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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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Specialised Surgical Instruments for Endoscopic and Endoscope-Assisted Neurosurgery: A Systematic Review of Safety, Efficacy and Usability. Cancers (Basel) 2022; 14:cancers14122931. [PMID: 35740595 PMCID: PMC9221041 DOI: 10.3390/cancers14122931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/03/2022] [Accepted: 06/08/2022] [Indexed: 02/05/2023] Open
Abstract
While there have been great strides in endoscopic and endoscope-assisted neurosurgical approaches, particularly in the treatment of deep-sited brain and skull base tumours, the greatest technical barrier to their adoption has been the availability of suitable surgical instruments. This systematic review seeks to identify specialised instruments for these approaches and evaluate their safety, efficacy and usability. Conducted in accordance with the PRISMA guidelines, Medline, Embase, CENTRAL, SCOPUS and Web of Science were searched. Original research studies that reported the use of specialised mechanical instruments that manipulate tissue in human patients, cadavers or surgical models were included. The results identified 50 specialised instruments over 62 studies. Objective measures of safety were reported in 32 out of 62 studies, and 20 reported objective measures of efficacy. Instruments were broadly safe and effective with one instrument malfunction noted. Measures of usability were reported in 15 studies, with seven reporting on ergonomics and eight on the instruments learning curve. Instruments with reports on usability were generally considered to be ergonomic, though learning curve was often considered a disadvantage. Comparisons to standard instruments were made in eight studies and were generally favourable. While there are many specialised instruments for endoscopic and endoscope-assisted neurosurgery available, the evidence for their safety, efficacy and usability is limited with non-standardised reporting and few comparative studies to standard instruments. Future innovation should be tailored to unmet clinical needs, and evaluation guided by structured development processes.
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Mandel M, Adada B, Borghei-Razavi H. Commentary: Endoscopic Transcortical-Transventricular Approach in Treating Third Ventricular Craniopharyngiomas—Case Series With Technical Note and Literature Review. Oper Neurosurg (Hagerstown) 2022; 22:e285-e286. [DOI: 10.1227/ons.0000000000000191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 11/19/2022] Open
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4
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Kageyama S, Nakagawa A, Kawaguchi T, Ohtani K, Endo T, Kyan M, Kusunoki T, Shimoda Y, Osawa SI, Kanamori M, Kuniyasu N, Tominaga T. Methodological assessment of the reduction of dissemination risk and quantification of debris dispersion during dissection with a surgical aspirator. BMC Res Notes 2022; 15:85. [PMID: 35236402 PMCID: PMC8889673 DOI: 10.1186/s13104-022-05947-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/02/2022] [Indexed: 11/24/2022] Open
Abstract
Objective We developed an actuator-driven pulsed water jet (ADPJ) device to achieve maximal lesion dissection with minimal risk of normal structural damage. Despite the unique dissection characteristics, there is a risk of dissemination of tissue dispersion; however, there is no established method to quantify the dispersion. Hence, this study aimed to assess the factors associated with dispersion and propose a simple experimental method using spectrophotometry to evaluate the degree of dispersion in a wet field. Results Methylene blue-stained brain phantom gelatin was immersed in a chamber with distilled water solution and dissected with an ADPJ. The dispersed gelatin solution was stirred and warmed to dissolve. The absorbance of the solution was measured spectrophotometrically. First, a reference standard curve was constructed to confirm the relationship between the absorbance and the amount of the dispersed gelatin. A clear proportional correlation was observed, which indicated that absorbance measurements can help evaluate the amount of dispersion. Using this method, we revealed that a high dissection force, insufficient suction, and inappropriate long distance between the nozzle tip and the target were associated with increased dispersion. This method might constitute a versatile and reliable approach to evaluate dispersion and aid in the development of surgical devices.
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Affiliation(s)
- Sosuke Kageyama
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Atsuhiro Nakagawa
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.,Department of Biodesign, Clinical Research, Innovation, Education Center, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Tomohiro Kawaguchi
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan. .,Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan.
| | - Kiyonobu Ohtani
- Institute of Fluid Science, Tohoku University, Sendai, Miyagi, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Manabu Kyan
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Tetsuya Kusunoki
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Yoshiteru Shimoda
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Shin-Ichiro Osawa
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Masayuki Kanamori
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Niizuma Kuniyasu
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.,Department of Neurosurgical Engineering and Translational Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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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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Das A, Gunasekaran A, Stephens HR, Mark J, Lindhorst SM, Cachia D, Patel SJ, Frankel BM. Establishing a standardized method for the effective intraoperative collection and biological preservation of brain tumor tissue samples using a novel tissue preservation system: A pilot study. World Neurosurg 2022; 161:e61-e74. [PMID: 35032716 DOI: 10.1016/j.wneu.2022.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/16/2022]
Abstract
Glioblastoma (GB) is an aggressive tumor exhibiting extensive inter- and intratumoral heterogeneity. Several possible reasons contribute to the historical inability to develop effective therapeutic strategies for treatment of GB. One such challenge is the inability to consistently procure high quality biologically preserved specimens for use in molecular research and patient derived xenograft (PDX) model development. Currently, no scientifically derived standardized method exists for intraoperative tissue collection specifically designed with the fragility of ribonucleic acid (RNA) in mind. In this investigation, we set out to characterize matched specimens from six GB patients comparing the traditional handling and collection processes of intraoperative tissue used in most neurosurgical operating rooms (ORs) versus an automated resection, collection, and biological preservation system (APS) which captures, preserves, and biologically maintains tissue in a prescribed and controlled microenvironment. Matched specimens were processed in parallel at various time points and temperatures, evaluating viability, RNA and protein concentrations, and isolation of GB cell lines. We found that APS-derived GB slices stored in an APS modified medium remained viable and maintained high quality RNA and protein concentration for up to 24 hours. Our results demonstrated that primary GB cell cultures derived in this manner had improved growth over widely used collection and preservation methods. By implementing an automated intraoperative system, we also eliminated inconsistencies in methodology of tissue collection, handling and biological preservation, establishing a repeatable and standardized practice that does not require additional staff or a lab technician to manage.
