Debilitating trigeminal neuralgia secondary to idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is characterized by raised intracranial pressure with unknown etiology. The most common neurological manifestations are headache and visual loss. Often, other cranial nerve impairments are also found, most commonly in the VI nerve. Trigeminal neuralgia (TN) is a debilitating condition that is most frequently caused by neurovascular pathology, but TN secondary to IIH is a rare and poorly described topic. Possible explanations of TN in these patients include the distortion of the local anatomy at CN entry zones and fluid displacement causing distortion of the Meckel's cave. In the case below we describe the clinical course of an obese female patient with TN-like pain who underwent a ventriculoperitoneal shunt to treat IIH and experienced complete resolution of both conditions.

Enhanced recovery after surgery in patients with normal pressure hydrocephalus undergoing ventriculoperitoneal shunting procedures

OBJECTIVE

Patients with idiopathic normal pressure hydrocephalus (iNPH) who undergo ventriculoperitoneal shunt (VPS) placement often belong to an older demographic, putting them at increased risk of postoperative delirium and related complications. Recent literature documenting the use of Enhanced Recovery After Surgery (ERAS) protocols in various disciplines of surgery has shown improved clinical outcomes, faster discharge, and lower readmission rates. Early return to a familiar environment (i.e., discharged home) is a well-known predictor of reduced postoperative delirium. However, ERAS protocols are uncommon in neurosurgery, especially intracranial procedures. We developed a novel ERAS protocol for patients with iNPH undergoing VPS placement to gain further insight regarding postoperative complications, specifically delirium.

METHODS

We studied 40 patients with iNPH with indications for VPS. Seventeen patients were selected at random to undergo the ERAS protocol, and twenty-three patients underwent the standard VPS protocol. The ERAS protocol consisted of measures to reduce infection, manage pain, minimize invasiveness, confirm procedural success with imaging, and shorten the length of stay. Pre-operative American Society of Anesthesiologists (ASA) grade was collected for each patient to indicate baseline risk. Rates of readmission and postoperative complications, including delirium and infection, were collected at 48 h, 2 weeks, and 4 weeks postoperatively.

RESULTS

There were no perioperative complications among the 40 patients. There was no postoperative delirium in any of the ERAS patients. Postoperative delirium was observed in 10 of 23 non-ERAS patients. There was no statistically significant difference between the ASA grade between the ERAS and non-ERAS groups.

CONCLUSIONS

We described a novel ERAS protocol for patients with iNPH receiving VPS focusing on an early discharge. Our data suggest that ERAS protocols in VPS patients might reduce the incidence of delirium without increasing the risk of infection or other postoperative complications.

Chiari Malformation Type 1 and Semi-Sitting Position - A Suitable Alternative for Patients with High BMI

OBJECTIVES

Chiari 1 malformation results from a mismatch between the posterior fossa bones and neural components. The management usually relies on surgical treatment. Despite being the most common assumed positioning, the prone position can be challenging in high BMI patients (>40 Kg/m2).

METHODS

Between February 2020 and September 2021, 4 consecutive patients with class III obesity underwent posterior fossa decompression. The authors describe nuances of the positioning and perioperative details.

RESULTS

No perioperative complications were reported. These patients are at a lower risk of bleeding and increased intracranial pressure as a consequence of low intra-abdominal pressure and venous return. In this context, the semi-sitting position, with the aid of accurate monitoring for venous air embolism, seems to be an advantageous surgical position in this group of patients.

CONCLUSION

We presented our results and technical nuances on positioning high BMI patients for posterior fossa decompression using a semi-sitting position.

Endoscopic endonasal optic nerve sheath decompression (EONSD) for idiopathic intracranial hypertension: Technical details and meta-analysis

BACKGROUND

The neurosurgical management of idiopathic intracranial hypertension (IIH) remains controversial. Although shunting and newer endovascular stenting techniques are part of the neurosurgical armamentarium to treat medically refractory IIH symptoms, optic nerve sheath fenestration has traditionally been performed by ophthalmologists.

OBJECTIVE

We present a detailed cadaveric dissection that simulates the endoscopic endonasal optic nerve sheath decompression (EONSD) technique along with the literature review.

METHODS

EONSD was performed in four freshly injected cadaveric specimens. Additionally, a systematic review from different electronic databases has been done.

