A Novel Foley Catheter-Based Brain Retraction Method for the Interhemispheric Approach: Technical Considerations and an Illustrative Video

BACKGROUND

Management of interhemispheric pathologies requires surgical intervention through a restricted anatomical corridor ensconced within critical cerebral structures. The use of retractors to facilitate operative access may cause damage to cerebral tissue. The development of an innovative retraction technique designed to alleviate cerebral damage in such cases is imperative. In this study, we present a novel and gentle retraction method to facilitate the interhemisferic approach.

METHODS

We retrospectively examined data of 9 right-handed patients who underwent surgical resection of interhemispheric lesions between 2021 and 2022. All patients underwent surgery for the first time because of this pathology. All operative specimens were histologically confirmed. Clinical characteristics, operative details, and follow-up data were retrospectively analyzed.

RESULTS

The new retraction technique was successfully applied to 8 tumor patients and 1 patient with an aneurysm. Eight patients had an anterior interhemispheric approach, and 1 patient had a posterior interhemispheric approach. Complete surgical excision was achieved in all patients with no postoperative complications. Postoperative Gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) showed no signs of ischemia or contusion. All patients exhibited significant improvements in their symptoms. An illustrative video that elucidates the removal of an interhemispheric epidermoid tumor, employing the anterior ipsilateral interhemispheric approach, featuring the novel retraction method.

CONCLUSIONS

The ideal retraction technique during the interhemispheric approach is still a challenge. Our novel retraction technique may help minimize brain parenchymal damage during surgical resection of interhemispheric lesions.

[Brain retraction injury]

This review is devoted to various techniques for reduction of brain damage during retraction. Searching for reports was carried out in Russian and English languages using the PubMed database (n=721) without restrictions on language, date and study design according to the following keywords: «brain retraction injury», «spatula brain retractors», «tubular brain retractors», «retractorless neurosurgery». Primary screening and exclusion of duplicate manuscripts allowed us to single out the main group of articles (n=121). Some reports were excluded due to non-compliance with inclusion criteria (no description of methods, few references and insufficient data). The final list included 32 studies which were represented by cohort studies, retrospective analyses of surgical interventions, as well as experimental and laboratory studies. Small number of publications did not allow us to obtain unambiguous conclusions. Further research is required to reduce brain retraction trauma.

Membrane Retraction Technique in Bypass Surgery for the Treatment of Adult Moyamoya Disease with Deep-Seated Recipient Artery

OBJECTIVE

To introduce a membrane retraction technique that can provide good exposure of deep-seated recipient arteries in cortical sulci and simplify the anastomosis procedure.

METHODS

Only those adult patients with moyamoya disease who underwent superficial temporal artery to middle cerebral artery bypass surgery during which the suitable recipient arteries were located deep in cortical sulci were included in this retrospective study. By placing 10-0 prolene sutures to the arachnoid membrane of the 2 banks of sulcus, arachnoid retraction was applied to pull the sulcus apart and then the deep-seated recipient arteries were exposed. Standard end-to-side anastomosis was completed. The mean occlusion time and successful rate were recorded and compared with those of the normal procedure.

RESULTS

From June to November 2019, 124 superficial temporal artery to middle cerebral artery bypass surgeries for the treatment of moyamoya disease were performed in Nanfang Hospital. The membrane retraction technique was used in 5 patients (5/110, 4.5%) and the success rates were 100%. The mean temporary occlusion time was 27.2 minutes. No procedure-related complications were observed. All patients recovered uneventfully. The postoperative angiograms confirmed good patency of bypass grafts in all 5 cases.

CONCLUSIONS

The membrane retraction technique is an effective and safe method for the treatment of adult patients with moyamoya disease with deep-seated recipient arteries within the sulci.

Tumor retractor: a simple and novel instrument for brain tumor surgery

Background

It is important to secure a surgical space during brain tumor surgery. One of the commonly used methods is to retract the brain. We hypothesized that the tumor can be retracted and that the normal brain tissue retraction can be minimized during surgery, and thus, the degree of collateral damage caused by brain retraction would be reduced.