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Affiliation(s)
- Arabinda Das
- Department of Neurosurgery (Neuro-oncology Division), Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Arunprasad Gunasekaran
- Department of Neurosurgery (Neuro-oncology Division), Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Joseph Mark
- NICO Corporation, Indianapolis, Indiana, USA
| | - Scott M Lindhorst
- Department of Neurosurgery (Neuro-oncology Division), Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Cachia
- Department of Neurosurgery (Neuro-oncology Division), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sunil J Patel
- Department of Neurosurgery (Neuro-oncology Division), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bruce M Frankel
- Department of Neurosurgery (Neuro-oncology Division), Medical University of South Carolina, Charleston, South Carolina, USA
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Hardesty DA, Montaser A, Kreatsoulas D, Shah VS, VanKoevering KK, Otto BA, Carrau RL, Prevedello DM. Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010-2018. J Neurosurg 2021; 136:393-404. [PMID: 34359021 DOI: 10.3171/2020.11.jns202494] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has evolved into a mainstay of skull base surgery over the last two decades, but publications examining the intraoperative and perioperative complications of this technique remain scarce. A prior landmark series of 800 patients reported complications during the first era of EEA (1998-2007), parallel to the development of many now-routine techniques and technologies. The authors examined a single-institution series of more than 1000 consecutive EEA neurosurgical procedures performed since 2010, to elucidate the safety and risk factors associated with surgical and postoperative complications in this modern era. METHODS After obtaining institutional review board approval, the authors retrospectively reviewed intraoperative and postoperative complications and their outcomes in patients who underwent EEA between July 2010 and June 2018 at a single institution. RESULTS The authors identified 1002 EEA operations that met the inclusion criteria. Pituitary adenoma was the most common pathology (n = 392 [39%]), followed by meningioma (n = 109 [11%]). No patients died intraoperatively. Two (0.2%) patients had an intraoperative carotid artery injury: 1 had no neurological sequelae, and 1 had permanent hemiplegia. Sixty-one (6.1%) cases of postoperative cerebrospinal fluid leak occurred, of which 45 occurred during the original surgical hospitalization. Transient postoperative sodium dysregulation was noted after 87 (8.7%) operations. Six (0.6%) patients were treated for meningitis, and 1 (0.1%) patient died of a fungal skull base infection. Three (0.3%) patients died of medical complications, thereby yielding a perioperative 90-day mortality rate of 0.4% (4 deaths). High-grade (Clavien-Dindo grade III-V) complications were identified after 103 (10%) EEA procedures, and multivariate analysis was performed to determine the associations between factors and these more serious complications. Extradural EEA was significantly associated with decreased rates of these high-grade complications (OR [95% CI] 0.323 [0.153-0.698], p = 0.0039), whereas meningioma pathology (OR [95% CI] 2.39 [1.30-4.40], p = 0.0053), expanded-approach intradural surgery (OR [95% CI] 2.54 [1.46-4.42], p = 0.0009), and chordoma pathology (OR [95% CI] 9.31 [3.87-22.4], p < 0.0001) were independently associated with significantly increased rates of high-grade complications. CONCLUSIONS The authors have reported a large 1002-operation cohort of EEA procedures and associated complications. Modern EEA surgery for skull base pathologies has an acceptable safety profile with low morbidity and mortality rates. Nevertheless, significant intraoperative and postoperative complications were correlated with complex intradural procedures and meningioma and chordoma pathologies.
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Affiliation(s)
- Douglas A Hardesty
- Departments of1Neurosurgery and.,2Otolaryngology-Head and Neck Surgery, Wexner Medical Center
| | - Alaa Montaser
- Departments of1Neurosurgery and.,3Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | | | | | | | - Bradley A Otto
- 2Otolaryngology-Head and Neck Surgery, Wexner Medical Center
| | | | - Daniel M Prevedello
- Departments of1Neurosurgery and.,2Otolaryngology-Head and Neck Surgery, Wexner Medical Center
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Endoscopic technology and repair techniques. HANDBOOK OF CLINICAL NEUROLOGY 2021; 170:217-225. [PMID: 32586493 DOI: 10.1016/b978-0-12-822198-3.00042-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
In this chapter, we describe advances in endoscopic endonasal surgery that have impacted skull base meningioma surgery. After reviewing the technical innovations in endoscopy, we describe the advances as they relate to each surgical step. We discuss preoperative planning and approach and the utility of neuronavigation and neuromonitoring. We then discuss endoscopic instrumentation, technology for tumor debulking (ultrasonic aspirators, radiofrequency ablators, suction debriders), and hemostatic agents as they relate to tumor resection and hemostasis. In the end, we discuss techniques of skull base reconstruction and closure (nasoseptal flap, gasket seal and bilayer button).
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Abstract
Brain metastases are the most common intracranial tumor and a leading cause of morbidity and mortality for patients with systemic cancer. En bloc surgical resection of brain metastases improves survival, local recurrence rates, and functional independence in patients with up to three metastases and controlled extracranial disease. Modern techniques and technologies provide the neurosurgeon with minimally invasive approaches, such as keyhole craniotomies and tubular retractors. Preoperative planning for tumors located in eloquent regions includes mapping with functional MRI and diffusion tensor imaging, and intraoperative mapping and monitoring with electrophysiologic techniques under general or awake anesthesia to preserve normal neurologic function.
