Rathke’s cleft cysts: A single-center case series

Background:

Rathke’s cleft cysts (RCCs) are common benign sellar or suprasellar lesions. The aim of this study is to report our experience on the management of 27 RCC cases.

Methods:

We retrospectively analyzed a series of 27 patients with symptomatic RCC who were referred to our department between January 2016 and January 2020. Data regarding patients’ demographics, clinical evaluations, laboratory and neuroimaging findings, pathologic records, surgical treatment, and complications were extracted from our electronic database. All patients underwent RCC removal through a direct endoscopic endonasal transsphenoidal (EETS) approach, except for two cases.

Results:

Data of 27 patients (3 men and 24 women; mean age: 38 years) with symptomatic RCC were reviewed. The most common presenting symptom was headache, occurring in 20 (74.0%) patients. In 16 (59.2%) cases, the tumor was primarily located in the sella turcica. Nine (33.3%) cases exhibited a secondary suprasellar extension.

Conclusion:

Our experience with RCC patients showed that EETS is a safe method of treatment, with minimal recurrence.

The Long Noncoding RNA MEG3 Retains Epithelial-Mesenchymal Transition by Sponging miR-146b-5p to Regulate SLFN5 Expression in Breast Cancer Cells

More and more studies have shown that long noncoding RNAs (lncRNAs) play essential roles in malignant tumors. The lncRNA MEG3 serves as a crucial molecule in breast cancer development, but the specific molecular mechanism needs to be further explored. We previously reported that Schlafen family member 5 (SLFN5) inhibits breast cancer malignant development by regulating epithelial-mesenchymal transition (EMT), invasion, and proliferation/apoptosis. Herein, we demonstrated that MEG3 was downregulated in pan-cancers and correlated with SLFN5 expression positively in breast cancer by bioinformatics analysis of TCGA and UCSC Xena data. Intervention with MEG3 positively affected SLFN5 expression in breast cancer cells. MEG3 repressed EMT and migration/invasion, similar to our previously reported functions of SLFN5 in breast cancer. Through bioinformatics analysis of starBase and LncBase data, 12 miRNAs were found to regulate both SLFN5 and MEG3, in which miR-146b-5p was confirmed to be regulated by MEG3 using MEG3 siRNA and overexpression method. MiR-146b-5p could bind to both SLFN5 3′UTR and MEG3, and inhibit their expression in a competing endogenous RNA mechanism, assayed by luciferase reporter and RNA pull down methods. Therefore, we conclude that MEG3 positively modulates SLFN5 expression by sponging miR-146b-5p and inhibits breast cancer development.

Consideration for Hemiballismus in the Differential Diagnosis: A Rare Case of Hyperosmolar Hyperglycemic State

We present a case of a 58-year-old male with a past medical history of hypertension and diabetes mellitus presenting to the emergency department with a complaint of abnormal and uncontrollable right arm jerking motions occurring since the afternoon on the day prior to presentation. Arm movements such as these may be consistent with either focal seizures or hemiballismus, a movement disorder classified as a choreiform subtype consisting of involuntary violent movements of an extremity with wide amplitudes. Although oftentimes focal seizures and hemiballismus are associated with neurologic etiologies such as strokes, the second most common cause of hemiballismus appears to be non-ketotic hyperosmolar hyperglycemia. While symptomatic treatment in managing focal seizures and hemiballismus may consist of benzodiazepines and dopamine receptor antagonists, respectively, it is important to treat the underlying cause, which in this case was the non-ketotic hyperosmolar hyperglycemic state associated with this patient’s long-standing history of poorly controlled diabetes mellitus.

The endoscopic transnasal approach to the lesions of the craniocervical junction: two case reports

The endoscopic endonasal approach (EEA) to the craniovertebral junction (CVJ) has recently been considered a safer alternative and less invasive approach than the traditional transoral approach because the complications associated with the latter are avoided or minimized. Here, we present two challenging cases of CVJ pathologies. The first case involved os odontoideum associated with anterior displacement of the occipitocervical junction where the EEA was used, followed by C0-C1-C2 fusion using a posterior approach to decompress the CVJ, and was complicated by rhinorrhea and Candida albicans meningitis. The second case involved basilar invagination with syringomyelia previously treated using a posterior approach, where aggravation of neuropathic symptoms required combined treatment with EEA and occipitocervical fusion of C0-C2-C3-C4, with the postoperative course challenged by operative site infection requiring drainage with debridement and antibiotic therapy. The EEA is an alternative approach for accessing the CVJ in well-selected patients. Knowledge of EEA complications is crucial for the optimal care of patients.

The FOXO family of transcription factors: key molecular players in gastric cancer

Gastric cancer (GC) is the fifth most frequently diagnosed cancer worldwide and the third leading cause of cancer-related death with an oncological origin. Despite its decline in incidence and mortality in recent years, GC remains a global public problem that seriously threatens patients' health and lives. The forkhead box O proteins (FOXOs) are a family of evolutionarily conserved transcription factors (TFs) with crucial roles in cell fate decisions. In mammals, the FOXO family consists of four members FOXO1, 3a, 4, and 6. FOXOs play crucial roles in a variety of biological processes, such as development, metabolism, and stem cell maintenance, by regulating the expression of their target genes in space and time. An accumulating amount of evidence has shown that the dysregulation of FOXOs is involved in GC progression by affecting multiple cellular processes, including proliferation, apoptosis, invasion, metastasis, cell cycle progression, carcinogenesis, and resistance to chemotherapeutic drugs. In this review, we systematically summarize the recent findings on the regulatory mechanisms of FOXO family expression and activity and elucidate its roles in GC progression. Moreover, we also highlight the clinical implications of FOXOs in GC treatment.

The Quadrangular Space, Endonasal Access to the Meckel Cave: Technical Considerations and Clinical Series

OBJECTIVE

An anteromedial corridor via an expanded endoscopic endonasal approach to the Meckel cave (MC) was described more than a decade ago. However, few clinical series or endoscopic endonasal technical contributions exist concerning this type of approach to this complex region.

METHODS

We present a detailed description of the surgical technique for this approach reviewing the original technique and adding clarifying conceptual notions. We conducted a multicenter retrospective study selecting patients who underwent endonasal endoscopic surgery for lesions exclusively limited to the MC in the past 6 years. Intraoperative and postoperative complications were analyzed. The study of 10 cadaveric specimens provides additional information.

RESULTS

We performed a fully endoscopic anteromedial corridor to the MC in 18 patients. The most prevalent pathologic finding was schwannoma of the V nerve in 4 patients. Sixth cranial nerve palsy (13 patients) and trigeminal dysfunction (10 patients) were the predominant preoperative clinical signs. There were no remarkable intraoperative complications. Corneal keratopathy caused by dry eye syndrome affected 3 patients and V2 residual neuralgia appeared postoperatively in 2 patients. Six patients recovered from sixth cranial nerve palsy, and 2 showed improvement in preoperatively referred facial pain.

CONCLUSIONS

The front door to the MC via the endonasal anteromedial corridor could be a good option. Understanding of the anatomy and the concept of the quadrangular space is crucial to performing this technique safely, which has few complications in experienced hands. Recovery from sixth nerve palsy is possible with this approach. Corneal keratopathy in these patients is a potential complication.

Recent advancements in the molecular biology of pituitary adenomas

INTRODUCTION

Pituitary adenomas are a common and diverse group of intracranial tumors arising from the anterior pituitary that are usually slow-growing and benign, but still pose a significant healthcare burden to patients. Additionally, they are increasing in both incidence and prevalence, leading to a need for better understanding of molecular changes in the development of these tumors.

AREAS COVERED

A PubMed literature search was conducted using the terms 'pituitary adenoma' in combination with keywords related to secretory subtype: lactotroph, somatotroph, corticotroph, gonadotroph and null cell, in addition to their transcription factor expression: PIT1, TPIT, and SF-1. Articles resulting from this search were analyzed, as well as relevant articles cited as their references. In this review, we highlight recent advances in the genetic and epigenetic characterization of individual pituitary adenoma subtypes and the effect it may have on guiding future clinical treatment of these tumors.

EXPERT OPINION

Understanding the molecular biology of pituitary adenomas is a fundamental step toward advancing the treatment of these tumors. Yet crucial knowledge gaps exist in our understanding of the underlying molecular biology of pituitary adenomas which can potentially be addressed by turning to differentially activated molecular pathways in tumor relative to normal gland.

