1
|
Vaz-Guimaraes F, Cartaxo HQ, da Fonte JE, Valença MM. Computed Tomography Assessment of the Retrolabyrinthine Approach. Cureus 2023; 15:e38394. [PMID: 37265889 PMCID: PMC10231662 DOI: 10.7759/cureus.38394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/03/2023] Open
Abstract
Introduction This study aimed to evaluate preoperative radiological assessments of the retrolabyrinthine approach to identify and describe anatomical constraints that may anticipate a more challenging situation for neurosurgeons and otolaryngologists specialized in skull base surgery. Materials and methods The study included 75 adult patients who underwent high-resolution computed tomography angiography scans of the head, with the aim of analyzing the side of the dominance of the sigmoid sinus (SS), the level of pneumatization of the mastoid portion of the temporal bone, and the height of the jugular bulb. Results The results showed that dominant SS and type 2 jugular bulbs were more common on the right side, while smaller type 1 bulbs were significantly more common on the left. Conclusions These findings provide valuable information for neurosurgeons and otolaryngologists in predicting the difficulty of the retrolabyrinthine approach based on preoperative radiological assessments.
Collapse
Affiliation(s)
| | | | - João E da Fonte
- Radiology and Diagnostic Imaging, Real Hospital Português, Recife, BRA
| | | |
Collapse
|
2
|
Vaz-Guimaraes F. Commentary: Robotic-Assisted vs Nonrobotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Cost-Utility Analysis. Neurosurgery 2022; 90:e34. [PMID: 34995252 DOI: 10.1227/neu.0000000000001800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 11/18/2022] Open
|
3
|
Lopes Rufino EP, Ribeiro da Costa Gomes ES, Silva Loureiro LM, Oliveira Eugenio P, Vaz-Guimaraes F. Brain Metastasis of Follicular Thyroid Carcinoma in Pregnancy: A Case Report and Literature Review. Cureus 2020; 12:e9337. [PMID: 32850211 PMCID: PMC7445421 DOI: 10.7759/cureus.9337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Brain metastases (BMs) related to cancer are quite common and represent the most common brain cancer. We present a rare case of a 32-year-old female, 36 weeks pregnant, admitted to the emergency with complaints of severe headache, vomiting, and left hemiparesis associated with drowsiness. Cranial tomography showed an image suggestive of an expansive lesion in the right front-temporo-insular region with an important mass effect. The result of biopsy with immunohistochemistry was compatible with metastasis of follicular thyroid carcinoma (FTC). The knowledge of neurological characteristics in the clinical analysis of patients with thyroid carcinoma must be highly valued, both in the correct interpretation of the signs and in the early investigation through skull imaging exams.
Collapse
Affiliation(s)
| | | | - Lucas M Silva Loureiro
- Faculty of Medical Sciences of the University of Pernambuco, Hospital Universitário Oswaldo Cruz, Recife, BRA
| | | | | |
Collapse
|
4
|
Khan AB, Goethe EA, Hadley CC, Rouah E, North R, Srinivasan VM, Gallagher KK, Fuentes A, Vaz-Guimaraes F. Infundibular Epidermoid Cyst: Case Report and Systematic Review. World Neurosurg 2019; 130:110-114. [DOI: 10.1016/j.wneu.2019.06.205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
|
5
|
Vaz-Guimaraes F, Nakassa ACI, Gardner PA, Wang EW, Snyderman CH, Fernandez-Miranda JC. Endoscopic Endonasal Approach to the Ventral Jugular Foramen: Anatomical Basis, Technical Considerations, and Clinical Series. Oper Neurosurg (Hagerstown) 2019; 13:482-491. [PMID: 28838115 DOI: 10.1093/ons/opx014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 01/15/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Surgical exposure of the jugular foramen (JF) is challenging given its complex regional anatomy and proximity to critical neurovascular structures. OBJECTIVE To describe the anatomical basis, surgical technique, and outcomes of a group of patients who underwent the endoscopic endonasal approach to the JF. METHODS Five silicon-injected anatomical specimens were prepared for dissection. Additionally, a chart review was conducted through our patient database, searching for endonasal exposure of the JF. Demographic data, clinical presentation, pathological findings, extent of resection in the JF, and occurrence of complications were analyzed. RESULTS The endonasal exposure of the JF requires 3 sequential steps: a transpterygoid, a "far-medial," and an "extreme-medial" approach. Mobilization or transection of the cartilaginous portion of the eustachian tube (ET) is necessary. In the clinical series, cranial neuropathies were the presenting symptoms in 16 patients (89%). Eighteen tumors (10 chondrosarcomas, 7 chordomas, 1 adenocarcinoma) extended secondarily into the JF. Total tumor resection was achieved in 10 patients (56%), near total (≥90%) in 6 (33%), and subtotal (<90%) in 2 (11%). ET dysfunction (75% of cases), transient palatal numbness (17%), cerebrospinal fluid leakage (17%), and lower cranial nerve palsy (17%) were the most common postoperative complications. There were no carotid artery or jugular vein injuries. CONCLUSION The endoscopic endonasal approach to the JF requires mobilization or transection of the cartilaginous portion of the ET. This maneuver provides a safe infrapetrosal surgical route to the JF. It may be considered a valid option, in well-selected cases, for resection of malignant and recurrent cranial base tumors.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ana Carolina I Nakassa
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
6
|
Vaz-Guimaraes F, Fernandez-Miranda JC, Koutourousiou M, Hamilton RL, Wang EW, Snyderman CH, Gardner PA. Endoscopic Endonasal Surgery for Cranial Base Chondrosarcomas. Oper Neurosurg (Hagerstown) 2019; 13:421-434. [PMID: 28838112 DOI: 10.1093/ons/opx020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/24/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Microsurgical resection via open approaches is considered the main treatment modality for cranial base chondrosarcomas (CBCs). The use of endoscopic endonasal approaches (EEAs) has been rarely reported. OBJECTIVE To present the endoscopic endonasal experience with CBCs at our institution. METHODS Retrospective review of the medical records of 35 consecutive patients who underwent EEA for CBC resection between January 2004 and April 2013. Surgical outcomes and variables that might affect extent of resection, complications, and recurrence were analyzed. RESULTS Forty-eight operations were performed (42 EEAs and 6 open approaches). Gross-total resection was achieved in 22 patients (62.9%), near total (≥90% tumor resection) in 11 (31.4%). Larger tumors were associated with incomplete resection in univariate and multivariate analysis ( P = .004, .015, respectively). In univariate analysis, tumors involving the lower clivus and cerebellopontine angle were associated with increased number of complications, especially postoperative cerebrospinal fluid leak ( P = .015) and new cranial neuropathy ( P = .037), respectively. Other major complications included 2 cases of meningitis and deep venous thrombosis, and 1 case of hydrocephalus and carotid injury. Involvement of the lower clivus, parapharyngeal space, and cervical spine required a combination of approaches to maximize tumor resection ( P = .017, .044, .017, respectively). No predictors were significantly associated with increased risk of recurrence. The average follow-up time was 44.6 ± 31 months. CONCLUSIONS EEAs may be considered a good option for managing CBCs without significant posterolateral extension beyond the basal foramina and can be used in conjunction with open approaches for maximal resection with acceptable morbidity.
Collapse
Affiliation(s)
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Maria Koutourousiou
- Department of Neurolog-ical Surgery, University of Louisville, Louisville, Kentucky
| | | | - Eric W Wang
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
7
|
Vaz-Guimaraes F, Gardner PA, Fernandez-Miranda JC. Endoscope-Assisted Retrosigmoid Approach for Cerebellopontine Angle Epidermoid Tumor. J Neurol Surg B Skull Base 2018; 79:S409-S410. [PMID: 30456044 PMCID: PMC6240415 DOI: 10.1055/s-0038-1669983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/11/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives
Surgical resection is the only effective treatment modality for epidermoid tumors. Complete resection with preservation of neurological function must be pursued whenever possible, because it offers a cure for patients. However, the inability to identify hidden remnants, interdigitating around cranial nerves, especially in larger tumors, may be a contributing factor for incomplete resection. This operative video demonstrates the technical nuances in achieving complete resection of a cerebellopontine angle epidermoid tumor via an endoscope-assisted retrosigmoid approach.