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Affiliation(s)
- Joshua L Wang
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Doan Hall N1004, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - J Bradley Elder
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Doan Hall N1004, 410 West 10th Avenue, Columbus, OH 43210, USA
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Bakhsheshian J, Strickland BA, Jackson C, Chaichana KL, Young R, Pradilla G, Chen JW, Bailes J, Zada G. Multicenter Investigation of Channel-Based Subcortical Trans-Sulcal Exoscopic Resection of Metastatic Brain Tumors: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2020; 16:159-166. [PMID: 29912398 DOI: 10.1093/ons/opy079] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/19/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recent advancements have aimed to optimize visualization and minimize insult to healthy cortical and subcortical tissue through the use of tubular-based retractors. OBJECTIVE To investigate outcomes following resection of cerebral metastases using an integrated tubular retraction system with an exoscope and neuronavigation. METHODS A multicenter retrospective analysis of surgical outcomes in consecutive patients who underwent resection of a brain metastasis using a tubular retraction system and exoscope was performed. RESULTS Twenty-five patients were included, with a mean age of 61 yr (24-81 yr). Primary sources included lung (n = 13), breast (n = 3), renal cell (n = 3), and other (n = 6). Locations were frontal (n = 5), parietal (n = 8), cerebellar (n = 8), occipital (n = 3), and splenium (n = 1). Most lesions had a maximum diameter > 3.0 cm (n = 20) and a tumor depth > 4 cm (n = 14). Conversion to open (microscopic) craniotomy was not required in any case. Gross total resection was achieved in 20 cases (80.0%) and subtotal resection in 5 cases (20.0%). Median hospital stay was 2 d (1-12 d). All patients underwent postoperative radiation therapy. Perioperative complications developed in 1 patient (4.0%; hemiparesis and subsequent deep vein thrombosis). At 3-mo follow-up, no mortalities were observed, 19 patients (76.0%) demonstrated neurological improvements, 5 patients (20.0%) had a stable neurological exam, and 1 patient (4.0%) had a neurological decline. CONCLUSION Utilization of a channel-based, navigable retractor and exoscope is a feasible option for surgical resection of metastatic brain lesions.
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Affiliation(s)
- Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christina Jackson
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kaisorn L Chaichana
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald Young
- Brain and Spine Center of South Florida, Delray, Florida
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jefferson W Chen
- Department of Neurological Surgery, School of Medicine, University of California, Irvine, California
| | - Julian Bailes
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Shao J, Witek A, Borghei-Razavi H, Bain M, Recinos PF. Endoscopic Evacuation of Intracerebral Hematoma Utilizing a Side-Cutting Aspiration Device. Oper Neurosurg (Hagerstown) 2020; 18:E248-E254. [PMID: 31605109 DOI: 10.1093/ons/opz309] [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: 02/07/2019] [Accepted: 07/19/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is associated with a significant mortality of up to 50%, with almost all survivors suffering from debilitating functional compromise. In most cases, open craniotomy has failed to yield significant survival benefit. However, emerging evidence suggests that minimally invasive surgery (MIS) may yield clinically significant improvements in patient survival and quality of life in cases where open craniotomy has not shown benefit. CASE PRESENTATION We report the first documented usage of a side-cutting-aspiration device via an endoscopic approach for the evacuation of a 56cc hematoma, which was a technical modification on previous MIS techniques. The patient is a 50-yr-old female who was transferred emergently to our center with a National Institutes of Health Stroke Scale score of 27 and found to have a large hematoma involving her left basal ganglia. A minimally-invasive approach was elected due to evidence on the risks and suboptimal outcomes of open craniotomy in ICH evacuation. Neuronavigation was used to plan the surgical trajectory for ICH access. Evacuation took place in three main steps: 1) beginning at the center of the clot to remove bulk; 2) mobilizing clots from parenchymal walls to a safe zone via aspiration, followed by clot homogenization; and 3) re-expansion of the cavity via continuous irrigation to allow visualization of further clots. A final inspection was performed to ensure removal of all clots that could be safely removed. The dual functionalities of the device, namely, suction only and suction plus side-cutting functions, enabled key maneuvers, such as clot homogenization and controlled aspiration strength, to be safely performed. A near-total evacuation of the hematoma was achieved without damage to surrounding parenchyma. The patient experienced a rapid clinical course from comatose to discharge-ready in 5 d. At 30-d follow-up, the patient had residual expressive aphasia and was able to ambulate with the assistance of a quad cane. There are no radiographical signs of recurrent hemorrhage or parenchymal injury. Clinical follow-up with this patient is ongoing. CONCLUSION This is the first ICH evacuation with a side-cutting-aspiration device via an endoscopic approach. In our patient, this technique proved to be safe and efficacious, suggesting that this technique may be a promising addition to the armamentarium of MIS for ICH evacuation.
