Neurosurgery Blog


Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Surgical resection of skull-base chordomas: experience in case selection for surgical approach according to anatomical compartments and review of the literature

Acta Neurochir (2017) 159:1835–1845

Chordoma is a rare bony malignancy known to have a high rate of local recurrence after surgery. The best treatment paradigm is still being evaluated. We report our experience and review the literature. We emphasize on the difference between endoscopic and open craniotomy in regard to the anatomical compartment harboring the tumor, the limitations of the approaches and the rate of surgical resection.

Method: We retrospectively collected all patients with skullbase chordomas operated on between 2004 and 2014. Detailed radiological description of the compartments being occupied by the tumor and the degree of surgical resection is discussed.

Results: Eighteen patients were operated on in our facility for skull-base chordoma. Seventeen endoscopic surgeries were done in 15 patients, and 7 craniotomies were done in 5 patients. The mean age was 48.9 years (±19.8 years). When reviewing the anatomical compartments, we found that the most common were the upper clivus (95.6%) and lower clivus (58.3%), left cavernous sinus (66.7%) and petrous apex (∼60%). Most of the patients had intradural tumor involvement (70.8%). In all craniotomy cases, there was residual tumor in multiple compartments. In the endoscopic cases, the most difficult compartments for total resection were the lower clivus, and lateral extensions to the petrous apex or cavernous sinus.

Conclusions: Our experience shows that the endoscopic approach is a good option for midline tumors without significant lateral extension. In cases with very lateral or lower extensions, additional approaches should be added trying to achieve complete resection.

Image-guided endoscopic surgery for spontaneous supratentorial intracerebral hematoma

J Neurosurg 127:537–542, 2017

Endoscopic removal of intracerebral hematomas is becoming increasingly common, but there is no standard technique. The authors explored the use of a simple image-guided endoscopic method for removal of spontaneous supratentorial hematomas.

METHODS Virtual reality technology based on a hospital picture archiving and communications systems (PACS) was used in 3D hematoma visualization and surgical planning. Augmented reality based on an Android smartphone app, Sina neurosurgical assist, allowed a projection of the hematoma to be seen on the patient’s scalp to facilitate selection of the best trajectory to the center of the hematoma. A obturator and transparent sheath were used to establish a working channel, and an endoscope and a metal suction apparatus were used to remove the hematoma.

RESULTS A total of 25 patients were included in the study, including 18 with putamen hemorrhages and 7 with lobar cerebral hemorrhages. Virtual reality combined with augmented reality helped in achieving the desired position with the obturator and sheath. The median time from the initial surgical incision to completion of closure was 50 minutes (range 40–70 minutes). The actual endoscopic operating time was 30 (range 15–50) minutes. The median blood loss was 80 (range 40–150) ml. No patient experienced postoperative rebleeding. The average hematoma evacuation rate was 97%. The mean (± SD) preoperative Glasgow Coma Scale (GCS) score was 6.7 ± 3.2; 1 week after hematoma evacuation the mean GCS score had improved to 11.9 ± 3.1 (p < 0.01).

CONCLUSIONS Virtual reality using hospital PACS and augmented reality with a smartphone app helped precisely localize hematomas and plan the appropriate endoscopic approach. A transparent sheath helped establish a surgical channel, and an endoscope enabled observation of the hematoma’s location to achieve satisfactory hematoma removal.

The expanded trans/supraorbital approach for large space-occupying lesions of the anterior fossa

Acta Neurochir (2017) 159:881–887

The supraorbital rim often interferes with the required upward movement of the instruments for resection of large frontal-lobe tumours through a classic supraorbital craniotomy. Here, we present the expanded trans/supraorbital approach to overcome these limitations.

Methods After an eyebrow skin incision, a one-piece bone flap was created incorporating the orbital rim and roof. Basal extension of the craniotomy allowed for a better intracranial visualisation with improved manoeuvrability and angulation of the instruments without using brain retraction.

Conclusions This approach poses a feasible alternative to large frontal craniotomies for frontal-lobe tumours, for which a regular supraorbital craniotomy is insufficient.

