121 research outputs found
Endoscopic endonasal extradural posterior clinoidectomy: A key maneuver to access the retrosellar and upper retroclival area
No full textBackground: Endoscopic endonasal posterior clinoidectomy represents an important maneuver to improve access and visualization of the retrosellar and upper clivus area [1]. Three different techniques have been described in order to access and remove the posterior clinoid: 1) the intradural pituitary transposition [2], the interdural pituitary transposition [3] and a completely extradural technique [4].
Case description: We present here a case of retrosellar and retroclival chordoma that has been removed through endoscopic endonasal approach. Technical nuances of the endonasal extradural posterior clinoidectomy are presented.
Conclusion: Endoscopic endonasal extradural posterior clinoidectomy allows to access this complex anatomical region with the advantage of avoiding major bleeding from the cavernous sinus and endocrinological impairment
Anterior Petrosectomy With Intertentorial Approach
No full textBackground and objectives: The extradural anterior petrosal approach (EAPA) can present a challenge because it deals with critical structures in a narrow, confined corridor. It is associated with several potential approach-related risks including temporal lobe and venous injuries. Tentorial peeling has the potential to largely eliminate these risks during the approach and may offer more options for tailoring the dural opening to the anatomic region that one wants to expose.
Methods: Anatomic dissections of five adult injected non-formalin-fixed cadaveric heads were performed. Anterior petrosectomy with intertentorial approach (APIA) through a tentorial peeling was completed. Step-by-step documentation of the cadaveric dissections and diagrammatic representations are presented along with an illustrative case.
Results: Tentorial peeling separates the tentorium into a temporal tentorial leaf and posterior fossa tentorial leaf, adding a fourth dural layer to the three classic ones described during a standard EAPA. This opens out the intertentorial space and offers more options for tailoring the dural incisions specific to the pathology being treated. This represents a unique possibility to address brainstem or skull base pathology along the mid- and upper clivus with the ability to keep the entire temporal lobe and basal temporal veins covered by the temporal tentorial leaf. The APIA was successfully used for the resection of a large clival chordoma in the illustrative case.
Conclusion: APIA is an interesting modification to the classic EAPA to reduce the approach-related morbidity. The risk reduction achieved is by eliminating the exposure of the temporal lobe while maintaining the excellent access to the petroclival region. It also provides several options to tailor the durotomies based on the localization of the lesion
Caractéristiques cliniques, traitement et évolution chez les patients ayant présenté une rupture d’un anévrysme de l’artère cérébelleuse postéroinferieure
No full textLes anévrismes de l'artère cérébelleuse postérieure inférieure (PICA) sont relativement rares, représentant environ 0,5 à 3% de tous les anévrismes intracrâniens.
La majorité des patients présentent une hémorragie sous-arachnoïdienne (HSA). La gestion et le traitement de ces lésions sont difficiles en raison de l'emplacement de la PICA à proximité du tronc cérébral et des nerfs crâniens inférieurs et de la présence de vaisseaux perforants qui fournissent le tronc cérébral.
Bien que les données publiées soient contradictoires, les évidences disponibles en littérature semblent suggérer que les patients avec un anévrisme rompu de la PICA présentent un moins bon pronostic que celui d'un anévrisme rompu d'une localisation différente. Ce phénomène laisse suspecter que cela est secondaire aux caractéristiques anatomiques et fonctionnelles particulières de ces lésions.
Afin de pouvoir analyser la présentation clinique, schéma de traitement et évolution neurologique des patients présentant des anévrismes rompus de la PICA par rapport à d'autres anévrismes rompus de la circulation postérieure, nous avons effectué une analyse rétrospective des données anonymisées de 264 patients ayant présenté une hémorragie sous-arachnoïdienne secondaire à la rupture d'un anévrysme de la circulation postérieure . Les données ont été extrapolées du registre suisse SOS, qui fait partie d'une étude de cohorte nationale sur l'hémorragie sous-arachnoïdienne d'origine anévrysmale.
74 anévrysmes de la PICA représentaient 28% de la série; les caractéristiques cliniques et radiologiques à l'admission étaient comparables entre le groupe PICA et le groupe non-PICA. Le traitement chirurgical a été réalisé chez 28% des patients du groupe PICA et chez 4,8% des patients du groupe non PICA Aucune différence statistiquement significative n'a été trouvée entre les deux groupes en termes de complications après traitement. Une hydrocéphalie nécessitant un shunt définitif était nécessaire chez 21,6% des patients PICA (p = 0,6) ; un déficit d'un nerf crânien était présent en moyenne en un quart des patients dans le groupe PICA et non-PICA sans différence statistique (p = 0,3). Un outcome plus favorable (66,2%) a été rapporté dans le groupe PICA à la sortie (p <0,05) mais cette différence s'est estompée au fil du temps avec un outcome neurologique similaire à un an de suivi (p = 0,09) entre les deux groupes. L'estimation de Kaplan Meyer n'a montré aucune différence significative dans le taux de mortalité entre les deux groupes (p
= 0,08).