Design and Setting
Operative video of an endoscope-assisted retrosigmoid, approach for complete resection of a cerebellopontine angle epidermoid tumor. The patient was a 16-year-old female, who presented with 1-year history of worsening headaches and imbalance. Her neurological exam was normal, including normal cranial nerve function, and hearing. Radiological evaluation revealed an epidermoid tumor in the right cerebellopontine angle, extending to the interpeduncular cistern. Surgical resection was recommended. Given extension of the tumor across the midline, an endoscope-assisted procedure was planned to increase the odds of complete resection.
Results
The video demonstrates the surgical technique applied for tumor resection. The patient's clinical symptoms resolved completely after surgery and she remained neurologically intact. Postoperative magnetic resonance imaging (MRI) confirmed complete tumor resection. There were no postoperative complications.
Conclusions
The use of endoscopic techniques for resection of cerebellopontine angle epidermoid tumor is safe and effective and may increase the odds of complete resection, especially in larger tumors spreading across the midline, by enabling the surgeon clear visualization of deep-seated and contralateral relevant neurovascular structures, not readily accessible by the surgical microscope.
The link to the video can be found at:
https://youtu.be/X6YP_7OeQQE
.
Collapse
Affiliation(s)
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
8
|
Wagner K, Vaz-Guimaraes F, Camstra K, Lam S. Endoscope-assisted hemispherotomy: translation of technique from cadaveric anatomical feasibility study to clinical implementation. J Neurosurg Pediatr 2018; 23:178-186. [PMID: 30497226 DOI: 10.3171/2018.8.peds18349] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/22/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAppropriately chosen candidates with medically refractory epilepsy may benefit from hemispheric disconnection. Traditionally, this involves a large surgical exposure with significant associated morbidity. Minimally invasive approaches using endoscopic assistance have been described by only a few centers. Here, the authors report on the feasibility of endoscope-assisted functional hemispherotomy in a cadaver model and its first translation into clinical practice in appropriately selected patients.METHODSThree silicone-injected, formalin-fixed cadaver heads were used to establish the steps of the procedure in the laboratory. The steps of disconnection were performed using standard surgical instruments and a straight endoscope. The technique was then applied in two patients who had been referred for hemispherectomy and had favorable anatomy for an endoscope-assisted approach.RESULTSAll disconnections were performed in the cadaver model via a 4 × 2-cm paramedian keyhole craniotomy using endoscopic assistance. An additional temporal burr hole approach was marked in case the authors were unable to completely visualize the frontobasal and insular cuts from the paramedian vertical view. Their protocol was subsequently used successfully in two pediatric patients. Full disconnection was verified with postoperative tractography.CONCLUSIONSFull hemispheric disconnection can be accomplished with minimally invasive endoscope-assisted functional hemispherotomy. The procedure is technically feasible and can be safely applied in patients with favorable anatomy and pathology; it may lead to less surgical morbidity and faster recovery.
Collapse
Affiliation(s)
- Kathryn Wagner
- 1Department of Neurosurgery, Baylor College of Medicine; and.,2Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | - Kevin Camstra
- 1Department of Neurosurgery, Baylor College of Medicine; and
| | - Sandi Lam
- 1Department of Neurosurgery, Baylor College of Medicine; and.,2Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| |
Collapse
|
9
|
Wallach J, Ho AL, Kim LH, Chaudhuri AA, Chaudhary N, Vaz-Guimaraes F, Chang SD. Quantitative analysis of the safety and efficacy of microvascular decompression for patients with trigeminal neuralgia above and below 65 years of age. J Clin Neurosci 2018; 55:13-16. [PMID: 29954647 DOI: 10.1016/j.jocn.2018.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/04/2018] [Indexed: 11/19/2022]
Abstract
For medically-refractory trigeminal neuralgia (TN), microvascular decompression (MVD) is the first-line treatment, and has demonstrated the greatest efficacy and durability. However, due to potential surgical complications, a bias may exist against performing MVD in elderly patients. We sought to determine through a quantitative analysis whether MVD in the elderly is a safe and effective procedure for TN. We completed a Pubmed/SCOPUS literature search up to 12/2016 for eligible studies on MVD for TN. Only research articles with age stratification of results were included. In this quantitative analysis, we analyzed the data for the six articles identified in the literature comparing MVD for a group of patients ≥65 years with an elderly group <65 years. A total of 1483 were included. 455 patients were ≥65 years (mean 70.8 years, range 65-89 years) and 1028 patients were <65 years (mean 53.4 years, range 19-64 years). Composite mean follow-up time was 51.6 months for the elderly group, and 55.1 months for the young group. Following MVD, each group had 1 mortality (p = 0.43). There were 21 serious morbidities in the elderly group (4.62%) and 32 in the young group (3.11%) (p = 0.11). In addition, 15 patients (1.46%) in the elderly group and 24 patients (1.62%) in the young group experienced a cerebrospinal fluid leak (p = 0.23). TN recurrence rates 9.23% in the young group and 13.33% in the elderly group (p = 0.070). In conclusion, for properly-selected surgical candidates, MVD should not be ruled out on the basis of age ≥65 years.
