chirurgico con soluzione fisiologica. La punta dell’aspiratore non tocca mai il tessuto cerebrale, potrebbe aspirarlo, ma sulla punta aspirante viene sempre posizionato un cotonino per evitare di danneggiare il tessuto cerebrale. Inizialmente gli aspiratori erano cannule di vetro, in seguito, per esigenze particolari sono stati prodotti e usati spiratori metallici di varia forma.

 

 

 

1970. CLAMP PER CHIUDERE LA CAROTIDE.

 

La clamp per chiudere la carotide era in uso negli anni ’70 per la chiusura controllata (con EEG) e lenta (2-3 giorni) della carotide interna da cui dipendeva un aneurisma cerebrale giudicato inoperabile. Lo scopo era quello di ridurre l’afflusso di sangue in aneurismi cerebrali che per le loro dimensioni andavano oltre ogni possibilità chirurgica e ad elevato rischio di rottura. Naturalmente si era ben coscienti che nel chiudere una carotide si correvano grossi rischi per il paziente, per cui venivano fatti preliminarmente delle prove di chiusura manuale della carotide al collo  sotto controllo Elettroencefalografico per verificare la tolleranza della chiusura stessa senza effetti collaterali.

Dopo aver isolato chirurgicamente al collo la carotide su cui si voleva applicare la clamp veniva passata una pinza passafili sotto la stessa, con una pinza curva (in alto), una fettuccia in gomma morbida. Alzando la carotide con la fettuccia in gomma morbida si poteva inserire la parte inferiore della clamp a forma di U sotto la carotide e la parte superiore con la vite andava inserita sopra la carotide nell’apposita scanalatura. Sulla vite esterna si inseriva un tubicino metallico che faceva da guida ad un piccolo cacciavite che inserito sulla vite centrale faceva scendere la piastrina mobile contro la base della clamp riducendo così, gradualmente, lo spazio dove si trovava la carotide fino a chiuderla.

 

 

 

1970. AGHI PER CAROTIDOGRAFIA, BRACHIALGRAFIA RETROGRAFA.

 

Aghi per carotidografia e brachialgrafia.

La carotidografie le brachialgrafie retrograde sono state eseguite fino alla fine degli anni ’70 per studiare i vasi cerebrali e i loro spostamenti per effetto dei tumori cerebrali. L’introduzione della Tomografia Assiale Computerizzata (TAC realizzata nel 1974) ha permesso di “fotografare” il contenuto della scatola cranica mostrando per la prima volta la morfologia cerebrale e dei ventricoli in vivo. Da allora gli studi angiografici divennero sempre più rari.

[carotidografia e vertebralgrafia]

L’ago ha una punta a flauto ed è dotato di un mandrino che lo ostruisce al momento della puntura dell’arteria carotide secondo il flusso ematico. Tolto il mandrino esce il sangue che conferma la corretta introduzione nel lume dell’arteria, quindi l’ago viene introdotto ulteriormante l’ago nel lume per mantenere la sua stabilità durante l’iniezione del mezzo di contrasto. Tenendo l’ago con la mano sinistra, veniva collegata una sinistra con 5 ml di mezzo di contrasto e tirate conpemporaneamente le cinque lastre che fotografavano il contrasto all’interno dei vasi cerebrali. Con la stessa procedura veniva eseguita l’angiotomografia carotidea per studi di dettaglio.

Nell’attività di neuro-diagnostica è stata inserita anche l’angiotomografia per lo studio dei dettagli morfologici degli aneurismi cerebrali da cui ne è conseguita una ralazione:

Giunta F., Bollati A., Lenzi A., Marini G., Orlandini A., Bergonzini R., L’angiotomographie dans l’etude des aneurismes cerebraux, IX Congrès de Radiologie de Culture Latine, Venezia, 15-19 ottobre 1974.

L’impiego dell’angiotomografia nello studio degli aneurismi cerebrali richiede una collaborazione tra il neurochirurgo ed il radiologo, dato per scontato che in questi casi più che in altri le modalità tecniche e metodologiche devono essere correlate alle problematiche cliniche.

In effetti, l’angiotomografia nei malati portatori di un aneurisma cerebrale ci impongono dei problemi molto importanti, perchè si tratta sempre di soggetti molto delicati che possono, talora, peggiorare improvvisamente in seguito a stress anche modesti. L’intervento del neuroradiologo deve pertanto essere molto prudente in questi ammalati durante l’esecuzione di esami con mezzo di contrasto e soprattutto nella selezione di coloro che dovranno essere studiati con una tecnica complessa come l’angiotomografia.

Nella maggior parte dei casi una angiografia standard, soprattutto se è completata dalle proiezioni oblique, è sufficiente per la diagnostica: l’angiotomografia  non deve quindi essere considerato come un esame di routine, ma trova una indicazione solo se il neuroradiologo deve risolvere dei problemi diagnostici particolari, come: -dimostrare l’esistenza o meno di un aneurisma; -precisare il punto di impianto del suo colletto. Inoltre l’angiotomografia permette: -di fare una diagnosi differenziale degli aneurismi con un colletto e le dilatazioni aneurismatiche fusiformi; -di stabilire i rapporti tra la formazione aneurismatica e le arterie più vicine.

Abbiamo osservato nel periodo 1971-1974, 88 casi di aneurismi cerebrali; l’angiotomografia è stata praticata solamente in 25 casi nella necessità di raccogliere elementi diagnostici affidabili per l’intervento chirurgico.

