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Serrano Sponton L, Alhoobi M, Archavlis E, Shaaban AT, Dumour E, Nimer A, Conrad J, Kantelhardt SR, Ayyad A. Endoscopic-assisted paramedian supracerebellar infratentorial approach to the posterior portion of the third ventricle: anatomical study and surgical cases. J Neurosurg Sci 2024; 68:390-402. [PMID: 35416454 DOI: 10.23736/s0390-5616.22.05622-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To date, morphometrical data providing a systematic quantification of accessibility and operability parameters to the boundaries of the posterior portion of the third ventricle (PTV) when applying an endoscopic-assisted paramedian supracerebellar infratentorial approach (EPSIA) are lacking. We performed an anatomical study and complemented our findings with surgical cases. METHODS Eight EPSIAs towards the PTV were performed in cadaveric specimens. Optimal approach angles (OA), surgical freedom (SF) and operability indexes (Oi) to the PTV boundaries were assessed. Additionally, a 54-year-old man and 33-year-old woman were operated on PTV tumors applying the EPSIA. RESULTS Sagittal OA to ventricle's roof and floor was 36±1.4° and 25.5±3.5° respectively, axial OA to the ipsilateral and contralateral ventricle's wall were 9.5±1.3° and 28.5±1.6°. SF was maximal on the contralateral wall (121.2±19.3mm2), followed by the roof (112.7±18.8mm2), floor (106.6±19.2mm2) and ipsilateral wall (94.1±15.7mm2). SF was significantly lower along the ipsilateral compared the contralateral wall (P<0.01) and roof (P<0.05). Facilitated surgical maneuvers with multiangled exposure were possible up to 8.5±1.07mm anterior to ventricle's entrance, whereas surgical maneuvers were possible but difficult up to 15.25±3.7mm. Visualization of more anterior was possible up to a distance of 27±2.9mm, but surgical maneuvers were barely feasible. EPSIA enabled successful resection of both PTV tumors and postoperative course was uneventful. CONCLUSIONS EPSIA can be effective for approaching the PTV, enabling surgery along all boundaries, but especially on its roof and contralateral wall. In the not-enlarged ventricle, surgical maneuvers are feasible up to the level of the Monro foramen, becoming more limited anteriorly.
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Affiliation(s)
- Lucas Serrano Sponton
- Department of Neurosurgery, Sana Klinikum Offenbach, Offenbach am Main, Germany -
- Department of Neurosurgery, Mainz University Medical Center, Mainz, Germany -
| | - Mohammed Alhoobi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Ahmed T Shaaban
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Elias Dumour
- Department of Neurosurgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Amr Nimer
- Department of Neurosurgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jens Conrad
- Department of Neurosurgery, Mainz University Medical Center, Mainz, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, Mainz University Medical Center, Mainz, Germany
| | - Ali Ayyad
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
- Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany
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Khaleghi M, Wu KC, Prevedello DM. Fully Endoscopic Minimally Invasive Trans-Eyebrow Supraorbital Translaminar Approach to Third Ventricle Craniopharyngiomas: Technical Nuances and Stepwise Illustrative Description. World Neurosurg 2024; 186:78-86. [PMID: 38522791 DOI: 10.1016/j.wneu.2024.03.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Traditional microsurgical approaches for addressing intraventricular craniopharyngioma provide limited access to the retrochiasmatic area and tumors with significant lateral or rostrocaudal extensions. Extended endoscopic endonasal approaches can effectively overcome many of limitations, yet they require a favorable working angle between the optic chiasm and pituitary gland, as well as the involvement of the third ventricle floor by the tumor. METHODS Herein, the authors describe the surgical nuances of a keyhole technique for resecting third ventricle craniopharyngiomas via a fully endoscopic minimally invasive trans-eyebrow supraorbital translaminar approach (ESOTLA). A case description detailing the key surgical steps and application of the approach is provided, along with a series of cadaveric photographs to highlight the relevant anatomy and step-by-step dissection process. RESULTS The patient is a 44-year-old man who presented with polyuria, low urine specific gravity, and panhypopituitarism. Brain magnetic resonance imaging revealed a solid-cystic heterogeneous-enhanced retrochiasmatic mass within the third ventricle, consistent with craniopharyngioma. A 1-stage ESOTLA was indicated based on the narrow pituitary-chiasm angle and the high functional status of the patient. Near-total resection was achieved, and no new postoperative neurologic or endocrine change was observed. Targeted therapy was implemented based on the histologic result, and the most recent surveillance magnetic resonance imaging showed no evidence of the residual tumor. CONCLUSIONS By combining a keyhole approach with variable-angle endoscopic visualization through a smaller bony and soft tissue exposure, ESOTLA can provide enhanced illumination within the third ventricle, potentially addressing cosmetic concerns and limited exposure area/angle of freedom associated with its conventional microsurgical counterpart.
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Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, The James Cancer Center Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The James Cancer Center Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The James Cancer Center Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.
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Zhang C, Yan Z, Wang X, Li Y, Zhang H. Quantitative analysis of exposure and surgical maneuverability of three purely endoscopic keyhole approaches to the floor of the third ventricle. J Neurosurg Sci 2024; 68:327-337. [PMID: 34545733 DOI: 10.23736/s0390-5616.21.05455-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The quantitative anatomic analysis of comprehensively endoscopic approaches to the third ventricle is scarce at present. The objective of the study is to quantitatively assess and compare the exposure and microsurgical maneuverability of three absolutely endoscopic keyhole approaches, including interhemispheric transcallosal transchoroidal (TCTC), frontal transforminal transchoroidal (TFTC) and supraorbital subfrontal translamina terminalis (SFTL) approaches. METHODS Anatomical dissections and exposure of the important structures of the third ventricle were performed using six formalin-fixed cadaveric human heads (twelve sides) under endoscope. Tubular retractor system was used in the TFTC approach. Quantitative anatomical relationship between the important landmarks were obtained. Moreover, the exposure and surgical operability of three approaches were evaluated through applying the rating scale and accomplishing the quantitative anatomic analysis, area of surgical freedom and angle of attack. RESULTS The mediolateral, anteroposterior (AM: between aqueduct and mammillary body; IM: between infundibular recess and mammillary body) and superoinferior distance of TCTC, TFTC and SFTL approaches were 4.0±1.0, 4.2±0.4, 4.1±1.1 mm; 17.3±1.4, 17.6±0.5, 12.8±3.3 mm (AM); 7.7±0.3, 7.8±0.5 mm, not measured (IM); and 5.6±0.3, 7.8±0.8, 7.8±1.5 mm, respectively. Similar to TFTC, the exposed landmarks of TCTC were almost scored a "4" by three neurosurgeons except the infundibular recess scored a "3" according to the rating scale. During the SFTL approach, apart from the roof, the majority of the landmarks were scored a "4" except for the infundibular recess, which was scored a "3." The mean area of surgical freedom of TCTC (0° endoscope: 220±47; 30°: 247±56 mm2) was not significantly different from that of TFTC approach (0° endoscope: 216±49; 30°: 245±53 mm2) under same endoscope, P>0.05. Mean angle of attack of TCTC (0° endoscope: 21±4°; 30°: 26±4°) was significantly larger than that of TFTC approach (0° endoscope: 16±3°; 30°: 19±3°), P<0.05. CONCLUSIONS Purely endoscopic TCTC and TFTC approaches offer brilliant exposure of the anterior, middle and posterior third ventricle. TCTC approach may have better surgical maneuverability than TFTC approach. Despite the long working distance, the whole third ventricle are exposed well except for the roof in the SFTL approach, and surgical manipulation can be accomplished smoothly.