The mononostril endonasal transethmoidal-paraseptal approach

Acta Neurochir (2017) 159:453–457

The use of endoscopes in transnasal surgery offers increased visualization. To minimize rhinological morbidity without restriction in manipulation, we introduced the mononostril transethmoidal-paraseptal approach.

Methods The aim of the transethmoidal-paraseptal approach is to create sufficient space within the nasal cavity, without removal of nasal turbinates and septum. Therefore, as a first step, a partial ethmoidectomy is performed. The middle and superior turbinates are then lateralized into the ethmoidal space, allowing a wide sphenoidotomy with exposure of the central skull base.

Conclusions This minimally invasive transethmoidal-paraseptal approach is a feasible alternative to traumatic transnasal concepts with middle turbinate and extended septal resection.

Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients


Neurosurg Focus 41 (3):E3, 2016

The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994–2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts.

Results A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1–230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p < 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p < 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor.

Conclusions ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.

Endo ICG videoangiography: localizing the carotid artery in skull-base endonasal approaches

Endo ICG videoangiography- localizing the carotid artery in skull-base endonasal approaches

Acta Neurochir (2016) 158:1351–1353

In this work, the applicability of ICG-VA to skull base endoscopic surgery and its capacity to locate the internal carotid artery are shown.

Methods: An adapted optical module to perform ICG-VA was used to perform endoscopic procedures. There were two intraoperative phases of interest that were used to evaluate the ICA: upon exposure of the skull base and during the intradural exploration.

This new tool for obtaining ICA images in real time (as opposed to with navigation), and it is demonstrated that this tool provides a superior ability to detect the margins of the ICA compared with the Doppler technique. On the other hand, the present technique also provides enhancement of the artery through the bone of the skull base without the need for drilling.

Conclusions: ICG-VA is a safe and effective technique for locating the ICA in skull-base expanded endonasal surgery. Furthermore, this technique can provide real-time guidance for the surgeon and increase safety for the patient.

Avoidance and management of perioperative complications of endoscopic third ventriculostomy

Usefulness of Intraoperative Magnetic Resonance Ventriculography During Endoscopic Third Ventriculostomy

J Neurosurg 123:1414–1419, 2015

Although endoscopic third ventriculostomy (ETV) is a minimally invasive procedure, serious perioperative complications may occur due to the unique surgical maneuvers involved. In this paper the authors report the complications of elective and emergency ETV and their surgical management in 412 patients from July 2006 to October 2012 at Dhaka Medical College Hospital (a government hospital) and other private hospitals in Dhaka, Bangladesh. The authors attempted some previously undescribed simple maneuvers that may help to overcome the difficulties of managing complications.

METHODS The complication rate was determined by recording intraoperative changes in pulse and blood pressure, bleeding episodes, serum electrolyte abnormalities, CSF leakage, and neurological deterioration in the immediate postoperative period.

RESULTS Intraoperative complications included hemodynamic alterations in the form of tachycardia, bradycardia, and hypertension. Bleeding was categorized as major in 2 cases and minor in 68 cases. Delayed recovery from anesthesia occurred in 14 cases, CSF leakage from the wound in 11 cases, and electrolyte imbalance in 5 cases. Postoperatively, 2 patients suffered convulsions and 1 had evidence of third cranial nerve injury. Three patients died as a result of complications.

CONCLUSIONS Complications during endoscopy can lead to serious consequences that may sometimes be very difficult to manage. The authors have identified and managed a large number of complications in this series, although the rate of complications is consistent with that in other reported series. These complications should be kept in mind perioperatively by both surgeons and anesthesiologists, as prompt detection and action can help minimize the risks associated with neuroendoscopic procedures.

A basic model for training of microscopic and endoscopic transsphenoidal pituitary surgery: the Egghead

A basic model for training of microscopic and endoscopic transsphenoidal pituitary surgery- the Egghead

Acta Neurochir (2015) 157:1771–1777

Transsphenoidal endoscopic surgery has gained popularity in the last 2 decades and is becoming a standard technique for resection of pituitary adenomas. In contrast to their ENT colleagues, neurosurgical residents have practically no endoscopic experience when they reach the training stage for transsphenoidal procedures.

We have developed an affordable method for repetitive training in endoscopic (and microscopic) work in a narrow channel, allowing training of the basic movements needed for resection of pituitary adenoma.