Nei primi casi della nostra serie l’angiotomografia è stata fatta su una sola lastra, ad una profondità stabilita in precedenza. Più recentemente abbiamo adottato una cassetta multilastre, che dà delle immagini senza dubbio di minore definizione ma ugualmente valide per la diagnostica. L’angolo di pendolamento è stato di 30°, con tempi di esposizione di un secondo. Per ciascuna angiotomografia si iniettano 4 ml circa di mezzo di contrasto, riperuti due o tre volte al massimo.

In conclusione, noi pensiamo che l’angiotomografia possa dare al neurochirurgo delle informazioni essanziali che l’angiografia standard talora non può dare; questi dati possono rappresentare degli elementi decisivi nella scelta della tecnica operatoria.

 

 

 

AGO PER PUNTURA SUBARACNOIDEA LOMBARE E SUBOCCIPITALE

 

La puntura subaracnoidea lombare veniva utilizzata per eseguire la pneumo-encefalografia per lo studio dei processi espansivi cerebrali, soprattutto quelli endoventricolari,  saccoradicolografie per le ernie del disco lombo-sacrali e mielografie per i processi espansivi midollari.

Anche per la terapia del dolore neoplastico incoercibile vengono utilizzati gli stessi aghi lombari per la neurolisi dei nervi: nervo trigemino nel dolore facciale e le radici spinali per i dolori periferici.

Nell’ambito della Terapia del Dolore Neoplastico è stata acquisita una notevole esperienza ed è stata portata una innovazione: la neurolisi del trigemino nel dolore neoplastico facciale. L’esperienza acquisita è stata portata al Congresso:

1975, settembre, 5-8. Firenze. First World Congress on Pain, sponsored by International Asociation for the Study of Pain.

“In un caso riportato da Wilkinson nel 1964 la soluzione del fenolo in cisterna magna ha causato l’improvvisa comparsa di una paraplegia. Nel settembre del 1973, durante l’iniezione intratecale di fenolo al 5% in glicerina a livello di C2 si sono osservati la comparsa di un formicolio al lato destro del naso, nistagmo, movimenti clonici delle palpebre di destra e della bocca a destra senza effetti collaterali pericolosi. In seguito a questo si è considerato che forse il fenolo non era poi così pericoloso come si era pensato in precedenza qundo viene iniettato in cisterna magna.

Ventitre iniezioni di fenolo sono state somministrate nella cisterna magna di venti pazienti. Il paziente veniva messo in posizione laterale e, dopo l’anestesia locale della cute, venivano iniettati da 0,5 a 1,4 ml di fenolo in glicerina al 5% . Nella maggioranza dei casi il quinto, settimo e ottavo nervo cranico sono stati interessati. Il solo effetto a lunga durata osservato è stata una cefalea diffusa, che era dovuta probabilmente alla perdita di liquor. Il sollievo dal dolore risultava immediato dopo l’iniezione, e durava da alcuni giorni ad alcuni mesi.

Gli autori conludono che soluzioni di fenolo iniettati in cisterna magna è un trattamento facile, sicuro e ripetibile per il dolore alla faccia e alla bocca dovuto ad un cancro.”

 

 

1977. KANDEL e PERESEDOVA, Stereotactic clipping of arterial aneurysm and arterious malformations, J. Neurosurg. 1977, 4, 12-23.

Scatola contenente il posaclip stereotassico: DISPOSITIVO KANDEL-PERESEDOVA PER IL CLIPPING STEREOTASSICO DEGLI ANEURISMI DEL CERVELLO

IL PORTACLIP  STEREOTASSICO CON LE CLIP IN PRIMO PIANO

La scatola con il posaclip stereotassico mi è stato donato negli anni ’80 da Aldo Spallone, neurochirurgo di Roma, che avevo conosciuto ad un Congresso della Società Italiana di Neurochirurgia. Il prof. Spallone aveva lo aveva ricevuto da colleghi e amici neurochirurghi di Mosca che lui aveva visitato tempi addietro. Il motivo del dono era di fare un presente a chi aveva introdotto l’utilizzo il primo casco stereotassico entrato in Italia agli inizi degli anno ’80.

Di seguito la pubblicazione  del dispositivo sul Journal of Neurosurgery nel 1977.

Stereotaxic clipping of arterial aneurysms and arteriovenous malformations. Edward I. Kandf.l, M.D., D.Sc., and Vyacheslav V. Peresedov, M.D., Neurosurgical Clinic, Institute of Neurology, Moscow, USSR

In carefully selected cases of arterial aneurysms and deep-seated arteriovenous malformations (AVM), when direct attack may be dangerous or impossible, the authors advocate stereotaxic clipping. A special device and technique for its application are described. The instrument is introduced through a trephine opening and clipping is monitored by angiography. Successful results have been obtained in 10 operations performed on eight patients, three of whom had arterial aneurysms (two internal carotid and one anterior cerebral-anterior communicating) and five with AVM’s.

Key Words • aneurysm surgery • arteriovenous malformation • stereotaxic surgery • arterial aneurysms • stereotaxic clipping

In spite of remarkable advances in the surgery of cerebral arterial and arteriovenous aneurysms, the intensive search for new methods of operative treatment is continuing in an effort to reduce the rate of serious complications and mortality. Stereotaxic techniques have undergone outstanding development during the last two decades. One of the most important advantages of the stereotaxic method is that it avoids manipulation of blood vessels and retraction of the brain, which leads to vasospasm, brain edema, and the danger of aneurysm rupture.

In the literature we found no description of stereotaxic clipping of arterial or arteriovenous aneurysms through an ordinary burr hole. Development of such a technique was prompted by the feasibility and accuracy of modern stereotaxic surgery and the discrete angiographic target made by an aneurysm or an artery located deep in the brain. After our special devic for stereotaxic clipping was constructed in 1972, we performed many experiments on technical models, animals, and cadavers. The preliminary reports describing our method of stereotaxic clipping have been published previously.’10 The first operation on a patient with a previously giant, inoperable hemispheric arteriovenous aneu rysm was performed in 1973. To date we have carried out 10 operations on eight carefully selected patients. It is the purpose of this paper to present details of the instrumentation, operative technique, and clinical results of the stereotaxic clipping of arterial and arteriovenous aneurysms.