The Effect of Hemoglobin Concentration on Hyperbaric Oxygen and Non-hyperbaric Oxygen in the Treatment of Hypertensive Intracerebral Hemorrhage After Operation at the High Altitude

Background

The prognosis of hypertensive intracerebral hemorrhage (HICH) is poor at high altitudes. The objective of this study was to explore whether hyperbaric oxygen (HBO) can improve the results of computed tomography perfusion (CTP) imaging and the neurological function of patients with HICH, and influence the hemoglobin concentration.

Method

The patients with HICH were treated with puncture and drainage. Twenty-one patients (51.22% of 41 patients in total) were treated with HBO after the operation, and the other patients received conventional treatment. CTP was performed twice, and all indices were measured. Scatter plots were used to determine the effect of hemoglobin concentration on CTP imaging. Receiver operating characteristic (ROC) curves were plotted to analyze the effects of hemoglobin concentration and hematoma volume on recovery results. The patients were followed up for 6 months.

Results

Forty-one patients with HICH were treated with puncture and drainage. In total, 21 were treated with HBO after the operation, and 20 received conventional treatment as the control group. No significant differences in the CBV and CBF values of the two groups were noted before treatment. After 10 days, the values of CBV and CBF in the HBO group were significantly higher than those in the control group. A scatter diagram showed there was no significant in the HBO group, but significant correlation for the CBV and CBF values in the control group’s hematoma center and margin. The ROC curves showed that hematoma volume had an influence on prognosis of the control group. The Glasgow Coma Scale (GOS) scores of the HBO group were significantly higher than those of the control group (p < 0.05).

Conclusions

HBO therapy can improve the postoperative CBV and CBF values of patients with HICH and ameliorate their prognoses. There was no significant correlation between HBO group and hemoglobin concentration on admission.

Analysis of the Therapeutic Effect and Prognostic Factors of 126 Patients With Hypertensive Cerebral Hemorrhage Treated by Soft-Channel Minimally Invasive Puncture and Drainage

Background

Surgery is the main method for the clinical treatment of hypertensive cerebral hemorrhage. Traditional craniotomy faces the disadvantages of the long operation time, easy to cause secondary injury to patients during the operation, and prone to infection after the operation, which is not conducive to the rehabilitation of patients. At present, it is urgent to find a surgical scheme, which can clear hematoma in time, protect brain tissue, and effectively reduce surgical trauma in the clinic.

Materials and Methods

The case database of our hospital was consulted, and the clinical data of patients with hypertensive intracerebral hemorrhage (HICH) treated with soft channel minimally invasive puncture and drainage from February 2018 to October 2021 were retrospectively analyzed. Patients were evaluated for efficacy, and the changes in serum C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), homocysteine (Hcy), endothelin (ET), and vasopressin (AVP) levels before surgery, 3 days after surgery, and 7 days after surgery were analyzed. Clinical data were collected and Logistic regression was used to analyze the prognostic factors.

Results

Finally, according to the inclusion and exclusion criteria, 126 patients were selected as the research object. Among them, there were 24 cases (19.05%) of recovery, 47 cases (37.30%) of markedly effective, 34 cases (26.98%) of effective, 11 cases (8.73%) of ineffective, and 10 cases (7.94%) of death. The total effective rate was 83.33%. The hematoma was basically removed in 116 cases (92.06%). The average evacuation time of hematoma was (7.82 ± 1.63) days. Post-operative intracranial infection occurred in 2 cases (1.59%) and post-operative rebleeding occurred in 5 cases (3.97%). The average hospital stay was (34.16 ± 16.59) days. Serum CRP, TNF-α, IL-6, Hcy, ET, and AVP levels of all patients on the third and seventh days after surgery were lower than those before surgery, and those on the seventh day after surgery were lower than those on the third day after surgery (p < 0.05). The differences in pre-operative Glasgow Coma Scale (GCS) score, bleeding volume, ventricular rupture, complicated cerebral hernia, and attack time to surgery between the good prognosis group and the bad prognosis group were statistically significant (p < 0.05). Pre-operative GCS score, bleeding volume, ventricular rupture, complicated cerebral hernia, and onset time to surgery were all independent factors that affect the prognosis of patients (p < 0.05).

Conclusion

Soft-channel minimally invasive puncture and drainage treatment of HICH has a significant effect, which is conducive to the complete removal of hematoma, reducing hospitalization time, while adjusting the balance and stability of various cytokines, and improving patient prognosis. Pre-operative GCS score, bleeding volume, rupture into the ventricle, complicated cerebral hernia, and time from onset to operation are all independent factors that affect the prognosis of patients.

Surgical outcomes and quality of life in Rathke's cleft cysts undergoing endoscopic transsphenoidal resection: a multicentre study and systematic review of the literature

OBJECTIVE

To establish the effect of endoscopic endonasal surgery (EES) on quality-of-life (QoL) in symptomatic Rathke cleft cyst (RCC).

METHODS

Analysis of 38 patients with RCC treated by EES, with regular overall (ASBQ-35) and sinonasal-specific (SNOT-22) QoL assessment during the first postoperative year. A systematic literature review of large case series was performed with pooled analysis.

RESULTS

In our series, mean age was 53.6 years with a female predominance (73.7%). Larger cysts were seen in males (p < 0.01), those with hypogonadism (p = 0.04), and visual dysfunction (p = 0.04). Complete normalisation of vision was seen in 83.3%. Persistence of visual dysfunction postoperatively was associated with diabetes (p = 0.005), hypertension (p = 0.02), suprasellar only location (p = 0.001), and monocular field cut (p = 0.02). Surgery did not significantly effect hormonal function. Sinonasal QoL transiently worsened after surgery, resolving within 3 weeks. A parallel transient worsening of overall QoL normalised by 6 weeks, and remained at preoperative baseline thereafter. These results were comparable to the literature, where 76.4% demonstrated improvement of vision and 13.1% had recurrence after treatment. There was no significant difference in outcomes between EES and microscopic approaches.

CONCLUSIONS

We report longitudinal QoL outcomes in RCC for the first time. Vision commonly improves with surgery, but endocrinopathy is likely to persist. Microvascular risk-factors may compromise visual improvement. Surgery causes a transient worsening of sinonasal symptoms that resolves within 3-6 weeks, but patients may not experience significant improvement in QoL within the first postoperative year.

Epileptic manifestations, pathophysiology, and imaging characteristics of non-ketotic hyperglycaemia: a review of the literature and a report of two cases with irreversible cortical vision loss

The purpose of this review is to create more awareness regarding the epileptic manifestations of non-ketotic hyperglycaemia, which are not widely recognised, and to assist understanding of the pathophysiology involved. Given that type II diabetes is one of the common causes of morbidity worldwide, it is important to appreciate the various neurological manifestations of non-ketotic hyperglycaemia.Here, I present two cases and review the existing literature. Both patients developed irreversible vision loss, which is a novel finding because only transient visual defects have previously been reported. The review includes a detailed discussion of the pathophysiology and characteristic magnetic resonance imaging (MRI) findings of patients with defects in cerebral lobar regions, which were associated with a variety of clinical manifestations. These manifestations can be ascribed to epileptic phenomena involving various parts of the cerebrum.Hyperglycaemia can lead to the irreversible loss of vision. Early diagnosis and treatment on the basis of the clinical features and characteristic MRI findings are important to avoid an epilepsia partialis continua-like state and irreversible visual impairment.

Reverse Trans-Sellar Neuroendoscopic Management of a Large Rathke's Cleft Cyst Causing Obstructive Hydrocephalus: A Case Report

Symptomatic Rathke’s cleft cysts (RCCs) can be treated by surgical procedures, usually through an endonasal transsphenoidal corridor using either a microscope or an endoscope. We report a large suprasellar extended RCC causing obstructive hydrocephalus, which was efficiently managed by a novel surgical route named “reverse” trans-sellar approach using transventricular neuroendoscopy. A 48-year-old woman complained of persistent headache and a tendency to fall that had begun 6 months previously. The images obtained from MRI scan showed intra- and supra-sellar cystic masses occupying the third ventricle with obstruction of the foramina of Monro and the aqueduct of Sylvius. The cystic wall showed a slight enhancement, and the cystic contents showed iso-signal intensity on T1-and T2-weighted images. Instead of trans-nasal trans-sellar surgery, we decided to operate using a conventional transventricular endoscope. A thin cystic capsule, which blocked the foramina of Monro and the aqueduct of Sylvius, was fenestrated and removed and a third ventriculostomy was performed. The defect in the infundibulum between sellar and suprasellar cysts was widened and used as a corridor to drain cystic contents (reverse trans-sellar route). The final pathological finding revealed an RCC with focal metaplasia. We efficiently managed a large RCC by transventricular neuroendoscopic surgery with cyst fenestration and third ventriculostomy and simultaneously drained the sellar contents using a novel surgical route. Reverse trans-sellar neuroendoscopic surgery is a relevant treatment option for selective patients with large suprasellar extensions of RCCs.

