Category: Surgical technique

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How to deal with the superior petrosal vein in microvascular decompression for trigeminal neuralgia?

Neurosurg Focus 59(3):E12, 2025

Sectioning the superior petrosal vein at its main trunk while maintaining venous crossflow is a safe and effective strategy during microvascular decompression for trigeminal neuralgia, improving surgical access without significantly increasing venous-related complications, according to a large retrospective study.

• Management of the superior petrosal vein (SPV) during microvascular decompression (MVD) for trigeminal neuralgia (TN) is controversial, with concerns about operative field access and potential complications.

• A retrospective study evaluated a technique of SPV division at its main trunk near the superior petrosal sinus, maintaining venous crossflow through contributories, in 171 out of 217 patients (79%).

• No statistically significant increase in venous-related complications was observed in the SPV division group compared to the preservation group.

• Only 3 possibly venous-related complications occurred in the SPV division group, all of which were mild and transient.

• Anatomical variations of the SPV require careful intraoperative assessment and preservation of collateral venous drainage for safety.

• Preoperative imaging and intraoperative techniques (e.g., indocyanine green angiography) are recommended to assess collateral flow before SPV division.

• The study concludes that SPV division at the main trunk with preservation of crossflow is a safe strategy that improves surgical exposure during MVD for TN.

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Neuroapraxia of Trigeminal Nerve Controlled by Neuromonitoring During Microvascular Decompression in Multiple Sclerosis Patients Affected by Drug-Resistant Trigeminal Neuralgia Recurrent After Previous Operations

Operative Neurosurgery 29:295–300, 2025

This case series reports the first use of intraoperative neuromonitoring-controlled neuroapraxia of the trigeminal nerve with a temporary aneurysm clip during microvascular decompression for drug-resistant, recurrent trigeminal neuralgia in multiple sclerosis patients, showing immediate pain relief and no complications at up to 10 months’ follow-up.

• Trigeminal neuralgia (TN) in multiple sclerosis (MS) patients is difficult to treat and often recurs after surgery.

• This report describes the first 3 cases of recurrent, drug-resistant MS-related TN treated with intraoperative neuromonitoring (IONM)-controlled neuroapraxia during microvascular decompression (MVD).

• Neuroapraxia was induced by applying a temporary titanium aneurysm clip to the trigeminal nerve for up to 30 seconds, with real-time IONM to avoid nerve damage.

• All patients achieved immediate pain relief and maintained Barrow Neurological Institute pain score I at 9–10 months follow-up, with no major complications.

• Compared to previous techniques, this approach minimized complications by reducing clip time and using neuromonitoring.

• This technique may offer a safe, promising option for MS patients with recurrent TN, but larger studies with longer follow-up are needed.

• The study’s main limitation is the small patient number and short follow-up period.

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Open Microsurgical Versus Endovascular Management of Unruptured and Ruptured Brain Aneurysms

Operative Neurosurgery 29:171–180, 2025

This review compares open microsurgical clipping and endovascular techniques for treating unruptured and ruptured brain aneurysms, discussing their respective risks, benefits, and outcomes. It emphasizes individualized treatment decisions based on aneurysm characteristics, patient factors, and advances in both surgical and endovascular modalities.

• Microsurgical clipping and endovascular techniques are the main treatments for intracranial aneurysms, each with distinct risks and benefits.

• Clipping offers more durable repairs and lower retreatment rates but is more invasive and has higher short-term morbidity, especially in ruptured aneurysms.

• Endovascular treatments (coiling, stenting, flow diverters) are less invasive, have shorter recovery, and are preferred for older patients or those with comorbidities, but have higher recurrence and retreatment rates.

• Aneurysm characteristics such as size, location, morphology, and patient age/comorbidities are critical in selecting the optimal treatment.

• Posterior circulation aneurysms and wide-necked or complex aneurysms often favor endovascular approaches due to surgical risks.

• Clipping is particularly advantageous for younger patients, anterior circulation, and when hematoma evacuation or fenestration is needed.