Instrumentation

Our special device for stereotaxic clipping (Patent No. 452336) was constructed for use with our previously described stereotaxic apparatus (Fig. I).6,7 The device was made in two models differing only in the size of the outer diameter of the tube (2.9 and 3.6 mm, respectively). The surgeon chooses a suitable device before the operation depending on the measurement of the diameter of the artery or the neck of the aneurysm as seen angiographically. If the artery or neck is 3 mm in diameter, the thinner device with the 5 mm clip opening must be used; if the artery diameter is about 5 mm, the device with the 7 mm clip opening should be used.

The device is a stainless steel tube 17 cm long with a conical narrowing at one end. At the other end is a special structure for controlling clip movements and disconnecting the clip from the device. There are also two metal pivots for inserting into the tube. One has a thin terminal segment that protrudes from the tip of the tube for several millimeters. This pivot is inserted into the tube before its stereotaxic introduction into the brain. The thin tip must reach the target point and its location must be angiographically verified. The second pivot carries on its tip a special clip and replaces the first one through a collet designed for this purpose.

The special removable stainless steel clips of different sizes (Fig. 1 right) permit the clipping of Vessels from 1 to 7 mm in diameter. The chosen clip is easily attached to the tip of the second pivot before its insertion into the cannula. The clip passing the conical narrowing at the tip of the cannula is consecutively squeezed and opened.

Operative Technique

Careful study of both projections of the preoperative angiograms is essential. The target point must be chosen in accordance with several factors. The afferent artery (or arteries) must be clipped far enough from the arteriovenous aneurysm to avoid dangerous contact with angiomatous tissue or large draining veins. It is necessary to check the orientation of the target vessel in frontal, sagittal, and horizontal planes, because the insertion of the tube and the clip perpendicular to the vessel or the aneurysmal neck is of utmost importance. The site for the burr hole is selected to avoid insertion of the device through a functionally important brain area.

The operation is carried out under neuroleptoanalgesia or general or local anesthesia with routine premedication. The patient’s head is placed supine in the stereotaxic frame and fixed by two sharp pins. A 25-mm burr hole is made by coronal trephine; the burr hole can be placed at any point, but we prefer to make it near the coronal suture. The stereotaxic apparatus with clipping device attached is fixed in the burr hole. Because repeated intraoperative angiography is essential, a needle or catheter is inserted percutaneously into the carotid artery.

The target point is transferred from the angiograms to the plain films and stereotaxic calculation is made for the correct orientation of the clipping device. The calculated angles of correction are checked on the protractors of the stereotaxic device. All operations are made under the control of an image amplifier with television monitoring. (Image amplifier manufactured by Optische Industrie “De oude Delft,” Delft, Holland)

After coagulating the cortical point, the first pivot is inserted through the cannula into the brain until it touches the target point. This movement is checked by consecutive angiography using Polaroid film. The first pivot is replaced by the second, which carries the squeezed clip. By turning a special ring of the control structure on the outer end of the device, it is possible to open the clip and check the degree of the opening in millimeters. Careful and slow introduction of the clip a little deeper permits accurate application upon the vessel or aneurysmal neck.

Before clipping, blood pressure is lowered by intravenous Arfonad to 60 to 70 mm Hg. If the next angiogram verifies the correct position of the clip, turning of the ring squeezes the clip until its full closure. Another angiogram is performed to show the effective clipping of the aneurysm or the afferent artery. Immediately after clipping, the patient is awakened so that normal function of the contralateral extremities can be confirmed. If function is satisfactory, neuroleptoanalgesia is repeated and blood pressure is increased gradually. The clip is released from the pivot by pushing a button on the outer part of the device. Under television control the tube is withdrawn from the brain.

If it is necessary to clip two or more vessels, the entire procedure is repeated. In case of failure such as partial or wrong clipping, or development of hemiparesis, the clip may be opened and withdrawn into the tube by slightly turning the ring on the outer end of the device. The duration of the clipping operation is between IV2 and 2 hours.

Summary of Cases

Each of the eight patients in this series was examined preoperatively by bilateral axillary and carotid angiography and, when necessary, by angiography in oblique projections and with cross compression. Cerebral blood flow (CBF) was investigated in five patients before and after operation using the Kety-Schmidt method as modified by us.8

Arterial Aneurysms

Four stereotaxic clipping operations were carried out on three patients aged 44, 46, and 49 years. In the initial stage of our study we selected three types of arterial aneurysms to investigate the possibilities offered by the new method: a supraclinoid aneurysm, an anterior communicating aneurysm, and an anterior cerebral artery aneurysm.

The supraclinoid aneurysm of the internal carotid is the most common type of aneurysm. The narrow necks of the majority of these aneurysms make them particularly suitable for stereotaxic clipping, as the following case illustrates.

Case I. This 49-year-old woman was admitted after two severe subarachnoid hemorrhages (SAH’s) 17 months and 1 month respectively before admission. After admission her general condition was satisfactory. She had paralysis of the left third nerve, light hemiparesis of the right side, and signs of sensorimotor aphasia. A four-vessel angiographic study demonstrated a bilobed supraclinoid saccular aneurysm (14 X 7 mm in lateral projection) arising from the left internal carotid in the region of its junction with the posterior communicating artery (Fig. 2 A). The aneurysmal neck was narrow. There was mild spasm of the carotid.