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Affiliation(s)
- Changfu Zhang
- Department of Neurosurgery, College of the First Clinical Medicine, Dalian Medical University, Dalian, China
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Zhengcun Yan
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Xiaodong Wang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yuping Li
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hengzhu Zhang
- Department of Neurosurgery, College of the First Clinical Medicine, Dalian Medical University, Dalian, China -
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
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Khaleghi M, Wu KC, Prevedello DM. Endoscopic Supraorbital Translaminar Approach. Adv Tech Stand Neurosurg 2024; 52:171-182. [PMID: 39017794 DOI: 10.1007/978-3-031-61925-0_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
Surgical selection for third ventricle tumors demands meticulous planning, given the complex anatomic milieu. Traditional open microsurgical approaches may be limited in their access to certain tumors, prompting the exploration of alternative techniques. The endoscopic supraorbital translaminar approach (ESOTLA) has emerged as a promising alternative for managing these tumors. By combining a minimally invasive keyhole approach with endoscopic visualization, the ESOTLA provides enhanced illumination and a wider angle of view within the third ventricle. This unique advantage allows for improved access to retrochiasmatic tumors and reduces the need for frontal lobe and optic chiasm retraction required of microscopic techniques, decreasing the risk of neurocognitive and visual deficits. Complications related to the ESOTLA are rare and primarily pertain to cosmetic issues and potential compromise of the hypothalamus or optic apparatus, which can be minimized through careful subarachnoid dissection. This chapter offers a comprehensive description of the technical aspects of the ESOTLA, providing insights into its application, advantages, and potential limitations. Additionally, a case description highlights the successful surgical extirpation of an intraventricular papillary craniopharyngioma via the ESOTLA followed by targeted therapy. To better illustrate the stepwise dissection through this novel approach, a series of cadaveric and intraoperative photographs are included.
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Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, The James Cancer Hospital and Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Kyle C Wu
- Department of Neurosurgery, The James Cancer Hospital and Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The James Cancer Hospital and Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Teping F, Oertel J. The minimally invasive transventricular endoscopic approach to third ventricular lesions in pediatric patients-all-rounder with limitations? Childs Nerv Syst 2023; 39:3381-3389. [PMID: 37515720 PMCID: PMC10684406 DOI: 10.1007/s00381-023-06096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 07/31/2023]
Abstract
INTRODUCTION The surgical management of third ventricular lesions poses unique challenges, requiring careful consideration of various approaches and techniques. This study focuses on the transventricular transforaminal endoscopic approach and aims to provide insights into its indications, limitations, technical nuances, and potential complications in pediatric patients. METHODS A retrospective analysis was conducted using data from a 13-year period on pediatric patients who were subjected to transforaminal endoscopic surgery for third ventricular lesions. The study utilized a prospectively maintained internal database, extracting demographic data, preoperative assessment, surgical details, and postoperative follow-up information. The surgical technique is presented in detail, and exemplary case reports highlight relevant surgical considerations. RESULTS Out of 578 endoscopic transforaminal procedures, 24 surgeries were performed on pediatric patients with third ventricular lesions. Performed procedures consisted of cyst resection (13 cases), solid tumor resection (4 cases), and tumor biopsies with CSF pathway restoration (7 cases). The mean age at the time of surgery was 7.6 years. Postoperatively, 14 patients showed transient nausea and vomiting (58.3%); 10 patients showed pneumocephalus on postoperative MRI (41.7%). No emergency postoperative re-interventions nor perioperative mortality were observed. CONCLUSION The endoscopic transventricular transforaminal approach is a safe approach for lesion resection, CSF pathway restoration, and tumor biopsy in pediatric patients with third ventricle lesions. The author's results support the use of this minimally invasive technique as an alternative to more extensive approaches, particularly to the interforniceal interhemispheric approach. However, surgical success is highly dependent to the individual surgeon's experience and moreover to a suitable indication setting. Careful preoperative planning and knowledge of the approaches' pro and cons is mandatory for successful application of this approach.
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Affiliation(s)
- Fritz Teping
- Department of Neurosurgery, Faculty of Medicine, Saarland University, Kirrbergerstraße, Building 90.5, D-66421, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Faculty of Medicine, Saarland University, Kirrbergerstraße, Building 90.5, D-66421, Homburg, Germany.
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Gladi M, Di Rienzo A, Fasinella MR, Aiudi D, Balercia P, Dobran M, Iacoangeli M. Ruptured proximal pontine artery aneurysm and association with cerebellopontine angle cistern arterial venous malformation fed by the same artery: A surgical challenge. Surg Neurol Int 2023; 14:352. [PMID: 37941615 PMCID: PMC10629327 DOI: 10.25259/sni_246_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/29/2023] [Indexed: 11/10/2023] Open
Abstract
Background The coexistence of hyper-inflow aneurysms and cerebellopontine angle cistern (CPAc) arterial venous malformations (AVMs) have been rarely reported and most commonly associated with high risk of bleeding. Case Descriptions We present two cases of CPAc AVMs admitted for acute subarachnoid hemorrhage from rupture of a parent right pontine artery aneurysm. Admission history, neurology at presentation, pre/post-operative imaging, approach selection, and results are thoroughly reviewed and presented. The acute origin angle of the vessel from the basilar artery made both malformations unsuitable for endovascular treatment. The surgical strategy was differently tailored in the two patients, respectively, using a Le Fort I/transclival and a Kawase approach. The aneurysm was clipped in the first case, and the AVM was excised in the second one, as required by the anatomical context. Aneurysm exclusion and AVM size reduction were obtained in the first case, while complete AVM removal and later aneurysm disappearance were obtained in the second one. A high-flow cerebrospinal fluid leak in the first case was successfully treated by an endoscopic approach. Both patients experienced a satisfactory neurological outcome in the follow-up. Conclusion Pontine artery aneurysms, especially when associated with CPAc AVMs, represent a surgical challenge, due to their rarity and anatomical peculiarity, which typically requires complex operative approaches. Multimodal preoperative imaging, appropriate timing, and accurate target selection, together with versatile strategies, are the keys to a successful treatment.
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Affiliation(s)
- Maurizio Gladi
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Alessandro Di Rienzo
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Maria Rossella Fasinella
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Denis Aiudi
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Paolo Balercia
- Department of Maxillo-Facial Surgery, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
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Robinow ZM, Peterson C, Riestenberg R, Waldau B, Yu N, Shahlaie K. Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis. J Neurol Surg B Skull Base 2023; 84:470-498. [PMID: 37671300 PMCID: PMC10477017 DOI: 10.1055/s-0042-1755575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/08/2022] [Indexed: 10/14/2022] Open
Abstract
Background Supraorbital eyebrow craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor and vascular pathologies. The purpose of this study was to investigate how patient cosmetic outcomes are affected by technique variations of this approach. Methods PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to PRISMA guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used, and the primary end points were patient satisfaction and percentage of permanent cosmetic complications. Results A total of 2,629 manuscripts were identified. Of those, 124 studies (8,241 surgical cases) met the inclusion criteria. Overall, 93.04 ± 11.93% of patients reported favorable cosmetic outcome following supraorbital craniotomy, and mean number of cases with permanent cosmetic complications was 6.62 ± 12.53%. We found that vascular cases are associated with more favorable cosmetic outcomes than tumor cases ( p = 0.0001). Addition of orbital osteotomy or use of a drain is associated with adverse cosmetic outcomes ( p = 0.001 and p = 0.0001, respectively). The location of incision, size of craniotomy, utilization of an endoscope, method of cranial reconstruction, skin closure, use of antibiotics, and addition of pressure dressing did not significantly impact cosmetic outcomes ( p > 0.05 for all). Conclusions Supraorbital craniotomy is a minimally invasive technique associated with generally high favorable cosmetic outcomes. While certain techniques used in supraorbital keyhole approach do not pose significant cosmetic risks, utilization of an orbital osteotomy and the addition of a drain correlate with unfavorable cosmetic outcomes.