Nos résultats montrent que les anévrismes rompus de la PICA présentent une issue favorable dans plus des 2/3 des cas à 1 an après le traitement, sans différence significative avec les autres localisations de la circulation postérieure. L'occlusion chirurgicale était la première option de traitement chez 28% des patients présentant des anévrismes rompus de la PICA, suggérant ainsi que, malgré le progrès du traitement endovasculaire, la chirurgie représente toujours une alternative de traitement valable. Nos résultats soutiennent la nécessité de maintenir les compétences microchirurgicales pour le traitement des anévrismes rompus de la PICA dans les centres neurovasculaires de référence.
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Background and purpose Aneurysms of the poste1ior inferior cerebellar aite1y (PICA) are relatively uncommon and evidence is sparse about patients presenting with ruptured PICA anewysms. We petfonned an analysis of the Swiss SOS national registJ.y to desctibe clinical presentation, treatment pattern, and neurological outcome of patients with rnptured PICA anewysms compared with other ruptured posterior circulation (PC) anewysrns.
Methods This was a retrospective analysis of anonymized data from the Swiss SOS registJ.y (Swiss Study on Anemysmal Subarachnoid Hemonhage; 2009- 2014). Patients with rnptured PC anewysms were subdivided into a PICA and non-PICA group. Clinical, radiologic al, and tJ·.e atment-related variables were identified, and their impact on the neurological outcome was dete1mined in ten11s of rnodified Rankin score at discharge and at 1 year of follow-up for the two groups.
Results Data from 1864 anewysmal subai·achnoid hemorrhage patients were reviewed. There were 264 patients with a ruptured PC anemysm. Seventy-four PICA anemysms represented 28% of the series; clinical and radiological characteristics at admission were comparable between the PICA and non-PICA group. Surgical tJ.·eatJ.nent was accomplished in 28% of patients in the PICA group and in the 4.8% of patients in the non-PICA group. No statistically significant difference was found between the two groups in tem1s of complications after treatment. Hydrocephalus requuing definitive shm1t was needed u12 l .6% of PICA patients
(p = 0.6); cranial nerve deficit was present in average a qua1ter of the patients in both PICA and non-PICA group with no
statistical difference (p = 0.3). A more favorable outcome (66.2%) was reported in the PICA group at discharge (p < 0.05) but this difference faded over time with a sunilar neurological outcome at 1-yeai· follow-up (p = 0 .09) between bath PICA and non PICA group. The Kaplan-Meyer estinrntion showed no significant difference in the mortality rate between bath groups (p = 0.08). Conclusions In the present study, patients with ruptured PICA anemysms had a favorable neurological outcome in more than two
thirds of cases, sunilar to patients with other ruptured PC anemy sms . Surgical tJ.·eatment remains a valid option in a third of cases with ruptured PICA anemysms
Combined Petrosal Intertentorial Approach: A Cadaveric Study of Comparison With the Standard Combined Petrosectomy
No full textBackground and objectives: The combined petrosal intertentorial approach (CPIA) has been proposed as an alternative to standard combined petrosal approach (SCPA). CPIA has been designed to maintain integrity of the temporal dura with a view to reduce temporal lobe morbidity and venous complications. This study has been designed to perform a quantitative comparison between these approaches.
Methods: Five human specimens were used for this study. CPIA was performed on one side and SCPA on the opposite side. The area of exposure (petroclival and brainstem), surgical freedom, and angles of attack to a predefined target were measured and compared.
Results: SCPA provided a significantly larger petroclival area of exposure (6.81 ± 0.60 cm2) over the CPIA (5.59 ± 0.59 cm2), P = .012. The area of brainstem exposed with SCPA was greater than with CPIA (7.17 ± 0.84 vs 5.63 ± 0.72, P = .014). The area of surgical freedom was greater in SCPA rather than in CPIA (8.59 ± 0.55 and 7.13 ± 0.96 cm2, respectively, P = .019). There was no significative difference between CPIA and SCPA in the vertical angles of attack for the Meckel cave, Dorello canal, and root entry zone of cranial nerve VII. Conversely, the horizontal angles of attack permitted by the CPIA were significantly smaller for the Meckel cave (52.36° ± 5.01° vs 64.4° ± 5.3°, P = .006) and root entry zone of cranial nerve VII (30.7° ± 4.4° vs 40.1° ± 6.2°, P = .025).