Long-Term Outcomes of Endoscopic Cyst Fenestration for Rathke Cleft Cyst

OBJECTIVE

We sought to elucidate the long-term surgical outcomes and incidence of recurrence and reoperation of endoscopic endonasal cyst fenestration for Rathke cleft cyst (RCC).

METHODS

A retrospective review of the chart and operation record of RCC surgical cases between January 2008 and August 2021 at our institution was conducted. Patient characteristics, intraoperative findings, and postoperative follow-up outcomes were evaluated.

RESULTS

A total of 27 patients were analyzed, with a median postoperative follow-up period of 52 months (range, 1-150 months). Preoperative symptoms were visual dysfunction (59%), headache (41%), and pituitary dysfunction (22%). Endoscopic cyst fenestration was performed in all patients. Ten (37%) patients had intraoperative cerebrospinal fluid leakage. Among them, the only patient in whom sellar floor reconstruction was not performed experienced a repair operation due to postoperative cerebrospinal fluid leakage. No patients experienced postoperative hypopituitarism. Preoperative headache, visual dysfunction, and pituitary hormone disorder improved in 73%, 75%, and 67% of patients, respectively. Although postoperative cyst regrowth was observed in 8 patients (30%), no patient experienced worsening or novel symptoms and none required reoperation.

CONCLUSIONS

Patients with a symptomatic RCC can be effectively treated with endoscopic endonasal cyst fenestration. Reversal of the presenting symptoms resulted, including headache, visual dysfunction, and pituitary hormone dysfunction, in the majority of patients. In our series, appropriate reconstruction of the sellar floor reduced the risk of postoperative cerebrospinal fluid leakage without impacting cyst regrowth. This simple technique appears to effectively disrupt cyst progression in most cases, even after a relatively long-term follow-up period.

Epileptic seizures during Non-Ketotic Hyperglycemia (NKH) in French Guiana: A retrospective study

INTRODUCTION

Epileptic seizures during non-ketotic hyperglycemia (NKH) represent a rare complication of uncontrolled diabetes mellitus. The definition associates a blood sugar level > 200mg/dL (11mmol/L), hyperosmolality, absence of ketosis, dehydration and seizure control after normalization of blood sugar levels.

MATERIAL AND METHODS

This retrospective observational study included patients hospitalized for epileptic seizures and NKH in the Cayenne Hospital Center between January 2010 and June 2020. The clinical, biological, and radiological results were collected.

RESULTS

18 out of 228 (7.9%) patients with both diabetes and epileptic seizures had NKH. The mean age of the 12 women and 6 men was 64.8 years. In 8 patients, brain imaging did not show acute lesions and the seizures disappeared with control of hyperglycemia by hydration and insulin. In 6 patients, the seizures revealed a stroke, hemorrhagic in 4 cases, ischemic in 2 cases. 4 patients had a seizure in a context of known vascular epilepsy. The epileptic seizures were mainly focal seizures with motor symptoms that could be repeated, focal to bilateral tonic-clonic or focal status.

CONCLUSION

Seizures in NKH are symptomatic of an acute brain lesion or vascular epilepsy more than 1 in 2 times. However, isolated NKH can cause seizures with a suggestive brain MRI.

LncRNA HLA-F-AS1 Enhances the Migration, Invasion and Apoptosis of Glioblastoma Cells by Targeting lncRNA MEG3

Background

Previous studies revealed the oncogenic role of long non-coding RNA (lncRNA) HLA-F-AS1 in colon cancer and breast cancer, while its role in other cancers is unclear. We predicted the direct interaction between HLA-F-AS1 and MEG3, which is a tumor suppressor lncRNA. We then assessed the interaction between HLA-F-AS1 and MEG3 in glioblastoma (GBM).

Methods

The expression levels of HLA-F-AS1 and MEG3 in GBM and paired non-tumor tissues from 60 GBM patients were analyzed by RT-qPCR. Overexpression of HLA-F-AS1 and MEG3 was achieved in GBM cells to explore the interaction between them. The direct interaction between them was confirmed by RNA pull-down assay. The roles of HLA-F-AS1 and MEG3 in cell invasion, migration and apoptosis were explored by Transwell assays and cell apoptosis assay.

Results

HLA-F-AS1 was highly expressed, and MEG3 was downregulated in GBM. Overexpression of HLA-F-AS1 reduced the expression levels of MEG3 while overexpression of MEG3 did not alter the expression of HLA-F-AS1. HLA-F-AS1 increased cell migration and invasion, but decreased cell apoptosis. MEG3 played opposite roles and reduced the effects of HLA-F-AS1 on cell behaviors.

Conclusion

HLA-F-AS1 may sponge MEG3 in GBM cells to promote cell invasion and migration, and to suppress cell apoptosis.

The Emerging Role of Non-Coding RNAs in Pituitary Gland Tumors and Meningioma

Long non-coding RNAs (lncRNAs), microRNAs (miRNAs), and circular RNAs (circRNAs) are non-coding transcripts which are involved in the pathogenesis of pituitary gland tumors. LncRNAs that participate in the pathogenesis of pituitary gland tumors mainly serve as sponges for miRNAs. CLRN1-AS1/miR-217, XIST/miR-424-5p, H19/miR-93a, LINC00473/miR-502-3p, SNHG7/miR-449a, MEG8/miR-454-3p, MEG3/miR-23b-3p, MEG3/miR-376B-3P, SNHG6/miR-944, PCAT6/miR-139-3p, lncRNA-m433s1/miR-433, TUG1/miR-187-3p, SNHG1/miR-187-3p, SNHG1/miR-302, SNHG1/miR-372, SNHG1/miR-373, and SNHG1/miR-520 are identified lncRNA/miRNA pairs that are involved in this process. Hsa_circ_0001368 and circOMA1 are two examples of circRNAs that contribute to the pathogenesis of pituitary gland tumors. Meanwhile, SNHG1, LINC00702, LINC00460, and MEG3 have been found to partake in the pathogenesis of meningioma. In the current review, we describe the role of non-coding RNAs in two types of brain tumors, i.e., pituitary tumors and meningioma.

Biomechanical evaluation of the craniovertebral junction after odontoidectomy with anterior C1 arch preservation: A finite element study

OBJECTIVE

Odontoidectomy with preservation of the anterior C1 arch can be increasingly achieved by an endoscopic endonasal approach. It is controversial whether preservation of the anterior C1 arch after odontoidectomy can prevent instability of the craniovertebral junction （CVJ） and avoid posterior fixation. The aim of this research was to investigate the biomechanical effect of the preserved anterior C1 arch after odontoidectomy.

METHODS

A validated finite element model of a whole cervical spine (occipital bone to T1) was constructed to study the biomechanical changes due to traditional odontoidectomy (TO) and odontoidectomy with preservation of the anterior C1 arch (OPC1).

RESULTS

The greatest biomechanical changes in the cervical spine model after TO and OPC1 occurred at C0-C1 and C1-C2. At C0-C1 and C1-C2, the motion changes of the TO and OPC1 models had no significant difference in flexion, extension and lateral bending. Compared with the intact model, motion increases of the two surgical models were both extremely significant at C1-C2 in extension (128.2% vs. 128.1%) and lateral bending (178% vs. 156%). In axial rotation, the TO approach produced more motions than the OPC1 approach, especially at C1-C2(90.3° under TO approach, and 74.6° under OPC1 approach).

CONCLUSIONS

Preservation of the anterior C1 arch after odontoidectomy can preserve the axial rotational motion at C0-C1 and C1-C2, whereas the motions in extension and lateral bending continue to have an extremely abnormal increase at C1-C2. Thus, instability of the CVJ still exists, and posterior internal fixation may also be required after OPC1.