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Affiliation(s)
- Zoe M. Robinow
- California Northstate University College of Medicine, Elk Grove, California, United States
| | - Catherine Peterson
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Robert Riestenberg
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Ben Waldau
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Nina Yu
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California Davis, Sacramento, California, United States
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Webb KL, Pruter WW, Hinkle ML, Walsh MT. Comparing Surgical Approaches for Craniopharyngioma Resection Among Adults and Children: A Meta-analysis and Systematic Review. World Neurosurg 2023; 175:e876-e896. [PMID: 37062335 DOI: 10.1016/j.wneu.2023.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/10/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Craniopharyngioma treatment often necessitates surgical resection. Conventional approaches, such as transcranial and transsphenoidal approaches, are predominantly used. However, a recently adopted supraorbital approach may be more efficacious. Thus, this meta-analysis and systematic review aimed to compare the efficacy of the transcranial, transsphenoidal, and supraorbital approaches for resection and treatment of craniopharyngiomas. METHODS This study was performed following PRISMA guidelines. Analyses were performed according to study design: (1) analyses for studies comparing several surgical approaches; and (2) analyses of all included studies. Random effects meta-analysis models were used to pool odds ratios among studies comparing several approaches. Similarly, categorical meta-regression models were used to examine the effect of surgical approach as a covariate of outcome data for all studies. Statistics were performed using Comprehensive Meta-Analysis software (CMA 3.3, Biostat, Englewood, NJ) (significance set at P < 0.05). RESULTS Patients were well-matched for age, sex, and preoperative comorbidities between groups stratified by surgical approach. Analyses including 22 studies that compared several approaches demonstrated that the transsphenoidal group had a greater occurrence of postoperative visual improvement (P < 0.0001), lesser occurrence of visual deterioration (P < 0.0001), and lower tumor recurrence rate (P = 0.015) compared with the transcranial group. Only 2 studies compared the supraorbital approach to another approach, limiting analyses. Analyses including all studies demonstrated that the supraorbital group did not differ to either the transcranial or transsphenoidal group for any examined variables. CONCLUSIONS The present study suggests that the transsphenoidal approach is associated with improved clinical outcomes for craniopharyngioma resection. There are limited data regarding the supraorbital approach, warranting future investigation.
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Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Wyatt W Pruter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kumar S, Sahana D, Rathore L, Jain A, Tawari M, Singh D, Sahu R, Madhariya SN. Extra-axial endoscopic third ventriculostomy: preliminary experience with a technique to circumvent conventional endoscopic third ventriculostomy complications. J Neurosurg 2023; 138:503-513. [PMID: 35901703 DOI: 10.3171/2022.5.jns22589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic third ventriculostomy (ETV) is mostly safe but may have serious complications. Most of the complications are inherent to the procedure's intra-axial nature. This study aimed to explore an alternative route to overcome inherent issues with conventional ETV. The authors performed supraorbital, subfrontal extra-axial ETV (EAETV) via the lamina terminalis. METHODS This prospective study began in October 2021 and included patients with obstructive triventricular hydrocephalus with a Glasgow Coma Scale score of 8 or more and a minimum follow-up of 3 months. Patients with multiloculated hydrocephalus and those younger than 1 year of age were excluded. The preoperative parameters etiology, symptoms, Evans' Index, frontal occipital horn ratio (FOHR), and third ventricle index were recorded. The surgical procedure is described. Postoperative evaluation included clinical (modified Rankin Scale [mRS]) and radiological assessment with CT and cine phase-contrast MRI. Preoperative and postoperative parameters were compared statistically. RESULTS Ten patients were included in this study. Six patients had acute hydrocephalus, and 4 had chronic hydrocephalus. After EAETV, all patients showed clinical improvement. An mRS score of 0 or 1 was achieved in 9 patients, but the mRS score remained at 4 in a patient with tectal tuberculoma. There was a significant reduction in Evans' Index, FOHR, and third ventricle index after EAETV (p < 0.05). The mean percent reduction in Evans' Index was 20.80% ± 13.89%, the mean percent reduction in FOHR was 20.79% ± 12.98%, and the mean percent reduction in the third ventricle index was 37.45% ± 14.74%. CSF flow voids were seen in all cases. The results of CSF flow quantification parameters were as follows: mean peak velocity 3.82 ± 0.93 cm/sec, mean average velocity 0.10 ± 0.05 cm/sec, mean average flow rate 46.60 ± 28.58 μL/sec, mean forward volume 39.90 ± 23.29 μL, mean reverse volume 34.10 ± 15.98 μL, mean overall flow amplitude 74.00 ± 27.61 μL, and mean stroke volume 37.00 ± 13.80 μL. One patient developed a minor frontal lobe contusion. The frontal air sinus was breached in 5 patients, but none had CSF rhinorrhea. Transient supraorbital hypesthesia was seen in 3 patients. No patient had electrolyte disturbance or change in thirst or fluid intake habits. CONCLUSIONS EAETV is a feasible, safe, and effective surgical alternative to conventional ETV.
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Affiliation(s)
- Sanjeev Kumar
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Debabrata Sahana
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Lavlesh Rathore
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Amit Jain
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Manish Tawari
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
| | - Deepak Singh
- 2Department of Neuro-anesthesia, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh; and
| | - Rajiv Sahu
- 1Department of Neurosurgery, DKS Post Graduate Institute and Research Center, Raipur Chhattisgarh
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Endoscopic transcortical expanded transforaminal transvenous transchoroidal approach to third ventricle lesion resection using an endoport. J Clin Neurosci 2022; 106:166-172. [DOI: 10.1016/j.jocn.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
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Nemir J, Maric LS, Trbojevic T, Zarkovic K, Jadrijević-Cvrlje F. Papillary tumor of the pineal region in pediatric patient – A case report. Surg Neurol Int 2022; 13:488. [DOI: 10.25259/sni_867_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/24/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Papillary tumor of the pineal region (PTPR) represents a rare and histologically distinct subgroup of tumors originating in the pineal region. Few pediatric cases have been reported so far in the literature; therefore, clinical data are scarce.
Case Description:
We describe a case of PTPR in a 9-year-old girl who presented with a 5-month history of excessive appetite and weight gain. The patient underwent neuroimaging procedures and total gross surgical resection with postoperative adjuvant local radiotherapy, which from our experience was the best treatment choice as an attempt to avoid local recurrence. During 78-month follow-up, the patient from our study manifested no disease recurrence.
Conclusion:
PTPR should be included in the differential diagnosis of pineal region masses.
