Background: The aim of this study was to identify the anatomic landmarks of sella turcica on the surface of the head, and to investigate the feasibility of studying sella turcica anatomy individually by three-dimensional computed tomography (3D-CT) before an endonasal transsphenoidal operation.Patients and Methods: The three-dimensional anatomic structures of the heads of 49 patients were studied by 3D-CT using image reconstruction with surgical clip image registration. The tip of the nose and the apex of the ear helix were used as surface markers on the head, and the locations of the sphenoid sinus and sellar floor with respect to a line defined by these 2 markers were investigated. Using an endonasal transsphenoidal approach with a surgical trajectory guided by the nose tip-ear apex line and 3D-CT anatomic images of the sella turcica, 12 patients with pituitary adenoma were treated surgically.Results: The nose tip-ear apex line passed through the sphenoid sinus in 100% of the cases and through the sellar floor in 41.4% of the cases. The mean distance from the sellar floor clivus point perpendicularly to the nose tip-ear apex line was 3.5 +/- 2.0 mm. The 3D-CT imaging clearly showed the configuration of the sphenoid sinus, bone septum, optic protuberance, carotid protuberance and the sellar floor. 12 pituitary adenomas were resected totally.Conclusion: The nose tip-ear apex line provides a precise, simple, and practical tool for orienting the sphenoid sinus, sellar floor and surgical trajectory of the endonasal transsphenoidal approach. 3D-CT images more clearly and intuitively display the sella turcica anatomy. Preoperative 3D-CT increases the surgeon's confidence in endonasal transsphenoidal operations and should be routinely performed in patients with pituitary adenomas.
Background: The laparoscopically assisted ventriculoperitoneal (VP) shunt has been widely used in the clinical treatment of hydrocephalus for its simplicity and reliability. Despite significant improvements in shunt procedures, shunt complications remain common. Our clinical experiences suggest that the fixation of the distal (peritoneal) shunt catheter using threads and hemoclips may partially contribute to complications of the distal shunt including obstruction of the shunt and infection. In this study, we explored a novel fixation method in the laparoscopically assisted VP shunt with use of the liver falciform ligament as a natural support for fixation of the distal shunt catheter.Methods: 10 patients with hydrocephalus underwent laparoscopically assisted VP shunt and the distal shunt catheter was placed into the hepatodiaphramatic space and the catheter was traversed through 2-3 drilled holes in the liver falciform ligament without using any artificial material for fixation.Results: In all the patients who received surgery with the adopted new procedure the clinical symptoms were alleviated. The size of cerebral ventricles returned to normal after 1 week. The distal catheters were in the hepatodiaphragmatic space in 9 of 10 patients, while in 1 patient it migrated to the peritoneal cavity underneath the liver. All the 9 patients were followed up for 1 year and no surgery-related catheter obstructions and infections were observed.Conclusions: The modified laparoscopically assisted VP shunt in the treatment of hydrocephalus with fixation of the distal shunt catheter to a natural anatomic structure could potentially reduce the necessity of repeat surgery for addressing the complications caused by catheter obstruction and infections, reduce the chance of adhesions, and would be of benefit to those patients who need future revisions.
BACKGROUND:Microvascular decompression is an effective method of treatment in trigeminal neuralgia. It may fail if a compressing vessel is overlooked during surgery. The endoscope has an edge over the microscope in visualizing such conflicts. MATERIALS AND METHODS:This is a prospective study of 51 patients. Preoperative computed tomography and magnetic resonance imaging scans were performed in all the cases. A 4 − 5 cm retroauricular skin incision was made and an about 3 cm craniectomy was performed. A 0° 4 mm telescope supported by the holder was used after the dural opening. A 2 by 6 cm sheet prepared from hand gloves was used to protect the brain. A Karl Storz 30° telescope was used for the visualization of the trigeminal nerve from the pons to Meckel's cave and dissection of the anterior conflict. Small pieces of dura patch were interposed between the nerve and the vessel. The microscope was not used at any stage. Post-operative infection, cerebrospinal fluid leak, cranial nerve deficit, failure of procedure in terms of pain relieves and recurrences of pain were recorded. The follow-up period ranged from 24 to 55 months with an average of 36 months. RESULTS:There was no mortality or any major permanent complications. The duration of stay ranged from 3 to 10 days with an average of 3.6 days. The pain was relieved in 48 patients. CONCLUSION:Endoscopic vascular decompression is an effective and safe alternative to endoscopic assisted microvascular decompression in trigeminal neuralgia.
