Application of three-dimensional angiography in elderly patients with meningioma

Transcription

1 Application of three-dimensional angiography in elderly patients with meningioma Poster No.: C-0123 Congress: ECR 2012 Type: Scientific Paper Authors: X. Han, J. Chen, K. Shi; Haikou/CN Keywords: Neuroradiology brain, Head and neck DOI: /ecr2012/C-0123 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Purpose To investigate the value of preoperative three-dimensional angiography in an elderly population of patients suffering from intracranial meningiomas. Page 2 of 18

3 Methods and Materials Preoperative imaging using MSCTA or 3D CE-MRA was performed in 42 patients over age 60 with meningiomas (simulation group). The preoperative information was analyzed on a three-dimensional post-processing workstation to identify tumor oppression, invasion of important intracranial vessels, venous sinuses, and nerves to assess the surgical risk and determine the resection plan and surgical approach. The control group was comprised of 28 elderly meningioma patients who did not undergo preoperative imaging. Page 3 of 18

4 Results 30 of the 42 patients were to undergo total removal procedures with surgical resections, and the other 12 patients were to undergo subtotal or partial removal procedures based on the preoperative analysis of the angiography images. Of the 12-subtotal/partial cases, two had tumors with a wide base spanning two regions or the midline, and since the operating window through the small incision was limited and removal of the whole tumor was difficult, an expanded joint surgery program was available to increase the operation visual field. Given the physical conditions of the patients, subtotal or partial surgery was required for decompression and reduction of brain dysfunction (Figure 1,2). The angiography images in two cases showed that major intracranial arteries were embedded in the tumor, making removal of the whole tumor risky because of the embedded arteries or large artery branches feeding the tumor. When intraoperative findings indicated that the internal carotid artery or the first-grade branches of the cerebral arterial circle were embedded in the tumor or that branches of the arteries were feeding the tumor, it was risky to strip them away (Figure 3,4). Of the three cases in which angiography showed that the brain stem or functional areas had been invaded by the tumor, complete tumor removal was difficult because of the adhesions and unclear boundaries between the tumor body and the brain stem or brain parenchyma (Figure 5,6). Angiography identified two cases in which the tumor body was so deep in the brain that intracranial arteries impeded the operation window (Figure 7,8). In another two cases, angiography showed that the venous sinuses had been invaded and collateral circulation was less developed (Figure 9,10). In addition, the narrow sinus cavity also had adhesions and unclear boundaries between the tumor and the sinus wall. After surgery, the surgical programs and surgical pathways in all 42 cases were deemed appropriate (Figure 5,6), and damage to the important cranial vessels and nerves was effectively avoided. In the simulated group of 34 patients with total tumor removal, the results were good and the total removal rate was 78.5%. In the control group of 21 patients with total removal, the total removal rate was 71.4% (P>0.05). In the simulation group, 15 cases presented postoperative complications (no patients died), and the occurrence was 35.71% (15/42), which was lower than the control group (50%, 14/28; one patient died of respiratory failure), and there was no statistically significant difference (P>0.05). Blood transfusions in the simulation group (530.95± ml) were significantly lower than the control group (621.43± ml) (t=2.01, p=0.049<0.05). The operation time in the simulation group (257.14±72.63 min) was significantly lower than the control group (307.50±88.18 min), and the difference was statistically significant (t=2.61, P=0.011<0.05). Page 4 of 18

5 Images for this section: Fig. 1: sagittal 3D image indicates the location relationship among tumor, cranial fossa base, seller region and anterior cerebral artery. Page 5 of 18

6 Fig. 2: horizontal 3D image indicates the location relationship among tumor, anterior and middle anterior cerebral artery. male#64y#with a history of hypertension for more than 10 years and coronary heart disease, admitted to the hospital after half a year of visual field defects, dizziness and headaches. The CT scan showed giant meningiomas in the olfactory groove of the anterior cranial fossa. MSCTA showed that the tumor grew across the anterior and middle cranial fossa base, and the pituitary and optic nerve were involved (indicated by black arrows). The anterior cerebral artery, middle cerebral artery and arterial ring were pushed to the side (indicated by white arrows) and wrapped by the left middle cerebral artery. We planned to operate through the joint approach under the double foreheads. The simulation operation indicted that it would be difficult and very risky to operate on tumors on the far side of middle cranial fossa. Because a Joint pterional approach operation would be complex and have a long operation time and potential for Page 6 of 18

