Le laser au dioxide de carbone et la craniotomie stereotaxique. [Carbon dioxide laser and stereotaxic craniotomy]

This article describes the development and contemporary clinical applications for a computer interactive volumetric stereotactic system in CT and/or MRI-based resection of superficial and deep seated intracranial lesions. The carbon dioxide laser was found to be particularly useful in the resection of deep seated lesions by this volumetric stereotactic method for three reasons: 1) the CO2 laser is a convenient tool for removing tissue from the depths of a deep cavity, 2) it is relatively hemostatic, and 3) the precision provided by the CO2 laser renders it safer than other methods for dissecting tumors from important brain tissue, e.g. the internal capsule. The specific clinical methods of the technique: data acquisition, computer based surgical planning, and interactive stereotactic open surgery are discussed. The clinical experience in 500 consecutive cases in the resection of various lesions from specific anatomical areas is presented. Total overall morbidity was 7% and mortality 1%. We have found the technique of most benefit in the resection of histologically circumscribed intra-axial lesions

Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral arteriovenous malformations

✓ An alternative theory is proposed to explain the brain edema and hemorrhage that may occur after resection of high-flow intracerebral arteriovenous malformations (AVM's). This theory, termed “occlusive hyperemia,” is based on a retrospective analysis of operative dictations along with postoperative imaging studies (191 angiograms and 273 computerized tomography scans) in 295 cases of intracerebral AVM's operated on at the Mayo Clinic between 1970 and 1990. In this series, 34 cases (12%) of postoperative deterioration were documented, of which 15 were due to incomplete resection of the AVM. Of the remaining 19 cases, six had brain edema alone and 13 had hemorrhage with edema, despite complete excision of the AVM. In these 19 cases, the AVM's were greater than 6 cm in diameter in 10 patients, between 3 and 6 cm in six, and less than 3 cm in three. Obstruction of the venous drainage system was observed in 14 (74%) of the 19 cases. Ten of these 14 were due to obstruction of the primary venous drainage of the brain parenchyma immediately surrounding the lesions, while four were due to obstruction of other venous structures. In no case was a rapid circulation identified on postoperative angiograms. The flow pattern was slow or stagnant in former AVM feeders and their parenchymal branches. It is proposed that postoperative intracranial hemorrhage and/or brain edema in AVM patients may be due to: 1) obstruction of the venous outflow system of brain adjacent to the AVM, with subsequent passive hyperemia and engorgement; and 2) stagnant arterial flow in former AVM feeders and their parenchymal branches, with subsequent worsening of the existing hypoperfusion, ischemia, and hemorrhage or edema into these areas. Supportive hemodynamic evidence for this theory was derived from the literature.</jats:p