• New endovascular devices (flow diverters, WEB) expand treatment options but require further study for long-term outcomes.

• Treatment decisions should be individualized, ideally at centers with expertise in both techniques, considering rupture status, anatomy, and patient factors.

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Comparison of suboccipital craniectomy versus suboccipital cranioplasty in foramen magnum decompression for adult Chiari malformation

J Neurosurg Spine 43:237–245, 2025

This retrospective study compared suboccipital craniectomy and cranioplasty for foramen magnum decompression in adult Chiari malformation. Both techniques improved symptoms and syrinx size, but cranioplasty incurred higher costs without significant clinical or radiological advantages. Cost considerations should be discussed during shared decision-making.

• Suboccipital craniectomy and suboccipital cranioplasty are two surgical techniques for foramen magnum decompression (FMD) in adult Chiari malformation.

• Both procedures significantly improve preoperative symptoms and reduce syrinx size, with no significant difference in clinical outcomes.

• Suboccipital craniectomy results in a greater increase in subarachnoid space compared to cranioplasty.

• No significant differences were found in surgical time, estimated blood loss, or cervical alignment between the two groups.

• Suboccipital cranioplasty incurs higher daily medical costs due to the use of plates and screws for bony reconstruction.

• Both techniques have similar rates of complications and secondary surgeries.

• The additional costs of cranioplasty should be discussed with patients during shared decision-making.

• Study limitations include retrospective design, small sample size, surgeon preference, and shorter follow-up for cranioplasty.

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Microsurgical pineal cyst fenestration: A safe and effective treatment strategy in patients with symptomatic pineal cyst syndrome

Acta Neurochirurgica (2025) 167:179

Microsurgical fenestration of pineal cysts significantly improved symptoms in 94% of non-hydrocephalic patients with nonspecific symptoms, with no mortality or severe adverse events. Cyst size and radiological features did not predict outcomes. The study supports fenestration as a safe, effective treatment, but optimal indications remain unclear.

• Microsurgical fenestration of pineal cysts (PC) was studied as a treatment for symptomatic patients without hydrocephalus.

• Most patients had nonspecific symptoms like headache, dizziness, and sleep disturbances; nearly all saw surgery as a last resort.

• 47 patients were analyzed, with an average follow-up of about 7 years post-surgery.

• Significant symptom improvement was observed: mean pain score (VAS) dropped from 7 to 1, with 96% reporting relief.

• No mortality or severe complications occurred; minor complications included CSF leaks (10%) and one surgical site infection.

• No clinical or radiological factors predicted better outcomes; even small cysts could benefit from surgery.

• Fenestration of both anterior and posterior cyst walls was seen as key to success, potentially safer than full resection.

• Further research is needed to define indications, optimal technique, and pathophysiology of symptomatic pineal cysts.

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Minimally Invasive and Cost-Effective Access to Deep-Seated Intracranial Lesions Using 19F Peel-Away Sheath Introducer and “Dynamic” Retraction

Operative Neurosurgery 29:118–124, 2025

This study introduces a minimally invasive, cost-effective technique for resecting deep-seated brain lesions using a 19F peel-away sheath introducer and dynamic retraction. In 13 patients, the method proved safe and effective, achieving high rates of gross total resection with minimal complications and reduced costs.

A novel, cost-effective minimally invasive technique for deep-seated intracranial lesions uses a 19F peel-away sheath introducer and “dynamic” retraction.

• This approach was evaluated in 13 patients with various brain pathologies, including glioblastoma, metastases, cavernous malformations, pilocytic astrocytoma, and colloid cyst.

• Gross total resection was achieved in 11 of 13 cases, with minimal complications and most patients remaining neurologically stable or improved postoperatively.

• The technique involves a small craniotomy, insertion of the 19F introducer using image guidance, and lining the corridor with cottonoid strips after sheath removal for retractorless, dynamic retraction.

• Compared to standard tubular retractor systems, this method reduces cost (introducer: ~$252 vs. commercial systems: $695–$4000) and potentially lessens brain trauma.