7 trauma and the patient's age and clinical symptoms, we developed a partial resection program to alleviate the clinical symptoms of the patient. After surgery, the symptoms of the patient were relieved without any complications. Fig. 3: indicates original 3D image. Page 7 of 18

8 Fig. 4: indicates the characteristics of blood vessel inside tumor. male#71y. A CT examination outside the hospital showed meningiomas in the anterior cranial fossa, and the chief complaint was dizziness. MSCTA inspection in our hospital showed that the anterior cerebral artery was deeply wrapped. The three-dimensional simulation indicated that the anterior cerebral artery was deeply wrapped and blood vessels were feeding the tumor (indicated by the white arrows), increasing the risks of the surgery. A subtotal resection strategy to protect the anterior cerebral artery was formulated prior to surgery. Intraoperative arterial protection was good, and the patient recovered well after the operation without complications. Page 8 of 18

9 Fig. 5: The spatial location relationship between tumor and blood vessel, 3D rebuild image indicates the spatial location relationship between tumor and blood. Page 9 of 18

10 Fig. 6: sagittal 3D rebuild image indicates the location relationship between tumor and brain stem. male#67y#admitted for dizziness and unsteady gait. SCTA showed that the adjacent basilar artery and main branches of the posterior cerebral artery were shifted by the tumor. Therefore, complete removal of the tumor would be difficult, and the risk of injuring the brain stem, posterior artery, and basilar artery was high. Surgery was performed via lateral mini-incisional block partial resection of the tumors. Black arrows indicate where it was necessary to avoid arteries, and white arrows indicate the optimal approach. Page 10 of 18

11 Fig. 7: 3D rebuild image indicate the location relationship between tumor and blood vessel in flank view. (left) Page 11 of 18

12 Fig. 8: 3D rebuild image indicate the location relationship between tumor and blood vessel in flank view. (right) female#66y#with a history of coronary heart disease and diabetes, presented with dizziness and unsteady gait for more than three months. CT inspection on admission showed meningiomas beneath the tentorial compressing the brain stem. MSCTA showed infratentorial meningiomas compressing the brain stem located deep in the brain and wrapped by bilateral posterior cerebral arteries, which was more significant on the right side (indicated by white arrows). The tumor was clipped between the two arteries. If operated through a Popper approach only one side of the artery could be taken into account. Blind operation on both sides of arteries lead to serious consequences, and after the artery exited the tumor, it turned and had branches feeding the cerebellar region (indicated by black arrows). Forced total removal would bring about injuries and lead to blood supply disorders of the cerebellum. Therefore we applied the Page 12 of 18

13 program of capsule block resection using a small incision approach for the purpose of decompression, but we did not deal with the parts of the tumor deep into the artery angled far away from the operation window. The patient recovered well after surgery. Fig. 9: 3D rebuild image indicates the spatial location relationship between tumor and superior sagittal sinus, and the compensation of collateral venous pathway. Page 13 of 18

14 Fig. 10: coronary image indicate the location, shape and size of tumor. female#64y#mainly complained of dizziness and vomiting for thre e days, without a clear past history. The MR showed frontal and superior sagittal sinus meningiomas and the clinical manifestation presented symptoms of high intracranial pressure. 3D CE-MRV showed that the meningioma was in the center of the superior sagittal sinus, violated the sinus cavity, and presented sinus stenosis which was not completely blocked (indicated by white arrows). Collateral venous circulation had been established but was still imperfect (indicated by black arrows). Total resection of the tumor and ligation of the vein sinus could cause cerebral edema and other serious complications. Given the patient's age and physical condition, we developed a subtotal resection program for the purpose of decompression of the sinus cavity tumors and performed electrocoagulation on the tumor within the sinus cavity. Page 14 of 18

15 Page 15 of 18

16 Conclusion Use of three-dimensional angiography to perform a preoperative risk assessment for meningiomas in the elderly contributed to the development of effective surgical planning and operation approach in clinical practice, thereby decreasing surgical trauma and complications as well as improving the prognosis of patients. Page 16 of 18

17 References Funding sources: National Science Foundation of Hainan Province (808246). Page 17 of 18

18 Personal Information Address correspondence to Han Xiangjun, Radiology of Haikou Hospital, Xiangya Medical College, Central South University. Hai Kou City, Hai Nan Province, China, , Tel: (0898) , Page 18 of 18