Collapse
Affiliation(s)
- Jonathan Wallach
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States; Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Aadel A Chaudhuri
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States
| | - Navjot Chaudhary
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Francisco Vaz-Guimaraes
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Steven D Chang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States.
| |
Collapse
|
10
|
Vaz-Guimaraes F, Koutourousiou M, de Almeida JR, Tyler-Kabara EC, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience. J Neurosurg 2018; 130:1-11. [PMID: 29547084 DOI: 10.3171/2017.7.jns162783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 07/24/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEpidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of endoscopic endonasal approaches for resection of these tumors has been rarely reported.METHODSThe authors retrospectively reviewed the medical records of 21 patients who underwent endoscopic endonasal surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.RESULTSTotal resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0.008 and 0.0005, respectively). In the whole series, surgical complications were seen in 6 patients (28.6%). No complications were observed in patients with extradural cysts. Among the 15 patients with intradural cysts, the most common surgical complication was postoperative CSF leak (5 patients, 33.3%), followed by postoperative intracranial infection (4 patients, 26.7%). Larger cysts and postoperative CSF leak were associated with intracranial infection (p = 0.012 and 0.028, respectively). Subtotal resection was marginally associated with intracranial infection when compared with total resection (p = 0.091). All patients with neurological symptoms improved postoperatively with the exception of 1 patient with unchanged abducens nerve palsy.CONCLUSIONSEndoscopic endonasal approaches may be effectively used for resection of epidermoid and dermoid cysts in carefully selected cases. These approaches are recommended for cases in which a total or near-total resection is possible in addition to a multilayer cranial base reconstruction with vascularized tissue to minimize the risk of intracranial infection.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- 1Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 2Department of Neurosurgery, Michael E. DeBakey VA Medical Center/Baylor College of Medicine, Houston, Texas
| | - Maria Koutourousiou
- 1Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John R de Almeida
- 3Otolaryngology and
- 4Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Ontario, Canada; and Departments of
| | | | | | | | | | - Paul A Gardner
- 1Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
11
|
Vaz-Guimaraes F, Ehni BL. Commentary: Hospital Length of Stay and Readmission Rate for Neurosurgical Patients. Neurosurgery 2018; 82:182-184. [DOI: 10.1093/neuros/nyx290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/01/2017] [Indexed: 11/14/2022] Open
|
12
|
Vaz-Guimaraes F, GARDNERl PA, Fernandez-Miranda JC, Wang E, Snyderman CH. Endoscopic endonasal skull base surgery for vascular lesions: a systematic review of the literature. J Neurosurg Sci 2016; 60:503-513. [PMID: 27327518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Endoscopic endonasal skull base surgery for vascular lesions is a controversial topic in neurosurgical practice. Concerns regarding the ability to effectively work through the relatively narrow and deep endonasal corridor and manage serious hemorrhagic complications such as inadvertent internal carotid artery (ICA) injury during endoscopic surgery (EES) are relevant sources of disagreement between neurosurgeons. Nevertheless, following careful preoperative evaluation, EES may be indicated for rare, well-selected cases, including medially-projecting paraclinoid aneurysms and cavernous malformations (CMs) located next to the ventral surface of the brainstem. To date, only small retrospective case series and case reports, attesting the safety, feasibility and technical aspects of the EES for aneurysm clipping, CM resection and arterio-venous malformations (AVMs), have been published in the literature. EVIDENCE ACQUISITION In this manuscript, we conducted a systematic review of the literature applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on EES for treatment of intracranial vascular lesions. We discuss the indications, advantages, limitations and technical aspects of EES for vascular lesions. EVIDENCE SYNTHESIS AND CONCLUSIONS Although rarely indicated, EES may be considered as an alternative treatment and part of the armamentarium of cerebrovascular neurosurgeons dealing with these challenging lesions.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh Medical Center and School of Medicine, Pittsburgh, PA, USA -