In April, 1974, stereotaxic clipping of the aneurysm neck was carried out under general anesthesia. A trephine opening was made 3 cm posterior from coronal suture and 3 cm to the left of the midline. The stereotaxic apparatus with clipping device was installed, and a catheter was percutaneously introduced into the left common carotid artery. The target (aneurysmal neck) was transferred from angiograms to the plain films (two views) and stereotaxic calculations were made. The tip of the first pivot reached the target point at a depth of 76 mm. The pivot was then replaced by another with a compressed clip. It was put on the aneurysm neck and its position was confirmed by control angiography (Fig. 2 B and C). Arterial pressure was lowered to 70 mm Hg.

The patient was awakened for several minutes for a check of movements, but no
changes were noted. The clip was closed slowly by means of the button on the external part of the device. One more control angiogram showed that the aneurysm neck had been clipped and that there was non-filling of the aneurysm. The clip was then released and the device was withdrawn. The operation was performed under continuous television monitoring. The bone button was then put in place. The duration of the operation was 1 hour and 40 minutes. There were no postoperative complications and no neurological changes. The patient could walk 3 days after surgery.

Control angiography 2 weeks later demonstrated the elimination of the aneurysm (Fig. 2 D and E). The lumen of the internal carotid artery at the level of the clip was not changed. At 16 months postoperatively the patient’s condition was good, and she returned to work. Aphasia and third nerve paralysis have disappeared completely.

In spite of a remarkable improvement in the results of direct attack on anterior communicating artery aneurysms, the technical difficulties and rate of complications remain serious unsolved problems. Logue11 and Ahmed and Sedzimir1 proposed the open clipping of the dominant anterior cerebral artery for thrombosis of aneurysms of the anterior communicating artery. We believe that the stereotaxic clipping of the neck of such an aneurysm may be done in exceptionally rare cases, but that clipping of the dominant anterior cerebral artery is also technically possible. This point of view is confirmed by the following case.

Case 2. This 44-year-old man began to suffer from sudden headaches and repeated vomiting in December, 1974, and on one occasion he lost consciousness for 3 hours. Initially he showed signs of meningeal irritaion; he had slight pyramidal signs on the ight side and bloody spinal fluid. After adnission 3 weeks later, he complained of a headache, but his general condition was satisfactory.

Right-sided axillary and carotid angiography disclosed a saccular aneurysm of theanterior communicating artery. Left carotid angiography showed no filling of the aneurysm. The aneurysmal neck was not clearly visible (Fig. 3 A). Since clipping the aneurysmal neck seemed to be technically impossible, stereotaxic clipping of the dominant right anterior cerebral artery was performed (Fig. 3 B). The burr hole was made 1 cm anterior to the coronal suture and 3 cm to the right of the midline. The distance from the cortex to the target was 62 mm. The clip was placed on the artery under television control.

Postoperative carotid angiography showed that the clip had slipped and the aneurysm had refilled. A second stereotaxic operation was done 2 weeks later through the same burr hole (Fig. 3 C). The second clip was placed proximal to the first and 10 mm from the bifurcation of the internal carotid artery (Fig. 3 D). The postoperative course was free from complications. Subsequent left carotid angiography showed that the anterior cerebral artery was clipped and the aneurysm no longer filled (Fig. 3 E). The control examination 9 months postoperatively showedthat the patient was in excellent condition. He is working full time and has no complaints.

It was reasonable to suppose that stereotaxic clipping of the distal branch of the anterior cerebral artery would be technically easy and less dangerous. The following case illustrates this procedure.

Case 3. This 46-year-old man was admitted in February, 1975, after a severe SAH. After light physical strain he developed severe headaches and vomiting, followed by a generalized seizure and unconsciousness. Neurological examination showed he wasconfused, had severe meningeal signs, and right-sided hemiparesis. Lumbar puncture disclosed bloody cerebrospinal fluid. The patient’s general condition improved, but headache, vertigo, weakness of the right extremities, and loss of memory remained. Total cerebral angiography showed a widenecked berry aneurysm of the left frontopolar artery.

Stereotaxic clipping of the feeding frontopolar artery was performed under neuroleptoanalgesia. A burr hole was placed 1 cm

TABLE 1

The CBF in five patients with AVA’s before and after clipping feeding vessels

Case

No.

Total CBF*

Local CBFf (ml 100 gm/min)

Preoperative

Postoperative

Preoperative

Postoperative

Value
(ml min)

% of
Normal

Value

(ml/min)

% of
Normal

AVA

Hemis.

Opp.

Hemis.

AVA

Hemis.

Opp.

Hemis.

4

2422.7

322.1

1894.9

252.6

210.4

135.7

167.1

103.6

5

1945.3

259.4

788.2

105.0

163.7

114.2

62.5

50.1

6

980.7

130.8

807.8

107.7

102.0

38.1

80.4

35.1

7

1647.8

219.7

1066.1

142.2

125.0

110.4

82.2

70.1

8

1015.0

135.3

708.4

94.5

81.4

63.6

51.4

49.8

*The normal total CBF was 750 ml, min.

The normal local CBF was 55 ml/100 gm/min.

anterior to the coronal suture. The artery was clipped at a depth of 61 mm from the cortex. Immediately after the operation the rightsided hemiparesis became more pronounced, but completely disappeared after 1 week. Control angiography showed non-filling of the aneurysm. The patient is in good condition and has no complaints 7 months postoperatively.

Arteriovenous Aneurysms

It is known that only approximately 50% of hemispheric arteriovenous aneurysms (AVA’s) can be totally removed. The radical extirpation of the remaining 50% is impossible because of their size or deep-seated location. It is widely accepted that by diminishing the blood flow to the AVA and thus its volume, the risk of intracranial hemorrhage and the rate of seizures may be reduced. For this purpose several techniques have been successfully applied during the last decade, including artificial embolization, and the introduction of special balloon catheters.