BACKGROUND:Dislocation of ventriculoperitoneal (VP) shunt catheters is a well known complication after treatment of cerebrospinal fluid disorders; however, secondary perforation of the liver capsule by the catheter is exceptional. The literature on VP shunt complications involving the liver, their possible pathomechanisms and minimally invasive recovery strategies in reference to our own experience is reviewed.CASE REPORT:We present a patient who suffered penetration of the liver by the peritoneal catheter of her VP shunt. Causing intermittent epigastric pain, the shunt tip was found to have progressively dislocated into the liver, as documented by CT scans. A laparoscopic approach was indicated to recover the shunt. The peritoneal catheter was found to be covered by widespread adhesions, consistent with peritoneal fibrosis. After local adhesiolysis, it was successfully recovered without shunt dysfunction, hemorrhage of the liver, or biliary fistula. After 4 months, dislocation recurred with formation of a subdiaphragmatic pseudocapsule. Early formation of fibrosis was detected during laparoscopic revision surgery. Although bacterial smears from both laparoscopic surgeries did not show any pathological findings, the patient presented with an abscess in the Douglas pouch 4 months later. Coagulase-negative staphylococci were found on ultrasound-guided insertion of a pigtail catheter. The VP shunt had to be replaced by a ventriculoatrial shunt. The infection was treated successfully with piperacillin. The subsequent 6 months follow-up period was without adverse events.CONCLUSION:The treatment of choice in this exceptional case of intrahepatic shunt dislocation was laparoscopic recovery of the catheter. Laparoscopy allowed good visualization during adhesiolysis, immediate exclusion of hemorrhage or bile fistula at the puncture site, as well as function control and safe deposition of the shunt tip. Chronic infection as an underlying cause of peritoneal fibrosis has to be ruled out.
Background: Anterior cervical discoidectomy with or without fusion is a well established surgical remedy for cervical prolapsed intervertebral disc (PIVD) disease. If fusion is done by an iliac bone graft then internal fixation is commonly used to keep the graft in position. This study was conducted to determine the efficacy and tolerability of shape memory alloys, especially NiTi (nickel titanium) clips in the stabilization of grafts following anterior cervical discoidectomy.Methods: 133 NiTi clips were applied in 119 patients between January 2002 and December 2008. The patients age ranged from 38-60 years. There were 66 male and 53 females. Various indications for fixation of the spine included degenerated cervical spondylosis with single level PIVD (105) and two level PIVD in 14 patients. The cine mode fluoroscopy confirmed the perioperative correct placement of grafts and clips in all the patients. Follow-up ranged from 2 to 8 years (mean: 4.6 years).Results: Single level discoidectomy was performed in 105 patients and two level disc removal was done in 14 patients. A single NiTi clip was applied in all the cases except for 14 cases of two level PIVD. No procedural complication or adverse reaction to the clip was noted. There was no movement at the operated level in dynamic lateral view X-ray of cervical spine at the 1(st) postoperative day as well as on follow-up. Graft extrusion was seen in one patient on the 2(nd) day after surgery and was reoperated. Bony fusion occurred in all patients after 9-12 months of surgery. There was no incidence of breakage or dislodgement of the clip from the site where it was inserted. No artifact was noted in cervical MRI done in 33 patients.Conclusion: NiTi clips are a simple alternative for cervical spine stabilization after discoidectomy. Their insertion is simple, minimally invasive, does not require any special set of instruments and they are much more economical than other established methods of treatment. These clips are accepted well by human tissue and do not interfere with MRI.