• Postoperative imaging showed minimal brain damage, with only one patient exhibiting minor diffusion changes without clinical consequences.

• Limitations include small sample size and retrospective design, but the technique may be especially valuable in resource-limited settings.

• Authors conclude this method is safe, technically feasible, and a viable alternative to more expensive tubular retraction systems for deep brain lesions.

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The Transtemporal Isthmus Approach for Insular Glioma Surgery

Operative Neurosurgery 28:478–486, 2025

This study presents a transtemporal isthmus approach for insular glioma surgery, achieving maximal safe resection. This method utilizes a widened temporal isthmus to access the insular lobe, ensuring significant tumor removal while preserving neurological function. The approach is shown effective for both low- and high-grade gliomas.

• The study introduces a transtemporal isthmus approach for the resection of insular gliomas, aiming for maximal and safe tumor removal.

• This surgical method involves the use of MRI and functional neuronavigation guidance, along with intraoperative electrophysiological monitoring.

• The approach is particularly beneficial for tumors involving zones III and IV of the Berger-Sanai classification.

• Gross total resection was achieved in 64.9% of low-grade and 87.5% of high-grade gliomas.

• The temporal isthmus is widened by the tumor, providing a surgical corridor for resection.

• The median postoperative Karnofsky performance score was 90, indicating good functional preservation.

• Muscle strength and speech were nearly normal in all patients three months post-surgery.

• The study suggests this approach is effective for safe and maximal tumor resection, while preserving essential functions.

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The risk of intraoperative venous air embolism from neurosurgical procedures performed in the lounging position

J Neurosurg 142:797–807, 2025

The study investigated the risk of venous air embolism (VAE) during neurosurgery in the lounging position, finding no permanent sequelae or fatal events. Despite a 51.4% VAE detection rate, no hemodynamic instability occurred, suggesting experienced teams can safely use this position.

Study Overview

• Objective: Assess venous air embolism (VAE) risk and outcomes in lounging position neurosurgery.

• Study Design: Retrospective analysis of 1000 patients from 2010 to 2020.

• Primary Focus: VAE incidence, severity, and associated complications.

Key Findings

• VAE Detection: 51.4% of patients experienced VAE, with no grade 5 events.

• Complications: 0.3% developed acute respiratory distress syndrome (ARDS) linked to VAE grade.

• No Permanent Sequelae: No patients suffered permanent neurological deficits from VAE.

Patient Demographics

• Mean Age: 47.7 years; 56.5% female.

• Common Pathologies: 94.9% had posterior fossa tumors, mainly vestibular schwannomas.

Surgical Approach and Positioning

• Lounging Position: Feet elevated above head to improve venous return.

• Surgical Benefits: Reduced intracranial pressure and improved surgical field visibility.

Risk Factors and Outcomes

• High-Grade VAE: Associated with older age and lower BMI.

• No PFO Contraindication: PFO is not linked to paradoxical embolism in this cohort.

• Outcome Predictors: Preoperative KPS score is most relevant for clinical outcomes.

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Surgical Strategy for Dumbbell-Shaped Cervical Schwannoma at the Vicinity of the Vertebral Artery

Operative Neurosurgery 28:165–174, 2025

• Objective: The study proposes a surgical strategy for preserving the vertebral artery (VA) during the excision of dumbbell-shaped cervical schwannomas using anatomic layers, specifically the perineurium.

• Methods: A retrospective analysis was conducted on 37 patients who underwent surgery for cervical schwannomas from January 2004 to July 2023.

• Results: The perineurium acted as a protective barrier during surgery, preventing VA injury in most cases. Gross total resection was achieved in 67.6% of patients.

• Complications: VA injury occurred in one patient, but no new neurological deficits were reported post-surgery.

• Subperineurial Dissection: This technique is crucial for safeguarding adjacent structures and preventing VA injury.

• Residual Tumor Management: Residual tumors were observed in some cases, with regrowth occurring near the neural foramen requiring secondary surgery.