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Affiliation(s)
- Jakob Nemir
- Department of Neurosurgery, University Hospital Center Zagreb, Zagreb, Croatia
| | - Lorna Stemberger Maric
- Department of Pediatric Infectious Diseases, University Hospital for Infectious Diseases, Dr. Fran Mihaljevic, Zagreb, Croatia
| | - Tena Trbojevic
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Kamelija Zarkovic
- Department of Pathology, Clinical Medical Centre Zagreb, Zagreb, Croatia
| | - Filip Jadrijević-Cvrlje
- Department of Pediatrics, Division of Hematology and Oncology, Children’s Hospital Zagreb, Zagreb, Croatia
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Zhou Y, Wei J, Jin T, Hei Y, Jia P, Lin J, Yang S, Jiang X, Liu W, Gao D. Extended endoscopic endonasal approach for resecting anterior intrinsic third ventricular craniopharyngioma. Front Oncol 2022; 12:998683. [PMID: 36248957 PMCID: PMC9562125 DOI: 10.3389/fonc.2022.998683] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/05/2022] [Indexed: 12/02/2022] Open
Abstract
Background The surgical treatment of the extended endoscopic endonasal approach (EEEA) is a safe and effective treatment for suprasellar craniopharyngiomas. However, due to damage to the hypothalamus and third ventricle floor (TVF), EEEA is generally regarded as unsuitable in treating intrinsic third ventricle craniopharyngioma (ITVC) that is entirely within the third ventricle. Until now, there have been only a small number of reports using EEEA to treat TVC via a supra-infrachiasmatic approach. Given that the translamina terminalis (TLT) corridor was used in the transcranial subfrontal approach, EEEA via a suprachiasmatic approach may be feasible and practical to treat ITVC. In the current study, we accumulated experience applying the suprachiasmatic translamina terminalis (STLT) corridor for anterior treatment of ITVC. Methods From March 2016 to December 2020, 14 patients with ITVC in our center were analyzed retrospectively. All patients underwent surgery by EEEA via an STLT corridor. The multilayer reconstruction technique was adopted to achieve skull base reconstruction. Data concerning the patient’s tumor resection, vision, hypophyseal hormone, and complications were collected. Results Gross-total resection was achieved in 13 (92.8%) of14 patients, with achievement of near-total (90%) resection in the remaining 1 patient. Nine cases (64.3%) were papillary craniopharyngiomas, and the other 5 cases were adamantinomatous subtypes. Postoperatively, 3 patients with pituitary insufficiency received hormone replacement therapy. No permanent diabetes insipidus or hypothalamic obesity was found. All pairs showed significant improvement or stability in vision except 1 patient who encountered visual deterioration. No other neurological deficit occurred postoperatively. Observation results for the exudation of nasal tissue and the length of hospitalization were satisfactory. After a mean follow-up period of 26.2 months, tumor recurrence was not observed. Conclusion TLT is a minimally invasive corridor used in EEEA for treating anterior ITVC without increasing risks of visual and hormonal deficits. The multilayered reconstruction technique we used is a safe and effective method for achieving watertight closure and avoiding cerebrospinal fluid leaks and infection. The endonasal approach via STLT provides a new, safe and efficacious operative strategy that should be considered a surgical alternative in treating ITVC.
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Affiliation(s)
- Yuefei Zhou
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jialiang Wei
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Department of Health Service, Fourth Military Medical University, Xi’an, China
| | - Tao Jin
- Department of Neurosurgery, An Kang Center Hospital, An Kang, China
| | - Yue Hei
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Pengfei Jia
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jincai Lin
- Department of Neurosurgery, Mao Ming People’s Hospital, Mao Ming, China
| | - Shuangwu Yang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaofan Jiang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Weiping Liu
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Dakuan Gao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- *Correspondence: Dakuan Gao,
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Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 158:e509-e542. [PMID: 34775096 DOI: 10.1016/j.wneu.2021.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Supraorbital eyebrow keyhole craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor resection and aneurysm clipping. The purpose of this study is to provide a contemporary review on the outcomes related to this approach and to determine whether they vary with the type of pathology and the addition of an endoscope. METHODS PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used. RESULTS A total of 2629 manuscripts were identified. of those, 124 studies (8241 surgical cases) met the inclusion criteria. Mean total complication rate was 26.7 ± 25.7% and the mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross total tumor resection or complete aneurysm clipping, was achieved in 83.6 ± 21.5% of the cases. Vascular pathologies were associated with greater technical success, lower total complications, and longer length of hospital stay compared with tumor cases (P < 0.05 for all). For vascular cases, addition of the endoscope yielded lower technical success (P = 0.001) and lower complication rate (P = 0.041). The use of the endoscope for tumor pathologies did not affect technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate (P > 0.05). CONCLUSIONS The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate for both vascular and tumor pathologies.
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Cai Y, Xiong Z, Xin C, Chen J, Liu K. Endoscope-Assisted Microsurgery in Pediatric Cases With Pineal Region Tumors: A Study of 18 Cases Series. Front Surg 2021; 8:641196. [PMID: 34414209 PMCID: PMC8368719 DOI: 10.3389/fsurg.2021.641196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/08/2021] [Indexed: 11/29/2022] Open
Abstract
Background: An endoscope-assisted technique was recently introduced to microsurgery (MS) and may compensate for the disadvantages of MS for deep-seated lesions. This study was performed to identify the effectiveness and safety of endoscopic-assisted microsurgery (EAM) and share our experience of EAM for pediatric cases with pineal region tumors. Method: We retrospectively analyzed the clinical data of consecutive pediatric cases with pineal region tumors treated by EAM or MS from January 2016 to June 2020. These data included the patient population, clinical manifestations, preoperative examination findings, surgical approach, pathological results, and clinical outcomes. The clinical outcomes were analyzed in the EAM group and MS group with a focus on the gross total resection (GTR) rate, postoperative hydrocephalus remission rate, and Karnofsky performance score (KPS). Studies on the surgical management of children with pineal region tumors in the last decade were reviewed. Result: Eighteen children successfully underwent tumor resection via MS (n = 8) or EAM (n = 10). The children's mean age was 11.4 ± 4.7 years, and the male to female ratio was 7:2. Seventeen patients (94.4%) complicated preoperative hydrocephalus, and 16 (88.9%) presented headache with nausea and/or vomiting. The pathological examination revealed germ cell tumors in 11 (61.1%) patients, neuroepithelial tumors in 4 (22.2%) patients, and a pineoblastoma, arachnoid cyst, and atypical teratoid rhabdoid tumor in 1 (5.6%) patient each. GTR was more commonly achieved in the EAM than MS group (80.0 vs. 50.0%, respectively), and the postoperative hydrocephalus remission rate was higher in the EAM than MS group (87.5 vs. 50.0%, respectively). At a mean follow-up time of 23.6 ± 11.5 weeks, the mean improvement of the KPS 6 months postoperatively was greater in the EAM than MS group (24.0 ± 9.7 vs. 17.5 ± 7.1 points, respectively). Conclusion: EAM combines endoscopic and microsurgical techniques and can be safely and effectively performed to achieve GTR of pineal region tumors in pediatric patients. In children with pineal region tumors who have obstructive hydrocephalus, EAM could improves hydrocephalus remission rates by checking and clearing the midbrain aqueduct under visualization.
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Affiliation(s)
- Yuankun Cai
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Zhongwei Xiong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Can Xin
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Kui Liu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
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15
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Colasanti R, Giannoni L, Dallari S, Liverotti V, Aiudi D, Di Rienzo A, Rossi F, Iacoangeli M. Application of a Scanner-Assisted Carbon Dioxide Laser System for Neurosurgery. World Neurosurg 2021; 153:e250-e258. [PMID: 34175485 DOI: 10.1016/j.wneu.2021.06.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite potential advantages, broad carbon dioxide (CO2) laser diffusion in neurosurgery was historically prevented by several operative limitations. Nonetheless, in recent decades, significant improvements, in particular the development of surgical scanners, have made CO2 laser surgery easier and reproducible. The aim of this study was to report our preliminary experience with the SmartXide2 CO2 laser system. METHODS The SmartXide2 laser system is a CO2 laser with a radiofrequency-excited laser source, a surgical scanner, and a high-precision micromanipulator, which are connected to the surgical microscope. Ten different brain and spinal tumors were treated to evaluate the laser system potential in different neurosurgical scenarios. Four illustrative cases were presented. RESULTS The CO2 laser was used together with the traditional instruments in every step of the procedures, from the initial pial incision (intra-axial tumors) or early debulking (extra-axial lesions), to progressive tumor removal, and, lastly, for surgical cavity hemostasis. No injury to the surrounding neurovascular structures was observed. Postoperative neuroimaging confirmed complete tumor removal and showed a marked reduction of preoperative surrounding edema without signs of cerebral/medullary contusions. CONCLUSIONS In selected cases, the SmartXide2 CO2 laser system could be a helpful, reliable, and safe surgical instrument to treat different cerebral and spinal lesions. It addresses some of the limitations of laser systems and is able to cut/ablate and coagulate the tissue simultaneously, with minimal lateral thermal spread, preserving the surrounding eloquent neurovascular structures. Moreover, having no consumable accessories, it is also cost-effective.