BACKGROUND:In 1908, Anton and von Bramann proposed the Balkenstich method, a corpus callosum puncture which created a communication between the ventricle and subarachnoid space. This method offered the benefit of providing continuous CSF diversion without the implantation of cannula or other shunting devices, yet it received only slight reference in the literature of the time. It remained a novel and perhaps underutilized approach at the time Cushing began expanding his neurosurgical practice at the Johns Hopkins Hospital.MATERIALS AND METHODS:Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records of the Johns Hopkins Hospital for the period 1896-1912 were reviewed. Patients operated upon by Harvey Cushing were selected.RESULTS:7 patients underwent puncture of the corpus callosum for treatment of hydrocephalus. 6 patients were treated for obstructive hydrocephalus secondary to presumed intracranial lesions. 1 patient was treated for congenital hydrocephalus.CONCLUSION:The series reported here documents Cushing's early use of the corpus callosum puncture to divert CSF in patients with obstructive hydrocephalus secondary to intracranial tumors, as well as an attempt to use the procedure in a pediatric patient with congenital hydrocephalus. Notably, 3 patients developed new onset left-sided weakness post-operatively, possibly due to retraction injury upon the supplementary motor intra-operative manipulations.
Background: Transforaminal percutaneous endoscopic lumbar discectomy (PELD) has become a routine surgical procedure because it is minimally invasive. Perioperative complications such as dural injury, infection, nerve root irritation and recurrence can occur not only with PELD, but also with conventional open microsurgery. In contrast, post-operative dysesthesia (POD) due to existing dorsal root ganglion (DRG) injury is a unique complication of PELD. When POD occurs, even if the traversing root has been successfully decompressed, it hinders swift recovery and delays the return to daily routines. Thus, prevention of POD is the key to successful and widespread use of PELD.Material and Methods: From January 2006 to December 2008, 154 patients underwent percutaneous endoscopic discectomy by floating retraction technique at 160 disc levels under local anesthesia. This approach towards the superomedial border of the lower pedicle and the cannula can be placed by gentle retraction of the root with perineural fat instead of direct compression of dorsal root ganglion. The clinical outcomes were assessed using the Visual Analogue Scale (VAS, 0-10 point) for radicular pain and low back pain, and using the Oswestry Disability Index (ODI) for functional status. Perioperative complications and recurrence were reviewed.Results: The mean age was 45 years, the mean operative time was 36 min and the mean follow-up period was 3.4 years. The mean hospital stay for endoscopic discectomy was 1.8 days. No patient underwent repeated PELD or convert microsurgery by incomplete removal of the ruptured particle. All patients experienced early relief of symptoms, as determined by VAS and OM. No patient developed POD. 1 patient experienced dural injury. There was 1 case of discitis. The recurrence rate was 1.95% (3 patients).Conclusion: Transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation is a safe and effective procedure. The floating retraction technique is recommended to avoid development of POD.
Background: We report a series of 527 patients with unilateral vestibular schwannomas (VS) who underwent fully endoscopic resection of their tumors during the period of October, 2001 to July, 2010. Patients' outcomes were evaluated, with specific regard to hearing preservation, facial nerve function, postoperative complications and completeness of the resection.Methods: The patient population consisted of 527 cases with unilateral VS(s); patients with neurofibromatosis type 2 (NFT2) were excluded from this study. Tumors ranged in size from 0.3-5.8 cm, most tumors were less than 4 cm in diameter (mean: 2.8 cm). Tumors were removed via 2.0 cm "keyhole" retrosigmoid craniotomies.Results: Utilizing the fully endoscopic technique, 94% of tumors were completely removed; subtotal removal was performed in 6% of patients in an attempt to preserve their hearing. Anatomic preservation of the facial nerve was achieved in all of the patients. Functionally, measurable hearing (serviceable/some) was preserved in 57% of cases that had either "serviceable" or "some" hearing pre-operatively. There were no major neurological complications such as quadriparesis, hemiparesis, bacterial or aseptic meningitis, permanent lower cranial nerve deficits, or deaths.Conclusion: From our experience, we conclude that the endoscope is ideally suited for a minimally invasive approach for resection of vestibular schwannomas.