Methods In collaboration with colleagues in the ENT Department, Cantonal Hospital St. Gall, and the Technical University of Zurich, a three-dimensional model of the nasal cavity was developed and patented. The Egghead model consists of a 3D synthetic reconstruction of the head nasal cavity and sphenoid sinus. A boiled egg represents the sella. For validation, 17 neurosurgical residents from the Department of Neurosurgery, University Hospital of Basel, and Department of Neurosurgery, Cantonal Hospital of St. Gall, St. Gall, Switzerland, and two experts performed a standardized procedure mimicking a transsphenoidal pituitary procedure by dissecting a corridor to the egg yolk and resecting it, respecting the surrounding egg white. This procedure was performed under both microscopic and video-endoscopic visualization. A score for the precision and speed of the surgical performance was developed and used.

Results The model allows repetitive training of the resection of the egg yolk under sparing of the egg white after careful opening of the shell. The validation data showed a steeper learning curve using the endoscopic technique than performing the same task using the microscope. After three repetitions, the quality of resection was better with the endoscopic technique.

Conclusions Our model, the Egghead, is affordable, offers tactile feedback and allows infinite repetitions in basic training for pituitary surgery. It can be used for training of advanced neurosurgical residents, who thus far have very few possibilities of acquiring endoscopic experience.

Combined rigid and flexible endoscopy for tumors in the posterior third ventricle

Combined rigid and flexible endoscopy for tumors in the posterior third ventricle

J Neurosurg 122:1341–1346, 2015

Tumors leading to occlusion of the sylvian aqueduct include those of pineal, thalamic, and tectal origins. These tumors cause obstructive hydrocephalus and thus necessitate a CSF diversion procedure such as an endoscopic third ventriculostomy (ETV), often coupled with an endoscopic biopsy (EBX). Lesions located posterior to the massa intermedia pose a technical challenge, as the use of a rigid endoscope for performing both an ETV and EBX is limited. The authors describe their experience using a combined rigid and flexible endoscopic procedure through a single bur hole for both procedures in patients with posterior third ventricular tumors.

Methods Since January 2012, patients with posterior third ventricular tumors causing hydrocephalus underwent dual ETV and EBX procedures using the combined rigid-flexible endoscopic technique. Following institutional review board approval, data from clinical, radiological, surgical, and pathological records were retrospectively collected.

Results Six patients 3.5–53 years of age were included. Lesion locations included pineal (n = 3), fourth ventricle (n = 1), aqueduct (n = 1), and tectum (n = 1). The ETV and EBX were successful in all cases. Pathologies included pilocytic astrocytoma, pineoblastoma, ependymoma Grade II, germinoma, low-grade glioneural tumor, and atypical choroid plexus papilloma. One patient experienced an immediate postoperative intraventricular hemorrhage necessitating evacuation of the clots and resection of the tumor, eventually leading to the patient’s death.

Conclusions The authors recommend using a combined rigid-flexible endoscope for endoscopic third ventriculostomy and biopsy to approach posterior third ventricular tumors (behind the massa intermedia). This technique overcomes the limitations of using a rigid endoscope by reaching 2 distant regions.

The transmaxillary endoscopic approach to the inferior part of the orbit

The transmaxillary endoscopic approach to the inferior part

Acta Neurochir (2015) 157:625–628

Transmaxillary endoscopic approach to the inferior part of the orbit was demonstrated on cadaveric preparations; however, its clinical application has not been reported. We describe a clinically useful technique of the transmaxillary approach to the lower orbit.

Methods A four-hand technique is essential for extensive preparation within the orbit; therefore, the tools have to be introduced into the maxillary sinus through two ports: either through the canine fossa and antrostomy or through antrostomy using the bi-nostril transseptal approach.

Conclusion Intraorbital pathologies located in the inferior retrobulbar space can be successfully operated on using the transmaxillary endoscopic approach.

The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding

The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding-1

J Neurosurg 122:511–518, 2015

The gold-standard surgical approach to the odontoid is via the transoral route. This approach necessitates opening of the oropharynx and is associated with risks of infection, and swallowing and breathing complications. The endoscopic endonasal approach has the potential to reduce these complications as the oral cavity is avoided. There are fewer than 25 such cases reported to date. The authors present a consecutive, single-institution series of 9 patients who underwent the endonasal endoscopic approach to the odontoid.