During the last 3 years we performed six operations of stereotaxic clipping of hemispheric AVA’s in five patients ranging in age from 13 to 45 years. The dominant signs were subarachnoid-parenchymatous hemorrhages, seizures, pyramidal tract signs, pulsating bruit in the head, and headaches. The aneurysms were located in the right hemisphere in three cases, in the left in one, and in the region of the corpus callosum and third ventricle in one. Four aneurysms were of large or giant size: in three, volumes varied from 42 to 190 cu cm and one had a volume of 23 cu cm.

Four widespread AVA’s were supplied by several arteries and two by arteries from both sides. Only one relatively small aneurysm was supplied by a branch of the middle cerebral artery.

Study of CBF appears to be the objective criterion for the evaluation of clipping operation in AVA’s. Five of our patients were investigated before and after surgery by our modification of the Kety-Schmidt nitrous oxide method.7 It is well known that total and hemispheric CBF in the presence of an AVA is substantially increased. In our five cases, total CBF consisted respectively of about 131%, 135%, 219%, 259%, and 322% of normal volume (750 ml/min) (Table 1). As previously described,7 the rate of increase has correlated well with the volume of the AVA. The hemispheric CBF was greatly increased mostly in the hemisphere in which the AVA was located. In cases of giant and large AVA’s, the opposite hemispheric CBF was also increased. After stereotaxic clipping of afferent vessels, total CBF decreases markedly in all cases — ranging from 23.1% to 154.4% (mean 72%). In three cases CBF became practically normal; in two cases, although reduced, it remained very high. One of these two cases, Case 4, had a giant AVA.

Because there is still no definite solution to the problem of inoperable AVA’s we concentrated our efforts on the clipping of feeding vessels as a mode of palliative treatment of large and giant aneurysms. Three cases briefly described below illustrate this point. The first case (Case 4, which was our first such operation, done in 1973), may be of particular interest because bilateral clipping was carried out.

Case 4. For about 30 years this 45-year-old man had suffered from pulsating headaches, which had become continuous and severe several years before admission. He had suffered seizures for about 10 years. At first they were local but later became generalized and more frequent. Slight left-sided hemiparesis developed 2 years before admission.

Four-vessel angiography showed a giant AVA (193 cu cm), occupying the right parietal, temporal, and occipital lobes. It was supplied by greatly enlarged arteries from both sides, by right middle and left anterior cerebral arteries and to a lesser extent by branches of right anterior and posterior cerebral arteries (Fig. 4 A). The aneurysm was evaluated as absolutely inoperable.

In January, 1973, through a burr hole near the coronal suture, stereotaxic clipping of the enlarged (6 mm) branch of the right middlecerebral artery was carried out. Two clips were applied. There were no complications after surgery. Control angiography showed a marked decrease of the aneurysm volume (Fig. 4 B) and of the total and hemispheric CBF (Table 1). The headaches became less severe.

Six months later stereotaxic clipping of the large branch of the anterior cerebral artery (Fig. 4 C) was performed on the other side. No complications were noted. Correct clipping was confirmed angiographically and consequent substantial decrease in volume was achieved (Fig. 4 D). After the second operation there was a marked clinical improvement: severe headaches and seizures disappeared completely in the 2‘/2-year follow-up period.

Case 5. This 25-year-old man had a history of two severe subarachnoid-parenchymatous hemorrhages with consequent long-lasting, right-sided hemiparesis. He also had up to three seizures per month. Four-vessel angi- ography indicated a very large AVA (153 cu cm) deep in the left temporal lobe and fed mainly by the left middle and posterior cerebral arteries (Fig. 5 A). It was decided that total removal of the lesion was technically impossible.

In April, 1974, stereotaxic clipping of the large feeding branch of the left middle cerebral artery was performed and confirmed angiographically. After clipping, the AVA was not visualized by angiography (Fig. 5 B). The CBF decreased by two thirds on the aneurysmal side and by half on the other side and has become near normal. There was no complication after operation.

At 1 1/2 years after surgery there have been no seizures or signs of intracranial hemorrhage. The neurological deficit has diminished markedly and the patient’s general condition is good.

Case 6. This 42-year-old man had an SAH I month before admission. For 16 years he had suffered from frequent seizures. Angiography showed a large arteriovenous malformation (128 cu cm) located in the mediobasal part of the right temporal lobe and supplied by enlarged branches of the right middle and posterior cerebral arteries. Because of its size and location the aneurysm was evaluated as inoperable. In May, 1974, stereotaxic clipping of the large branch of the middle cerebral artery was carried out. Remarkable reduction of the aneurysm volume and substantial decrease of CBF (Table 1) were achieved.

During a 1-year follow-up period there have been no intracranial hemorrhages and no seizures. The patient’s general condition is good and he is working full time.

The next case illustrates the possibility of stopping flow to a middle-sized AVA deep in a poorly accessible region of the brain.

Case 7. This 13-year-old boy had sustained four severe intraventricular hemorrhages during a period of 4 years. He was admitted 3 weeks after the last bleed. Bilateral angiography showed a middle-sized (42 cumm) arteriovenous malformation, involving deep medial structures, the corpus callosum, and the third ventricle. The aneurysm was supplied mainly by the right pericallosal artery and, to a lesser extent, by branches of the right middle and both posterior cerebral arteries (Fig. 6 A). The deep bilateral location of the aneurysm made it inoperable.

