The transsylvian approach is "minimally invasive" but not "atraumatic"

OBJECTIVE: In light of the competition between microneurosurgery and alternative methods such as stereotactic radiosurgery, we tested the hypothesis that changes in the cerebral circulation after microneurosurgery are common among patients without evidence of cerebrovascular or neoplastic disease. METHODS: Blood flow velocities (BFVs) were recorded with transcranial Doppler ultrasonography, before surgery and every other day after surgery, for a group of 50 patients who underwent transsylvian selective amygdalohippocampectomies for treatment of hippocampal sclerosis. Hexamethylpropylene amine oxime-single-photon emission computed tomographic testing, including acetazolamide testing of cerebrovascular reactivity, was performed during the second postoperative week for 20 of the 50 patients. RESULTS: BFVs in basal arteries ipsilateral to the surgical approach increased significantly (P < 0.001) from preoperative baseline values of approximately 52 +/- 13 cm/s (mean +/- standard deviation) to values of approximately 86 +/- 27 cm/s on postoperative Day 3 and reached their maximal values of approximately 115 +/- 37 cm/s after a median of 7 days. BFVs in contralateral vessels exhibited a similar but somewhat attenuated pattern. Hexamethylpropylene amine oxime-single-photon emission computed tomography demonstrated ipsilateral regions of hypoperfusion in 100.0% of the cases and contralateral hypoperfusion in 80.0%. Cerebrovascular reactivity was impaired in 83.3% of the cases ipsilaterally and in 33.3% contralaterally. CONCLUSION: A significant proportion of patients who undergo microneurosurgical procedures develop bilateral alterations of their cerebral circulation. The elevations in mean BFV values represent cerebral vasospasm. Because these changes remain asymptomatic for the majority of patients, the transsylvian approach can be considered "minimally invasive" but not "atraumatic." Alternative surgical routes and alternative treatment modalities should be investigated in a similar manner.