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Longatti P, Gioffrè G, Fiorindi A, Siddi F, Boaro A, Basaldella L, Sala F, Feletti A. The Cerebral Aqueduct Compliance: A Simple Morphometric Model. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01253. [PMID: 39016607 DOI: 10.1227/ons.0000000000001269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/12/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES This work aimed to identify different configurations of the adytum of the cerebral aqueduct suggesting its safe neuroendoscopic navigation. This concept is intimately connected to the physiological aqueductal dilatability or compliance, which is relatively ignored in the literature. A better knowledge of the extent of physiological aqueductal dilatability might better define the ideal diameter and safer features of dedicated flexible endoscopes. METHODS The study includes 45 patients operated on using a flexible scope with a 3.9-mm diameter, where the structural elements of the adytum of the cerebral aqueduct are clearly visible. Patients were grouped according to the pathology (colloid cyst/normal anatomy, intraventricular hemorrhage, tetraventricular obstructive hydrocephalus, normal pressure hydrocephalus, and distal membranous aqueductal stenosis). A simple geometrical scheme was applied to the endoscopic anatomy of the aqueductal adytum in relation to the posterior commissure to measure its pathologic deformations. Eventual damages to the aqueduct walls caused by the endoscope were also reported. RESULTS Proceeding from normal anatomy to hydrocephalic condition, the ratio between the commissure and the aqueductal access area progressively decreases, while the vertex angle increases. Interestingly, the entity of the ependymal damages due to the passage of the endoscope correlates with such measures. CONCLUSION The cerebral aqueduct, excluding atrophic processes, is provided with a certain degree of dilatability, which we estimate to be around a diameter of 4 mm. This represents the maximum size for a flexible neuroendoscope for a safe aqueductal neuronavigation. The schematic model of the aqueductal adytum as a triangle defines 3 different aqueductal patterns and can be helpful when an intraoperative decision on whether to navigate the aqueduct must be taken.
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Affiliation(s)
| | - Giorgio Gioffrè
- Unit of Neurosurgery, Neuro-cardio-vascular Department, Azienda AULSS2 Marca Trevigiana, Treviso , Italy
| | - Alessandro Fiorindi
- Neurosurgical Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Spedali Civili, University of Brescia, Brescia , Italy
| | - Francesca Siddi
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona , Italy
| | - Alessandro Boaro
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona , Italy
| | - Luca Basaldella
- UOC Neurochirurgia, Ospedale dell'Angelo, AULSS3 Serenissima, Chirignago-Zelarino , Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona , Italy
| | - Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona , Italy
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Lefevre E, Quang ML, Chotard G, Knafo S, Mengelle P, Taupin Y, Liguoro D, Jecko V, Vignes JR, Roblot P. Upper end of the central canal of the human spinal cord: Quantitative anatomical study and 3D modeling. Clin Anat 2024. [PMID: 38860594 DOI: 10.1002/ca.24196] [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: 02/29/2024] [Revised: 05/15/2024] [Accepted: 05/31/2024] [Indexed: 06/12/2024]
Abstract
The upper end of the central canal of the human spinal cord has been repeatedly implicated in the pathogenesis of various diseases, yet its precise normal position in the medulla oblongata and upper cervical spinal cord remains unclear. The purpose of this study is to describe the anatomy of the upper end of the central canal with quantitative measurements and a three-dimensional (3D) model. Seven formalin-embalmed human brainstems were included, and the central canal was identified in serial axial histological sections using epithelial membrane antigen antibody staining. Measurements included the distances between the central canal (CC) and the anterior medullary fissure (AMF) and the posterior medullary sulcus (PMS). The surface and perimeter of the CC and the spinal cord were calculated, and its anterior-posterior and maximum lateral lengths were measured for 3D modeling. The upper end of the CC was identified in six specimens, extending from the apertura canalis centralis (ACC) to its final position in the cervical cord. Positioned on the midline, it reaches its final location approximately 15 mm below the obex. No specimen showed canal dilatation, focal stenosis, or evidence of syringomyelia. At 21 mm under the ACC in the cervical cord, the median distance from the CC to the AMF was 3.14 (2.54-3.15) mm and from the CC to the PMS was 5.19 (4.52-5.43) mm, with a progressive shift from the posterior limit to the anterior third of the cervical spinal cord. The median area of the CC was consistently less than 0.1 mm2. The upper end of the CC originates at the ACC, in the posterior part of the MO, and reaches its normal position in the anterior third of the cervical spinal cord less than 2 cm below the obex. Establishing the normal position of the upper end of this canal is crucial for understanding its possible involvement in cranio-cervical junction pathologies.