It was decided to clip the main feeder of the aneurysm, the pericallosal artery. Successful stereotaxic clipping of the artery was performed in December, 1973. Control angiography showed that the AVA no longer filled through the artery (Fig. 6 B). The CBF was markedly decreased (Table 1). There were no postoperative complications. During a 20-month follow-up period there have been no hemorrhages. The boy is in good condition and continues to attend school.

The next case is important for the evaluation of the dipping method. In this case the method has been used for the management of an AVA that undoubtedly could have been completely removed by classic open surgery. It is well known that AVA’s supplied by one feeder are rare. Their total extirpation may usually be achieved without great technical difficulties. Nevertheless, to study the possibilities of stereotaxic clipping we decided to employ it in a case of operable AVA. It should be emphasized that surgery totally eliminated the aneurysm from the circulation.

Case 8. This 26-year-old man was admitted several hours after a single subarachnoidparenchymatous hemorrhage. The marked post-bleeding hemiparesis gradually disappeared. Angiography showed a small AVA (23 cu mm) in the right parietotemporal region. There was only one thin feeding branch from the middle cerebral artery (Fig. 7 A). In November, 1973, this branch was clipped without complications (Fig. 7 B). control angiography showed the complete exclusion of the malformation from the circulation (Fig. 7 C). Postoperative CBF investigation demonstrated a return to normal (Table 1).

About 2 years after surgery the patient is in good condition without neurological deficit. Intracranial hemorrhage has not recurred.

Discussion

Early attempts to apply the stereotaxic technique to deep-seated and poorly accessible arteriovenous malformations (AVM’s) were made by Guiot, et al. ,5 and Riechert and Mundinger.14 These authors used a combination of stereotaxic technique and the classic direct approach. After ordinary flap craniotomy a stereotaxic device was installed and directed through a small cortical incision toward the aneurysm. In this way Guiot, et al.. could either coagulate small AVM’s or clip middle cerebral artery aneurysms. Riechert and Mundinger14 reported four cases with deep AVM’s successfully operated on by this method.

Alksne and Rand 2, 3 developed the technique of magnetic thrombosis of intracranial aneurysms. A magnetic cannula 6 mm in diameter was placed stereotaxically at the dome of the aneurysm and after the puncture of its wall with a fine needle, a suspension of iron wqs introduced into the aneurysm, causing thrombosis.

Mullan12 reported wide experience in producing stereotaxic intraaneurysmal thrombosis by means of several fine steel needles inserted into the aneurysmal sac, after which positive direct electric current was applied. The results were satisfactory in most cases, but in a series of 61 patients there were four postoperative deaths directly attributed to the procedure, while eight cases showed incomplete obliteration.

Four patients with anterior communicating-anterior cerebral arterial aneurysms were operated on by Samotokin and Hilko,15 who stereotaxically introduced thin electrodes into aneurysms followed by anodal electrolysis for 1 to 3 hours. This operation was combined with intravenous infusion of coagulants. In all cases aneurysm volume was reduced by 30% to 40%, but complete thrombosis was not achieved. One case of successful stereotaxic thrombosis of an anterior communicating arterial aneurysm and another case of stereotaxic electrocoagulation of a single vessel feeding a small AVM in the frontal lobe of an 8-year-old child have also been reported. 4, 13

Despite these encouraging results the stereotaxic method of managing arterial and arteriovenous aneurysms has not been common neurosurgical practice.

The main purpose of this study was to reach a higher degree of safety in the performance of surgery of arterial and arteriovenous aneurysms. In this connection it is important to note that after 10 operations of stereotaxic clipping there was no mortality and in only one case was there hemiparesis lasting several days. It should be emphasized that patients as a rule endured the operation very easily and were able to walk 2 to 3 days after surgery. Brain trauma secondary to stereotaxic clipping is less than during classic open surgery.

Our experience with stereotaxic clipping is relatively limited, but it is possible to draw the preliminary conclusion that this new method may be rational and advisable in the following instances:

1. In carefully selected cases of arterial aneurysms in which direct attack is too dangerous or technically impossible.

2. In giant and deep-seated AVM’s as a palliative operation for the diminution of the aneurysm volume.

3. In selected cases of AVA’s fed by a single artery, as a method of radical treatment.

It is reasonable to suppose that the future development of the method will offer new technical possibilities and will be useful in vascular neurosurgery.

References

1. Ahmed RH. Sedzimir CB: Ruptured anterior communicating aneurysm. A comparison of medical and specific surgical treatment. J Neurosurg 26:213-217, 1967.

2. Alksne JF: Progress on the magnetically controlled stereotactic thrombosis of intracranial aneurysms. Confin Neurol 34:368-373, 1972.

3. Alksne JF, Rand RW: Current status of metallic thrombosis of intracranial aneurysms. Prog Neurol Surg 3:212-229, 1969.

4. Cahan LD. Rand RW: Stereotaxic coagulation of a paraventricular arteriovenous malformation. Case report. J Neurosurg 39:770-774, 1973

5. Guiot G, Rougerie J, Sachs M, et al: [Stereotaxic localization of deep vascular intracerebral malformations.] Sem Hop Paris 36:1134-1143, 1960 (Fre).

6. Kandel El: New stereotactic apparatus and cryogenic device for stereotactic surgery. Confin Neurol 37:128-132, 1975.

7. Kandel El, Kukin AV: [A new stereotactic apparatus.] Vopr Neirokhir 36:56-58, 1972 (Rus).

8. Kandel El, Nicolaenko EM: [Investigation of cerebral circulation and gas exchange in patients with arteriovenous aneurysms of the brain hemispheres.] Vopr Neirokhir 35:36-42, 1971 (Rus).