| | | | | | | | | |
Collapse
|
13
|
Gardner PA, Vaz-Guimaraes F, Jankowitz B, Koutourousiou M, Fernandez-Miranda JC, Wang EW, Snyderman CH. Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results. World Neurosurg 2015; 84:1380-93. [PMID: 26117084 DOI: 10.1016/j.wneu.2015.06.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/15/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may use the same techniques through an alternative corridor. The aim of this article is to report a series of patients who underwent an endoscopic endonasal approach (EEA) for microsurgical clipping of intracranial aneurysms. METHODS We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures are discussed. RESULTS Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal internal carotid artery (n = 9) and vertebrobasilar system (n = 2). The internal carotid artery aneurysms projected medially, whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all patients. In all cases, aneurysms were completely occluded. Among complications, 3 patients had postoperative cerebrospinal fluid leakage and 2 other patients had meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms. CONCLUSIONS EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery, working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.
Collapse
Affiliation(s)
- Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maria Koutourousiou
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
14
|
Vaz-Guimaraes F, Rastelli MM, Fernandez-Miranda JC, Wang EW, Gardner PA, Snyderman CH. Impact of Dynamic Endoscopy and Bimanual-Binarial Dissection in Endoscopic Endonasal Surgery Training: A Laboratory Investigation. J Neurol Surg B Skull Base 2015; 76:365-71. [PMID: 26401478 DOI: 10.1055/s-0034-1544124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/25/2014] [Indexed: 12/11/2022] Open
Abstract
Objective The lack of a standard technique may be a relevant issue in teaching endoscopic endonasal surgery (EES) to novice surgeons. The objective of this article is to compare different endoscope positioning and microsurgical dissection techniques in EES training. Methods A comparative trial was designed to evaluate three techniques: group A, one surgeon performing binarial two-hands dissection using an endoscope holder (rigid endoscopy); group B, two surgeons performing a combined binarial two- and three-handed dissection with one surgeon guiding the endoscope (dynamic endoscopy); and group C, two surgeons performing a binarial two-hands dissection with one surgeon dedicated to endoscope positioning and the other dedicated to a two-handed dissection. Trainees were randomly assigned to these groups and oriented to complete surgical tasks in a validated training model for EES. A global rating scale, and a specific-task checklist for EES were used to assess surgical skills. Results The mean scores of the global rating scale and the specific-task checklist were higher (p = 0.001 and 0.002, respectively) for group C, reflecting the positive impact of dynamic endoscopy and bimanual dissection on training performance. Conclusions We found that dynamic endoscopic and bimanual-binarial microdissection techniques had a significant positive impact on EES training.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Milton M Rastelli
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States ; Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
15
|
Vaz-Guimaraes F, Su SY, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Hemostasis in Endoscopic Endonasal Skull Base Surgery. J Neurol Surg B Skull Base 2015. [PMID: 26225320 DOI: 10.1055/s-0034-1544119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
William Halsted established the basic principles of modern surgical technique highlighting the importance of meticulous hemostasis and careful tissue handling. These concepts hold true today and are even more critical for endoscopic visualization, making hemostasis one of the most relevant cornerstones for the safe practice of endoscopic endonasal surgery (EES) of the skull base. During preoperative assessment, patients at higher risk for serious hemorrhagic complications must be recognized. From an anatomical point of view, EES can be grossly divided in two major components: sinonasal surgery and sellar-cranial base surgery. This division affects the choice of appropriate technique for control of bleeding that relies mainly on the source of hemorrhage, the tissue involved, and the proximity of critical neurovascular structures. Pistol-grip or single-shaft instruments constitute the most important and appropriately designed instruments available for EES. Electrocoagulation and a variety of hemostatic materials are also important tools and should be applied wisely. This article describes the experience of our team in the management of hemorrhagic events during EES with an emphasis on technical nuances.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Shirley Y Su