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Affiliation(s)
- Etienne Lefevre
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
- Laboratory of Anatomy, University of Bordeaux, Bordeaux, France
| | - Megane Le Quang
- Pathology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Guillaume Chotard
- Pathology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Steven Knafo
- Department of Neurosurgery, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Pierre Mengelle
- Ecole Nationale Supérieure de Création Industrielle - Les Ateliers, Paris, France
| | - Yanis Taupin
- Laboratory of Anatomy, University of Bordeaux, Bordeaux, France
| | - Dominique Liguoro
- Laboratory of Anatomy, University of Bordeaux, Bordeaux, France
- Department of Neurosurgery A, University Hospital of Bordeaux, Bordeaux, France
| | - Vincent Jecko
- Laboratory of Anatomy, University of Bordeaux, Bordeaux, France
- Department of Neurosurgery A, University Hospital of Bordeaux, Bordeaux, France
| | | | - Paul Roblot
- Laboratory of Anatomy, University of Bordeaux, Bordeaux, France
- Department of Neurosurgery A, University Hospital of Bordeaux, Bordeaux, France
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da Silva AC, Silva SM, Alves H, Cunha-Cabral D, Pinto FF, Fernandes-Silva J, Arantes M, Andrade JP. Stereotactic anatomy of the third ventricle. Surg Radiol Anat 2024; 46:271-283. [PMID: 38374441 PMCID: PMC10960742 DOI: 10.1007/s00276-024-03312-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 01/19/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Endoscopic third ventriculostomy (ETV) is a surgical procedure that can lead to complications and requires detailed preoperative planning. This study aimed to provide a more accurate understanding of the anatomy of the third ventricle and the location of important structures to improve the safety and success of ETV. METHODS We measured the stereotactic coordinates of six points of interest relative to a predefined stereotactic reference point in 23 cadaver brain hemi-sections, 200 normal brain magnetic resonance imaging (MRI) scans, and 24 hydrocephalic brain MRI scans. The measurements were statistically analyzed, and comparisons were made. RESULTS We found some statistically significant differences between genders in MRIs from healthy subjects. We also found statistically significant differences between MRIs from healthy subjects and both cadaver brains and MRIs with hydrocephalus, though their magnitude is very small and not clinically relevant. Some stereotactic points were more posteriorly and inferiorly located in cadaver brains, particularly the infundibular recess and the basilar artery. It was found that all stereotactic points studied were more posteriorly located in brains with hydrocephalus. CONCLUSION The study describes periventricular structures in cadaver brains and MRI scans from healthy and hydrocephalic subjects, which can guide neurosurgeons in planning surgical approaches to the third ventricle. Overall, the study contributes to understanding ETV and provides insights for improving its safety and efficacy. The findings also support that practicing on cadaveric brains can still provide valuable information and is valid for study and training of neurosurgeons unfamiliar with the ETV technique.
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Affiliation(s)
- Alexandra Campos da Silva
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal
| | - Susana Maria Silva
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal
- CINTESIS@RISE, Rua Dr. Plácido da Costa, s/n, 4200‑450, Porto, Portugal
| | - Hélio Alves
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal
| | - Diogo Cunha-Cabral
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal
- Health Local Unit of Matosinhos Otorhinolaryngology, Hospital Pedro Hispano, Rua Dr. Eduardo Torres, 4464-513, Matosinhos, Portugal
| | - Filipe F Pinto
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal
| | - João Fernandes-Silva
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal
| | - Mavilde Arantes
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal
- CINTESIS@RISE, Rua Dr. Plácido da Costa, s/n, 4200‑450, Porto, Portugal
- Division of Neuroradiology, Radiology Service, Portuguese Institute of Oncology, Rua Dr. António Bernardino de Almeida 865, 4200‑072, Porto, Portugal
| | - José Paulo Andrade
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200‑319, Porto, Portugal.