The rhinopharyngeal flap for reconstruction of lower clival and craniovertebral junction defects

OBJECTIVE

The endoscopic endonasal approach (EEA) to the lower clivus and craniovertebral junction (CVJ) has been traditionally performed via resection of the nasopharyngeal soft tissues. Alternatively, an inferiorly based rhinopharyngeal (RP) flap (RPF) can be dissected to help reconstruct the postoperative defect and separate it from the oropharynx. To date, there is no evidence regarding the viability and potential clinical impact of the RPF. The aim of this study was to assess RPF viability and its impact on clinical outcome.

METHODS

A retrospective cohort of 60 patients who underwent EEA to the lower clivus and CVJ was studied. The RPF was used in 30 patients (RPF group), and the nasopharyngeal soft tissues were resected in 30 patients (control group).

RESULTS

Chordoma was the most common surgical indication in both groups (47% in the RPF group vs 63% in the control group, p = 0.313), followed by odontoid pannus (20% in the RPF group vs 10%, p = 0.313). The two groups did not significantly differ in terms of extent of tumor (p = 0.271), intraoperative CSF leak (p = 0.438), and skull base reconstruction techniques other than the RPF (nasoseptal flap, p = 0.301; fascia lata, p = 0.791; inlay graft, p = 0.793; and prophylactic lumbar drain, p = 0.781). Postoperative soft-tissue enhancement covering the lower clivus and CVJ observed on MRI was significantly higher in the RPF group (100% vs 26%, p < 0.001). The RPF group had a significantly lower rate of nasoseptal flap necrosis (3% vs 20%, p = 0.044) and surgical site infection (3% vs 27%, p = 0.026) while having similar rates of postoperative CSF leakage (17% in the RPF group vs 20%, p = 0.739) and meningitis (7% in the RPF group vs 17%, p = 0.424). Oropharyngeal bacterial flora dominated the infections in the control group but not those in the RPF group, suggesting that the RPF acted as a barrier between the nasopharynx and oropharynx.

CONCLUSIONS

The RPF provides viable vascularized tissue coverage to the lower clivus and CVJ. Its use was associated with decreased rates of nasoseptal flap necrosis and local infection, likely due to separation from the oropharynx.

Endoscopic Endonasal Resection of Symptomatic Rathke Cleft Cysts: Total Resection or Partial Resection

Objective: Rathke cleft cysts (RCC) are benign sellar lesions, and endoscopic endonasal surgery (EES) for symptomatic RCC is becoming increasingly popular, but total resection or partial resection (TR or PR) of the cyst wall is still inconclusive. The aim of this study was to review the complications and clinical prognoses associated with total and partial resection of the cyst wall by EES.

Methods: We retrospectively analyzed a series of 72 patients with symptomatic RCC treated by EES from -January 2011 to June 2019 at Shenzhen University First Affiliated Hospital. For these 72 cases, 30 were treated with TR and 42 were treated with PR. Intra- and post-operative complications and clinical prognosis were investigated.

Results: All 72 patients underwent a pure EES. In the TR group, 10 patients (33.3%) had intraoperative cerebrospinal fluid leakage (CSF leak), three patients (10%) had postoperative CSF leak, eight patients (26.7%) had postoperative diabetes insipidus (DI), eight patients (26.7%) had postoperative electrolyte disturbance, and 12 patients (40%) had temporary hypopituitarism postoperatively. While in the PR group, three patients (7.1%) had intraoperative CSF leak, two patients (4.8%) had postoperative DI, three patients (7.1%) had postoperative electrolyte disturbance, four patients (9.5%) had temporary hypopituitarism postoperatively, and no cases experienced postoperative CSF leak. The intra- and post-operative complications were significantly higher in TR group then PR group (P _{IntraoperativeCSFleak} = 0.004, P _{Post−operativeCSFleak} =0.036, P _TransientDI = 0.008, P _{Temporaryhypopituitarism} = 0.002, P _{Permanenthypopituitarism} = 0.036, P _{Electrolytedisturbance} = 0.023). No significant differences in post-operative improvement and recurrence.

Conclusions: EES is a safe and effective approach for the treatment of symptomatic RCC. Complete sucking out the cyst contents and partial resection of the cyst wall may be sufficient for treatment, and total resection of the cyst wall is associated with a higher incidence of complications.

Preoperative Diagnosis of Suprasellar Hemangioblastoma with Four-Dimensional Computed Tomography Angiography: Case Report and Literature Review

Purpose Our case report presents the first case of suprasellar hemangioblastoma diagnosed preoperatively with dynamic computed tomography angiography (four-dimensional [4D] CTA) in a patient without Von Hippel-Lindau (VHL) disease. We illustrate the imaging characteristics of these exceedingly rare tumors and discuss the role of 4D CTA in confirming this diagnosis and guiding surgical management. Finally, we present a literature review of imaging findings, differential diagnosis, management, and prognosis.

Case A 39-year-old woman known for diabetes mellitus type II and dyslipidemia presented with headache, bitemporal hemianopsia, and mild hyperprolactinemia. Initial diagnosis of suprasellar meningioma separate from pituitary gland was revised to definitive diagnosis of suprasellar hemangioblastoma after 4D CTA.

Conclusion Suprasellar hemangioblastomas are extremely rare, often associated to VHL disease. They present as enhancing as suprasellar mass with prominent intra- and peritumoral vascular flow-voids on magnetic resonance imaging. 4D CTA confirms their vascular nature, demonstrates characteristic rapid shunting with feeding arteries, and enlarged draining veins, and is important in guiding surgical management.

Endonasal Endoscopic Fenestration of Rathke's Cleft Cysts: Whether to Leave the Fenestration Open or Closed?

Introduction  Rathke's cleft cysts (RCC) are generally treated with transsphenoidal fenestration and cyst drainage. If no cerebrospinal fluid (CSF) leak is created, the fenestration can be left open. If CSF is encountered, a watertight closure must be created to prevent postoperative CSF leak, though sellar closure has theoretically been linked with higher recurrence rate. In this study, we investigate the relationship between sellar closure, rate of postoperative CSF leak, and RCC recurrence. Methods  Retrospective review of a prospective database of all endoscopic endonasal RCC fenestrations and cases were divided based on closure. The "open" group included patients who underwent fenestration of the RCC, whereas the "closed" group included patients whose RCC was treated with fat and a rigid buttress ± a nasoseptal flap. The rate of intra- and postoperative CSF leak and radiographic recurrence was determined. Results  The closed group had a higher rate of suprasellar extension (odds ratio [OR]: 8.0, p  = 0.032) and intraoperative CSF leak ( p ≤ 0.001). There were 54.8% intraoperative CSF leaks and no postoperative CSF leaks. Radiologic recurrence rate for the closed group (35.0%) was three times higher than the open group (9.1%; risk ratio [RR] = 3.85, p  = 0.203), but not powered to show significance. None of the radiologic recurrences required reoperation. Conclusion  Maintaining a patent fenestration between an RCC and the sphenoid sinus is important in reducing the rate of radiographic recurrence. Closure of the fenestration may be required to prevent CSF leak. While closure increases the rate of radiographic recurrence, reoperation for recurrent RCC is still an uncommon event.

Bilateral striatum with high-signal intensity on T1-weighted MRI: A case of hemichorea induced by nonketotic hyperglycemia

Hemichorea induced by nonketotic hyperglycemia is a rare complication of diabetes mellitus. Here we present a case of 80-year-old female patient. She had a history of involuntary movement of the left body. Imaging examination showed abnormal signs of bilateral basal ganglia. After relevant treatment was conducted, the patient's hemichorea symptoms were significantly improved. Imaging features of nonketotic hyperglycemia Hemichorea plays a very important role in diagnosing and treatment of this disease. Introduction: Hemichorea refers to the involuntary movements of one or more limbs of the same side. These movements are continuous and irregular, variable amplitude, and usually involve the arms and legs together. Stroke is the most common reason, hyperglycemia is relatively rare. Characteristic imaging findings can be very suggestive of diagnosis, and also closely related to the development of disease. Here we present a case of hemichorea induced by nonketotic hyperglycemia which was confirmed by bilateral abnormal signals of basal ganglia in MRI.