Methods The charts of 9 patients who underwent endonasal endoscopic surgery to the odontoid between January 2005 and August 2013 were reviewed. The clinical presentation, radiographic findings, surgical management, complications, and outcome, particularly with respect to time to extubation and feeding, were analyzed. Radiographic measurements of the distance between the back of the odontoid and the front of the cervicomedullary junction (CMJ) were calculated, as well as the location of any residual bone fragments.

Results There were 7 adult and 2 pediatric patients in this series. The mean age of the adults was 54.8 years; the pediatric patients were 7 and 14 years. There were 5 females and 4 males. The mean follow-up was 42.9 months. Symptoms were resolved or improved in all but 1 patient, who had concurrent polyneuropathy. The distance between the odontoid and CMJ increased by 2.34 ± 0.43 mm (p = 0.03). A small, clinically insignificant fragment remained after surgery, always on the left side, in 57% of patients. Mean times to extubation and oral feeding were on postoperative Days 0.3 and 1, respectively. There was one posterior cervical wound infection; there were 2 cases of epistaxis requiring repacking of the nose and no instances of breathing or swallowing complications or velopharyngeal insufficiency.

Conclusions This series of 9 cases of endonasal endoscopic odontoidectomy highlights the advantages of the approach in permitting early extubation and early feeding and minimizing complications compared with transoral surgery. Special attention must be given to bone on the left side of the odontoid if the surgeon is standing on the right side.

A combined dual-port endoscope-assisted pre- and retrosigmoid approach to the cerebellopontine angle

A combined dual-port endoscope-assisted pre- and retrosigmoid approach to the cerebellopontine angle- an extensive anatomo-surgical study

Neurosurg Rev (2014) 37:597–608

The use of the endoscope in the cerebellopontine angle (CPA) has been suggested to minimize cerebellar retraction and reduce the size of the craniotomy. 3D endoscopy combines the benefits of conventional 2D endoscopy with the added benefit of stereoscopic perception, though improved visualization alone does not guarantee improved surgical maneuverability and a better surgical outcome. We propose a new combined dual-port endoscope-assisted pre- and retrosigmoid approach to improve visualization and accessibility of the CPA with shortened distances and increased surgical maneuverability of neurovascular structures.

We analyze surgical exposure and maneuverability of this approach and compare it with the surgical microscopic and a conventional single-port endoscope-assisted retrosigmoid approach. This combined pre- and retrosigmoid approach was performed on eight cadaveric heads (16 sides). The endoscopic probe was inserted through the presigmoid surgical port while surgical manipulation was performed through the retrosigmoid corridor. The CPA was divided into three compartments, from medial to lateral, the anteromedial, and the middle and the posterolateral. The microscope provided good visualization of the posterolateral and middle compartments, whereas poor visualization was offered of the anteromedial compartment. The dual-port endoscopic approach dramatically improved visualization and surgical maneuverability of the anteromedial compartments, clivus, and related neurovascular structures. Additionally, the 3D endoscope allowed for a better understanding of the surgical anatomy of the CPA and improved visualization of structures located in the anteromedial compartments towards the midline.

This approach allowed for full realization of the benefits of endoscopic-assisted technique by improving surgical access and maneuverability.

Endoscopic lateral orbitotomy

Endoscopic lateral orbitotomy

Acta Neurochir (2014) 156:1897–1900

Lateral orbitotomy can be minimalized using contemporary endoscopy.

Methods Anatomy of the temporal fossa/orbital wall junction is described. The attachment of the temporal fascia is cut off from the orbital rim through a 1.5 cm skin incision in the lateral orbital wrinkle. The temporal muscle is detached from the bone to create a space for the telescope. An appropriate bone opening in the lateral orbital wall is created with the aid of neuronavigation to handle intraorbital pathology.

Conclusion Endoscopic lateral orbitotomy is an original alternative to the microsurgical Krönlein approach and yields good functional and cosmetic results.