9. Kandel El, Peresedov VV: [Method of stereotactic clipping of the feeding vessels of arteriovenous aneurysms, in Ugrumov VM: Diagnostics and Surgical Treatment of Cerebrovascular Diseases.] Leningrad: Leningrad Institute of Neurosurgery, 1974, pp 182-185 (Rus).

10. Kandel El, Peresedov VV: [Stereotactic clipping of an arterial aneurysm of the brain.] Vopr Neirokhir 39:13-15, 1975 (Rus).

11. Logue V: Surgery in spontaneous subarachnoid hemorrhage. Operative treatment of aneurysms on the anterior cerebral and anterior communicating artery. Br Med J 1:473-479, 1956.

12. Mullan S: Experiences with surgical thrombosis of intracranial berry aneurysms and carotid cavernous fistulas. J Neurosurg 41:657-671, 1974.

13. Rand RW, Mosso JA: Treatment of cerebral aneurysms by stereotaxic ferromagnetic silicone thrombosis. Bull Los Angeles Neurol Soc 38:21-23, 1972.

14. Riechert T, Mundinger F: Combined stereotaxic operation for treatment of deep-seated angiomas and aneurysms. J Neurosurg 21:358-363, 1964.

15. Samotokin BA, Hilko VA: [Aneurysms and Arteriovenous Fistulas of the Brain.] Leningrad: Meditsina, 1973 (Rus).

_______________
Address reprint request to: Edward I. Kandel,
M.D., Neurosurgical Clinic, Institute of Neurology, Moscow D-367, USSR.

Fig. 1. Left: Stereotactic clippingdevice in assembly with stereotactic apparatus. Right: The clipping device is shown unassembled (right), and with open clip on the tip and first pivot (left). Three clips pf different sizes are shown (center).

Fig. 2. Case 1. Angiograms showing a supraclinoid internal carotid aneurysm before operation (A), during stereotaxic clipping (B, C) and two weeks after operation (D, E).

Fig. 3. Case 2. Angiograms showing an anterior communicating artery aneurysm before operation (A), after clipping of the anterior cerebral artery (B), and during the second operation (the first clip slipped) (C). Right (D) and left (E) carotid angiograms show the result of a second, more proximal clipping of the anterior cerebral artery. The aneurysm did not fill.

Fig. 4. Case 4. Angiograms showing a giant AVA, supplied by bilateral arteries. A: Before surgery. B: After stereotaxic clipping of tne significantly hypertrophic branch of the right middle cerebral artery (note two clips), the AVA volume was markedly reduced. C: During the second operation on the other side clipping of the left anterior cerebral artery was carried out. D: After clipping, the remaining part of the AVA supplied by this artery was eliminated.

Fig. 5. Case 5. Angiograms of a large AVA supplied by middle and posterior cerebral arteries before (A) and after (B) clipping of middle cerebral artery. The aneurysm was not visualized.

Fig. 6. Case 7. Angiograms of a middle-sized AVA supplied mainly by pericallosal artery. A: During the operation. B: After stereotaxic dipping of the artery the aneurysm did not fill.

Fig. 7. Case 8. Angiograms of a small AVA supplied only by one branch of the middle cerebral artery just before (A), during (B), and after (C) stereotaxic clipping. The aneurysm was totally excluded from the circulation.

 

 

 

1980. REGGISPATOLE CEREBRALI A DUE BRACCIA FLESSIBILI.

 

Fissato al bordo della craniotomia questo reggispatole poteva tenere in posizione fissa, senza l’aiuto di un secondo operatore le due spatole che permettevano il libero accesso nel profondo del campo chirurgico.

 

 

 

SPATOLE CEREBRALI FLESSIBILI

 

SPATOLE E DISSETTORI

 

Spatole e dissettori per manipolazioni varie

Microdissettore per aneurismi

 

 

 

SPATOLE CEREBRALI FLESSIBILI, ELASTICHE E TRASPARENTI.

Le Spatole Cerebrali Flessibili e Trasparenti sono state realizzate in policarbonato che unisce la massima resistenza ed trasparenza ad una flessibilità. La trasparenza è utile a controllare il cervello e la sua sofferenza ischemica sotto la spatola e la flessibilità permette di adattarla in ogni situazione. Inoltre al termine del manico vi è una presa per la fibra ottica utile a portare ulteriore luce proprio nel profondo della cavità operatoria. La sterilizzazione avviene tramite il cloruro di etilene in confezioni apposite.

 

 

 

 

1983. CASCO STEREOTASSICO DI LEKSELL TC COMPATIBILE

 

Nel 1980 veniva pubblicata una novità che riguardava il Casco Stereotassico di Leksell, già in uso in neurochirurgia dagli anni ’50, per adattarlo all’uso con la Tomografia Computerizzata. Questo adattamento prevedeva che il calcolo delle coordinate del target su cui fare una biopsia o una lesione venisse eseguito sulle immagini di una TC eseguita sul paziente con il casco montato sul cranio dello stesso. La TC mostrava quindi il cranio del paziente, i punti fiduciali come riferimenti per il calcolo del target e la lesione intracerebrale su cui intervenire.

[ima TC cranio con il calcolo del target]

Casco Stereotassico di Leksell montato su un cranio a scopo didattico. A sinistra proiezione obliqua anterio-superiore. A destra immagine laterale.

 

Ago per biopsia stereotassica di Sedan. È stato usato anche l’ago per biopsia di Backlund che termina con una spirale (vedi immagine sotto)

A sinistra, biopsia cerebrale con spirale di Backlund. A destra, una piccola parte del materiale biopsiato veniva strisciato e colorato (in una studio attrezzato accanto alla sala operatoria) per una conferma della correttezza del prelievo mentre il rimanente veniva incluso e preparato per lo studio con le metodologie in uso in neuropatologia.