Methods

The tumor retractor had a 90°, hard, and sharp tip for fixation of the tumor. The distal part of the retractor has a malleable and thin blade structure. By adjusting the angle of the distal malleable part of the tumor retractor, the operator can make the retracting angle additionally. Retractors with thin blade can be used in a conventional self-retraction system. To pull and hold the tumor constantly, the tumor retractor is held by a self-retraction system. The surgical technique using a tumor retractor is as follows: The first step is to fix the retractor to the tumor. The second step is to pull the retractor in the operator’s desired direction by applying force. After the tumor is pulled by adjusting the degree of force and angle, the surgical arm should be held in place to maintain the tumor retracted state.

Results

The tumor retractor was used to minimize the brain retraction, pulling the tumor in the opposite direction from the surrounding brain tissue. In clinical cases, we can apply the tumor retractor with good surgical outcomes.

Conclusions

A tumor retractor can be used to pull a tumor and minimize the brain retraction.

Microvascular anatomy of the cerebellar parafloccular perforating space

OBJECT

The cerebellopontine angle is a common site for tumor growth and vascular pathologies requiring surgical manipulations that jeopardize cranial nerve integrity and cerebellar and brainstem perfusion. To date, a detailed study of vessels perforating the cisternal surface of the middle cerebellar peduncle—namely, the paraflocculus or parafloccular perforating space—has yet to be published. In this report, the perforating vessels of the anterior inferior cerebellar artery (AICA) in the parafloccular space, or on the cisternal surface of the middle cerebellar peduncle, are described to elucidate their relevance pertaining to microsurgery and the different pathologies that occur at the cerebellopontine angle.

METHODS

Fourteen cadaveric cerebellopontine cisterns (CPCs) were studied. Anatomical dissections and analysis of the perforating arteries of the AICA and posterior inferior cerebellar artery at the parafloccular space were recorded using direct visualization by surgical microscope, optical histology, and scanning electron microscope. A comprehensive review of the English-language and Spanish-language literature was also performed, and findings related to anatomy, histology, physiology, neurology, neuroradiology, microsurgery, and endovascular surgery pertaining to the cerebellar flocculus or parafloccular spaces are summarized.

RESULTS

A total of 298 perforating arteries were found in the dissected specimens, with a minimum of 15 to a maximum of 26 vessels per parafloccular perforating space. The average outer diameter of the cisternal portion of the perforating arteries was 0.11 ± 0.042 mm (mean ± SD) and the average length was 2.84 ± 1.2 mm. Detailed schematics and the surgical anatomy of the perforating vessels at the CPC and their clinical relevance are reported.

CONCLUSIONS

The parafloccular space is a key entry point for many perforating vessels toward the middle cerebellar peduncle and lateral brainstem, and it must be respected and protected during surgical approaches to the cerebellopontine angle.

The history of brain retractors throughout the development of neurological surgery

Early neurosurgical procedures dealt mainly with treatment of head trauma, especially skull fractures. Since the early medical writings by Hippocrates, a great deal of respect was given to the dura mater, and many other surgeons warned against violating the dura. It was not until the 19th century that neurosurgeons started venturing beneath the dura, deep into the brain parenchyma. With this advancement, brain retraction became an essential component of intracranial surgery. Over the years brain retractors have been created pragmatically to provide better visualization, increased articulations and degrees of freedom, greater stability, less brain retraction injury, and less user effort. Brain retractors have evolved from simple handheld retractors to intricate brain-retraction systems with hand-rest stabilizers. This paper will focus on the history of brain retractors, the different types of retractors, and the progression from one form to another.

Microsurgical resection of deep-seated lesions using transparent tubular retractor: pediatric case series

BACKGROUND

To facilitate effective resection of deep-seated brain lesions without causing significant trauma to the overlying cortex, the authors used a transparent plastic tubular retractor to approach these lesions.

METHODS

Between July 2009 and January 2011, we used an 11-mm diameter transparent plastic tubular retractor in combination with a frameless stereotactic navigation system to remove 18 deep lesions.

RESULTS

Gross total resection of the lesions was achieved in 14 of 18 patients, and subtotal removal occurred in four patients. Effective resection of lesions was achieved in all patients through small size craniotomy window and small cortical incision. The histopathologic diagnosis was established in all 18 patients: 3 hematomas, 3 cavernous angioma, 7 low-grade glioma, 2 dysembryoplastic neuroepithelial tumor, 1 choroid plexus papilloma, 1 abscess, and 1 meningioma.

CONCLUSION

Microsurgery using a transparent tubular retractor guided by a neuronavigation system facilitated accurate and effective removal of these deep-seated brain lesions.