Access to Meckel's cave for biopsies of indeterminate lesions: a systematic review

Accessing Meckel's cave (MC) is surgically challenging. Open approaches are complex and often correlated with high morbidity. Endoscopic approaches emerged in the last decade as feasible alternatives to open approaches, especially for sampling indeterminate lesions. This article first analyses available routes to approach Meckel's cave and presents furthermore an illustrative case. We conducted a systematic review and reported according to the guidelines for preferred reporting items for systematic reviews and meta-analyses (PRISMA). Various surgical approaches identified through the search are evaluated and discussed in detail. Additionally, we report on a case of woman with a lesion in MC, which was accessed through an endoscopic transpterygoid approach subsequently diagnosed as a diffuse large B cell lymphoma. Our search delivered 75 articles that included case reports (n = 21), cadaveric studies (n = 32), clinical articles (n = 16), review of the literatures (n = 3), as well as technical notes (n = 2) and a radiological manuscript (n = 1). Open routes included lateral approaches with many variations, mainly intra- and extradural pterional approaches and anterior petrosal, as well as a retrosigmoid intradural suprameatal and a lateral transorbital approach. Endoscopically, MC was reached via approaches that included transpterygoid, transorbital or infraorbital fissure routes. Percutaneous approaches, e.g. through the foramen ovale, were also described. Multiple surgical approaches to MC are currently available. Their different characteristics as well as individual patient factors, such as clinical history and the localization of the disease, have to be considered when choosing a surgical corridor. Studies included in this review highlight the endonasal endoscopic transpterygoidal technique as an excellent corridor for biopsies in the ventral MC.

Ophthalmic Manifestations of Rathke's Cleft Cyst and Its Association to Radiological Characteristics

PURPOSE

To evaluate the ophthalmic features of Rathke's cleft cyst (RCC) and its association with radiological characteristics.

METHODS

In this retrospective single-center study, patients who showed typical findings suggestive of RCC on magnetic resonance imaging (MRI) and underwent relevant ophthalmic examination were recruited retrospectively. Patients were stratified into two groups according to the presence or absence of ophthalmic symptoms related to RCC. We reviewed patients' demographic information, initial symptoms, endocrinological status, ophthalmic features, and characteristics of MRI. Height, size and location of RCC, as well as the optic chiasm displacement assessed from MRI.

RESULTS

Thirty-three patients (20 women and 13 men) were included in this study from among 335 patients with RCC on MRI. Fifteen patients had ophthalmic manifestation related to the cyst (Ophthalmic group), whereas 18 patients were not (Non-ophthalmic group). Headache was the most common initial symptom (15 patients, 45.5%), followed by visual disturbance (7, 21.2%), diplopia (1, 3.0%), retro-orbital pain (1, 3.0%), galactorrhea (1, 3.0%), and peripheral extremity discomfort (1, 3.0%). In seven asymptomatic patients (21.2%), the lesion was an incidental finding during a regular medical examination. Ophthalmic manifestation included visual field defect (14 patients, 93.3%) and diplopia (1 patient, 6.7%). The height, volume, and the coronal and sagittal displacements were larger in the ophthalmic group (P < .001, all). Eleven patients who manifested ophthalmic symptoms underwent excision surgeries and nine of them (81.8%) experienced visual function improvement.

CONCLUSION

Appropriate ophthalmic examinations are warranted in patients with RCC, and treatment should be actively considered in patients with ophthalmic manifestations.

A 360° Approach to the Craniovertebral Junction in a Cadaveric Laboratory Setting: Historical Insights, Current, and Future Perspectives in a Comparative Study

BACKGROUND

We herein outline the experience matured in our equipped Cranio-Vertebral Junction Laboratory for anatomic dissection.

METHODS

An extreme lateral approach (ELA) was performed on 4 fresh cadavers and submandibular approach was performed on 5. An endoscope and navigation-assisted far lateral approach (FLA) was performed in 5 injected specimens. In these specimens, a transoral approach was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances.

RESULTS

As calculated with neuronavigation, statistically significant differences both in the explored craniocaudal (P = 0.003) and lateral (P = 0.008) distances were observed between the transoral approach and endoscopic endonasal approach. In FLA, neuronavigation facilitated identification and partial removal of the occipital condyle; in one case, during endoscopic intradural exploration, tearing of the emerging roots of the 11th cranial nerve occurred. In ELA, the site where the accessory nerve pierces into the sternocleidomastoid muscle was found at a distance from the tip of the mastoid between 3 and 4 cm.

CONCLUSIONS

During dissections, as in the clinical setting, endoscope and image guidance give the surgeon a constant orientation, increasing the accuracy and the safety of the approach. Nonetheless, the encumbrance of the endoscope could represent a limit in deep and narrow corridors as those running across the craniovertebral junction, especially in "oblique" FLA and ELA, in which the surgical target is often hidden by a delicate tangle of nerves and vessels. Its use appears more suitable and safer in "straight" approaches as transoral and transnasal in which there are no neurovascular structures interposed.

Endoscopic Transnasal Odontoidectomy for Ventral Decompression of the Craniovertebral Junction: Surgical Technique and Clinical Outcome in a Case Series of 19 Patients

BACKGROUND

Abnormalities and pathologies of the craniovertebral junction as well as space-occupying lesions of the odontoid process can result in myelopathy symptoms. A staged procedure with posterior stabilization and anterior transnasal endoscopic decompression is recently considered a less invasive alternative to the transoral approach. We present a considerably large case series focused on the operative technique and the long-term neurological clinical outcome.

OBJECTIVE

To determine the safety and efficacy of odontoidectomy performed via an endoscopic transnasal approach.

METHODS

We retrospectively reviewed all patients treated in our neurosurgical department from January 2009 to January 2020. Demographics, pre- and postoperative clinical status, and operative technique and complications were extracted and analyzed.

RESULTS

In total, 22 transnasal operations were performed in 19 patients from January 2009 to January 2020. All but one patient underwent posterior C1-C2 instrumentation prior to the anterior transnasal computed tomography (CT)-navigated full-endoscopic decompression. The median duration of symptoms before surgery was 3 mo. Complications occurred in 1 patient who died from septic organ failure because of his initial diagnosis of osteomyelitis. Postoperative CT imaging showed sufficient decompression in 16 patients, and 3 patients underwent a transnasal endoscopic re-decompression (16%).

CONCLUSION

Transnasal endoscopic odontoidectomy presents a safe procedure with a satisfying clinical and radiological postoperative outcome.

Vascular pedicled flaps for skull base defect reconstruction

OBJECTIVE

Techniques for reconstruction of skull base defects have advanced greatly since the introduction of the vascular pedicled nasoseptal flap in 2006. The objective of this review is to assess the current state of the field by examining both intranasal and extranasal techniques of vascular pedicled skull base defect repair, their indications and success rates, and novel techniques that are currently under investigation.

METHODS

A review of the literature describing the use of vascular pedicled flaps in skull base defect reconstruction was conducted using PubMed and Google Scholar.

RESULTS

The nasoseptal flap remains the most widely used vascular pedicled flap for endoscopic repair of skull base defects. Its ease of harvest, wide arch of rotation, and high success rates make it a popular choice among surgeons. Several variations including a "rescue" nasopseptal flap have been developed. Other less commonly used pedicled intranasal flaps include the middle turbinate flap and the posterior pedicled inferior turbinate flap. Additionally, several novel vascular pedicled flaps have been developed and tested in small cohorts of patients. Extranasal flaps such as the pericranial flap and the temporoparietal fascia flap are used less frequently than intranasal flaps. However, they remain valuable options for reconstruction in certain situations.

CONCLUSION

Advancements continue to be made in the field of skull base defect reconstruction using vascular pedicled flaps. Though the nasoseptal flap remains the most widely utilized option, additional intranasal techniques continue to be developed and tested to optimize surgical outcomes and patient care.

LEVEL OF EVIDENCE

NA.

Endoscopic endonasal cyst fenestration into the sphenoid sinus using the mucosa coupling method for symptomatic Rathke's cleft cyst: a novel method for maintaining cyst drainage to prevent recurrence

OBJECTIVE

Rathke's cleft cyst (RCC) is a benign cystic lesion with a relatively high incidence of local recurrence that occasionally requires repeat surgery. To prevent recurrence, simple cyst fenestration and drainage of the cyst contents to the sphenoid sinus is recommended, but it occasionally recurs. The authors postulated that obstruction of fenestration is a main cause of recurrence, and they developed a method, named the "mucosa coupling method (MC method)," that maintains persistent drainage. In this method, the RCC epithelium and the mucosa of the sphenoid sinus are connected, which promotes re-epithelialization between the two epithelia, maintaining persistent drainage. The outcome of this method was compared with that of conventional cyst fenestration.