Ago stereotassico per la puntura di un ascesso. Drenato parte dell’ascesso l’ago veniva sostituito con un cateterino che rimaneva inserito nella cavità ascessuale per ulteriori lavaggi con antibiotici nei giorni seguenti.

E’ stato eseguito un intervento d’urgenza per il drenaggio stereotassico di un ascesso nell’angolo ponto-cerebellare destro in una bimba di 7 anni giunta agli Spedali Civili con obnubilamento del sensorio ed una lunga storia di otite destra. La TC mostrava un processo espansivo interpretato come ascesso ed è stata operata d’urgenza con tecnica stereotassica perchè si riteneva, di concerto con l’anestesista, che difficilmente avrebbe sopportato un intervento cranitomico in fossa posteriore, sia per la posizione prona sia per la durata dello stesso.

Dall’ago stereotassico fuoriesce ul liquido dal tipico colore di “olio per motore”, si tratta del liquido contenuto in una cisti di un craniofaringioma.

La paziente è stata trattata con l’inserimento di una soluzione di Yttrio colloidale secondo la metodica di Olof Backlund. Non si sono verificati gli effetti collaterali temuti sulle vie ottiche, e neanche sulla produzione ormonale: la paziente ha sempre avuto il ciclo mestruale e dopo qualche anno ha anche avuto un figlio.

A sinistra, un paziente sul tavolo operatorio, dopo aver eseguita la Tonografia Computerizzata per il calcolo del target. A destra una immagine di controllo della posizione della punta dell’ago stereotassico eseguita con il Neurogil (scanner radiologico).

Template per l’inserimento di semi radioattivi per l’irradiazione interstiziale dei tumori cerebrali. L’asta va montata sulle guide porta-aghi dell’arco stereotassico con, a destra il distanziatore con vite e, a sinistra, i template in teflon con i fori in cui inserire le cannule porta-isotopi. Sotto i template con misure diverse.

 

A sinistra. L’apparecchio stereotassico è stato anche usato come guida di precisione per eseguire interventi in tumori profondi con tecnica “a cielo aperto”. A destra. Un grafico presentato nel 1990 con la statistica dei primi casi di biopsia stereotassica.

L’utilizzo dell’apparecchiatura stereotassica è stata usata anche in tumori del tronco con cui abbiamo pubblicato, assieme  ai colleghi di Stoccolma, questo articolo:

1987. Mathisen J.R., Giunta F., Marini G., Backlund E-O., Transcerebellar Biopsy in the Posterior Fossa: 12 Years Experience. Surg. Neurol., 1987, 28, 100-4.

 

 

 

 

1980. POSACLIP PER ANEURISMI DELLE ARTERIE ENDOCRANICHE

 

 

 

 

 

 

2006. CONGRESSO ASCO (American Society of Clinical Oncology) AD ATLANTA (USA)

Alternative schedules of adjuvant temozolomide in glioblastoma multiforme: a 6-year experience.

Background. Temozolomide (TMZ) is an oral alkylating agent with proven efficacy in the therapy of glioblastoma multiforme (GBM). The activity of TMZ is drug-exposure dependent, however dosages are primarily limited by myelotoxicity. In the attempt to increase survival while limiting toxicity, we treated GBM patients (pts) with one of 3 alternative adjuvant TMZ schedules, including a low-dose daily regimen.

Methods. We assessed the overall survival and the development of grade 3-4 mielotoxicity in pts with GBM who were treated in our centre (November 1998-October 2005), following surgery, with one of the following TMZ schedules: standard schedule (SS: 200-300 mg/m2 x 5 days, every 28 days); extended schedule (ES: 150 mg/m2 x 7 days every 15 days); daily schedule (DS: 75 mg/m2 daily). Pts were treated until death or tumour progression. The analysis of survival was based on the Kaplan-Meier (KM) and the Cox models. Adverse events were graded according to NCICTC 3.0.

Results. We evaluated 117 pts (73 m, 44 f, avg. age 57 yrs, 53% received radiotherapy, RT) with histologically diagnosed gliomas (GBM=92.3%) treated with TMZ SS (tot pts=48, RT pts=22, no. cycles: 1÷33, avg 6) or ES (tot pts=35; RT pts=19, no. cycles: 1÷43, avg 16) or DS (tot pts=34; RT pts=21, days of treatment: 25÷671, avg 212). The overall survival significantly differed among the 3 schedules (KM), with DS providing the best outcome (p=0.0357, log-rank). Median survival time was markedly increased in DS pts (DS=29.47 months; ES=15.73 months; SS=11.90 months) as well as the survival rate at 2 yrs after diagnosis (DS=51%; ES=30%; SS=21%). DS, but not ES, significantly reduced the mortality hazard ratio (HR) compared to SS (Cox: HR=0.494; IC95% 0.253-0.966, p=0.039). Grade 3-4 myelotoxicity (leukopenia, LP; neutropenia, NP; thrombocytopenia,TP) occurred less frequently with DS (NP=2.9%; TP=2.9%; any=5.9%) than with ES (LP=11.4%; NP=14.3%; TP=17.1%; any=28.6%) and SS (LP=14.6%; NP=8.3%; TP=20.8%; any=22.9%).

Conclusions. In our experience with adjuvant TMZ in GBM, a continuous daily dose of 75 mg/m2 was on the whole more advantageous than a standard monthly or a biweekly regimen, as it resulted in the highest overall survival with the lowest hematologic toxicity.

 

 

2006, 6 giugno, Brescia. Corso di aggiornamento. TUMORI CEREBRALI: INTEGRAZIONE TERAPEUTICA MULTIDISCIPLINARE