Optimal entry point for endoscopic colloid cyst resection

Endoscopic approach to colloid cysts

J Neurosurg 121:790–796, 2014

An optimal entry point and trajectory for endoscopic colloid cyst (ECC) resection helps to protect important neurovascular structures. There is a large discrepancy in the entry point and trajectory in the neuroendoscopic literature.

Methods. Trajectory views from MRI or CT scans used for cranial image guidance in 39 patients who had undergone ECC resection between July 2004 and July 2010 were retrospectively evaluated. A target point of the colloid cyst was extended out to the scalp through a trajectory carefully observed in a 3D model to ensure that important anatomical structures were not violated. The relation of the entry point to the midline and coronal sutures was established. Entry point and trajectory were correlated with the ventricular size.

Results. The optimal entry point was situated 42.3 ± 11.7 mm away from the sagittal suture, ranging from 19.1 to 66.9 mm (median 41.4 mm) and 46.9 ± 5.7 mm anterior to the coronal suture, ranging from 36.4 to 60.5 mm (median 45.9 mm). The distance from the entry point to the target on the colloid cyst varied from 56.5 to 78.0 mm, with a mean value of 67.9 ± 4.8 mm (median 68.5 mm). Approximately 90% of the optimal entry points are located 40–60 mm in front of the coronal suture, whereas their perpendicular distance from the midline ranges from 19.1 to 66.9 mm. The location of the “ideal” entry points changes laterally from the midline as the ventricles change in size.

Conclusions. The results suggest that the optimal entry for ECC excision be located at 42.3 ± 11.7 mm perpendicular to the midline, and 46.9 ± 5.7 mm anterior to the coronal suture, but also that this point differs with the size of the ventricles. Intraoperative stereotactic navigation should be considered for all ECC procedures whenever it is available. The entry point should be estimated from the patient’s own preoperative imaging studies if intraoperative neuronavigation is not available. An estimated entry point of 4 cm perpendicular to the midline and 4.5 cm anterior to the coronal suture is an acceptable alternative that can be used in patients with ventriculomegaly.

High-Resolution Angioscopic Imaging During Endovascular Neurosurgery

High-Resolution Angioscopic Imaging During Endovascular Neurosurgery

Neurosurgery 75:171–180, 2014

Endoluminal optical imaging, or angioscopy, has not seen widespread application during neurointerventional procedures, largely as a result of the poor imaging resolution of existing angioscopes. Scanning fiber endoscopes (SFEs) are a novel endoscopic platform that allows high-resolution video imaging in an ultraminiature form factor that is compatible with currently used distal access endoluminal catheters.

OBJECTIVE: To test the feasibility and potential utility of high-resolution angioscopy with an SFE during common endovascular neurosurgical procedures.

METHODS: A 3.7-French SFE was used in a porcine model system to image endothelial disruption, ischemic stroke and mechanical thrombectomy, aneurysm coiling, and flowdiverting stent placement.

RESULTS: High-resolution, video-rate imaging was shown to be possible during all of the common procedures tested and provided information that was complementary to standard fluoroscopic imaging. SFE angioscopy was able to assess novel factors such as aneurysm base coverage fraction and side branch patency, which have previously not been possible to determine with conventional angiography.

CONCLUSION: Endovascular imaging with an SFE provides important information on factors that cannot be assessed fluoroscopically and is a novel platform on which future neurointerventional techniques may be based because it allows for periprocedural inspection of the integrity of the vascular system and the deployed devices. In addition, it may be of diagnostic use for inspecting the vascular wall and postprocedure device evaluation.

Endoscopic endonasal treatment of 103 craniopharyngiomas

Endoscopic endonasal treatment of 103 craniopharyngiomas

J Neurosurg 121:100–113, 2014

Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas.

Methods. The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated.

Results. The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3–246 months).

Conclusions. The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.

Endoscopic endonasal approach in the management of skull base chordomas

Endoscopic approach skull base chordomas

Neurosurg Rev (2014) 37:217–225

Skull base chordomas represent very interesting neoplasms, due to their rarity, biological behavior, and resistance to treatment. Their management is very challenging. Recently, the use of a natural corridor, through the nose and the sphenoid sinus, improved morbidity and mortality allowing also for excellent removal rates.