Background: No anatomic data are available addressing the surgical indication for upper BA aneurysms via the supraorbital keyhole approach (SOKA).Objective: An anatomic study of the SOKA to the upper BA via the optico-carotid window (OCW) was designed. Our clinical experience is reported.Methods: After completing the SOKA craniotomy on 8 cadaveric heads, the width and length of OCW and the length of the supraclinoid internal carotid artery (SCICA) were measured. Measurement of the following was carried out through the OCW: (i) linear distance (a) of the BA from the most proximal point of visualization of the BA to the posterior clinoid process level, (ii) perpendicular distance (b) from the most distal point of visualization along the elongation of the BA to the anterior fossa level. After posterior clinoidectomy and orbitectomy, the measurement of (a) and (b) was repeated.Results: The width and length of OCW and the SCICA length were 7.6 +/- 2.1 mm, 11.6 +/- 2.3 mm, and 12.7 +/- 2.4mm. The distance (a) was 5.0 +/- 1.2 mm, increased by 3.4 +/- 1.0 mm after posterior clinoidectomy. The distance (b) was 12.8 +/- 2.6 mm, increased by 3.3 +/- 1.2 mm after orbitectomy. 9 aneurysms were completely clipped.Conclusion: When the width and length of the OCW are > 5 mm and > 7 mm, respectively, the SOKA can meet the requirement of exposure and manipulation of the upper BA. The upper BA aneurysms located < 10 mm higher than the anterior fossa and not more than 5 mm lower than the PCP can be treated via the SOKA. Posterior clinoidectomy and orbitectomy can increase the proximal and the distal exposure of the BA, respectively.
BACKGROUND:The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positioning exist. Here, we report a simple, safe, and quick positioning technique which maximizes patient safety, surgeon comfort, and intraoperative view.METHODS:We reviewed the senior author's prospective surgical database for retrosigmoid approaches to the posterior fossa and noted any complications or difficult exposures.RESULTS:Over 970 retrosigmoid operations were performed over the course of 19 years. There were no positioning-related complications and no aborted surgeries due to inadequate exposure. No normal cerebellum was ever resected to increase exposure and no retractor was ever used in the posterior fossa.CONCLUSIONS:Supine positioning for the retrosigmoid approach is an excellent and safe positioning alternative.
BACKGROUND:Clival chordomas are difficult tumors to treat, particularly when they have already grown beyond the confines of the clivus.PATIENT:We report the case of a 52-year-old man with a clival mass consistent with a chordoma with a prominent extension into the right middle fossa. At the patient's request, he underwent a simple endonasal biopsy to confirm the diagnosis. A second debulking procedure was planned to debulk the remnant tumor. However, follow-up magnetic resonance imaging showed that much of the middle fossa tumor had decompressed itself through the clival defect into the patient's pharynx.RESULTS:The patient underwent additional clival debulking and proton-beam therapy. After 44 months of follow-up, he had no clinical or radiographic progression of disease.CONCLUSION:It is intriguing to think that leaving a path for easy egress for a chordoma from the clivus may prevent it from building up in the bone and spreading.
BACKGROUND:True aneurysms of the ophthalmic artery (OA) are extremely rare and most often arise at the origin of this artery. We present the endovascular management of a ruptured intraorbital OA aneurysm and of an associated dural arteriovenous fistula (dAVF).PATIENT:A patient with a ruptured intraorbital ophthalmic artery aneurysm, associated with a dAVF with cortical drainage presented with acute visual loss and intra- and periorbital hematoma. The aneurysm was treated by endovascular coil occlusion. The dAVF was occluded by transvenous obliteration of the draining basal vein of Rosenthal. Both intraorbital ophthalmic artery aneurysms and their rupture are extremely rare.CONCLUSION:Transvenous treatment of dAVFs is well feasible even with very far going catheterization, in this case to the origin of the basal vein of Rosenthal.