• Conclusion: Subperineurium dissection is a vital strategy in preventing VA injury during schwannoma resection.

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Management of incisional cerebrospinal fluid leak in open cranial surgeries and the “folding technique” in duraplasty

Neurosurg Focus 58(2):E7, 2025

• The study focuses on the management of incisional cerebrospinal fluid (CSF) leaks in open cranial surgeries, emphasizing the “folding technique” in duraplasty as an alternative to conventional methods.

• The incidence of iatrogenic incisional CSF leaks was found to be 1.8% among 2149 patients who underwent open cranial surgeries between 2019 and 2024.

• Conservative methods like resuturing and acetazolamide were initially used for CSF leak management, but more invasive procedures like lumbar external drainage (LED), external ventricular drainage (EVD), or surgical reexploration were required when these methods failed.

• The folding technique in duraplasty is highlighted as an effective method for achieving watertight closure, reducing the risk of CSF leakage.

• The study noted that patients who underwent radiotherapy had a longer interval between surgery and leakage onset, suggesting a potential risk factor for delayed CSF leakage.

• Meningitis was a complication in 23.1% of patients with CSF leaks, and the study underscores the importance of maintaining a watertight dura to prevent such complications.

• The study concludes that the folding technique could be a worthy replacement for conventional suturing techniques in dural repair, potentially lowering morbidity associated with CSF leaks.

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Dural and cranial reconstruction techniques in retrosigmoid craniotomy: key factors associated with CSF leaks in 225 patients

Neurosurg Focus 58(2):E8, 2025

This study evaluated the effectiveness of various dural closure and bone reconstruction techniques in preventing CSF leakage following retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors. The goal was to identify whether newer combinations of reconstructive materials offer any advantage in reducing CSF leaks and improving surgical outcomes.

METHODS The authors conducted a retrospective review of 225 patients who underwent a retrosigmoid craniotomy for CPA neoplasms between January 2018 and August 2024. Patient demographics, intraoperative reports, and postoperative complications were analyzed. Various reconstructive methods, including the use of TachoSil, HydroSet, autologous or heterologous dural patches, and bone flap repositioning, were compared. CSF-related complications such as CSF leakage, infections, and postoperative hydrocephalus were systematically evaluated.

RESULTS CSF leakage occurred in 31% of cases (n = 69), while CSF infections and postoperative hydrocephalus were noted in 6% and 7% of patients, respectively. HydroSet combined with bone flap repositioning significantly reduced CSF leakage (p = 0.008), as did the combination of HydroSet and heterologous dural patches (p = 0.007). TachoSil did not show a significant reduction in CSF leakage. Craniectomy with titanium mesh or heterologous cranioplasty was not associated with any CSF leaks. No other single or combined techniques showed significant associations with CSF leakage.

CONCLUSIONS HydroSet in combination with bone reconstruction and heterologous patches demonstrated superior outcomes in reducing CSF leaks. TachoSil did not significantly affect leakage rates, with less definite results. Refining surgical techniques and selecting appropriate materials for dural and bone reconstruction may help reduce complications and improve patient outcomes in CPA tumor surgeries using the retrosigmoid approach.

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Microsurgical preservation of lenticulostriate artery perforators in insular glioma: the two point antegrade skeletonization technique

Acta Neurochirurgica (2025) 167:11

Reaching parenchymal segments of the lateral lenticulostriate artery (LSA) perforators, which represent the medial resection limit in insular gliomas (IG), remains a challenge. The currently described methods are indirect and sometimes, imprecise.

Methods We report an antegrade direct skeletonization technique to identify these tiny arteries at the medial end of IGs with an illustrative case of grade 2 astrocytoma. The patient recovered uneventfully following a near total tumor resection without any postoperative radiological ischemia in the LSA territory.

Conclusions Our microsurgical technique of antegrade LSA skeletonization may be useful in insular gliomas with a sharp medial border.

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Comparing surgical clipping with endovascular treatment for unruptured middle cerebral artery aneurysms: a systematic review and updated meta-analysis

J Neurosurg 142:116–126, 2025

Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA.