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Affiliation(s)
- Roberto Colasanti
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General University Hospital, Ancona, Italy.
| | - Luca Giannoni
- Clinical Research & Practice Department, El.En. Group, Calenzano, Italy
| | - Stefano Dallari
- Department of ENT Surgery, "A. Murri" General Hospital, Fermo, Italy
| | - Valentina Liverotti
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General University Hospital, Ancona, Italy
| | - Denis Aiudi
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General University Hospital, Ancona, Italy
| | - Alessandro Di Rienzo
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General University Hospital, Ancona, Italy
| | - Francesca Rossi
- Institute of Applied Physics, National Research Council of Italy, Florence, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General University Hospital, Ancona, Italy
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Abstract
INTRODUCTION Since the early use of the endoscopic view for treating simple intrasellar pituitary adenomas, the skull base surgery has experienced an unprecedented revolution elevating the treatment of skull base lesions to the next level in proficiency and excellence of care. METHODS We have reviewed the preclinical and clinical evidence supporting the use of the endoscope in the treatment of skull base lesions. In this article, we aim to discuss and provide a wide view of the current indications and future perspectives of the endoscopic endonasal approaches (EEA) and of the endoscopic transcranial approaches. RESULTS As in the development of any other technique, EEA have gone through a transformation process from theoretical anatomic models to a pragmatic clinical use. Along the way, EEA have required several modifications, as well as pushbacks in the application of this technique in some indications. This process has resulted in the provision of an additional tool to the current surgical armamentarium that allows the skull base surgeon to face most challenging lesions along the skull base. CONCLUSIONS The judicious combination of transcranial and endoscopic-transnasal approaches warrants highest chances of achieving satisfactory tumors resection with a reduced risk of complications.
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17
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Kong L, Xiao X, Pan C, Zhang L. Trans-lamina terminalis suprategmental approach for ventral midbrain lesions: Technical note. J Clin Neurosci 2020; 83:25-30. [PMID: 33342626 DOI: 10.1016/j.jocn.2020.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/16/2020] [Accepted: 11/23/2020] [Indexed: 11/16/2022]
Abstract
Surgical resection of lesions located in the ventral midbrain is challenging. Few approaches and safe entry zones (SEZs) have been proposed and used to remove this type of lesion, and each has its limitations. Using two illustrating cases, the authors describe a trans-lamina terminalis suprategmental approach for removing ventral midbrain lesions. This approach provides a straight surgical trajectory with sparse neurovascular structures and can be performed with a standard pterional or subfrontal craniotomy. It may be the ideal approach for ventromedial midbrain lesions extending towards the third ventricle.
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Affiliation(s)
- Lu Kong
- Department of Neurosurgery, Qingdao Municipal Hospital, 266071 Qingdao, China
| | - Xiong Xiao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, 100070 Beijing, China
| | - Changcun Pan
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, 100070 Beijing, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, 100070 Beijing, China.
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18
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Mathkour M, Hanna J, Ibrahim N, Scullen T, Kilgore MD, Werner C, Cormier I, Spencer P, Keen JR, Bui CJ. Papillary tumor of the pineal region in pediatric populations: An additional case and systematic review of a rare tumor entity. Clin Neurol Neurosurg 2020; 201:106404. [PMID: 33360024 DOI: 10.1016/j.clineuro.2020.106404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
Papillary tumors of the pineal region (PTPR) are a rare tumor entity first described in 2003, later codified in the 2007 WHO tumor classification system. PTPRs most commonly occur in the third and fourth decades, with exceedingly rare presentations in pediatric populations. Herein, we present an additional case of a 10-year-old female found to have PTPR in conjunction with Trisomy 21 managed successfully with cerebrospinal fluid diversion and gross total resection (GTR). Three years after resection she has returned to baseline without recurrence. We also performed a comprehensive review of the current literature discussing the diagnosis, treatment, and pathophysiologic correlations in children. Diagnosis and management of PTPRs is a topic that is increasingly garnering attention in the literature given the recent characterization of this tumor entity. However, relatively little is known about the presentation of PTPRs in pediatric populations. In adults, PTPRs have been linked with several chromosomal and genetic abnormalities; however this correlation is limited in pediatric literature. Although GTR is the mainstay for treatment, the application of adult treatment protocols may not be advisable due to age and the developmental changes of the CNS in children.
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Affiliation(s)
- Mansour Mathkour
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA; Neurosurgery Division, Surgery Department, Jazan University, Jazan, Saudi Arabia.
| | - Joshua Hanna
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Naser Ibrahim
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Tyler Scullen
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Mitchell D Kilgore
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Cassidy Werner
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Ian Cormier
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Pierce Spencer
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Joseph R Keen
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Cuong J Bui
- Ochsner Health System, Department of Neurosurgery, New Orleans, LA, USA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
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19
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Aldave G. Enhancing access to the suprasellar region: the transcallosal translamina terminalis approach. J Neurosurg Pediatr 2020; 26:572-577. [PMID: 32858510 DOI: 10.3171/2020.5.peds20369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/19/2020] [Indexed: 11/06/2022]
Abstract
Craniopharyngioma represents one of the most challenging brain tumors to treat. Surgery may be the definitive treatment, and multiple surgical approaches have been described, each based on different anatomical considerations. Some approaches require working through narrow corridors that do not often provide a sufficient view of the critical anatomical structures around the tumor. The choice of the right approach is key for optimizing resection and minimizing risk. In this paper, the author presents the case of a pediatric patient with a large suprasellar craniopharyngioma who underwent complete resection of the tumor through a novel approach: a transcallosal translamina terminalis corridor. This particular transcallosal corridor, behind the anterior communicating artery, allows the optimal opening of the lamina terminalis extending up to the anterior commissure. This novel variation of the traditional operation provides a wider exposure of the tumor compared with the classic approaches through the lamina terminalis. This technique has not been sufficiently described in the pediatric literature. The author describes it here as an alternative method for treating patients with sellar and suprasellar tumors.
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20
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Yamaki VN, Solla DJF, Ribeiro RR, da Silva SA, Teixeira MJ, Figueiredo EG. Papillary Tumor of the Pineal Region: Systematic Review and Analysis of Prognostic Factors. Neurosurgery 2020; 85:E420-E429. [PMID: 30989225 DOI: 10.1093/neuros/nyz062] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 02/08/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical outcomes and biological behavior of papillary tumors of the pineal region (PTPR) are still under investigation. The best therapeutic strategy has not been defined. OBJECTIVE To perform a comprehensive patient-level analysis of all PTPR cases and identify their clinical features, treatment options, and prognostic factors. METHODS A search of the medical databases for case series and reports on PTPRs from January 2003 to June 2017 was performed. Data addressing PTPR's clinical presentation, imaging, treatment, and histological features were. Variables associated with the primary outcome of 36-mo survival were identified through Cox regression models. RESULTS The initial search yielded 1164 studies, of which 71 were included (60 case reports and 11 case series), containing 177 patients (mean age 33.0 ± 15.3 yr and 53.2% male). Intracranial hypertension and hydrocephalus prevailed as the clinical picture. Surgery was performed on 82.0% and gross total resection (GTR) was achieved on 71.4%. A total of 56.8% recurred after a median 29 mo (quartiles 10.5-45.5). The 36-mo survival rate was 83.5% (95% confidence interval [CI] 76.2-89.2%). Good functional outcomes (Glasgow Outcome Scale 4/5) were observed in 60.0%. The variables of interest were inconsistently reported and the multivariable analysis final sample was 133 patients. After adjustment for age, tumor size (each additional centimeter, hazard ratio [HR] 1.99, 95% CI 1.12-3.53, P = .019) and surgical treatment (HR 0.16, 95% CI 0.05-0.45, P = .001) were associated with 36-mo survival. CONCLUSION Tumor size and surgery are associated with improvement in 36-mo survival. We did not observe any significant benefits from GTR or adjuvant treatments.