Background: We report on a dual percutaneous fixation in 2 patients with a double thoracic spine fracture. The advantages and limitations of this new approach for treating traumatic spinal fractures are reviewed.Clinical Presentation: A 67-year-old male was admitted following a fall from a height of 3m. A neurological examination revealed sub-T11 motor and sensory paraparesis. There were a T6 vertical body and bi-articular fracture and a T11 vertebral burst fracture with > 75% posterior wall damage. A 40-year-old male was admitted after a suicide attempt. A neurological examination revealed sub-T11 paraplegia. There were a T7 vertebral body fracture with intact posterior wall and a T11 burst fracture with > 75% posterior wall damage.Surgical Technique: The same technique was used in both cases. 2 minimally invasive percutaneous fixations of the 2 fractures were performed. In a third step, we performed a T10-T12 open laminectomy. This technique helped to limit blood loss and avoid an over-long fixation. Pedicle screw targeting was optimal. 16 months later, the neurological status was normal in patient 1 and there was neurological improvement in patient 2. No secondary segmental kyphotic deformities appeared.Conclusion: Percutaneous fixation enables the treatment of an acute thoracic spine fracture. With appropriate presurgical planning, this technique can be applied to all thoracic vertebrae. Spinal cord injuries justify the use of laminectomy together with percutaneous fixation, in order to limit erector muscle injury and blood loss.
Background: Surgical treatment of deep-seated tumors such as supratentorial intraventricular and thalamic-pineal-tectal region tumors carries a risk of postoperative deficits due to possible damage to deep cerebral veins including the internal cerebral vein. It is often difficult to identify whether the vessel encountered during surgery needs to be preserved or not through the small operative field. Therefore, preoperative evaluation of deep venous structures is important. We evaluated the usefulness of 3-Tesla magnetic resonance imaging (3 T MRI) for this purpose.Methods: First, the ability to detect deep venous structures was compared with both 3-dimensional computed tomographical angiography (3D-CTA) and 3 T MRI in patients without any damage to deep venous structures. Images of 7 consecutive patients suffering from insuloopercular gliomas who underwent both imaging modes for the identification of lateral striate arteries were reconstructed for evaluation of the deep cerebral veins. Subsequently, surgery for tumors at the supratentorial intraventricular and thalamic-pineal-tectal regions was prospectively performed with preoperative evaluation of deep venous system only using 3 T MRI.Results: Information on the deep venous systems acquired by 3 T MRI was as useful as that acquired by 3D-CTA. Until today, we have treated 8 cases of supratentorial intraventricular and thalamic-pineal-tectal region tumors with preoperative evaluation of the deep venous system using 3 T MRI without any morbidity.Conclusion: Information on the deep venous system obtained with 3 T MRI aids the surgery of supratentorial intraventricular and thalamic-pineal-tectal region tumors. As the required sequences of 3 T MRI are same as those necessary for the neuronavigation system, and 3 T MRI can be achieved without the use of iodine-based contrast agents, 3 T MRI can be an alternative for preoperative evaluation of the deep venous systems.
Background: Intraventricular tumors account for approximately 3% of adult brain tumors and 16% of childhood and adolescent brain tumors. Half of the intraventricular tumors in adults and one quarter of those in children are found in the lateral ventricles. Ependymoma, astrocytoma, oligodendroglioma, choroid plexus papilloma, meningioma and subependymal giant cell astrocytoma are the common tumors encountered at this particular site. A germinoma at this site is rare. Microsurgery of intraventricular tumors can be challenging and is performed with potential functional and cognitive complications.Case Report: A 25-year-old female harboring an intraventricular tumor at the foramen of Monro with resultant obstructive hydrocephalus underwent a right intraventricular endoscopic resection of the tumor by means of frameless neuronavigation guidance and temporary external ventricular drainage. Histology showed the tumor to be a germinoma. The post-operative imaging showed that there was some residual tumor tissue in the fornix. Concerned with possibility of cerebrospinal fluid seeding, we administered postoperative adjuvant craniospinal irradiation. The patient was discharged with a Glascow outcome scale score of 5 and at last the 6-month follow-up there was no evidence of recurrence.Conclusion: This report suggests that in selected cases endoscopic resection of an intraventricular tumor under frameless neuronavigation guidance is feasible and safe. The target can be precisely located and procedure-related adverse events can be minimized.