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Affiliation(s)
- Jianning Shao
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Alex Witek
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Hamid Borghei-Razavi
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.,Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mark Bain
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pablo F Recinos
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.,Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Packer RA, McGrath S. Onscreen-guided resection of extra-axial and intra-axial forebrain masses through registration of a variable-suction tissue resection device with a neuronavigation system. Vet Surg 2020; 49:676-684. [PMID: 32220078 DOI: 10.1111/vsu.13414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 01/10/2020] [Accepted: 03/07/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe a novel surgical technique in which neuronavigation is used to guide a tissue resection device during excision of forebrain masses in locations difficult to visualize optically. STUDY DESIGN Short case series. ANIMALS Six dogs and one cat with forebrain masses (five neoplastic, two nonneoplastic) undergoing excision with a novel tissue resection device and veterinary neuronavigation system. METHODS The animals and resection instrument were coregistered to the neuronavigation system. Surgery was guided by real-time onscreen visualization of the resection instrument position relative to the preoperative MR images. Surgical outcome was evaluated by calculating residual tumor volume according to postoperative MRI. RESULTS The technique was technically simple and led to the collection of diagnostic tissue samples in all cases. Postoperative MRI was available in six cases, two with gross-total resection, three with near-total resection, and one with subtotal resection. CONCLUSION Neuronavigation-guided resection of intra-axial and extra-axial brain masses with the resection device resulted in gross-total or near-total resection in five of six animals with tumors otherwise difficult to visualize. Risk of brain shift limited absolute reliance on navigation images. CLINICAL SIGNIFICANCE Real-time neuronavigation assistance is a feasible method for guidance and successful resection of brain masses that are poorly visualized because of intra-axial or deep location, tumor appearance, or hemorrhage.
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Affiliation(s)
- Rebecca A Packer
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
| | - Stephanie McGrath
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado
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13
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Abstract
Tuberculum sellae meningiomas are challenging tumors that can cause significant morbidity for patients because of their proximity to critical neurovascular structures. By studying the anatomy of the tuberculum, the manner in which these tumors grow and cause deficits becomes apparent, as also the challenges associated with surgical removal and management. The necessary preoperative workup and grading scales for preoperative evaluation of tuberculum meningiomas are discussed. Traditional open cranial approaches for resection are discussed and contrasted with the endoscopic endonasal approach. Finally, postoperative management, patient outcomes, and adjuvant therapy for management of residual tumor are considered.
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Affiliation(s)
- Stephen T Magill
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health of South Florida, Miami, FL, United States; Division of Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
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14
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Lin M, Bakhsheshian J, Strickland B, Rennert RC, Chu RM, Chaichana KL, Zada G. Exoscopic resection of atrial intraventricular meningiomas using a navigation-assisted channel-based trans-sulcal approach: Case series and literature review. J Clin Neurosci 2020; 71:58-65. [DOI: 10.1016/j.jocn.2019.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/24/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022]
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Zusman E, Sidorov M, Ayala A, Chang J, Singer E, Chen M, Desprez PY, McAllister S, Salomonis N, Chetal K, Prasad G, Kang T, Mark J, Dickinson L, Soroceanu L. Tissues Harvested Using an Automated Surgical Approach Confirm Molecular Heterogeneity of Glioblastoma and Enhance Specimen's Translational Research Value. Front Oncol 2019; 9:1119. [PMID: 31750239 PMCID: PMC6843001 DOI: 10.3389/fonc.2019.01119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022] Open
Abstract
Glioblastoma (GBM) is the most aggressive primary brain tumor in adults. Designing effective individualized therapies for GBM requires quality fresh tissue specimens, and a comprehensive molecular profile of this highly heterogenous neoplasm. Novel neuro-surgical approaches, such as the automated resection NICO Myriad™ system, are increasingly used by neurosurgeons to better reach the invasive front of tumors. However, no information exists on how harvesting GBM tissue using this approach may impact the translational research value of the sample. Here, we set out to characterize matched specimens from 15 patients, where one tissue sample was obtained using traditional tumor de-bulking (herein referred to as “en bloc” sample), and the other sample was obtained using the MyriadTM System (herein referred to as “Myriad” sample). We investigated the fidelity of patient derived xenografts (PDXs) for each sample type to the corresponding human tissues and evaluated the added value of sequencing both samples for each patient. Matched en bloc and Myriad samples processed in parallel, were subjected to the following assays: cell viability, self-renewal, in vivo tumorigenicity using an orthotopic model of glioma, genomic sequencing, and pharmacological testing using PI3K-MTOR pathway inhibitors. Our results demonstrate that primary GBM cultures derived from matched specimens grew at similar rates (correlation coefficient R = 0.72), generated equivalent number of neurospheres, and had equivalent tumorigenic potential in vivo (mouse survival correlation coefficient R = 0.93). DNA Sequencing using the Illumina tumor panel amplicons revealed over 70% concordance in non-synonymous mutations between matched human GBM specimens. PDX genomic profiles were also highly concordant with the corresponding patient tissues (>70%). RNA sequencing of paired GBM samples revealed unique genomic variants and differential gene expression between the en bloc and Myriad specimens, with the former molecularly resembling the “tumor core” and the latter resembling the “invasive tumor front” signature. Functionally, we show that primary-derived GBM cells—obtained after fresh specimen's dissociation—are more effectively growth-inhibited by co-targeting non-overlapping mutations enriched in each sample type, suggesting that profiling both specimens more adequately capture the molecular heterogeneity of GBM and may enhance the design accuracy and efficacy of individualized therapies.