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Affiliation(s)
- Vitor Nagai Yamaki
- Department of Neurosurgery, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Renan Ribeiro Ribeiro
- Department of Pathology, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Saul Almeida da Silva
- Department of Neurosurgery, School of Medicine, Universidade de Sao Paulo, Sao Paulo, Brazil
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21
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Muscas G, Battista F, Lastrucci G, Della Puppa A. An Alternative Route to the Posterior Half of the Third Ventricle: The Transoccipital Horn Approach. Technical Note. World Neurosurg 2019; 132:223-229. [PMID: 31518749 DOI: 10.1016/j.wneu.2019.08.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/30/2019] [Accepted: 08/31/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lesions arising or abutting in the posterior half of the third ventricle are approached through established routes to avoid damage of essential brain structures. Occasionally, the features of the lesion require rethinking these traditional routes and tailoring the surgical approach to cause fewer debilitating sequelae to the patient. We introduce a modification of previously described transcortical approaches to lesions of the posterior third ventricle. The technique and possible indications are discussed. METHODS Two cases of posterior third ventricle tumors are presented. In both patients, a small posterior fossa and large tentorial veins located along the surgical route, as well as the position of the lesion underneath the internal cerebral veins, encouraged the concept of a novel transoccipital horn approach that was developed to access the tumor with less postoperative deficits. RESULTS Both lesions were removed with transitory postoperative visual deficits. CONCLUSIONS The transoccipital horn approach is a feasible alternative to other surgical routes to the posterior part of the third ventricle in cases of particularly challenging anatomy and tumor characteristics. It allows reaching the lesion along its major axis, fully exploiting the natural space created by the tumor in its growth and avoiding the internal cerebral veins.
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Affiliation(s)
- Giovanni Muscas
- Departments of Neurosurgery, Neuroscience, Psychology, Pharmacology, and Child Health, University of Florence, Careggi, Florence, Italy.
| | - Francesca Battista
- Departments of Neurosurgery, Neuroscience, Psychology, Pharmacology, and Child Health, University of Florence, Careggi, Florence, Italy
| | - Giancarlo Lastrucci
- Departments of Neurosurgery, Neuroscience, Psychology, Pharmacology, and Child Health, University of Florence, Careggi, Florence, Italy
| | - Alessandro Della Puppa
- Departments of Neurosurgery, Neuroscience, Psychology, Pharmacology, and Child Health, University of Florence, Careggi, Florence, Italy
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Choque-Velasquez J, Resendiz-Nieves J, Jahromi BR, Colasanti R, Raj R, Vehviläinen J, Tynninen O, Collan J, Niemelä M, Hernesniemi J. Extent of Resection and Long-Term Survival of Pineal Region Tumors in Helsinki Neurosurgery. World Neurosurg 2019; 131:e379-e391. [PMID: 31369883 DOI: 10.1016/j.wneu.2019.07.169] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pineal region tumors represent challenging surgical lesions with wide ranges of survival reported in different surgical series. In this article, we emphasize the role of complete microsurgical resection (CMR) to obtain a favorable long-term outcome of pineal region tumors. METHODS We report a retrospective study of pineal region tumors operated on in Helsinki Neurosurgery between 1997 and 2015. Information was obtained from the hospital records, and an evaluation of the Finnish population register was conducted in July 2018 to determine the current status of the patients. RESULTS A total of 76 pineal region tumors were operated on. The survival was 62% at a mean follow-up of 125 ± 105 months (range, 0-588 months), and the disease-related mortality was limited to 14 patients (18.4%). Up to July 2018, 29 patients had died. Two patients died 1 and 3 months after surgery of delayed thalamic infarctions, 12 patients of disease progression, and 15 had non-disease-related deaths. Only 1 patient was lost in the long-term follow-up. Ten of 14 disease-related deaths occurred during the first 5 years of follow-up: 5 diffuse gliomas, 3 germ cell tumors, 1 grade II-III pineal parenchymal tumor of intermediate differentiation, and 1 meningioma. CMR was linked to better tumor-free survival and long-term survival, with the exception of diffuse gliomas. CONCLUSIONS CMR, in the setting of a multidisciplinary management of pineal region tumors, correlates with favorable survival and with minimal mortality. Surgically treated grade II-IV gliomas constitute a particular group with high mortality within the first 5 years independently of the microsurgical resection.
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Affiliation(s)
- Joham Choque-Velasquez
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Julio Resendiz-Nieves
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Roberto Colasanti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy; Department of Neurosurgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Juho Vehviläinen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Olli Tynninen
- Department of Pathology, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Juhani Collan
- Department of Radiation Oncology, Cancer Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Juha Hernesniemi
- "Juha Hernesniemi" International Center for Neurosurgery, Henan Provincial Peopleás Hospital, Zhengzhou, China
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Eroglu U, Shah K, Bozkurt M, Kahilogullari G, Yakar F, Dogan İ, Ozgural O, Attar A, Unlu A, Caglar S, Cohen Gadol AA, Ugur HC. Supraorbital Keyhole Approach: Lessons Learned from 106 Operative Cases. World Neurosurg 2019; 124:e667-e674. [PMID: 30659969 DOI: 10.1016/j.wneu.2018.12.188] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 12/21/2018] [Accepted: 12/23/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The supraorbital keyhole approach through an eyebrow incision has been a potentially less invasive approach as an alternative to the standard pterional craniotomy. We aimed to review procedures for anterior and middle cranial fossa lesions and identify lessons learned from addressing various pathologies through this approach. METHODS We retrospectively reviewed 106 consecutive patients who underwent this approach. We documented patients' age, sex, pathology, clinical results, extent of tumor resection, complications, use of endoscope, and cosmetic results. RESULTS Our series addressed a variety of pathologies. Male patients accounted for 55% of the cohort and mean age was 51.7 (2-79) years. Notably, 52% of patients underwent resection of extra-axial masses. Gross total resection was achieved in 74.4% of intra-axial lesions according to postoperative imaging. Two (1.9%) patients developed transient ptosis. One (0.9%) patient developed an allergic reaction to titanium. No cerebrospinal fluid fistula or rhinorrhea occurred. Three patients developed temporary diabetes insipidus after resection of parasellar lesions (2 craniopharyngiomas and 1 pituitary adenoma). In 14 patients with olfactory groove meningiomas, 6 (42.8%) suffered from absence or diminished olfaction postoperatively, and 2 (14.2%) developed postoperative anosmia. Five (38.5%) patients underwent a subsequent resection of recurrent glial tumors. Four weeks postoperatively, 95% of patients demonstrated acceptable cosmetic results. Cosmetic results for 6 (5%) patients were unavailable. CONCLUSIONS The supraorbital keyhole approach may be safely used for various lesions within the anterior and middle cranial fossa. The effectiveness and limitations of this approach and possible complications are discussed. This is a valuable approach for selected patients.