METHODS

In a consecutive series of 40 patients with RCC, the surgical strategy was changed during the study period: from December 2009 to September 2014 (the conventional period), 24 patients were scheduled to be treated using the conventional fenestration method, whereas from September 2014 to September 2017 (the MC period), 16 patients were scheduled to be treated using the MC method. However, because of an intraoperative CSF leak, the fenestration was closed during surgery in 3 patients in the conventional period and 2 in the MC period; therefore, these 5 patients were excluded from the analysis. Twenty-one patients treated with the conventional fenestration method (conventional group) and 14 patients treated with the MC method (MC group) were analyzed. All patients regularly underwent MRI after surgery to detect reaccumulation of cyst contents. The rate of reaccumulation with and without reoperation, visual outcomes, endocrinological outcomes, and postoperative complications were compared between these two groups.

RESULTS

The median follow-up period in all 35 patients was 48.0 months (range 1-96 months), 54.0 months (range 1-96 months) in the conventional group and 35.5 months (range 12-51 months) in the MC group. No reaccumulation was detected on MRI in the 14 patients in the MC group, whereas it was noted in 9 (42.9%) of 21 patients in the conventional group, and 2 of these 9 patients required repeat surgery. There were no significant differences in visual and endocrinological outcomes and complications between these two groups.

CONCLUSIONS

The MC method for RCC is effective for preventing obstruction of cyst fenestration, which contributes to preventing cyst reaccumulation. Furthermore, this method is equivalent to the conventional fenestration method in terms of visual and endocrinological outcomes and the complication rate.

Outcomes of Middle Turbinate Flap in the Reconstruction of Non-tumorous Ventral Skull Base Defects - an Institutional Review

Objective

Middle turbinate (MT) flap, based on the branches of sphenopalatine artery is one of the commonest mucosal flaps used in endoscopic skull base surgery. The objective of this study is to analyze the outcomes of the MT flap in the reconstruction of non-tumorous ventral skull base defects.

Methods

A retrospective review of patients was done from 2010-19. Patients who underwent reconstruction for non-tumorous ventral skull base defects using middle turbinate (MT) flap were included in the study. The parameters assessed include patient demography, primary etiology, site of the defect, size of the defect, graft materials used, outcomes and postoperative complications.

Results

A total of 13 patients who met the study criteria were included. Three (23.07%) of the patients had meningo-encephalocele, while the remaining 10 (76.93%) had CSF fistula. Isolated foveal defect (53.8%) was the most common site involved, followed by isolated cribriform, combined cribriform-foveal and combined foveal-planar defects. Graft materials used were fascia lata, fat and septal cartilage. MT flap was successfully harvested in 11 (84.6%) patients, with successful outcome in 10/11 patients. Hypoplastic MT was present in two patients, who subsequently required Hadad flap for defect closure. No major complications were reported in the postoperative period.

Conclusion

The MT flap is effective in the reconstruction of selective skull base defects. Appropriate surgical technique and expertise are required for successful harvest. Further studies are required to analyze its outcomes in various skull base defects.

Surgical outcomes of posterior occipito-cervical decompression and fusion for basilar invagination: A prospective study

STUDY DESIGN

A Prospective Study.

OBJECTIVE

To assess results of posterior occipito-cervical decompression and fusion operated with intra-operative traction/manipulation and instrumented reduction in cases of Basilar Invagination(BI).

METHODS

Total 22 patients of 8-65 years with diagnosed BI were operated for posterior occipito-cervical fusion by intra-operative traction/manipulation and instrumented reduction. Fusion was done using autologous bone graft taken from iliac crest. Immediate post-operative, first month and then every 3 months' follow-up examination were done for minimum period of 2 years.

RESULTS

22 patients (10 males,12 females) with mean age of 23.9 years having BI were included. 11 patients had C1 occipitalization, 4 had platybasia and 9 had atlanto-axial dislocation (AAD). 1 patient with os odontoideum with kyphotic deformity expired on 4th postoperative day due to respiratory insufficiency (mortality rate 4.54%). Neurological improvement by at least by one grade according to RANAWAT's and/or NURICK'S scale was observed in 17/21 patients (80.95%). 3 patients remained static and 1 had neuro-worsening. Mean mJOA score of 13.14 improved to 16.24. All had reduction of dens below foramen magnum according to McRae, chamberlain line and Ranawat index. Bone graft fused in all patients as confirmed with CT scan and dynamic X-rays. 1 wound dehiscence and 1 asymptomatic implant loosening were seen on follow-up.

CONCLUSION

Surgical treatment of BI with intra-operative traction/manipulation, instrumented reduction and posterior occipito-cervical fusion can achieve good correction of radiology, functional performance and clinical neurology as well as excellent fusion rates without adverse effects of trans-oral surgery.

An alternative path to atrial lesions through a contralateral interhemispheric transfalcine transcingular infra-precuneus approach: A case report

Background:

The surgical management of lesions located in the trigone of the lateral ventricle remains a neurosurgical challenge. Previously described approaches to the atrium include the transtemporal, parietal transcortical, parietal trans intraparietal sulcus, occipital transcingulate, posterior transcallosal, and transfalcine transprecuneus. However, reaching this area specifically through the cingulate cortex below the subparietal sulcus has not been described thus far.

Case Description:

We present here the removal of a left atrial meningioma through a right parietal “contralateral interhemispheric transfalcine transcingular infra-precuneus” approach and compare it with previously described midline approaches to the atrium. To accomplish this, a right parietal craniotomy was performed. After the left subprecuneus cingulate cortex was exposed through a window in the falx, a limited corticotomy was performed, which allowed the tumor to be reached after deepening the bipolar dissection by 8 mm. Postoperative magnetic resonance imaging showed complete resection of the lesion sparing the corpus callosum, forceps major, and sagittal stratum. Although this approach disrupts the posterior cingulate fasciculus, no deficits have been described so far after unilaterally disrupting the posterior cingulate cortex or the posterior part of the cingulate fasciculus. In fact, a thorough postoperative cognitive examination did not show any deficits.

Conclusion:

The “contralateral interhemispheric transfalcine transcingular infra-precuneus” approach combines the advantages of several previously described approaches. Since it conserves the major white matter tracts that surround the atrium and has a shorter attack angle than the contralateral transfalcine transprecuneus approach, we believe that it could be a potentially new alternative path to reach atrial lesions.

A Case Report of Nonketotic Hyperglycemic Seizures: A Diagnostic Dilemma

Nonketotic hyperglycemia (NKH) is a rare but serious complication of uncontrolled diabetes mellitus that occurs acutely with a mortality rate of more than 50%. This condition presents with a clinical syndrome consisting of profound hyperglycemia, hyperosmolality, and dehydration. Infrequently, the patients also present with seizure activity. The most common types of seizures observed in this condition are focal seizures, as opposed to the generalized seizures observed in hypoglycemia-induced seizures. Though various hypotheses tried to explain NKH-induced seizure activity, the actual mechanism remains unknown. The treatment modalities include the management of hyperglycemia and circulatory collapse. However, the role of anti-epileptics is controversial. We herein illustrate an atypical case of focal faciobrachial seizures in a young female patient, which occurred as a rare complication of NKH. A 21-year-old female was admitted with multiple jerking and spasmodic movements of the right upper limb and face, with no significant neurological findings. Past medical history was significant for uncontrolled type 2 diabetes mellitus and multiple episodes of focal seizures. On laboratory examination, serum osmolarity was 309 mOsm/L, blood glucose was 364 mg/dL, HbA1c was 12.1%, and ketone bodies were absent. MRI brain showed large subtle T2 FLAIR (T2-weighted fluid-attenuated inversion recovery) cortical hyperintensities in the left frontal, temporal, parietal, and occipital regions with subcortical hypointense areas. The EEG illustrated a background slowing and generalized spikes, polyspikes, and sharp-wave discharges with post-ictal slowing. The patient's seizures were initially refractory to insulin therapy and resolved with the use of dual anti-epileptics. Thus, to conclude, our case represents a diagnostic dilemma with MRI findings pointing towards NKH as the underlying etiology of focal seizures, with the resolution of seizures only occurring with the addition of anti-epileptics to insulin therapy.

