Endoscopic transnasal odontoidectomy to treat basilar invagination with congenital osseous malformations

PURPOSE

Transoral resection of the odontoid has been accepted as a standard procedure to decompress the cervicomedullary junction during the past several decades. The endoscopic transnasal odontoidectomy is emerging as a feasible surgical alternative to conventional microscopic transoral approach. In this article, we describe several operative nuances and pearls from our experience about this approach, which provided successful decompression.

METHODS

From September 2009 to April 2010, three consecutive patients with basilar invagination, of which the etiology was congenital osseous malformations, underwent endoscopic transnasal odontoidectomy. All patients presented with myelopathy. The last two cases also received occipitocervical fixation and bone fusion during the same surgical episode to ensure stability.

RESULTS

All the patients were extubated after recovery from anesthesia and allowed oral food intake the next day. Cerebrospinal fluid rhinorrhea was found in the second case and cured by continuous lumber drainage of cerebrospinal fluid. No infection was noted. The average follow-up time was more than 24 months. Remarkable neurological recovery was observed postoperative in all patients.

CONCLUSION

The endoscopic transnasal odontoidectomy is a feasible approach for anterior decompression of pathology at the cervicomedullary junction. The advantages over the standard transoral odontoidectomy include elimination of risk of tongue swelling and teeth damaging, improvement of visualization, alleviation of prolonged intubation, reduction of need for enteral tube feeding and less risk of affecting phonation. The minimally invasive access and faster recovery associated with this technique make it a valid alternative for decompression of the ventral side of the cervicomedullary junction.

Endoscopic endonasal resection of symptomatic Rathke cleft cysts

We aimed to retrospectively evaluate the transsphenoidal endoscopic endonasal approach (EEA) for the resection of symptomatic Rathke's cleft cysts (RCC) in 23 patients (11 male, 12 female, average age 43 years). The patients were followed-up for between 3 months and 36 months. Headache was the primary pre-operative symptom (15/23, 65%) and all patients with headache improved after surgery. Seven patients with initial visual symptoms (9/23, 39%) also improved after treatment. Three of the six patients with pre-operative pituitary dysfunction (6/23, 26%) showed post-operative improvement. There was no permanent pituitary dysfunction. One patient developed temporary diabetes insipidus and two patients had a post-operative infection. Three patients had post-operative cerebrospinal fluid leaks, two of which were repaired using the EEA and the other using a lumbar drain. Two patients had recurrent cysts and both patients refused reoperation. We concluded that the EEA is safe and effective in the treatment of symptomatic RCC. Fenestration and aspiration of the cysts with partial excision of the cyst wall is usually sufficient.

Suprasellar hemangioblastoma mimicking a craniopharyngioma: result of extended endoscopic transsphenoidal approach--case report

Hemangioblastoma in the suprasellar region is rare. We present a case of a suprasellar hemangioblastoma that underwent surgical resection using an extended endoscopic transsphenoidal approach. A 64-year-old female patient presented with headache and decreased visual acuity for the last four years, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 2.5 cm irregular lesion in the suprasellar region. Our preoperative presumptive diagnosis was craniopharyngioma. The patient underwent an extended endoscopic transsphenoidal approach, the mass was subtotally removed. An endoscopic endonasal repair was needed due to the cerebrospinal fluid (CSF) leak. However, 1 month later, the patient got disturbance of consciousness because of the hydrocephalus. Ventriculoperitoneal shunt was used to solve the problem. Pathological findings were compatible with hemangioblastoma. Suprasellar hemangioblastoma is very rare. Any highly vascular lesions located in the suprasellar region should alert the surgeon to the possibility of hemangioblastoma. Extended endoscopic transsphenoidal approach adopted by us should not be the first choice of the treatment procedure for this kind of large and vascular tumor.

lncRNA MEG3 inhibits pituitary tumor development by participating in cell proliferation, apoptosis and EMT processes