METHODS The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with ≥ 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score ≤ 2 or Glasgow Outcome Scale score ≥ 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I 2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger’s test.

RESULTS The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08–0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20–0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01–10.92, p < 0.01).

CONCLUSIONS This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study’s findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.

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Efficacy and Safety of C3 Laminectomy Combined with Open-Door Laminoplasty versus Open-Door Laminoplasty Alone: A Systematic Review and Meta-Analysis

World Neurosurg. (2024) 192:98-108

BACKGROUND: To evaluate efficacy and safety between C3 laminectomy + open-door laminoplasty and open-door laminoplasty alone.

METHODS: Electronic databases were systematically searched up to January 2024. Review Manager 5.4 was applied to manage the data and perform the review. Cochrane Library, PubMed, OVID, and Web of Science were searched for studies comparing C3 laminectomy + open-door laminoplasty and open-door laminoplasty alone. Forest plots were constructed for each analysis group.

RESULTS: After selection, 9 eligible articles included 10 comparison groups, with a combined 320 patients who underwent C3 laminectomy + open-door laminoplasty and 355 who underwent open-door laminoplasty alone. There was no difference in operative time, blood volume, Japanese Orthopaedic Association score, Japanese Orthopaedic Association recovery score, visual analog scale score, Neck Disability Index, complications, axial symptoms, T1 slope, range of motion, and cervical sagittal vertical axis. C3 laminectomy D open-door laminoplasty was superior in C2-C7 Cobb angle.

CONCLUSIONS: Although C3 laminectomy + open-door laminoplasty has theoretic advantages, meta-analysis results show that the 2 surgical procedures are similar in terms of clinical symptoms improvement, sagittal balance, and complications. C3 laminectomy combined + open-door laminoplasty is superior only in the preservation of cervical lordosis. The limited number of studies may affect the reliability and generalizability of the results. Future high-quality, multicenter randomized controlled trials are needed to verify efficacy and safety.

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Microsurgical anatomy and approaches to thalamic gliomas. Part 2: Maximal safe resection of thalamic gliomas improves outcomes.

J Neurosurg 141:1472–1483, 2024

As presented in Part 1 of this series, thalamic gliomas (TGs) are deep-seated, difficult-to-access tumors surrounded by vital neurovascular structures. Given their high operative morbidity, TGs have historically been considered inoperable lesions. Although maximal safe resection (MSR) has become the treatment standard for lobar and even deep-seated mediobasal temporal and insular gliomas, the eloquent location of TGs has precluded this management strategy, with biopsy and adjuvant treatment being the mainstay. The authors hypothesized that MSR can be achieved with low morbidity and mortality for TGs, thus resulting in improved outcomes.

METHODS A retrospective single-center study was performed on all TG patients from 2006 to 2020. Clinical, imaging, and pathology reports were obtained. Univariate and multivariate analyses were performed to determine prognostic variables. Case examples illustrate various approaches and the rationale for staging resections of more complex TGs.

RESULTS A total of 42 patients (26 males, 16 females), among them 12 pediatric (29%) cases, were included. Their mean age was 36.0 ± 21.4 (median 30, range 3–73) years. The median maximal tumor diameter was 45 (range 19–70) mm. Eighteen patients (43%) had a prior stereotactic needle tumor biopsy, with the ultimate diagnosis changed for 7 patients (39%) following microsurgical resection. The most common surgical approaches were transtemporal (29%), anterior interhemispheric transcallosal (29%), and superior parietal lobule (25%). Overall, the combined subtotal and grosstotal resection rate was 95% (n = 40). Low-grade gliomas (LGGs; grades I and II) comprised one-third of the group, whereas half of the patients had glioblastoma multiforme. There were no operative mortalities. Although temporary postoperative motor deficits were observed in 12 patients (28.6%), all improved during the early postoperative period except 1 (2.4%), who had mild residual hemiparesis. Two patients required CSF diversion for hydrocephalus. The 2-year overall survival rate was 90% for LGG patients and 15% for high-grade glioma (HGG) patients. Multivariate analysis revealed that histological grade, age, and extent of resection were independent prognostic factors associated with survival.