Prospective analysis of 54 patients harboring a skull base chordoma that were managed by extended endonasal endoscopic approach (EEA). Among the 54 patients treated (during a 72 months period), 21 were women and 33 men, undergoing 58 procedures. Twenty-two cases (40 %) were recurrent and 32 (60 %) newly diagnosed chordomas. Among the 32 newly diagnosed chordomas, a gross total resection was achieved in 28 cases (88%), a near total (>95%of tumor) in 2 cases (6%), a partial (>50 % of tumor) in 2 cases (6 %). Among the 22 recurrent chordomas, resection was complete in 7 cases (30 %), near total in 7 (30%), and partial in 8 (40 %). The global gross total resection rate was 65 % (35/54 cases). Four patients (11 %) recurred and 4 (11 %) progressed within a mean follow-up of 34 months (range 12–84 months). Four patients (11 %) were re-operated; one patient (1.8 %) died due to disease progression, one patient (1.8 %) died 2 weeks after surgery due to a massive bleeding from an ICA pseudo aneurysm. CSF leakage occurred in four patients (8 %), and meningitis in eight cases (14 %). No new permanent neurological deficit occurred.

The EEA management of skull base chordomas requires a long and gradual learning curve that once acquired offers the possibility of either similar or better resection rates as compared to traditional approaches while morbidity is improved.

Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures

Treatment of acromegaly by endoscopic transsphenoidal surgery

Acta Neurochir (2014) 156:441–449

This single-institution, consecutive series of transsphenoidal procedures included all patients in a defined population of 2.6 million inhabitants who underwent surgery during a specific time period.

Objective We sought to determine the surgical complication rate and overall survival rate after transsphenoidal surgery for pituitary adenoma.

Methods All transsphenoidal procedures for histologically verified pituitary adenomas performed between September 2002 and February 2011 at our institution were included in this study. The data were obtained from a prospectively collected database and from reviewing medical records. No patients were lost to follow-up, and the median follow-up time was 28 months.

Results A total of 506 transsphenoidal procedures were performed on 446 patients. There were 268 microscopic and 238 endoscopic procedures involving 352 non-functioning and 154 hormone-secreting adenomas. A total of 73 % of the procedures were primary surgeries, and 27 % were repeat surgeries for tumor recurrence. The overall complication rate was 9.1 %. The three most frequent complications were cerebrospinal fluid (CSF) leakage (4.7 %), meningitis (2 %), and visual deterioration (2 %). Multivariate analyses showed that the overall risk for complications increased with older age, surgery for recurrent tumors, and surgery performed by a low-volume surgeon. There was no significant difference in the overall complication rate between the microsurgical and endoscopic techniques. The rate of surgical mortality was 0.6 %, and the overall survival rates at 1 and 5 years were 95 % and 90 %, respectively. The only negative predictor of survival was older age.

Conclusions Transsphenoidal surgery for pituitary adenomas has a low complication rate and a low rate of mortality. We did not find a significant difference in the complication rate between endoscopic and microscopic techniques.

Identification of the internal carotid artery at the superior part of the cavernous sinus during endoscopic endonasal cavernous sinus tumor surgery

Identification of the internal carotid artery in cavernous sinus during endoscopic endonasal cavernous sinus tumor surgery

Acta Neurochir (2014) 156:475–479

Identification of the internal carotid artery (ICA) is essential for successful endoscopic endonasal cavernous sinus tumor surgery. This study aimed to develop a method for identifying the ICA in cavernous sinus tumors at the superior part of the cavernous sinus.

Methods Ten fresh cadavers were studied with a 4-mm 0° and 30° endoscope to identify surgical landmarks of the ICA in the cavernous sinus. Clinical cases of cavernous sinus tumors were surgically treated using an endoscopic transpterygoid approach.

Results Anatomical study indicated the ICA at the superior part of the cavernous sinus can be identified using three steps: 1) exposure of the optic nerve sheath by drilling the optic canal; 2) identification of the proximal orifice of the optic nerve sheath at the transition of the optic nerve sheath and dura mater of the tuberculum sellae; and 3) identification of the clinoid segment of the ICA at the distal dural ring just below the proximal orifice of the optic nerve sheath. Although the ICA was encased and transposed by tumors in preliminary surgical cases, the clinoid segment of the ICA was safely exposed at the superior part of the cavernous sinus using this method.