Pituitary tumors do not pose a threat to life but can cause visual disturbances and serious clinical syndromes, such as infertility and metabolic syndrome. Therefore, screening of key genes involved in the occurrence and development of pituitary tumors can provide new targets for the treatment of pituitary tumors. The aim of the present study was to investigate the molecular mechanism of long non‑coding (lnc.) RNA maternally expressed 3 (MEG3) in cell proliferation, apoptosis and epithelial‑mesenchymal transition (EMT) processes of pituitary tumor. Tissue samples were obtained from 34 patients who underwent surgical treatment of pituitary tumors. Pituitary tumor cells (GH3 and MMQ) were transfected with pcDNA3.1(+)‑MEG3, short hairpin (sh)MEG3, microRNA (miR)‑23‑3p inhibitor or their controls using Lipofectamine^® 2000. Reverse transcription‑quantitative PCR and western blot analyses were used to detect the levels of MEG3, miR‑23b‑3p and FOXO4, as well as proliferation‑, apoptosis‑ and EMT‑associated genes and proteins. Cell Counting Kit‑8 and flow cytometry assays were performed to detect proliferation and apoptosis, and Transwell assay was undertaken to assess invasion and migration. Luciferase reporter and RNA pulldown assays were performed to verify the binding between lncRNA MEG3, miR‑23b‑3p and FOXO4. Pearson's correlation analysis was used to analyze the correlation between expression levels of MEG3, miR‑23b‑3p and FOXO4. lncRNA MEG3 was expressed at lower levels in pituitary tumor tissues and cells. Overexpression of lncRNA MEG3 inhibited proliferation, invasion and migration and accelerated apoptosis of pituitary tumor cells. lncRNA MEG3 negatively regulated miR‑23b‑3p expression levels, while miR‑23b‑3p negatively regulated FOXO4 expression levels. Overexpression of lncRNA MEG3 inhibited the EMT process in pituitary tumor cells. miR‑23‑3p inhibitor rescued the effect of shMEG3 on proliferation, invasion, migration, apoptosis and the EMT process in pituitary tumor cells. lncRNA MEG3 inhibited pituitary tumor development by participating in cell proliferation, apoptosis and the EMT process, which may present a novel target for pituitary tumor treatment.

Anatomical study on Meckel cave with endoscopic endonasal, endo-maxillary sinus, and endo-pterygoid process approaches

Objective

To study anatomical structures related to Meckel cave with endonasal endoscopic approach and to provide an anatomical basis for endoscopic surgery in Meckel cave.

Methods

Meckel cave of 5 adult skulls (10 sides) were fixed with 10% formalin. The anatomical structures of Meckel cave and the related zones adjacent to Meckel cave were observed and measured with endoscopic endonasal approach.

Results

Endoscopic endonasal, endo-maxillary sinus, and endo-pterygoid process approaches were successfully applied in observation of the anatomical structures of meckel cave and the rerated zones adjacent to Meckel cave and in measurement of distances between related anatomical structures for each case of samples. The relevant data were obtained. The distance between the front mouth of palatovaginal canal and vidian canal was 21.4±7 mm, the distance between opening of sphenoid sinus to the upper margin of the choana was 22.3±2.8 mm, the distance between the opening of vidian and foramen rotundum was 7.57±0.7 mm and the length of the pterygoid canal was 13.3±1.2 mm. Based on these data, the positions of the related important structures can be roughly located during surgical operation and various important structures in Meckel cave and its adjacent zones can be found out in a convenient and safe way.

Conclusion

1) It is feasible to use endonasal endoscopic approach to perform surgical operation in Meckel cave; 2) Use of endonasal endoscopic approach can protect and fully take the advantage of the vidian nerve to locate the position of foramina lacerum of the internal carotid artery during surgical operation; and 3) the observational and experimental data obtained with this approach can provide the rational basis for clinical operation procedures.

Nonketotic hyperglycemia-related epileptic seizures

Nonketotic hyperglycemia-related seizures (NKH) are rare. We report a case of NKH-related seizures in a patient following a traumatic brain injury.

Middle Turbinate Mucosal Flap in Endoscopic Skull Base Reconstruction

AIM

To explore the indications, operation techniques and benefits of pedicled middle turbinate mucosal flap in endoscopic skull base reconstruction.

MATERIAL AND METHODS

The patients, who underwent endonasal endoscopic surgery from October 2009 to June 2010 in our department, were involved in this study. Multi-layer skull base reconstruction was performed in four cases by pedicled middle turbinate mucosal flap combined with fascia lata, artificial dura mater, fat and other reconstruction materials. The results of surgery were assessed in the follow-up period.