Arterial spin labeling hyperperfusion in seizures associated with non-ketotic hyperglycaemia: is it merely a post-ictal phenomenon?

A 53-year-old chronic uncontrolled diabetic patient presented with one episode of generalized seizures followed by drowsiness and post-ictal confusion. MR imaging at admission revealed left temporal subcortical T2/FLAIR hypointensities with overlying cortical T2/FLAIR hyperintensities and increased perfusion on arterial spin labeling (ASL). Follow-up imaging at 4- and 8-week interval revealed persistent ASL hyperperfusion with significant resolution of conventional MR imaging findings. Delayed persistent ASL hyperperfusion suggests that hyperglycemia-induced increased blood-brain barrier permeability rather than a mere post-ictal phenomenon in non-ketotic hyperglycemia (NKH) and may result in long-term cognitive disturbances.

Parietal interhemispheric transfalcine transtentorial approach for posterior incisural space lesions: from the lab to the operative room

The operative approach to the posterior incisural space is challenging because of its deep location, the surrounding eloquent areas, and the intimate relationship with the deep veins. Several approaches have been proposed to manage the lesions in this region: supratentorial, infratentorial and a combination of them. Brain retraction, injury to the occipital lobe and corpus callosum, and venous bleeding are the principle drawbacks of these routes. We performed anatomical dissection study using 10 embalmed human cadaver specimens injected with colored latex exploring a different route, parietal interhemispheric transfalcine transtentorial (PITT). Then we used a PITT approach on two patients with posterior incisural space (PIS) lesions. The PITT approach led to successful and safe complete removal of PIS lesions in our cases. No complications were reported. The present approach could be a valuable option in case of PIS lesions, especially those associated with downward displacement of the deep venous complex; thanks to the gravity it reduce the complications related to the occipital lobe retraction and manipulation. Moreover, cutting the superior-anterior edge of the tentorium, the sub-tentorial space could be reached.

Focal Neurological Seizure due to Hyperglycemic Hyperosmolar Non-Ketotic Syndrome in Undiagnosed Diabetes Mellitus

Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) is a life-threatening complication of type 2 diabetes mellitus with a wide range of presenting symptoms. Neurological symptoms, such as coma, can also be part of the manifestation of HHNS; however, focal seizures remain a rare but notable association. 

A 85-year-old male patient with no history of diabetes presented to our emergency department complaining of a two-day history of twitching movements of his left wrist. Laboratory findings suggested HHNS and his hemoglobin A1c were found to be 10.2%. He was aggressively treated in the intensive care unit with fluids and insulin which also resolved his seizure episodes. He was ultimately discharged in stable condition without any seizure-like activity while having good glycemic control. 

According to the American Diabetes Association, about 25% of all individuals 65 years and older have diabetes mellitus. With an increasing prevalence, the complications of uncontrolled diabetes are also becoming more notable. While the neurological deficits associated with HHNS are focal, the mechanism by which this occurs is still poorly understood and underreported warranting further studies. 

[Anatomy of anterior craniovertebral junction in endoscopic transnasal approach]

Modern achievements in endoscopic technologies ensure extending the indications for endoscopic transnasal approach in skull base surgery. Knowledge on topographic anatomy of craniovertebral junction is a prerequisite for surgical interventions in this area. Transnasal endoscopic surgery of craniovertebral junction is a relatively new field. Therefore, this manuscript and similar anatomical studies are extremely important for neurosurgeons.

Anterior release without odontoidectomy for irreducible atlantoaxial dislocation: transoral or endoscopic transnasal?

PURPOSE

To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial dislocation (IAAD).

METHODS

From June 2006 to January 2017, 35 consecutive patients with IAAD underwent transoral (Tr-Oral group) or endoscopic transnasal (Tr-Nasal group) release and posterior fixation and fusion in our department. Clinical neurological recovery (Japanese Orthopedic Association (JOA) score) and radiological reduction parameters including atlantodontoid interval (ADI), space available for the cord (SAC) and cervicomedullary angle (CMA) were analyzed and compared. The operation duration, blood loss, length of intensive care unit (ICU)/hospital stay and complications were recorded.

RESULTS

All 35 patients (18 and 17 patients in the Tr-Oral and Tr-Nasal groups, respectively) were followed up for a mean of 36.4 months (range, 21-60 months). All patients achieved excellent anatomical reduction and clinical neurological recovery, with no significant differences between the two groups. The JOA score, ADI, SAC and CMA were not significantly different between the two groups at various postoperative points. Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group, the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay, earlier extubation and earlier oral intake than the Tr-Oral group.

CONCLUSION

The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD. Compared to the transoral approach, the endoscopic transnasal route is less invasive with earlier extubation and oral intake, shorter hospital/ICU stays and lower medical costs, which is conducive to enhanced recovery after surgery.

Sporadic Pituitary Stalk Hemangioblastoma: A Rare Case Report and Review of the Literature

Supratentorial hemangioblastomas have rarely been described in the literature. Pituitary stalk hemangioblastomas are extremely rare and almost always are associated with von Hippel Lindau disease. Herein, we report a sporadic case of pituitary stalk hemangioblastoma in a 36-year-old male and review the current literature regarding this pathology. In our case, complete resection of the lesion was achieved using the transglabellar approach.

Chiari malformation type I and basilar invagination originating from atlantoaxial instability: a literature review and critical analysis

Introduction

Recently, a novel hypothesis has been proposed concerning the origin of craniovertebral junction (CVJ) abnormalities. Commonly found in patients with these entities, atlantoaxial instability has been suspected to cause both Chiari malformation type I and basilar invagination, which renders the tried and tested surgical decompression strategy ineffective. In turn, C1-2 fusion is proposed as a single solution for all CVJ abnormalities, and a revised definition of atlantoaxial instability sees patients both with and without radiographic evidence of instability undergo fusion, instead relying on the intraoperative assessment of the atlantoaxial joints to confirm instability.

Methods

The authors conducted a comprehensive narrative review of literature and evidence covering this recently emerged hypothesis. The proposed pathomechanisms are discussed and contextualized with published literature.

Conclusion

The existing evidence is evaluated for supporting or opposing sole posterior C1-2 fusion in patients with CVJ abnormalities and compared with reported outcomes for conventional surgical strategies such as posterior fossa decompression, occipitocervical fusion, and anterior decompression. At present, there is insufficient evidence supporting the hypothesis of atlantoaxial instability being the common progenitor for CVJ abnormalities. Abolishing tried and tested surgical procedures in favor of a single universal approach would thus be unwarranted.

Hyperglycaemia-related occipital lobe seizures

Recognition of the role of hyperglycaemia in seizures is vital, because they tend to refractory to antiepileptic drugs and respond to insulin therapy and hydration.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Rathke's cleft cysts following transsphenoidal surgery: long-term outcomes and development of an optimal follow-up strategy

BACKGROUND

In patients with symptomatic Rathke's cleft cyst, transsphenoidal surgery is highly effective at preventing further visual loss and usually allows for some recovery of vision. However, cyst recurrence and the need for re-operation are well recognized. To this end, the aim of this study was to investigate patterns of recurrence and long-term outcomes and to use this information to develop an optimal follow-up strategy.

METHOD

A prospectively maintained database was searched over a 10-year period between 1 January 2008 and the 1 January 2018 to identify all adults that underwent transsphenoidal surgery with a new diagnosis of Rathke's cleft cyst. A retrospective case note review was performed for each patient to extract data on their presentation, investigation, treatment, and outcome.

RESULTS

In all, 61 eligible patients were identified. The median follow-up was 34 months (range 2-112 months). In the 22 patients with pre-operative visual loss, the outcomes at 6 months were as follows: normal vision (2/22; 9.1%), improved but not normal (7/22; 31.8%), stable (12/22; 54.5%), worse but not blind (1/22; 4.5%), and blind (0/22; 0%). The overall rate of regrowth and re-operation in our study was 19.7 and 11.5%, respectively. The only factor that was significantly associated with recurrence was the presence of residual cystic disease on the post-operative MRI (p < 0.001).

CONCLUSIONS

We propose a follow-up strategy that stratifies patients at "low risk" if there is no residual cyst, with increasing interval scans, or "high risk" if there is residual cyst, with annual visual assessment and scans.