Conclusion: CPIA is associated with a reduction in terms of the area of surgical freedom (22%), skull base (18%), brainstem exposure (17%), and horizontal angles of attack (18%-23%) when compared with SCPA. This loss in terms of exposure is counterbalanced by the advantage of keeping the temporal lobe covered by an extra layer of meningeal tissue, thus possibly reducing the risk of temporal lobe injury and venous infarction. These results need to be validated with adequate clinical experience
Disease heterogeneity in IgG4-related hypophysitis: report of two histopathologically proven cases and review of the literature
No full textIgG4-related hypophysitis (IgG4-RH) is a rare disease, which can occur singularly or as manifestation of a systemic IgG4-related disease (IgG4-RD). Less than one hundred cases have been reported in the literature, very few of which were histopathologically documented. We analyzed the clinical, radiological, and histopathological features of two cases of IgG4-RH, the former observed in a 66-year-old man in the context of an IgG4-RD, and the latter affecting a 21-year-old woman, as an isolated lesion. In addition, we performed a comprehensive review of the previously published histopathologically documented cases of IgG4-RH. Pituitary samples from both patients showed dense lymphoplasmacytic infiltration, interstitial and storiform fibrosis, and high numbers of IgG4-positive plasma cells, consistent with IgG4-RH. From the literature review, we retrieved 18 papers reporting a total of 22 cases of histopathologically documented IgG4-RH. The revision of these cases, also including the two reported herein, showed an equal distribution of IgG4-RH in the two sexes, albeit significant clinico-pathological variation was found between cases arisen in female and male patients, respectively. In detail, IgG4-RH females were affected in their second-third decade of life, with a solitary pituitary lesion, low IgG4 serum level, and frequent association with autoimmune disorders. By contrast, IgG4-RH in men was a disease of the elderly, often in the context of a systemic IgG4-RD, with high IgG4 serum levels. Our study shows that IgG4-RH, as currently defined, is a clinically heterogenous disease, with different features in the two sexes. Indeed, cases diagnosed in young women, as our case 2, mostly do not present other evidence of IgG4-RD and might be better classified as lymphocytic hypophysitis with abundant IgG4+ plasma cells. For this reason, the histopathological examination of the pituitary lesion, particularly in female patients, may still be useful for a correct differential diagnosis with other variants of primary hypophysitis
State of the art in managing nontraumatic intracerebral hemorrhage
No full textNontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.</jats:p
Sports-related chronic repetitive head trauma as a cause of pituitary dysfunction
No full textTraumatic brain injury (TBI) is recognized as a cause of hypopituitarism even after mild TBI. Although over the past decade, a growing body of research has detailed neuroendocrine changes induced by TBI, the mechanisms and risk factors responsible for this pituitary dysfunction are still unclear. Around the world, sports—especially combative sports—are very popular. However, sports are not generally considered as a cause of TBI in most epidemiological studies, and the link between sports-related head trauma and hypopituitarism has not been investigated until recently. Thus, there is a paucity of data regarding this important concern. Because of the large number of young sports participants with near-normal life expectancy, the implications of undiagnosed or untreated postconcussion pituitary dysfunction can be dramatic. Understanding the pathophysiological mechanisms and risk factors of hypopituitarism caused by sports injuries is thus an important issue that concerns both medical staff and sponsors of sports. The aim of this paper was to summarize the best evidence for understanding the pathophysiological mechanisms and to discuss the current data and recommendations on sports-related head trauma as a cause of hypopituitarism.</jats:p
External Ventricular Drainage in Acute Cerebral Venous Thrombosis with Bilateral Thalamic Infarcts
No full textAbstractCerebral venous thrombosis (CVT) is an uncommon type of stroke with a considerable risk of mortality and morbidity (around 15% overall death or dependency rate in recent meta-analysis). We present the case of a 20-month-old girl who presented with an altered level of consciousness and motor impairment. Imaging studies showed deep CVT with bilateral thalamic edema, resulting in obstructive hydrocephalus due to third ventricle compression. An external ventricular drain was placed, along with intracranial pressure (ICP) monitoring. Evolution was favorable with near-complete neurological recovery. Anticoagulation is the mainstay of treatment of CVT. However, there are very few studies addressing shunting procedures in the management of associated intracranial hypertension. We believe that for patients presenting with bilateral thalamic edema and obstructive hydrocephalus, early shunting and ICP monitoring should be considered.</jats:p
Letter: Seizure Outcomes in Occipital Lobe and Posterior Quadrant Epilepsy Surgery: A Systematic Review and Meta-Analysis
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