RESULTS

No reconstruction-associated complications, such as cerebrospinal fluid leakage or infection were observed in four cases during the follow-up period for more than one year. All patients showed excellent recovery.

CONCLUSION

Pedicled middle turbinate mucosal flap for skull base reconstruction has the advantages of fast healing and low incidence of cerebrospinal fluid leakage. It provides satisfactory skull base reconstruction.

Unusual imaging appearance of a huge intracranial dermoid cyst located across the anterior and middle skull base

Intracranial dermoid cysts are rare congenital neoplasms. Typical dermoid cysts are well-circumscribed fat-density masses with no associated contrast enhancement. We report a woman with a dermoid cyst across the anterior and middle skull base of unusual imaging appearance. This report highlights the challenge facing the diagnosis and management of intracranial dermoid cysts with unusual primary imaging findings.

Clinical Research of Early Hyperbaric Oxygen Therapy on Patients with Hypertensive Cerebral Hemorrhage After Craniotomy

AIM

To observe the effect of early hyperbaric oxygen (HBO) therapy on the improvement of consciousness and prognosis of patients with severe brain damages after craniocerebral craniotomy.

MATERIAL AND METHODS

Eighty-one patients who had cerebral hemorrhage and underwent clearance of hematoma and decompressive craniectomy from August 2013 to August 2016 were retrospectively analyzed. The patients were divided into HBO and non-HBO therapy groups. The treatment effects were scored and subjected to corresponding statistical analysis.

RESULTS

There were significant differences in the Glasgow coma scale (GCS) scores at 3 and 5 weeks (t=2.293 and t=3.014, respectively, p < 0.05), and in Glasgow outcome scale (GOS) scores at 5 weeks and 3 months between the two groups (p < 0.05).

CONCLUSION

Early HBO therapy could improve the consciousness and prognosis of patients with cerebral hemorrhage after craniotomy.

Endoscopic endonasal transmaxillary transpterygoid approach to meckel cave: anatomical study and preliminary clinical results

OBJECTIVE

Tumors involving Meckel cave (MC) always present challenges to neurosurgeons. We performed an investigation of the anatomical characteristics of the endoscopic endonasal transmaxillary transpterygoid approach to MC as an alternative to routine transcranial approaches and further confirmed its efficacy in the clinical setting.

METHODS

Five adult fresh head specimens (10 sides) were studied to identify crucial anatomical landmarks and quantify the anatomical structures involved in the endoscopic endonasal transmaxillary transpterygoid approach. Two patients with a tumor involving the left MC were treated using the endoscopic endonasal transmaxillary transpterygoid approach.

RESULTS

The distance from the columella nasi to the choana, the sphenoid ostium, the anterior aperture of the palatosphenoidal canal (PSC), the sphenopalatine foramen, and the anterior aperture of the vidian canal (VC) was 66.5 ± 3.3 mm, 61.2 ± 1.6 mm, 64.6 ± 1.4 mm, 62.8 ± 2.3 mm, and 75.4 ± 3.3 mm, respectively. The distance from the anterior aperture of the VC to the anterior aperture of the PSC and the foramen rotundum (FR) was 2.1 ± 0.7 mm and 7.5 ± 0.7 mm, respectively; the length of the PSC and the VC was 6.4 ± 0.5 mm and 13.3 ± 1.2 mm, respectively. The landmarks of this route included the PSC, the VC, and the paraclival carotid prominence (CP). Subtotal resection and gross total resection were achieved in the first and second patients, respectively.

CONCLUSION

The anatomical landmarks of the endoscopic endonasal transmaxillary transpterygoid route are useful for clinical application. The endoscopic endonasal transmaxillary transpterygoid approach is an effective and minimally invasive route for certain tumors involving MC. Identifying the anatomical landmarks including the PSC, the VC, the FR, and the CP is crucial for safe manipulation.

Intraparenchymal hemorrhage after surgical decompression of an epencephalon arachnoid cyst: A case report

BACKGROUND

This study reports the clinical presentation of intraparenchymal hemorrhage as a rare complication after surgical decompression of an intracranial epencephalon arachnoid cyst (IEAC) at the posterior cranial fossa.