Endoscopic Endonasal Resection of Meckel's Cave Epidermoid Cysts: Case Discussion and Literature Review

Meckel's cave (MC) epidermoid cysts are relatively uncommon lesions. In cases where surgical excision is indicated, resection is often carried out via a frontosphenotemporal craniotomy from an anterolateral approach or a temporal craniotomy with or without a petrosectomy for a lateral corridor; both of these routes are associated with brain retraction and potential neurovascular injury. The anterior location of MC in the middle cranial fossa makes safe access via posterior fossa-based approaches—such as the retrosigmoid approach—challenging as well. Here, we present the cases of two patients diagnosed with epidermoid cysts in MC who underwent surgical resection via an endoscopic endonasal transpterygoid approach. Near-total resection was achieved in both cases, with only mild transient neurologic disturbances postoperatively. Radiographically, no evidence of residual disease was noted in either patient. We further review the nuances of an extended endoscopic endonasal approach to these lesions.

A Case of Sporadic Suprasellar Hemangioblastoma Mimicking Meningioma

Hemangioblastoma (HBL) in the suprasellar region is very rare and a few cases have been reported. Suprasellar HBL without von Hippel-Lindau disease is much rarer. A 76-year old male patient presented progressively deteriorating visual disturbance. MRI demonstrated solid suprasellar mass of 20 mm in diameter, broadly based to planum sphenoidale and diaphragm sella and dural tail sign after the administration of gadolinium diethylene triamine penta-acetic acid (Gd-DTPA). Preoperative diagnosis was meningioma. Total resection of the tumor was not accomplished because of massive hemorrhage, and the histopathologic examination revealed the tumor to be HBL. The visual disturbance of the patient was not improved. The authors reviewed the literature and considered a differential diagnosis of suprasellar tumors and treatment of suprasellar HBL.

Anatomical Aspects of the Transnasal Endoscopic Access to the Craniovertebral Junction

OBJECTIVE

Interest in endoscopic transnasal access has increased with continued technological advances in endoscopic technology. The goals of this study were to review the normal anatomy in transnasal endoscopic neurosurgery and outline the anatomical basis for an expanded surgical approach. Defining anatomical aspects of surgical endoscopy helps guide the surgeon by defining normal anatomy of the access vector.

METHODS

This anatomic study was conducted on 15 adult male cadaver specimens using various microsurgical tools and endoscopic instruments and 1 intraoperative case. The vasculature was injected with colored silicone to aid visualization. Different transnasal approach techniques were used, with angles of endoscope access at 0°, 30°, 45°, and 70° accordingly for extensive anatomical mapping.

RESULTS

The proximity of critical structures is different in each approach degree. A full understanding of the possible structures to be met during transnasal access is described. As a result of the study, anatomical aspects and important structures were outlined, and a surgical protocol was defined for minimal risk access in respect to normal anatomy of the area.

CONCLUSIONS

Thorough knowledge of topographic anatomy of the craniovertebral junction is required for performing minimal-risk surgical intervention in this region. It is important to know all anatomical aspects of the transnasal approach in order to reduce the risk of damage to vital structures. Transnasal endoscopic surgery of the craniovertebral junction is a relatively new direction in neurosurgery; therefore, anatomical studies such as the one described in this article are extremely important for the development of this access method.

Transoral Approach to the Craniovertebral Junction: A Neuronavigated Cadaver Study

More than 100 years after the first description by Kanavel of a transoral-transpharyngeal approach to remove a bullet impacted between the atlas and the clivus [1], the transoral approach (TOA) still represents the 'gold standard' for surgical treatment of a variety of conditions resulting in anterior craniocervical compression and myelopathy [2, 3]. Nevertheless, some concerns-such as the need for a temporary tracheostomy and a postoperative nasogastric tube, and the increased risk of infection resulting from possible bacterial contamination and nasopharyngeal incompetence [4-6]-led to the introduction of the endoscopic endonasal approach (EEA) by Kassam et al. [7] in 2005. Although this approach, which was conceived to overcome those surgical complications, soon gained wide attention, its clear predominance over the TOA in the treatment of craniovertebral junction (CVJ) pathologies is still a matter of debate [3]. In recent years, several papers have reported anatomical studies and surgical experience with the EEA, targeting different areas of the midline skull base, from the olfactory groove to the CVJ [8-19]. Starting from these preliminary experiences, further anatomical studies have defined the theoretical (radiological) and practical (surgical) craniocaudal limits of the endonasal route [20-25]. Our group has done the same for the TOA [26, 27] and compared the reliability of the radiological and surgical lines of the two different approaches. Very recently, a cadaver study, with the aid of neuronavigation, tried to define the upper and lower limits of the endoscopic TOA [28].

The Endoscopic Endonasal Approach for Treatment of Craniovertebral Junction Pathologies: A Minimally Invasive but not Minimal-Risk Approach

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White Matter Relationships Examined by Transillumination Technique Using a Lateral Transcortical Parietal Approach to the Atrium: Three-Dimensional Images and Surgical Considerations

BACKGROUND

Numerous lesions are found in the ventricular atrium (VA). Access is gained through many white matter tracts with great relevance and specific neurologic functions. It is important to understand the configuration of the most relevant structures surrounding this zone and, thus, select the safest entry zone on the lateral cerebral surface.

OBJECTIVE

We studied the white matter layers traversed in the lateral transcortical parietal approach through the intraparietal sulcus (IPS), adding a transillumination technique. With this knowledge, we selected the safest highway to improve this particular approach.

METHODS

An in-depth study of the white matter tracts was performed on 24 cerebral hemispheres (12 human whole brains). The Klingler technique and microsurgical dissection techniques were used under ×6 to ×40 magnification. The transillumination technique (torch illuminating the ventricular cavity) was used to expose the layers surrounding the VA and, thus, guide the dissection.

RESULTS

Taking the IPS on the cerebral surface as a reference, we identified the following white matter layers ordered from the surface to the ependyma: U fibers, superior longitudinal fascicle, arcuate fascicle, vertical occipital fascicle, sagittal stratum with the optic radiations, and tapetum fibers. The transillumination technique allowed for the easier identification of the white matter deep periventricular layers.

CONCLUSIONS

Knowledge of the main fascicles in the path and neighborhood of the VA allowed us to understand how certain neurologic functions can be affected by lesions at this level and to select the most appropriate way to avoid damaging relevant fascicles.

Branched-Chain Amino Acids and Seizures: A Systematic Review of the Literature

BACKGROUND

Up to 40% of patients with epilepsy experience seizures despite treatment with antiepileptic drugs; however, branched-chain amino acid (BCAA) supplementation has shown promise in treating refractory epilepsy.

OBJECTIVES

The purpose of this systematic review was to evaluate all published studies that investigated the effects of BCAAs on seizures, emphasizing therapeutic efficacy and possible underlying mechanisms.

METHODS

On 31 January, 2017, the following databases were searched for relevant studies: MEDLINE (OvidSP), EMBASE (OvidSP), Scopus (Elsevier), the Cochrane Library, and the unindexed material in PubMed (National Library of Medicine/National Institutes of Health). The searches were repeated in all databases on 18 February, 2019. We only included full-length preclinical and clinical studies that were published in the English language that examined the effects of BCAA administration on seizures.

RESULTS

Eleven of 2045 studies met our inclusion criteria: ten studies were conducted in animal models and one study in human subjects. Seven seizure models were investigated: the strychnine (one study), pentylenetetrazole (two studies), flurothyl (one study), picrotoxin (two studies), genetic absence epilepsy in rats (one study), kainic acid (two studies), and methionine sulfoximine (one study) paradigms. Three studies investigated the effect of a BCAA mixture whereas the other studies explored the effects of individual BCAAs on seizures. In most animal models and in humans, BCAAs had potent anti-seizure effects. However, in the methionine sulfoximine model, long-term BCAA supplementation worsened seizure propagation and caused neuron loss, and in the genetic absence epilepsy in rats model, BCAAs exhibited pro-seizure effects.

CONCLUSIONS

The contradictory effects of BCAAs on seizure activity likely reflect differences in the complex mechanisms that underlie seizure disorders. Some of these mechanisms are likely mediated by BCAA's effects on glucose, glutamate, glutamine, and ammonia metabolism, activation of the mechanistic target of rapamycin signaling pathway, and their effects on aromatic amino acid transport and neurotransmitter synthesis. We propose that a better understanding of mechanisms by which BCAAs affect seizures and neuronal viability is needed to advance the field of BCAA supplementation in epilepsy.