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Affiliation(s)
- Umit Eroglu
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Kushal Shah
- Department of Neurosurgery, University of Kansas, Kansas City, Kansas, USA
| | - Melih Bozkurt
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Gokmen Kahilogullari
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Fatih Yakar
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - İhsan Dogan
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Onur Ozgural
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Ayhan Attar
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Agahan Unlu
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Sükrü Caglar
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
| | - Aaron A Cohen Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA.
| | - Hasan Caglar Ugur
- Department of Neurosurgery, School of Medicine, Ankara University, Ibn-i Sina Hospital, Ankara, Turkey
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Choque-Velasquez J, Resendiz-Nieves JC, Jahromi BR, Colasanti R, Raj R, Tynninen O, Collan J, Hernesniemi J. Pineal Parenchymal Tumors of Intermediate Differentiation: A long-Term Follow-Up Study in Helsinki Neurosurgery. World Neurosurg 2018; 122:e729-e739. [PMID: 30391615 DOI: 10.1016/j.wneu.2018.10.128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/21/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare lesions with particular features compared with other pineal parenchymal tumors. METHODS We present a retrospective review of patients with histologically confirmed PPTIDs who were operated on in our department between 1997 and 2015. A demographic analysis and an evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiologic outcomes were conducted. RESULTS Fifteen patients with PPTIDs were operated on between 1997 and 2015. Gross total removal was achieved in 11 cases; 2 patients underwent near-total resection, 1 partial resection, and 1 received brachytherapy after an endoscopic biopsy. Nine patients required external radiation therapy (4 due to a pleomorphic histology of their lesion including pineoblastoma features in 3 of them; 3 after a subtotal resection; and 2 for tumor recurrence). No patient received chemotherapy. The survival rate of our patients was 57.1% at a mean follow-up of 137.2 ± 77.6 months (39-248 months). CONCLUSIONS A proper multidisciplinary management of PPTIDs based on a gross total removal of the lesion, and an adjuvant radiotherapy in selected cases, may improve the overall survival of these aggressive tumors.
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Affiliation(s)
- Joham Choque-Velasquez
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki and HUSLAB, Helsinki, Finland.
| | - Julio C Resendiz-Nieves
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki and HUSLAB, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki and HUSLAB, Helsinki, Finland
| | - Roberto Colasanti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy; Department of Neurosurgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki and HUSLAB, Helsinki, Finland
| | - Olli Tynninen
- Department of Pathology, Helsinki University Hospital, University of Helsinki and HUSLAB, Helsinki, Finland
| | - Juhani Collan
- Department of Oncology, Helsinki University Hospital, University of Helsinki and HUSLAB, Helsinki, Finland
| | - Juha Hernesniemi
- "Juha Hernesniemi" International Center for Neurosurgery, Henan Provincial Peoplés Hospital, Zhengzhou, People's Republic of China
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Papillary Tumor of the Pineal Region in Children: Presentation of a Case and Comprehensive Literature Review. World Neurosurg 2018; 117:144-152. [DOI: 10.1016/j.wneu.2018.06.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/03/2018] [Accepted: 06/04/2018] [Indexed: 11/17/2022]
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Choque-Velasquez J, Resendiz-Nieves J, Colasanti R, Collan J, Hernesniemi J. Microsurgical Management of Vascular Malformations of the Pineal Region. World Neurosurg 2018; 117:e669-e678. [DOI: 10.1016/j.wneu.2018.06.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
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Choque-Velasquez J, Colasanti R, Resendiz-Nieves JC, Raj R, Lindroos AC, Jahromi BR, Hernesniemi J. Venous air embolisms and sitting position in Helsinki pineal region surgery. Surg Neurol Int 2018; 9:160. [PMID: 30159204 PMCID: PMC6094495 DOI: 10.4103/sni.sni_128_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/18/2018] [Indexed: 11/04/2022] Open
Abstract
Background Nowadays, the sitting position has lost favor among neurosurgeons partly due to assumptions of increased complications, such as venous air embolisms (VAEs) and hemodynamic disturbances. The aim of our study is to describe the importance of some anesthetic considerations and the utility of antigravity trousers as well, together with a skillful neurosurgery and an imperative proper teamwork, in order to prevent the risk of severe VAE during pineal region surgery. We routinely use them for the variant of the sitting position we developed, the "praying position." Methods A retrospective review of 51 pineal lesions operated on in the "praying position" using antigravity trousers was carried out. In the "praying position" the legs of the patient are kept parallel to the floor. Hence, antigravity trousers are used to generate an adequate cardiac preload. Results VAE associated to persistent hemodinamic changes was nonexistent in our series. The rate of VAE was 35.3%. VAEs were diagnosed mainly by monitoring of the end-tidal CO2 (83.33%). A venous system lesion was the cause in most of the cases. When VAE was suspected, an inmediate reaction based on a good teamwork was imperative. No cervical spine cord injury nor peripheral nerve damage were reported. The average microsurgical time was 48 ± 33 min. Conclusions The risks of severe VAE during pineal region surgery in the "praying-sitting position" may be effectively prevented by some essential anesthetic considerations and the use of antigravity trousers together with a skillful neurosurgery, and an imperative proper teamwork.
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Affiliation(s)
| | - Roberto Colasanti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy.,Department of Neurosurgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | | | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Ann-Christine Lindroos
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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Choque-Velasquez J, Miranda-Solis F, Colasanti R, Ccahuantico-Choquevilca LA, Hernesniemi J. Modified Pure Endoscopic Approach to Pineal Region: Proof of Concept of Efficient and Inexpensive Surgical Model Based on Laboratory Dissections. World Neurosurg 2018; 117:195-198. [PMID: 29935314 DOI: 10.1016/j.wneu.2018.06.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE In recent decades endoscopic techniques have been increasingly used in neurosurgery as they may offer a valuable close-up view of the working area through a minimally invasive surgical corridor. Herein, we present an inexpensive and efficient endoscopic surgical model using a borescope, which was used for a "modified pure endoscopic approach" to the pineal region. METHODS A borescope video camera was connected to a 16-inch personal computer monitor. A standard midline suboccipital craniotomy was performed on 2 cadaveric heads in the Concorde position. Then, a "borescopic" supracerebellar infratentorial approach was executed, thus reaching the pineal region, which was exposed through an extensive arachnoid dissection. RESULTS Using the previously described model, we were able to provide excellent exposure of the main neurovascular structures of the pineal region, as shown by the intraoperative videos. In 1 specimen we identified an incidental pineal cyst that was meticulously dissected and removed. CONCLUSIONS Our proposed "borescopic" surgical model may represent an inexpensive and efficient alternative to conventional endoscopic techniques and could be used for training purposes, as well as even for clinical procedures, after a proper validation, particularly in economically challenging environments.