CASE SUMMARY

The clinical information of a patient with an IEAC was reported, and the related literature was reviewed. A female patient with nausea presented to our hospital. Computed tomography demonstrated an IEAC located at the posterior cranial fossa, which was large and required surgical intervention. After operation, postoperative intraparenchymal hemorrhage was detected. She had a good recovery with conservative treatment 1 mo later.

CONCLUSION

Though postoperative intraparenchymal hemorrhage is rare after surgical decompression of an IEAC, more attention should be paid to such a complication.

Image-Guided Endoscopic Endonasal Transmaxillary Transpterygoid Approach to Meckel's Cave

The aim of this report was to summarize our preliminary experience on the resection of tumors located in Meckel's cave via the endoscopic endonasal transmaxillary transpterygoid approach with image-guided system and to investigate the feasibility and efficacy of this approach. Two patients who had tumors in left Meckel's cave underwent surgical treatment using the image-guided endoscopic endonasal transmaxillary transpterygoid approach. This particular technique has advantages of no brain retraction, direct vision of tumor resection and protection of surrounding neurovascular structures. Neuronavigation increases the safety of the endoscopic approach.

Clinical Study of Dexmedetomidine in Combination with Butorphanol for the Treatment of Traumatic Brain Injury (TBI)

AIM

To explore whether the combination of dexmedetomidine (Dex) and butorphanol (But) could benefit patients with traumatic brain injury (TBI).

MATERIAL AND METHODS

A total of 208 TBI patients admitted from February 2018 to January 2020 were randomly divided into four groups as follows: control group (A), Dex group (B), But group (C), and combination of dexmedetomidine and butorphanol group (D). Four groups of patients were treated and studied clinically. Statistical analysis was performed to assess the changes in signs of life, oxygen saturation, serum neuroendocrine data, pain, and agitation scores.

RESULTS

The statistical data of signs of life and blood oxygen saturation of the four groups were compared, and the differences between group A and group D were statistically significant (p < 0.05), indicating that a combination of sedative and analgesic agents at low doses could improve the signs of life of TBI patients, and the safety was relatively good. The Glasgow Coma Scale (GCS) score of the group D on the 5th day post-surgery was improved compared with the control group (A group), suggesting that the combination of sedative and analgesic agents could improve patients' consciousness. The neuroendocrine data of the combination group showed little fluctuation, indicating that a combination of sedative and analgesic agents could significantly reduce the stress response. The scores of pain and agitation in the combination group were significantly improved on the 3rd and 5th days, suggesting that the combination group was better compared with the control group.

CONCLUSION

The combination of Dex and But was more stable for the treatment of vital signs. Compared with the individual treatment groups, the patients in the combination group had a rapid improvement. The time from treatment to stabilization was shortened, and the prognosis was significantly better compared with the control group. A combination of Dex and But at low doses could significantly maintain neuroendocrine stability. Meanwhile, a combination of sedative and analgesic agents had obvious synergistic effects on enhancing sedation and analgesia as well as anti-muscle tension. Collectively, the combination of Dex and But could significantly benefit the prognosis of TBI.

Case Report: Endoscopic trans-cerebellar medullary fissure approach for the management of brainstem hemorrhage

OBJECTIVE

Brainstem hematoma (BSH) is a high-risk condition that can lead to deadly and disabling consequences if not properly managed. However, recent advances in endoscopic techniques, employed for removing supratentorial intracerebral hemorrhage have shown significant improvements in operative morbidity and mortality rates compared to other approaches. In this study, we demonstrate the utility and feasibility of the endoscopic trans-cerebellar medullary fissure approach for the management of brain stem hemorrhage in carefully selected patients.

PATIENTS AND METHODS

A 55-year-old man presented to the emergency department in a comatose state with respiratory distress. A CT scan revealed the presence of a brainstem hemorrhage. Given the location of the hemorrhage and the need to quickly manage the associated developmental obstructive hydrocephalus and respiratory distress, an endoscopic trans-cerebellar medullary fissure approach was chosen as the most appropriate method of treatment.

RESULTS

Total resection was achieved, and the patient gradually improved postoperatively with no new neurological deficits. He is currently under routine follow-up and is conscious but has partial hemiplegia.

CONCLUSION

This approach provided direct visualization of the lesion and was minimally invasive. The endoscopic trans-cerebellar medullary fissure approach may be considered an alternative to open approaches for brainstem hemorrhage in carefully selected patients.

