60 research outputs found
Novel Dural-Splitting Operative Technique for Excision of Ventrally Located Spinal Meningiomas
No full textObjective: Spinal meningiomas are one of the frequently seen intradural extramedullary spinal tumors. They are almost always World Health Organization grade I, and a complete removal of the tumor can be curative. However, ventrally located spinal meningioma removal can be challenging due to the position in front of the spinal cord through a narrow corridor provided by routine dorsal approaches. Incomplete excision of the relatively inaccessible dural attachment can consequently lead to recurrence. We describe a safe and reproducible technique used to achieve Simpson grade I removal of ventrally located spinal meningioma. Methods: Since the spinal dura can be easily divided into inner and outer layers and the tumor usually spares the outer layer, we developed a simple technique to achieve total resection of the tumor and involved dura while leaving the outer dural layer intact. Results: An advantage of this procedure is that it exploits an interdural approach to allow early devascularization of the tumor without cord manipulation and provides access to the ventral dura to achieve Simpson grade I excision. Another advantage is complete dural closure to minimize postoperative cerebrospinal fluid leak or ventral cord herniation without the need for dural substitutes. Conclusion: Its novel interdural approach can be used for all ages and all spinal meningiomas.</p
Endoscopic sublabial transmaxillary approach to the inferior orbit:pearls and pitfalls—A comparative anatomical study
No full textObjective: Although orbital surgery has always represented a challenge for neurosurgeons, keyhole and endoscopic techniques are gradually surging in popularity maximizing functional and esthetic outcomes. This quantitative anatomical study first compared the surgical operability achieved through three endoscopic approaches within the inferior orbit: the endoscopic sublabial transmaxillary (ESTMax), the endoscopic endonasal transethmoidal (EETEth), and the endoscope-assisted lateral orbitotomy (ELO). Methods: Each of these approaches was performed bilaterally on five specimens. We described the ESTMax step-by-step, underlining its advantages and pitfalls in comparison with EETEth and ELO. Then, we assessed surgical measurements and operability in ESTMax, EETEth, and ELO. Results: The ESTMax provided the most favorable operative window (278.9 ± 43.8 mm2; EETEth: 240.8 ± 21.5 mm2, p < 0.001; ELO: 263.1 ± 19.8 mm2, p = 0.006), the broadest surgical field area (415.9 ± 26.4 mm2; EETEth: 386.7 ± 30.1 mm2, p = 0.041; ELO: 305.2 ± 26.3 mm2, p < 0.001), surgical field depths significantly shorter than EETEth (p < 0.001) but similar to ELO, the widest surgical angles of attack (45°–65°; EETEth: 20°–30°, p < 0.001; ELO: 25°–50°, p < 0.001), and the greatest surgical mobility areas (EETEth: p < 0.001; ELO: p < 0.001). Furthermore, the ESTMax allowed multi-angled exposure and handy maneuverability around all the inferior intraorbital targets. Small anterior antrostomy, blunt intraorbital dissections, direct targets’ approach, orbital floor reconstruction, and maxillary bone flap replacement may limit the ESTMax morbidity rates. Conclusions: The ESTMax is a minimally invasive “head-on” orbital approach that exploits endoscopic surgery advantages avoiding the cranio-orbital and trans-nasal approach limitations and possible complications. It represents a promising alternative to EETEth and ELO because of its optimal operability for resecting lesions extending into the entire inferior orbit.</p
Clinical tip:An anterior drawer simplifies development of a posterior flap in below knee amputation
No full textNonsynostotic Posterior Brachycephaly with Hindbrain Herniation
No full textBackground Positional plagiocephaly is the most common cause of cranial asymmetry. The underlying cause of Chiari-1 malformation has many possible theories, and anecdotally some pediatric neurosurgeons have had experience of severe cases of positional brachycephaly with Chiari-1. However, to date, there have been no published cases linking nonsynostotic plagiocephaly with Chiari-1 malformation. Case Description An 18-month-old boy presented with a head injury. On examination he had a Glasgow Coma Score of 15 with no focal neurologic deficits, but he was noted to have marked posterior brachycephaly. A computed tomography scan showed a slim left-sided hemispheric acute subdural hematoma with no mass effect, which was treated conservatively. Of note, all of his cranial vault sutures were open, and a diagnosis of incidental positional plagiocephaly was made. Subsequent magnetic resonance imaging as part of a work-up to exclude nonaccidental injury showed a small posterior fossa with a steep tentorium and herniation of the cerebellar tonsils to the level of the body of the second cervical vertebra. Conclusions Chronic hindbrain herniation is well reported in cases of craniosynostosis, but to our knowledge this is the first published case associated with nonsynostotic deformational plagiocephaly. We hypothesize that severe posterior plagiocephaly can cause disproportion of the posterior fossa: hindbrain volume ratio and acquired chronic cerebellar herniation. Nevertheless, positional plagiocephaly and Chiari-1 are common entities, and it is possible that the dual diagnoses were coincidental in this case. This report serves to raise awareness of a putative causal relationship between positional plagiocephaly, reduced posterior fossa volume, and hindbrain herniation.</p
Safety of Superior Petrosal Vein Sacrifice During Microvascular Decompression of the Trigeminal Nerve