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Affiliation(s)
- Edie Zusman
- NorthBay Medical Center, Fairfield, CA, United States
| | - Maxim Sidorov
- California Pacific Medical Center (CPMC) Research Institute, San Francisco, CA, United States
| | - Alexandria Ayala
- Pacific Brain and Spine Medical Group, Eden Medical Center-Sutter Research, Castro Valley, CA, United States
| | - Jimmin Chang
- Pacific Brain and Spine Medical Group, Eden Medical Center-Sutter Research, Castro Valley, CA, United States
| | - Eric Singer
- California Pacific Medical Center (CPMC) Research Institute, San Francisco, CA, United States
| | - Michelle Chen
- California Pacific Medical Center (CPMC) Research Institute, San Francisco, CA, United States
| | - Pierre-Yves Desprez
- California Pacific Medical Center (CPMC) Research Institute, San Francisco, CA, United States
| | - Sean McAllister
- California Pacific Medical Center (CPMC) Research Institute, San Francisco, CA, United States
| | - Nathan Salomonis
- Cincinnati Children's Hospital Medical Center (CCHMC) Biomedical Informatics, Cincinnati, OH, United States
| | - Kashish Chetal
- Cincinnati Children's Hospital Medical Center (CCHMC) Biomedical Informatics, Cincinnati, OH, United States
| | - Gautam Prasad
- Pacific Brain and Spine Medical Group, Eden Medical Center-Sutter Research, Castro Valley, CA, United States
| | - Tyler Kang
- Pacific Brain and Spine Medical Group, Eden Medical Center-Sutter Research, Castro Valley, CA, United States
| | - Joseph Mark
- NICO Corporation, Indianapolis, IN, United States
| | - Lawrence Dickinson
- Pacific Brain and Spine Medical Group, Eden Medical Center-Sutter Research, Castro Valley, CA, United States
| | - Liliana Soroceanu
- California Pacific Medical Center (CPMC) Research Institute, San Francisco, CA, United States
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Skull Base Neuroendoscopic Training Model Using a Fibrous Injectable Tumor Polymer and the Nico Myriad. J Craniofac Surg 2018; 29:e25-e28. [PMID: 29049148 DOI: 10.1097/scs.0000000000004042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The Myriad is an innovative, high precision tool for tumor resection, designed to work within narrow endoscopic corridors. Due to its application in technically demanding situations, the learning curve associated with its use might be extremely challenging and time-consuming.The authors describe the application of an already validated training model, the skull base injectable tumor model (ITM), to allow trainees to practice with the use of the Myriad during endoscopic skull base procedures.A formalin embalmed cadaveric head was used for technical assessment. Stratathane resin ST-504 derived polymer was injected to mimic skull base tumors and Myriad was used for tumor resection during different endoscopic procedures.An endoscopic endonasal transsphenoidal, a trans-planum trans-tuberculum, and a trans-clival approach have been performed after ITM injection. The Myriad was used for tumor debulking and blunt manipulation, qualitatively evaluating the technical challenges in performing the surgical dissection.Injectable tumor model demonstrates to be a valuable educational tool to train surgeons in the use of Myriad, potentially speeding up the learning curve in the acquirement of necessary technical skills in manipulating the instrument, even in case of demanding surgical situation.
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17
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Day JD. Transsulcal Parafascicular Surgery Using Brain Path® for Subcortical Lesions. Neurosurgery 2017; 64:151-156. [PMID: 28899061 DOI: 10.1093/neuros/nyx324] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/30/2017] [Indexed: 01/31/2023] Open
Affiliation(s)
- J D Day
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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18
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Frontal burr hole approach for neuroendoscopic resection of craniopharyngioma with the NICO Myriad device: report of two cases. Childs Nerv Syst 2017; 33:659-664. [PMID: 28324187 DOI: 10.1007/s00381-017-3386-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 03/10/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Craniopharyngiomas are challenging tumors to resect due to their deep location and proximity to vital structures. The perceived benefit of gross total resection may be tempered by the possibility of permanent disability. Minimally invasive techniques may reduce surgical morbidity while still allowing effective resection. The authors describe their initial experience with a neuroendoscopic transcortical, transventricular approach to two craniopharyngiomas. The surgeries were performed through a right frontal burr hole using the NICO Myriad, a side-cutting, aspiration device that fits through the working channel of a standard neuroendoscope. METHODS The imaging and medical records of two children (a 5-year-old male and a 9-year-old female) undergoing endoscopic resection of a craniopharyngioma with this technique were reviewed. Outcomes, results, and complications were noted. RESULTS A gross total resection was achieved in both patients. The operative time was 180 and 143 min, respectively. The estimated blood loss was 20 and 50 cm3, respectively. Both patients required a cerebrospinal fluid shunt. There were no surgical complications. CONCLUSIONS The NICO Myriad is an effective tool that allows a safe minimally invasive endoscopic resection of craniopharyngiomas in patients with amenable anatomy. Surgeons with experience in neuroendoscopy may be able to achieve a gross total resection of these challenging tumors through a minimally invasive burr hole approach.
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Gerard AWL, Tailor J, Gradil C, Thakur B, Zebian B. Letter to the Editor: Endoscopic resection of intraventricular choroid plexus papillomas in infants. J Neurosurg Pediatr 2017; 19:122-125. [PMID: 27715483 DOI: 10.3171/2016.5.peds16154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Jignesh Tailor
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Catia Gradil
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Bhaskar Thakur
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Bassel Zebian
- King's College Hospital NHS Foundation Trust, London, United Kingdom
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20
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Zebian B, Vergani F, Lavrador JP, Mukherjee S, Kitchen WJ, Stagno V, Chamilos C, Pettorini B, Mallucci C. Recent technological advances in pediatric brain tumor surgery. CNS Oncol 2016; 6:71-82. [PMID: 28001090 DOI: 10.2217/cns-2016-0022] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
X-rays and ventriculograms were the first imaging modalities used to localize intracranial lesions including brain tumors as far back as the 1880s. Subsequent advances in preoperative radiological localization included computed tomography (CT; 1971) and MRI (1977). Since then, other imaging modalities have been developed for clinical application although none as pivotal as CT and MRI. Intraoperative technological advances include the microscope, which has allowed precise surgery under magnification and improved lighting, and the endoscope, which has improved the treatment of hydrocephalus and allowed biopsy and complete resection of intraventricular, pituitary and pineal region tumors through a minimally invasive approach. Neuronavigation, intraoperative MRI, CT and ultrasound have increased the ability of the neurosurgeon to perform safe and maximal tumor resection. This may be facilitated by the use of fluorescing agents, which help define the tumor margin, and intraoperative neurophysiological monitoring, which helps identify and protect eloquent brain.