RESULTS

Bilateral EONSD was performed in all specimens without significant technical difficulties. Based on our experience, there is no need to expose the periorbita or orbital apex. The primary anatomic landmarks were the optic canal, the lateral opticocarotid recess, the tuberculum, the limbus, and the clinoid segment of the internal carotid artery. Based on the systematic review, 68 patients (77.9% female) underwent EONSD, with a mean age of 33.4 ± 6.9 years in adult patients. Follow-up ranged from 3 to 58 months across different studies. The pooled meta-analysis showed headache, papilledema, and visual disturbance improvement in 78% [95%CI 0.65-0.90], 72% [95%CI 0.61-0.83], and 88% [95%CI 0.80-0.96] of cases who underwent EONSD, respectively. The subgroup analysis showed there was no statistically significant difference between unilateral and bilateral EONSD in terms of different measured outcomes.

CONCLUSION

EONSD is a feasible surgical procedure that may obviate the need for shunting in patients with IIH. Although clinical studies showed that EONSD is a safe and effective technique, further studies are required to establish the preferences of either unilateral or bilateral approaches.

Anatomical Description and Literature Review of the Endoscopic Endonasal Transclival Transodontoid Approach Combined with the Endoscopic Transoral Decompression to the Anterior Craniovertebral Junction: A New Strategy

OBJECTIVE

To describe and evaluate the steps required to perform a combined endoscopic endonasal-transoral transclival transodontoid approach for anterior decompression of the craniovertebral junction.

METHODS

The endoscopic endonasal transclival transodontoid approach combined with the endoscopic transoral decompression was performed on four cadaveric specimens. This combined technique was evaluated, a review of the literature and the nuances, advantages and pitfalls are reported.

RESULTS

Adequate and wide anterior decompression was achieved in all specimens. This combined approach allowed the preservation of the anterior arch of C1 without injuring the Eustachian tube anatomy and avoiding internal carotid artery manipulation.

CONCLUSION

Mastery of both techniques allows for a safe and comfortable surgical corridor. The transoral and transnasal approaches should not be considered as "either / or" techniques, and instead as a complement to each other. However, as with every new or developing techniques, there is a steep learning curve, which requires ample training in the skull base laboratory.

INNV-27. SAFETY OF DIRECT ORAL ANTICOAGULANTS AS COMPARED TO LOW MOLECULAR WEIGHT HEPARIN IN TREATING VENOUS THROMBOEMBOLISM IN PATIENTS WITH PRIMARY BRAIN TUMORS AND BRAIN METASTASES

INTRODUCTION

Patients with brain tumors (PBTs) have a 20 to 30% incidence of venous thromboembolism (VTE) Recently, new direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, dabigatran and edoxaban, have gained popularity in treating VTE in cancer patients due to ease of administration and favorable safety profile. DOACs are also being used in treating VTE in in PBTs. While clinical trials have established the safety of DOAC use in systemic cancers, there is only limited literature on safety of DOAC in PBTs. In this review, we explore all prospective and retrospective studies to evaluate the safety of DOAC in comparison to LMWH in treating VTEs in PBTs.

METHODS

A search on PubMed database using keywords “Direct Oral Anticoagulant,” OR “Oral Anticoagulant,” AND “Cancer,” AND “Clinical Trial” was performed for clinical trials. Another search using keywords “Direct Oral Anticoagulants,” OR “Oral Anticoagulant,” AND “Brain Tumor,” AND “Retrospective.” was performed for retrospective studies.

RESULTS

Of 359 clinical trials in cancer patients, only 4 evaluating DOAC versus LMWH, included PBTs– Hokusai, Select D, ADAM VTE and EINSTEIN-DVT/PE. Four retrospective studies (Lee 2021, Carney 2019, Schwartz 2021 and Leader 2021) were identified.These four clinical trials enrolled a very limited number of PBTs (0.7, 1.5%, 2.7% and 6.8% of all patients). The risk of ICH with DOAC as compared to LMWH was low in Hokusai trial (OR = 0.93; CI=0.14-5.9) and uninformative in other 3 trials (0 episodes of ICH in either/both groups). All four retrospective studies showed no increase in incidence of ICH in the DOAC versus LMWH group in PBTs.

CONCLUSION

In the small number of prospective and retrospective studies which have evaluated the safety of DOAC in comparison to LMWH in brain tumors, the use of DOAC appears to be safe with no increase in the risk of ICH over LMWH.