No full textBackground Microvascular decompression (MVD) is a safe and effective treatment for trigeminal neuralgia. Cerebellar venous infarction is a complication associated with surgical sacrifice of the superior petrosal vein (SPV). The SPV intervenes between the trigeminal nerve and the surgeon. Optimal exposure of the cisternal trigeminal nerve, particularly at the brainstem, can be achieved by sacrificing the SPV. We analyzed a cohort of 224 patients to determine the frequency of cerebellar venous infarction. Methods Retrospective analysis of records and neuroradiology for patients undergoing trigeminal MVD at the Manchester Skull Base Unit between August 1st 2008 and July 31st 2015. Results A total of 184 of 224 (82%) patients had coagulation and division of the main stem of the SPV. There were no cases of venous infarction. There was one case of mild, transient, cerebellar symptoms and signs, with no radiologic evidence of venous infarction. This patient had SPV sacrifice at surgery but also had postoperative thrombosis of the transverse sinus. Venous sinus thrombosis affected 5 of 184 (2.7%) patients. A total of 208 of 224 (93%) patients had a good outcome with improvement or resolution of their trigeminal neuralgia at 3 months. Conclusions The overall rate of venous complications in this study was 2.7%; however, we had no cases of venous infarction in 184 patients who had sacrifice of the SPV. The incidence of venous infarction associated with SPV obliteration during MVD surgery is therefore <0.5%. SPV sacrifice may be used where necessary to optimize visualization of the root entry zone and maximize the chance of effective decompression of the trigeminal nerve.</p
Long-Term Outcomes of the Electrically Unresponsive, Anatomically Intact Facial Nerve Following Vestibular Schwannoma Surgery
No full textObjective The study aimed to determine long-term outcomes in patients with intraoperative electrical conduction block in an anatomically intact facial nerve (FN). Methods Single center retrospective review of prospectively collected database of all vestibular schwannoma surgeries between January 1, 2008 and August 25, 2015. Operative notes were reviewed and patients with anatomically intact FNs, but complete conduction block at the end of surgery were included for analysis. Results In total, 371 patients had vestibular schwannoma surgery of which 18 met inclusion criteria. Mean follow-up was 34.28 months and average tumor size was 28.00 mm. Seventeen patients had House-Brackmann Grade VI facial palsy immediately postoperatively and one patient was grade V. At 1 year, three patients remained grade VI (17%), two improved to grade V (11%), seven to grade IV (39%), six to grade III (33%), and one patient to grade II (6%). On extended follow-up, five patients (28%) had additional 1 to 2 score improvement in facial function. Subset analysis revealed no correlation of tumor size, vascularity, adherence to nerve, operative approach, extent of resection, splaying of FN, and recurrent tumor or sporadic tumors to the extent of FN recovery. Conclusion Intraoperative conduction block does not condemn a patient to permanent FN palsy. There is potential for a degree of recovery comparable with those undergoing nerve grafting. Our data do not clearly support a policy of same-surgery or early-postoperative primary nerve grafting in the event of a complete conduction block, and instead we favor monitoring for recovery in an anatomically intact nerve
The NLRP3 inflammasome as a target for sensorineural hearing loss
No full textSensorineural hearing loss is the most common type of hearing loss in adults and occurs due to damage of the inner ear caused by a range of factors including ageing, excessive noise, toxins, and cancer. Auto-inflammatory disease is also a cause of hearing loss and there is evidence that inflammation could contribute to hearing loss in other conditions. Within the inner ear there are resident macrophage cells that respond to insults and whose activation correlates with damage. The NLRP3 inflammasome is a multi-molecular pro-inflammatory protein complex that forms in activated macrophages and may contribute to hearing loss. The aim of this article is to discuss the evidence for the NLRP3 inflammasome and associated cytokines as potential therapeutic targets for sensorineural hearing loss in conditions ranging from auto-inflammatory disease to tumour-induced hearing loss in vestibular schwannoma
Comment on: SMARCB1 Gene Mutation Predisposes to Earlier Development of Glioblastoma: A Case Report of Familial GBM
No full textUtility of routine postoperative imaging in adults undergoing primary ventriculoperitoneal shunts
No full textBackgroundThere is currently no consensus on the usefulness of postoperative imaging after ventriculoperitoneal (VP) shunt insertion in adults. The aim of this study was to investigate the utility of routine postoperative imaging (CT head scans and radiographs) following primary VP shunt insertion in a general adult population treated at a tertiary neurosurgical centre.MethodsPatients undergoing primary VP shunt insertion between 2017–2021 were included. Actions taken based on routine postoperative imaging and need for subsequent shunt revision were recorded.Results236 patients were included. The median age was 63 years (range 17–90). There was a slight female preponderance (121/236, 51.3%). The median follow-up was 38.5 months (3.1 – 60.5 months). Acute intervention was employed in 9 patients (3.9%) on the basis of routine postoperative CT head scan. Routine postoperative radiographs did not result in reoperation. Around a quarter (28.8%) of patients had a shunt revision, most of whom underwent urgent primary shunt insertions. Postoperative ventricular catheter characteristics (position of shunt tip, tip relation to septum pellucidum, and intraventricular catheter distance) were not predictive of shunt revision. Surgical urgency (emergency vs. elective procedures) was associated with long-term shunt revision (OR = 2.80, 95% CI 1.42 – 5.53, p = 0.003).ConclusionsRoutine postoperative imaging rarely led to reoperation in adult patients undergoing primary VP shunt insertion. Patients undergoing emergency shunt insertions were at the highest risk for requiring revision
Ventricular metastatic dissemination of a paediatric craniopharyngioma:case report and literature review
No full textDistant intraventricular metastasis is extremely rare in childhood craniopharyngioma. Here, we report the isolated posterior ventricular recurrence of an adamantinomatous craniopharyngioma, in a child previously treated with surgery and proton beam therapy for local progression. The importance of surveillance imaging is highlighted, while specific surgical approaches and techniques are considered.</p
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