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Affiliation(s)
- Bassel Zebian
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK.,Department of Pediatric & Adult Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Francesco Vergani
- Department of Pediatric & Adult Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - José Pedro Lavrador
- Department of Pediatric & Adult Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Soumya Mukherjee
- Department of Neurosurgery, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - William John Kitchen
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Vita Stagno
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Christos Chamilos
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Benedetta Pettorini
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Conor Mallucci
- Department of Pediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
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Wright J, Chugh J, Wright CH, Alonso F, Hdeib A, Gittleman H, Barnholtz-Sloan J, Sloan AE. Laser interstitial thermal therapy followed by minimal-access transsulcal resection for the treatment of large and difficult to access brain tumors. Neurosurg Focus 2016; 41:E14. [DOI: 10.3171/2016.8.focus16233] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Laser interstitial thermal therapy (LITT), sometimes referred to as “stereotactic laser ablation,” has demonstrated utility in a subset of high-risk surgical patients with difficult to access (DTA) intracranial neoplasms. However, the treatment of tumors larger than 10 cm3 is associated with suboptimal outcomes and morbidity. This may limit the utility of LITT in dealing with precisely those large or deep tumors that are most difficult to treat with conventional approaches. Recently, several groups have reported on minimally invasive transsulcal approaches utilizing tubular retracting systems. However, these approaches have been primarily used for intraventricular or paraventricular lesions, and subtotal resections have been reported for intraparenchymal lesions. Here, the authors describe a combined approach of LITT followed by minimally invasive transsulcal resection for large and DTA tumors.
METHODS
The authors retrospectively reviewed the results of LITT immediately followed by minimally invasive, transsulcal, transportal resection in 10 consecutive patients with unilateral, DTA malignant tumors > 10 cm3. The patients, 5 males and 5 females, had a median age of 65 years. Eight patients had glioblastoma multiforme (GBM), 1 had a previously treated GBM with radiation necrosis, and 1 had a melanoma brain metastasis. The median tumor volume treated was 38.0 cm3.
RESULTS
The median tumor volume treated to the yellow thermal dose threshold (TDT) line was 83% (range 76%–92%), the median tumor volume treated to the blue TDT line was 73% (range 60%–87%), and the median extent of resection was 93% (range 84%–100%). Two patients suffered mild postoperative neurological deficits, one transiently. Four patients have died since this analysis and 6 remain alive. Median progression-free survival was 280 days, and median overall survival was 482 days.
CONCLUSIONS
Laser interstitial thermal therapy followed by minimally invasive transsulcal resection, reported here for the first time, is a novel option for patients with large, DTA, malignant brain neoplasms. There were no unexpected neurological complications in this series, and operative characteristics improved as surgeon experience increased. Further studies are needed to elucidate any differences in survival or quality of life metrics.
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Affiliation(s)
- James Wright
- 1Department of Neurological Surgery, University Hospitals Case Medical Center
| | - Jessey Chugh
- 1Department of Neurological Surgery, University Hospitals Case Medical Center
| | | | - Fernando Alonso
- 1Department of Neurological Surgery, University Hospitals Case Medical Center
| | - Alia Hdeib
- 1Department of Neurological Surgery, University Hospitals Case Medical Center
- 2Case Western Reserve University School of Medicine; and
| | | | | | - Andrew E. Sloan
- 1Department of Neurological Surgery, University Hospitals Case Medical Center
- 2Case Western Reserve University School of Medicine; and
- 3Case Comprehensive Cancer Center, Cleveland, Ohio
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22
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Minimally Invasive Transsulcal Resection of Intraventricular and Periventricular Lesions Through a Tubular Retractor System: Multicentric Experience and Results. World Neurosurg 2016; 90:556-564. [DOI: 10.1016/j.wneu.2015.12.100] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/29/2015] [Accepted: 12/30/2015] [Indexed: 11/20/2022]
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Sandberg DI. Endoscopic Resection of Intraventricular Brain Tumors in Children. World Neurosurg 2015; 89:708-9. [PMID: 26709154 DOI: 10.1016/j.wneu.2015.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/19/2022]
Affiliation(s)
- David I Sandberg
- Departments of Pediatric Surgery and Neurosurgery, University of Texas Health Science Center at Houston and Mischer Neuroscience Institute, Houston, Texas, USA.