- CINTESIS@RISE, Rua Dr. Plácido da Costa, s/n, 4200‑450, Porto, Portugal.
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Sahuquillo J, Moncho D, Ferré A, López-Bermeo D, Sahuquillo-Muxi A, Poca MA. A Critical Update of the Classification of Chiari and Chiari-like Malformations. J Clin Med 2023; 12:4626. [PMID: 37510741 PMCID: PMC10380265 DOI: 10.3390/jcm12144626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 06/27/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Chiari malformations are a group of craniovertebral junction anomalies characterized by the herniation of cerebellar tonsils below the foramen magnum, often accompanied by brainstem descent. The existing classification systems for Chiari malformations have expanded from the original four categories to nine, leading to debates about the need for a more descriptive and etiopathogenic terminology. This review aims to examine the various classification approaches employed and proposes a simplified scheme to differentiate between different types of tonsillar herniations. Furthermore, it explores the most appropriate terminology for acquired herniation of cerebellar tonsils and other secondary Chiari-like malformations. Recent advances in magnetic resonance imaging (MRI) have revealed a higher prevalence and incidence of Chiari malformation Type 1 (CM1) and identified similar cerebellar herniations in individuals unrelated to the classic phenotypes described by Chiari. As we reassess the existing classifications, it becomes crucial to establish a terminology that accurately reflects the diverse presentations and underlying causes of these conditions. This paper contributes to the ongoing discussion by offering insights into the evolving understanding of Chiari malformations and proposing a simplified classification and terminology system to enhance diagnosis and management.
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Affiliation(s)
- Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Dulce Moncho
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Clinical Neurophysiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Alex Ferré
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Sleep Unit, Pneumology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Diego López-Bermeo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Aasma Sahuquillo-Muxi
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Maria A Poca
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
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Longatti P, Feletti A, Basaldella L, Boaro A, Sala F, Fiorindi A. The Roof of the 4th Ventricle Seen From Inside: Endoscopic Anatomic Illustration-A Case Series. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00643. [PMID: 36867083 DOI: 10.1227/ons.0000000000000669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 01/04/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The anatomy of the roof of the fourth ventricle has been illustrated in many laboratory investigations, but in vivo reports of the roof anatomy and its variants are still lacking. OBJECTIVE To describe the topographical anatomy of the roof of the fourth ventricle explored through a transaqueductal approach that overcomes cerebrospinal fluid depletion, displaying in vivo anatomic images possibly quite close to normal physiological conditions. METHODS We critically reviewed the intraoperative video recordings of our 838 neuroendoscopic procedures, selecting 27 cases of transaqueductal navigation that provided good quality image details of the anatomy of the roof of the fourth ventricle. Twenty-six patients affected by different forms of hydrocephalus were therefore categorized into three groups: Group A: blockage of the aqueduct-aqueductoplasty, Group B: communicating hydrocephalus, and Group C: tetraventricular obstructive hydrocephalus. RESULTS Group A has shown what the roof of a normal fourth ventricle really looks like albeit the structures seemed overcrowded because of the narrow space. Images from groups B and C paradoxically allowed a more distinct identification of the roof structures flattened by ventricular dilation, making them more comparable with the topography traced on the laboratory microsurgical studies. CONCLUSION Endoscopic in vivo videos and images provided a novel anatomic view and an in vivo redefinition of the real topography of the roof of the fourth ventricle. The relevant role of cerebrospinal fluid was defined and outlined, as well as the effects of hydrocephalic dilation on some structures on the roof of the fourth ventricle.
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Affiliation(s)
| | - Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy
| | - Luca Basaldella
- Unit of Neurosurgery, Neuro-cardio-vascular Department, Azienda AULSS2 Marca Trevigiana, Treviso, Italy
| | - Alessandro Boaro
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy
| | - Alessandro Fiorindi
- Neurosurgical Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Spedali Civili, University of Brescia, Brescia, Italy
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