CONCLUSIONS Management of TGs is challenging, with resection avoided by many, if not most, neurosurgeons, especially for HGGs. The results reported here demonstrate improved outcomes with resection, particularly in younger LGG patients. The authors therefore advocate for MSR for a select cohort of TG patients using carefully planned surgical approaches, contemporary intraoperative adjuncts, and meticulous microsurgical techniques.

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Angiographic Features of Meningiomas Predicting Extent of Preoperative Embolization

Neurosurgery 95:1010–1025, 2024

Preoperative embolization is used as an endovascular adjunct to surgical resection of meningiomas. However, there is no standardized system to assess the efficacy or extent of embolization during the embolization procedure. We sought to establish a purely angiographic grading system to facilitate consistent reporting of the outcome of meningioma embolization and to characterize the anatomic and other features of meningiomas that predict the degree of devascularization achieved through preoperative embolization.

METHODS: We identified patients with meningiomas who underwent preoperative cerebral angiography and subsequent resection between 2015 and 2021. Demographic, clinical, and imaging data were collected in a research registry. We defined an angiographic devascularization grading scale as follows: grade 0 for no embolization, 1 for partial embolization, 2 for majority embolization, 3 for complete external carotid artery embolization, and 4 for complete embolization.

RESULTS: Eighty consecutive patients were included, 60 of whom underwent preoperative tumor embolization (20 underwent angiography with an intention to treat but ultimately not embolization). Embolized tumors were larger (59.0 vs 35.9 cc; P = .03). Gross total resection, length of stay, and complication rates did not differ among groups. The distribution of arterial feeders differed significantly across tumors in a location-specific manner. Both the tumor location and the identity of arterial feeders were predictive of the extent of embolization. Anterior midline meningiomas were associated with internal carotid (ophthalmic, ethmoidal) supply and lower devascularization grades (P = .03). Tumors fed by meningeal feeders (convexity, falcine, lateral sphenoid wing) were associated with higher devascularization grades (P < .01). The procedural complication rate for tumor embolization was 2.5%.

CONCLUSION: Angiographic outcomes can be graded to indicate the extent of tumor embolization. This system may facilitate consistency of reported angiographic results. In addition, arterial feeders vary in a manner predicted by tumor location, and these patterns correlate with typical degrees of devascularization achieved in those tumor locations.

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The endaural subtemporal keyhole: a novel minimally invasive approach to the middle cranial fossa

J Neurosurg 141:1063–1070, 2024

The goal of this study was to evaluate the feasibility of a minimally invasive approach to the middle cranial fossa using a novel endaural keyhole.

METHODS The charts of all patients who underwent this novel minimally invasive approach to the middle cranial fossa were retrospectively reviewed. In addition, cadaveric dissection was performed to demonstrate the feasibility of the endaural keyhole to the middle cranial fossa.

RESULTS Six patients (5 female and 1 male; age range 47–77 years) who underwent craniotomy for CSF leak (n = 3), intracerebral hematoma evacuation (n = 2), and tumor resection (n = 1) via the endaural subtemporal approach were identified. There were no approach-related complications noted. Representative imaging from cadaveric dissection is provided with a stepwise discussion of the procedure.

CONCLUSIONS The endaural subtemporal keyhole craniotomy provides a novel approach to middle fossa skull base pathology, as well as a minimally invasive approach to intra-axial pathology of the temporal lobe and basal ganglia. Further research is needed to establish the limitations and potential complications of this novel approach.

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Safe resection of a complex type 3 foramen magnum meningioma with dorsal displacement of the neurovascular bundle

Acta Neurochirurgica (2024) 166:376

We describe techniques for safe resection of a Type 3 foramen magnum meningioma with dorsal displacement of the accessory nerve rootlets and vertebral artery which limits ventral access to the tumor.