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24
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Prevedello DM, Ditzel Filho LFS, Fernandez-Miranda JC, Solari D, do Espírito Santo MP, Wehr AM, Carrau RL, Kassam AB. Magnetic resonance imaging fluid-attenuated inversion recovery sequence signal reduction after endoscopic endonasal transcribiform total resection of olfactory groove meningiomas. Surg Neurol Int 2015; 6:158. [PMID: 26539309 PMCID: PMC4604640 DOI: 10.4103/2152-7806.166846] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 05/13/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Olfactory groove meningiomas grow insidiously and compress adjacent cerebral structures. Achieving complete removal without further damage to frontal lobes can be difficult. Microsurgical removal of large lesions is a challenging procedure and usually involves some brain retraction. The endoscopic endonasal approaches (EEAs) for tumors arising from the anterior fossa have been well described; however, their effect on the adjacent brain tissue has not. Herein, the authors utilized the magnetic resonance imaging fluid attenuated inversion recovery (FLAIR) sequence signal as a marker for edema and gliosis on pre- and post-operative images of olfactory groove meningiomas, thus presenting an objective parameter for brain injury after surgical manipulation. METHODS Imaging of 18 olfactory groove meningiomas removed through EEAs was reviewed. Tumor and pre/postoperative FLAIR signal volumes were assessed utilizing the DICOM image viewer OsiriX(®). Inclusion criteria were: (1) No previous treatment; (2) EEA gross total removal; (3) no further treatment. RESULTS There were 14 females and 4 males; the average age was 53.8 years (±8.85 years). Average tumor volume was 24.75 cm(3) (±23.26 cm(3), range 2.8-75.7 cm(3)), average preoperative FLAIR volume 31.17 cm(3) (±39.38 cm(3), range 0-127.5 cm(3)) and average postoperative change volume, 4.16 cm(3) (±6.18 cm(3), range 0-22.2 cm(3)). Average time of postoperative scanning was 6 months (range 0.14-20 months). In all cases (100%) gross total tumor removal was achieved. Nine patients (50%) had no postoperative FLAIR changes. In 2 patients (9%) there was minimal increase of changes postoperatively (2.2 cm(3) and 6 cm(3) respectively); all others demonstrated image improvement. The most common complication was postoperative cerebrospinal fluid leakage (27.8%); 1 patient (5.5%) died due to systemic complications and pulmonary sepsis. CONCLUSIONS FLAIR signal changes tend to resolve after endonasal tumor resection and do not seem to worsen with this operative technique.
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Affiliation(s)
- Daniel M. Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Leo F. S. Ditzel Filho
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Juan C. Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Pittsburgh, PA 15213, USA
| | - Domenico Solari
- Department of Neurological Sciences, Division of Neurosurgery, University of Napoli Federico II, 80131 Naples, Italy
| | - Marcelo Prudente do Espírito Santo
- Department of Neurological Surgery, University of São Paulo, Central Institute of the University of São Paulo Medical School Clinical Hospital, São Paulo, Brazil
| | - Allison M. Wehr
- Department of Biomedical Informatics, Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH 43221, USA
| | - Ricardo L. Carrau
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amin B. Kassam
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Milwaukee, WI 53215, USA
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25
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Goodwin CR, Sankey EW, Jusué-Torres I, Elder BD, Kosztowski TA, Liu A, Hoffberger J, Lu J, Blitz AM, Rigamonti D. The Use of an Aspirating/Resecting Device to Reduce Stoma Closure Following Endoscopic Third Ventriculostomy for Aqueductal Stenosis. Oper Neurosurg (Hagerstown) 2015; 11:512-517. [PMID: 29506164 DOI: 10.1227/neu.0000000000000920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 06/10/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) is commonly used to treat obstructive hydrocephalus. Closure of the stoma can be associated with symptom recurrence and need for further surgical intervention. OBJECTIVE To describe the use of a side-cutting aspiration device for treatment of aqueductal stenosis in patients undergoing ETV. METHODS A retrospective review of 30 consecutive adults with aqueductal stenosis treated with ETV using an adjunct side-cutting aspiration device between 2011 and 2013 was performed. Patients included in the study ranged from 35 to 64 years of age. ETV success was determined by the absence of stoma closure (aqueductal and cisternal flow assessed by high-resolution, gradient-echo magnetic resonance imaging), post-ETV symptom recurrence, and need for subsequent surgical intervention. RESULTS Patients treated by using a side-cutting aspirator had no observed stoma closure (0%) and a 10% (n = 3) rate of post-ETV symptom recurrence. Three patients (10%) demonstrated a need for surgical revision following initial ETV with the side-cutting aspirator. CONCLUSION Adult patients with obstructive hydrocephalus secondary to aqueductal stenosis exhibited a low rate of stoma closure with the use of a side-cutting aspiration device, and a rate of complications comparable to the known literature. Likewise, patients treated with a side-cutting aspirator may have lower symptom recurrence post-ETV and require fewer revisions in comparison with the known literature. As such, a side-cutting aspirator may be considered as a useful adjunct to traditional ETV for the treatment of obstructive hydrocephalus secondary to aqueductal stenosis.