Positioning and design by computed tomography imaging in neuroendoscopic surgery of patients with chronic subdural hematoma

BACKGROUND

Neuroendoscopy is a very useful technique to Chronic Subdural Hematoma (CSH). But how to achieve the goal of treatment more minimally invasive?

AIM

To develop a simple, fast and accurate preoperative planning method in our way for endoscopic surgery of patients with CSH.

METHODS

From June 2018 to May 2020, forty-two patients with CSH, admitted to our hospital, were performed endoscopic minimally invasive surgery; computed tomography (CT) imaging was employed to locate the intracerebral hematoma and select the appropriate endoscopic approach before the endoscopic surgery. The clinical data and treatment efficacy were analyzed.

RESULTS

According to the learning of CT scanning images, the surgeon can accurately design the best minimally invasive neuroendoscopic surgical approach and realize the precise positioning and design of the drilling site of the skull and the size of the bone window, so as to provide the most effective operation space with the smallest bone window. In this group, the average operation time was only about 1 h, and the clearance rate of hematoma was about 95%.

CONCLUSION

Patients with CSH can achieve good therapeutic effect by using our way to positioning and design to assist the operation of CSH according to CT scan and image, and our way is very useful and necessary.

Comparison of the efficacy of neuronavigation-assisted intracerebral hematoma puncture and drainage with neuroendoscopic hematoma removal in treatment of hypertensive cerebral hemorrhage

OBJECTIVE

To compare neuronavigation-assisted intracerebral hematoma puncture and drainage with neuroendoscopic hematoma removal for treatment of hypertensive cerebral hemorrhage.

METHOD

Ninety-one patients with hypertensive cerebral hemorrhage admitted to our neurosurgery department from June 2022 to May 2023 were selected: 47 patients who underwent endoscopic hematoma removal with the aid of neuronavigation in observation Group A and 44 who underwent intracerebral hematoma puncture and drainage in control Group B. The duration of surgery, intraoperative bleeding, hematoma clearance rate, pre- and postoperative GCS score, National Institutes of Health Stroke Scale (NIHSS) score, mRS score and postoperative complications were compared between the two groups.

RESULTS

The duration of surgery, intraoperative bleeding and hematoma clearance were significantly lower in Group B than in Group A (p < 0.05). Conversely, no significant differences in the preoperative, 7-day postoperative, 14-day postoperative or 1-month postoperative GCS or NIHSS scores or the posthealing mRS score were observed between Groups A and B. However, the incidence of postoperative complications was significantly greater in Group B than in Group A (p < 0.05), with the most significant difference in incidence of intracranial infection (p < 0.05).

CONCLUSION

Both neuronavigation-assisted intracerebral hematoma puncture and drainage and neuroendoscopic hematoma removal are effective at improving the outcome of patients with hypertensive cerebral hemorrhage. The disadvantage of neuronavigation is that the incidence of complications is significantly greater than that of other methods; postoperative care and prevention of complications should be strengthened in clinical practice.

Feasibility study on intracranial pressure and prognosis of patients with moderate and severe craniocerebral injury using the Rotterdam computed tomography score: an observational study

Objective

The Rotterdam computed tomography (CT) score was used to evaluate the degree of coma and the prognosis of patients with moderate and severe craniocerebral injury, to analyze its feasibility, and to assess its value in guiding further clinical applications.

Methods

A total of 120 patients with moderate-to-severe craniocerebral injuries were selected as study participants, all of whom were treated at the Department of Neurosurgery of the Second Affiliated Hospital of Nantong University. All 120 patients underwent craniocerebral CT scans. The Glasgow Coma Scale was used to evaluate the degree of coma, and the Glasgow Outcome Scale was used to evaluate prognosis. The Rotterdam CT scores of patients with different degrees of coma and prognoses were compared.

Results

The Rotterdam CT score was significantly lower in patients with moderate coma than in those with severe coma (p < 0.05). The Rotterdam CT score of patients with a good prognosis was significantly lower than that of patients with a poor prognosis (p < 0.05).

Conclusion

The Rotterdam CT score is indicative of the degree of coma in patients with moderate and severe craniocerebral injuries and has prognostic value. The Rotterdam CT score also shows potential for broader clinical application.