Method Partial sectioning of the accessory nerve rootlets may help create larger working space. Topical lidocaine placement on the rootlets of the spinal accessory nerve may mitigate trapezius muscle contraction and facilitates further progress throughout tumor resection.

Conclusion Creating safe working corridors between the lower cranial nerves through mobilization or partial sectioning of rootlets in the case of CN XI facilitates tumor resection through a far lateral approach.

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Endoscopic Retrolabyrinthine Craniotomy for Exposure of the Trigeminal Nerve Root Entry Zone

Operative Neurosurgery 27:464–470, 2024

Exposure of the root entry zone (REZ) of the trigeminal nerve (TN) for microvascular decompression is commonly obtained with a retrosigmoid approach, with or without endoscopic assistance. We hypothesized that adequate exposure of the TN REZ could be obtained through an endoscopic retrolabyrinthine (RL) approach. We aim to quantify exposure of the REZ of the TN using endoscopic RL approach, with and without drilling of the suprameatal tubercle of the internal auditory canal.

METHODS: Surgical dissection was performed bilaterally on 3 embalmed cadaveric human heads at the anatomy laboratory of the House Institute. Heads were scanned for volumetric analysis using 3D Slicer software both before and after dissection. Extent of exposure was quantified in 2 ways: first, by assessment of the surgeon’s ability to visualize 16 predetermined anatomic landmarks with the endoscope and second, we estimated the “working” area by placing fiducials under the fully endoscopic view and calculating the resultant 3D volume.

RESULTS: Using the standard endoscopic RL approach, anaverageof 13.8 landmarks (range 12-16) was visualized. The estimated working volume exposed by the RL on each side of each head varied from 189.28 to 527.85 mm3 . Drilling of the suprameatal tubercle provided both increases in landmark visualization and, on average, an additional 55 mm 3 of working volume.

CONCLUSION: The endoscopic RL approach is a viable alternative to the standard retrosigmoid approach. Potential advantages of the RL include a more lateral trajectory that minimizes the need for cerebellar retraction and a shorter working distance and shallower angle to the cerebellopontine angle. Potential disadvantages include longer surgery time, increased technical difficulty of exposure, and potential for cerebrospinal fluid leak and or hearing loss.

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Microsurgical Resection of Brainstem Cavernous Malformations in Older Adults: A Multicenter, 30-Year Experience

Neurosurgery 95:669–675, 2024

Microsurgical resection is the only curative intervention for symptomatic brainstem cavernous malformations (BSCMs), but the management of these lesions in older adults (≥65 years) is not well described. This study sought to address this gap by examining the safety and efficacy of BSCM resection in a cohort of older adults.

METHODS: Records of patients who underwent BSCM resection over a 30-year period were reviewed retrospectively. Baseline characteristics and outcomes were compared between older (≥65 years) and younger (<65 years) patients.

RESULTS: Of 550 patients with BSCM who met inclusion criteria, 41 (7.5%) were older than 65 years. Midbrain (43.9% vs 26.1%) and medullary lesions (19.5% vs 13.6%) were more common in the older cohort than in the younger cohort (P = .01). Components of the Lawton BSCM grading system (ie, lesion size, crossing axial midpoint, developmental venous anomaly, and timing of hemorrhage) were not significantly different between cohorts (P ≥ .11). Mean (SD) Elixhauser comorbidity score was significantly higher in older patients (1.86 [1.06]) than in younger patients (0.66 [0.95]; P < .001). Older patients were significantly more likely than younger patients to have poor outcomes at final follow-up (28.9% vs 13.8%, P = .01; mean follow-up duration, 28.7 [39.1] months). However, regarding relative neurological outcome (preoperative modified Rankin Scale to final modified Rankin Scale), rate of worsening was not significantly different between older and younger patients (23.7% vs 14.9%, P = .15).

CONCLUSION: BSCMs can be safely resected in older patients, and when each patient’s unique health status and life expectancy are taken into account, these patients can have outcomes similar to younger patients.

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