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Affiliation(s)
- C Rory Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric W Sankey
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ignacio Jusué-Torres
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benjamin D Elder
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas A Kosztowski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ann Liu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jamie Hoffberger
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Lu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ari M Blitz
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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26
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Koutourousiou M, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Endoscopic endonasal surgery for olfactory groove meningiomas: outcomes and limitations in 50 patients. Neurosurg Focus 2015; 37:E8. [PMID: 25391163 DOI: 10.3171/2014.7.focus14330] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Recently, endoscopic endonasal surgery (EES) has been introduced in the management of skull base tumors, with constantly improving outcomes and increasing indications. The authors retrospectively reviewed the effectiveness of EES in the management of olfactory groove meningiomas. METHODS Between February 2003 and December 2012, 50 patients (64% female) with olfactory groove meningiomas underwent EES at the University of Pittsburgh Medical Center. The authors present the results of EES and analyze the resection rates, clinical outcome, complications, and limitations of this approach. RESULTS Forty-four patients presented with primary tumors, whereas six were previously treated elsewhere. The patients' mean age was 57.1 years (range 27-88 years). Clinical presentation included altered mental status (36%), visual loss (30%), headache (24%), and seizures (20%). The mean maximum tumor diameter was 41.6 mm (range 18-80 mm). All patients underwent EES, which was performed in stages in 18 giant tumors. Complete tumor resection (Simpson Grade I) was achieved in 66.7% of the 45 patients in whom it was the goal, and 13 (28.9%) had neartotal resection (> 95% of the tumor). Tumor size, calcification, and absence of cortical cuff from vasculature were significant factors that influenced the degree of resection (p = 0.002, p = 0.024, and p = 0.028, respectively). Tumor residual was usually at the most lateral and anterior tumor margins. Following EES, mental status was improved or normalized in 77.8% of the cases, vision was improved or restored in 86.7%, and headaches resolved in 83.3%. There was no postoperative deterioration of presenting symptoms. Complications were increased in tumors > 40 mm and included CSF leakage (30%), which was significantly associated with lobular tumor configuration (p = 0.048); pulmonary embolism/deep vein thrombosis, more commonly in elderly patients (20%); sinus infections (10%); and delayed abscess months or years after EES (6%). One patient had an intraoperative vascular injury resulting in transient hemiparesis (2%). There were no perioperative deaths. During a mean follow-up period of 32 months (median 22 months, range 1-115 months), 1 patient underwent repeat EES for tumor regrowth. CONCLUSIONS Endoscopic endonasal surgery has shown good clinical outcomes regardless of patient age, previous treatment, or tumor characteristics. Tumor size > 40 mm, calcification, and absence of cortical vascular cuff limit GTR with EES; in addition, large tumors are associated with increased postoperative complications. Significant lateral and anterior dural involvement may represent indications for using traditional craniotomies for the management of these tumors. Postoperative CSF leakage remains a problem that necessitates innovations in EES reconstruction techniques.
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27
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Ditzel Filho LFS, Prevedello DM, Jamshidi AO, Dolci RL, Kerr EE, Campbell R, Otto BA, Carrau RL, Kassam A. Endoscopic Endonasal Approach for Removal of Tuberculum Sellae Meningiomas. Neurosurg Clin N Am 2015; 26:349-61. [PMID: 26141355 DOI: 10.1016/j.nec.2015.03.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tuberculum sellae meningiomas are challenging lesions; their critical location and often insidious growth rate enables significant distortion of the superjacent optic apparatus before the patient notices any visual impairment. This article describes the technical nuances, selection criteria and complication avoidance strategies for the endonasal resection of tuberculum sellae meningiomas. A stepwise description of the surgical technique is presented; indications, adjuvant technologies, pitfalls and the relevant anatomy are also reviewed. Tuberculum sellae meningiomas may be safely and effectively resected through the endonasal route; invasion of the optic canals does not represent a limitation.
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Affiliation(s)
- Leo F S Ditzel Filho
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Ali O Jamshidi
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Ricardo L Dolci
- Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Edward E Kerr
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Raewyn Campbell
- Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Bradley A Otto
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Ricardo L Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
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28
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Su SY, Kupferman ME, DeMonte F, Levine NB, Raza SM, Hanna EY. Endoscopic resection of sinonasal cancers. Curr Oncol Rep 2014; 16:369. [PMID: 24445501 DOI: 10.1007/s11912-013-0369-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sinonasal malignancies, a rare group of tumors, are characterized by histological heterogeneity and poor survival. As improvements in image-guidance and endoscopic technologies became incorporated into head and neck oncologic and neurosurgical practice, the application of these technologies and techniques to the surgical management of sinonasal malignancy began. Over the past decade, there has been increasing evidence regarding the safety and oncological effectiveness of these techniques. Several institutions have reported their experience with endoscopic surgery and have shown reduced morbidity, better quality of life, and survival outcomes equivalent to those of open surgery in carefully selected patients. Endoscopic cranial base surgery is a rapidly evolving field. We review the literature on oncological outcomes, safety, quality of life, and recent technological advances.
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Affiliation(s)
- Shirley Y Su
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Suite 1445, Houston, TX, 77030-4009, USA,
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Neuroendoscopic Resection of Intraventricular Tumors and Cysts through a Working Channel with a Variable Aspiration Tissue Resector: A Feasibility and Safety Study. Minim Invasive Surg 2013; 2013:471805. [PMID: 23844287 PMCID: PMC3697810 DOI: 10.1155/2013/471805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 05/26/2013] [Indexed: 11/18/2022] Open
Abstract
Pure neuroendoscopic resection of intraventricular lesions through a burr hole is limited by the instrumentation that can be used with a working channel endoscope. We describe a safety and feasibility study of a variable aspiration tissue resector, for the resection of a variety of intraventricular lesions. Our initial experience using the variable aspiration tissue resector involved 16 patients with a variety of intraventricular tumors or cysts. Nine patients (56%) presented with obstructive hydrocephalus. Patient ages ranged from 20 to 88 years (mean 44.2). All patients were operated on through a frontal burr hole, using a working channel endoscope. A total of 4 tumors were resected in a gross total fashion and the remaining intraventricular lesions were subtotally resected. Fifteen of 16 patients had relief of their preoperative symptoms. The 9 patients who presented with obstructive hydrocephalus had restoration of cerebrospinal fluid flow though one required a ventriculoperitoneal shunt. Three patients required repeat endoscopic resections. Use of a variable aspiration tissue resector provides the ability to resect a variety of intraventricular lesions in a safe, controlled manner through a working channel endoscope. Larger intraventricular tumors continue to pose a challenge for complete removal of intraventricular lesions.
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