The cryoprobe device is commonly used by orbital surgeons for the extraction of intraorbital lesions. Cryoprobes provide a safe mechanism to manipulate fluid-filled tumors. Such lesions can present in locations in which intraoperative neurosurgical assistance is essential. The authors describe a technique whereby removal of an orbital hemangioma was facilitated by the aid of an endoscopic, transnasal cryoprobe while standard microsurgical dissection was performed concurrently via a transconjunctival approach.
Introduction: The shunt operation remains the standard procedure for the treatment of hydrocephalus. We describe a simple minilaparotomy method that involves perforation of the peritoneum with the surgeon's little finger.Technique: After placing a small paraumbilical incision at the skin and fascia, the little finger is introduced through the incision to perforate the pre-peritoneal fat and peritoneum. The finger should be inserted at a 30-45 degrees angle to the horizontal plane to avoid injuring the underlying viscera and major blood vessels and to put sufficient shear force on the peritoneum. A catheter is inserted into the abdominal cavity after visual confirmation of proper perforation.Conclusion: As the paraumbilical wound is not noticeable postoperatively due to the presence of the natural umbilical skin fold, this method yields a cosmetically appealing result.
BACKGROUND:The main purpose of this project is to define the major indications, preferences, techniques, limitations, and complications associated with intraventricular tumor removal using purely endoscopic techniques. METHODS:Published papers on neuroendoscopy were reviewed, and a questionnaire about purely endoscopic surgery for intraventricular brain tumors was designed. The questionnaire included details regarding neuroendoscopic techniques, surgeons' endoscopic experience, and clinical vignettes. 20 experienced neuroendoscopists from the 10 represented countries were surveyed. RESULTS:15 physicians (75%) responded to the survey, having an estimated 264 cumulative years of endoscopic experience. There was general agreement regarding: the instrumentation used, endoscope features, irrigation, technique of colloid cyst and solid intraventricular tumor removal, complications, future technologies, and the treatment of sample clinical vignettes. There was appreciable variability in endoscope control preferences. CONCLUSIONS:Endoscopic intraventricular surgery is a feasible minimally invasive alternative to open transcranial surgery for specific ventricular tumors. With the currently available instrumentation, the technique can be applied to small avascular solid intraventriclular tumors and colloid cysts of the third ventricle. The majority of the complications are based on hemostasis potential. The development of compatible instrumentation with an enhanced ability for solid tumor removal and more adequate hemostasis appear to be the principle limitations in furthering the technique of endoscopic removal of intraventricular brain tumors.
INTRODUCTION:Intracranial subdural empyema (ISDE) is a life-threatening intracranial infection. Early and precise detection, timely surgery, and appropriate antibiotic therapy are the keys to a more favorable clinical outcome. Treatment is aimed at complete evacuation of the empyema and eradication of the source of infection. However, in the case of elderly patients or patients with poor health, doctors hesitate to perform open cranial surgery under general anesthesia; thus, the choice of appropriate surgical method is fraught with many limitations.CASE REPORT:We present a case of ISDE in a 92-year-old woman who was successfully treated with continuous irrigation of the subdural space with antibiotics and drainage through 2 burr holes for 1 week without any complications.CONCLUSION:Continuous subdural irrigation is useful for the evacuation of pus and eradication of the source of infection, thereby resulting in a favorable outcome, especially in elderly patients and patients with poor health.