Conclusions Dural structures around the cavernous sinus are key to identifying the ICA at the superior part of the cavernous sinus. This method is expected to reduce the risk of ICA injury during endoscopic endonasal surgery for cavernous sinus tumors.

Keyhole Supracerebellar Transtentorial Transcollateral Sulcus Approach to the Lateral Ventricle

Keyhole Supracerebellar Transtentorial Transcollateral Sulcus Approach to the Lateral Ventricle

Neurosurgery 73[ONS Suppl 2]:onsE295–onsE301, 2013

Meningiomas of the lateral ventricles are commonly located in the atria. Surgical access to such tumors is challenging because of their deep location and proximity to critical neurovascular structures, particularly if situated on the dominant side. Although a number of approaches have been described in the literature, most carry the risk of postoperative neuropsychological, visual, or speech deficits, especially when operating on the dominant hemisphere. The supracerebellar transtentorial transcollateral sulcus (STTCS) approach offers the potential to circumvent functionally important structures, reducing the risk of these approach-related neurological deficits.

CLINICAL PRESENTATION: Two patients with dominant hemisphere trigonal meningiomas underwent surgical resection with the use of the STTCS approach. Neuronavigation was used to carefully plan the incision, craniotomy, and exposure, and also intraoperatively to orientate the operating surgeon at key steps, particularly when raising the tentorial flap in line with the tumor. Endoscopy was used to provide increased light intensity, an extended viewing angle, and higher magnification in comparison with a microscope. Specially designed tube-shaft instruments were also used to assist with manipulation through the narrow surgical corridor. In both cases, the tumors were fully resected without approach-related morbidity.

CONCLUSION: The STTCS approach provides good access to tumors located in the trigonal region, reducing the risk of iatrogenic language or visual field deficits. In dominant hemisphere lesions, in the hands of an experienced neurosurgeon, the STTCS approach is an effective alternative to existing techniques.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain


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3T MRI Integrated Neuro Suite

NeurosurgeryCNS: 3D In Vivo Modeling of Vestibular Schwannomas and Surrounding Cranial Nerves Using DIT

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 7

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 6

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 5

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 4

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 3

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 2

NeurosurgeryCNS: Microsurgery for Previously Coiled Aneurysms: Experience on 81 Patients: Video 1

NeurosurgeryCNS: Corticotomy Closure Avoids Subdural Collections After Hemispherotomy

NeurosurgeryCNS: Operative Nuances of Side-to-Side in Situ PICA-PICA Bypass Procedure

NeurosurgeryCNS. Waterjet Dissection in Neurosurgery: An Update After 208 Procedures: Video 3

NeurosurgeryCNS. Waterjet Dissection in Neurosurgery: An Update After 208 Procedures: Video 2

NeurosurgeryCNS. Waterjet Dissection in Neurosurgery: An Update After 208 Procedures: Video 1

NeurosurgeryCNS: Fusiform Aneurysms of the Anterior Communicating Artery

NeurosurgeryCNS. Initial Clinical Experience with a High Definition Exoscope System for Microneurosurgery

NeurosurgeryCNS: Endoscopic Treatment of Arachnoid Cysts Video 2

NeurosurgeryCNS: Endoscopic Treatment of Arachnoid Cysts Video 1

NeurosurgeryCNS: Typical colloid cyst at the foramen of Monro.

NeurosurgeryCNS: Neuronavigation for Neuroendoscopic Surgery

NeurosurgeryCNS:New Aneurysm Clip System for Particularly Complex Aneurysm Surgery

NeurosurgeryCNS: AICA/PICA Anatomical Variants Penetrating the Subarcuate Fossa Dura

Craniopharyngioma Supra-Orbital Removal

NeurosurgeryCNS: Use of Flexible Hollow-Core CO2 Laser in Microsurgical Resection of CNS Lesions

NeurosurgeryCNS: Ulnar Nerve Decompression

NeurosurgeryCNS: Microvascular decompression for hemifacial spasm

NeurosurgeryCNS: ICG Videoangiography

NeurosurgeryCNS: Inappropiate aneurysm clip applications

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