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States ; Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
16
|
Vaz-Guimaraes F, Gardner PA, Fernandez-Miranda JC. Fully endoscopic retrosigmoid approach for posterior petrous meningioma and trigeminal microvascular decompression. Acta Neurochir (Wien) 2015; 157:611-5; discussion 615. [PMID: 25596641 DOI: 10.1007/s00701-014-2332-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 12/22/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cerebellopontine angle tumor resection and cranial nerve microvascular decompression are usually performed with the aid of the surgical microscope. The endoscope is commonly used as an adjuvant. METHOD A retrosigmoid craniectomy is done. Upon dural opening, the endoscope is inserted into the operative field along the petrotentorial junction. Cerebrospinal fluid drainage provides a wider space for introduction of the endoscope and surgical instruments. Traditional microsurgical techniques are used during the entire procedure. CONCLUSION A fully endoscopic retrosigmoid approach is a safe and effective procedure for cerebellopontine angle tumor resection and cranial nerve microvascular decompression. KEY POINTS • Careful examination of preoperative studies is needed to identify anatomical peculiarities. • Patient positioning: the head must be gently flexed and its vertex gently tilted toward the floor. • Neurophysiologic monitoring and intraoperative navigation. • Craniectomy: partial exposure of the transverse and sigmoid sinuses. • Curvilinear dural incision reflected laterally to minimize the risk of sinus injury. • Opening the cerebellomedullary cistern for CSF drainage and cerebellar relaxation. • Dynamic endoscopy enhances depth perception and must be performed by a team with experience in endoscopic intracranial surgery. • Traditional microsurgical techniques have to be applied during the entire operation. • Multilayer reconstruction, including watertight dural closure. • Meningiomas causing brainstem shift are not suitable for endoscopic resection.
Collapse
Affiliation(s)
- Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, UPMC Presbyterian, Pittsburgh, PA, 15213, USA
| | | | | |
Collapse
|
17
|
Kaplan DJ, Vaz-Guimaraes F, Fernandez-Miranda JC, Snyderman CH. Validation of a chicken wing training model for endoscopic microsurgical dissection. Laryngoscope 2014; 125:571-6. [DOI: 10.1002/lary.24977] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 09/04/2014] [Accepted: 09/24/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Daniel J. Kaplan
- University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
| | - Francisco Vaz-Guimaraes
- Department of Neurological Surgery; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
| | - Juan C. Fernandez-Miranda
- Department of Neurological Surgery; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
| | - Carl H. Snyderman
- Department of Neurological Surgery; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
| |
Collapse
|
18
|
Gardner P, Vaz-Guimaraes F, De Almeida J, Koutourousiou M, Wang E, Fernandez-Miranda J, Snyderman C. Endoscopic Endonasal Surgery (EES) for Resection of Cranial Base Epidermoid and Dermoid Cysts: Advantages and Limitations. Skull Base Surg 2014. [DOI: 10.1055/s-0034-1384064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
19
|
Gardner P, Vaz-Guimaraes F, Rastelli M, Wang E, Fernandez-Miranda J, Snyderman C. The Role of Bimanual Dissection and Dynamic Endoscopy in Endoscopic Neurosurgical Training: Preliminary Results of a Laboratory Investigation. Skull Base Surg 2014. [DOI: 10.1055/s-0034-1384124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
20
|
Gardner P, Vaz-Guimaraes F, Miller R, Fernandez-Miranda J. Endoscopic-Assisted Cranial Nerve Microvascular Decompression (eMVD): Early Experience in a Large Referral Center. Skull Base Surg 2014. [DOI: 10.1055/s-0034-1384119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
21
|
Gardner P, Vaz-Guimaraes F, Koutourousiou M, Wang E, Fernandez-Miranda J, Snyderman C. Endoscopic Endonasal Surgery for Cranial Base Chondrosarcomas: Comparison to Open Approaches. Skull Base Surg 2014. [DOI: 10.1055/s-0034-1384065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|