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Affiliation(s)
- Joham Choque-Velasquez
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Alto Andina Anatomy and Physiology Research Center, National University of San Antonio Abad, Cusco, Italy.
| | - Franklin Miranda-Solis
- Alto Andina Anatomy and Physiology Research Center, National University of San Antonio Abad, Cusco, Italy; Microneuroanatomy Laboratory, University Andina, National University of San Antonio Abad, Cusco, Italy
| | - Roberto Colasanti
- Umberto I General Hospital, Politechnic University of Marche, Ancona, Italy; Ospedali Riuniti Marche Nord, Pesaro, Italy
| | | | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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A Case of Nongerminomatous Germ Cell Tumor of the Pineal Region: Risks and Advantages of Biopsy by Endoscopic Approach. Case Rep Med 2018; 2018:5106701. [PMID: 29713348 PMCID: PMC5866897 DOI: 10.1155/2018/5106701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/30/2018] [Accepted: 02/15/2018] [Indexed: 01/04/2023] Open
Abstract
A 21-year-old male was admitted to our department with headache and drowsiness. CT scan and MRI revealed acute obstructive hydrocephalus caused by a pineal region mass. The serum and CSF levels of beta-human chorionic gonadotropin (beta-hCG) were 215 IU/L and 447 IU/L, respectively, while levels of alpha-fetoprotein (AFP) were normal. A germ cell tumor (GCT) was suspected, and the patient underwent endoscopic third ventriculostomy (ETV) with biopsy. After four days from surgery, the tumor bled with mass expansion and ETV stoma occlusion; thus, a ventriculoperitoneal shunt was positioned. After ten months, the tumor metastasized to the thorax and abdomen with progression of intracerebral tumor mass. Despite the aggressive nature of this tumor, ETV remains a valid approach for a pineal region mass, but in case of GCT, the risk of bleeding should be taken into account, during and after the surgical procedure.
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Wu P, Colasanti R, Lee J, Scerrati A, Ercan S, Zhang J, Ammirati M. Quantitative evaluation of different far lateral approaches to the cranio-vertebral junction using the microscope and the endoscope: a cadaveric study using a tumor model. Acta Neurochir (Wien) 2018; 160:695-705. [PMID: 29479657 DOI: 10.1007/s00701-018-3502-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/14/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several far lateral approaches have been proposed to deal with cranio-vertebral junction (CVJ) tumors including the basic, transcondylar, and supracondylar far lateral approaches (B-FLA, T-FLA, and S-FLA). However, the indications on when to use one versus the other are not well systematized yet. Our purpose is to evaluate in an experimental cadaveric setting which approach is best suited to remove tumors of different sizes. METHODS We implanted at the CVJ, using a transoral approach, tumor models of different sizes (five 1-cm3 and five 3-cm3 tumors) in ten embalmed cadaveric heads. The artificial tumors were exposed via the three approaches using endoscopic-assisted microneurosurgical technique and neuronavigation. The skull base area exposed and the maneuverability linked to each approach were evaluated using neuronavigation. RESULTS In 1-cm3 tumors, the T-FLA and the S-FLA exposed a significantly larger skull base area than the B-FLA both using the microscope and the endoscope (P < 0.05); the T-FLA executed with the microscope provided wider vertical and horizontal maneuverability than the B-FLA (P = 0.030 and 0.017, respectively); the S-FLA executed with the endoscope provided wider vertical maneuverability than the T-FLA (P = 0.031). The S-FLA executed using the microscope and the endoscope provided wider vertical maneuverability than the B-FLA both in 1 and 3-cm3 tumors (P < 0.05). CONCLUSIONS In 1-cm3 tumors, the S-FLA and the T-FLA expose a wider skull base area than the B-FLA. In larger tumors, the exposure is similar for all three approaches. Use of the endoscope in an assistive mode may further increase the surgical exposure and maneuverability.
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Affiliation(s)
- Pengfei Wu
- Department of Neurosurgery, the First Affiliated Hospital, China Medical University, Shenyang, Liaoning, China
- The Dardinger Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Roberto Colasanti
- The Dardinger Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
- Department of Neurosurgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Jungshun Lee
- The Dardinger Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Alba Scerrati
- The Dardinger Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
- Institute of Neurosurgery, Catholic University, Rome, Italy
| | - Serdar Ercan
- The Dardinger Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Jun Zhang
- Department of Radiology and Wright Center of Innovation in Biomedical Imaging, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Mario Ammirati
- The Dardinger Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
- Department of Neurosurgery, Mercy Health/St. Rita Medical Center, 770 W High Street, Suite 220, Lima, OH, 45806, USA.
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Choque-Velasquez J, Colasanti R, Resendiz-Nieves JC, Gonzáles-Echevarría KE, Raj R, Jahromi BR, Goehre F, Lindroos AC, Hernesniemi J. Praying Sitting Position for Pineal Region Surgery: An Efficient Variant of a Classic Position in Neurosurgery. World Neurosurg 2018; 113:e604-e611. [PMID: 29499423 DOI: 10.1016/j.wneu.2018.02.107] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The sitting position has lost favor among neurosurgeons partly owing to assumptions of increased complications, such as venous air embolisms and hemodynamic disturbances. Moreover, the surgeon must assume a tiring posture. We describe our protocol for the "praying position" for pineal region surgery; this variant may reduce some of the risks of the sitting position, while providing a more ergonomic surgical position. METHODS A retrospective review of 56 pineal lesions operated on using the praying position between January 2008 and October 2015 was performed. The praying position is a steeper sitting position with the upper torso and the head bent forward and downward. The patient's head is tilted about 30° making the tentorium almost horizontal, thus providing a good viewing angle. G-suit trousers or elastic bandages around the lower extremities are always used. RESULTS Complete lesion removal was achieved in 52 cases; subtotal removal was achieved in 4. Venous air embolism associated with persistent hemodynamic changes was nonexistent in this series. When venous air embolism was suspected, an immediate reaction based on good teamwork was imperative. No cervical spine cord injury or peripheral nerve damage was reported. The microsurgical time was <45 minutes in most of the cases. Postoperative pneumocephalus was detected in all patients, but no case required surgical treatment. CONCLUSIONS A protocolized praying position that includes proper teamwork management may provide a simple, fast, and safe approach for proper placement of the patient for pineal region surgery.
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Affiliation(s)
| | - Roberto Colasanti
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | | | | | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | | | - Felix Goehre
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Neurosurgery, Stroke Center, Bergmannstrost Hospital Halle, Halle, Germany
| | | | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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Dobran M, Marini A, Nasi D, Liverotti V, Benigni R, Iacoangeli M, Scerrati M. Surgical treatment and outcome in patients over 80 years old with intracranial meningioma. Clin Neurol Neurosurg 2018. [PMID: 29518711 DOI: 10.1016/j.clineuro.2018.02.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Study of mortality rate and clinical outcomes in octogenarians patients operated for intracranial meningiomas. PATIENTS AND METHODS Clinical, radiological and surgical data of 25 elderly patients aging over 80 years old operated at our Department from 2013 to 2016 for intracranial meningiomas have been recorded and analyzed. One-month mortality and clinical outcome at six-months after surgery were evaluated. Logistic regression was used for detecting the risk factors influencing mortality and neurological functions. RESULTS The median age at diagnosis was 8185 years (range 80-87). Meningiomas were gross-total removed in 18 cases out of 25 (72%) and partially resected in 7 (28%). One-month post-operative mortality occurred in 2 pts out of 25 (8%). A close correlation was found between operative duration over 240 min and mortality (p = 0,0421). There was a significantly lower mortality in patients with ASA II rather than in patients with ASA III (p = 0,038). The median pre-operative KPS value was 743 (range 50-90) while at six-month follow-up was 82. The surgical time (p = 00,006) and size of the lesion >4 cm (p = 002) were a significant prognostic factors for clinical improvement at six-month follow-up. CONCLUSIONS The operative time and the ASA score are the most important prognostic factors for the mortality and neurological outcome of elderly patients over 80 years old operated for intracranial meningioma. Even if the number of patients is limited, our findings suggest that, after a careful preoperative stratification in elderly patients, it is possible to remove an intracranial meningioma with good results.
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Affiliation(s)
- Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy.
| | - Alessandra Marini
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Valentina Liverotti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Roberta Benigni
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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Supracerebellar Infratentorial Paramedian Approach in Helsinki Neurosurgery: Cornerstones of a Safe and Effective Route to the Pineal Region. World Neurosurg 2017; 105:534-542. [DOI: 10.1016/j.wneu.2017.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 11/22/2022]
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