Occipital venous sinus stenting for idiopathic intracranial hypertension and pulsatile tinnitus: A case series.

Venous sinus stenting for dural venous sinus outflow obstruction due to an intrinsic filling obstruction or extrinsic stenosis is an increasingly popular treatment strategy for idiopathic intracranial hypertension (IIH) and isolated pulsatile tinnitus (PT). The most common site of stenosis is the lateral venous sinus at the transverse-sigmoid junction. Approximately 10% of the population has a persistent occipital venous sinus (OVS), a variant that may be the dominant venous drainage pathway in the setting of a hypoplastic or aplastic transverse sinus. OVS stenosis has been rarely associated with IIH and isolated PT with only a handful published cases. We herein report a retrospective series of OVS stenting in five patients, four of whom presented with non-IIH PT and one with IIH.

Anatomical determinants of occipitocervical fusion in skull base chordoma resection: a systematic review of the literature with illustrative cases.

OBJECTIVE: Skull base chordomas are rare, locally osseo-destructive lesions that present unique surgical challenges due to their involvement of critical neurovascular and bony structures at the craniovertebral junction (CVJ). Radical cytoreductive surgery improves survival but also carries significant morbidity, including the potential for occipitocervical (OC) destabilization requiring instrumented fusion. The published experience on OC fusion after CVJ chordoma resection is limited, and the anatomical predictors of OC instability in this context remain unclear. METHODS: PubMed and Embase were systematically searched according to the PRISMA guidelines for studies describing skull base chordoma resection and OC fusion. The search strategy was predefined in the authors' PROSPERO protocol (CRD42024496158). RESULTS: The systematic review identified 11 surgical case series describing 209 skull base chordoma patients and 116 (55.5%) who underwent OC instrumented fusion. Most patients underwent lateral approaches (n = 82) for chordoma resection, followed by midline (n = 48) and combined (n = 6) approaches. OC fusion was most often performed as a second-stage procedure (n = 53), followed by single-stage resection and fusion (n = 38). The degree of occipital condyle resection associated with OC fusion was described in 9 studies: total unilateral condylectomy reliably predicted OC fusion regardless of surgical approach. After lateral transcranial approaches, 4 studies cited at least 50%-70% unilateral condylectomy as necessitating OC fusion. After midline approaches-most frequently the endoscopic endonasal approach (EEA)-at least 75% unilateral condylectomy (or 50% bilateral condylectomy) led to OC fusion. Additionally, resection of the medial atlantoaxial joint elements (the C1 anterior arch and tip of the dens), usually via EEA, reliably necessitated OC fusion. Two illustrative cases are subsequently presented, further exemplifying how the extent of CVJ bony elements removed via EEA to achieve complete chordoma resection predicts the need for OC fusion. CONCLUSIONS: Unilateral total condylectomy, 50% bilateral condylectomy, and resection of the medial atlantoaxial joint elements were the most frequently described independent predictors of OC fusion in skull base chordoma resection. Additionally, consistent with the occipital condyle harboring a significantly thicker joint capsule at its posterolateral aspect, an anterior midline approach seems to tolerate a greater degree of condylar resection (75%) than a lateral transcranial approach (50%-70%) prior to generating OC instability.

The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series.

BACKGROUND: Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited. METHODS: Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis and supported by comprehensive angiographic and intraoperative images. RESULTS: One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk for endovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation. CONCLUSIONS: This illustrative case series highlights the technical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.

Eclipse balloon-assisted straight sinus thrombectomy: A novel technique.

Cerebral venous sinus thrombosis comprises 0.5% of all strokes and usually affects young adults. Straight sinus involvement is relatively rare, and it is associated with poor prognosis. Intravenous anticoagulation is considered the first line of treatment. Endovascular approaches such as direct catheter thrombolysis, balloon-assisted thrombolysis, and mechanical thrombectomy may be more efficient and should be considered in cases in which there is involvement of the deep venous system, declining neurological status, or less invasive treatment options have failed. In this work, we describe a novel technique of ECLIPSE 2L balloon (Balt, Irvine, CA) assisted mechanical thrombectomy for straight sinus thrombosis and a review of dural sinus thrombosis management.

Far Lateral Approach With C1 Hemilaminotomy for Excision of a Ruptured Fusiform Lateral Spinal Artery Aneurysm: 2-Dimensional Operative Video.

The lateral spinal artery (LSA) represents the most rostral extent of the posterolateral arterial axis of the spinal cord and supplies both the posterior and lateral aspects of the spinal cord.1 The LSA originates from either the intradural segment of vertebral artery or the lateral segment of the posterior inferior cerebellar artery.1,2 It terminates at the level of C5 because it anastomoses with the posterior spinal artery. Although the LSA is in communication with the subarachnoid space, subarachnoid hemorrhage (SAH) due to an LSA aneurysm is rare.3-6 Moreover, accurate diagnosis of vascular pathologies involving the LSA is challenging because the LSA is typically too small to be visualized with conventional angiography.2 Here, we present the case of a 74-year-old woman who presented to our institution with headache, nausea, and confusion due to posterior fossa SAH without any visible vascular malformation on initial diagnostic cerebral angiography. A right frontal external ventricular drain was placed for communicating hydrocephalus. Immediate cerebral angiogram was within normal limits. Two-week follow-up angiogram demonstrated a fusiform right LSA aneurysm. The endovascular treatment was not an option because of the risk of occlusion of proximal perforators of the right posterior spinal artery, resulting in a long segment ischemia. The patient underwent a right far lateral transcondylar approach with C1 hemilaminotomy and excision of the LSA aneurysm. The postoperative course was uneventful. The patient was neurologically intact. Six-month follow-up angiogram showed no evidence of residual aneurysm. LSA pathologies should be kept in mind with posterior fossa SAH. Surgical excision is an effective treatment option in carefully selected patients. The patient consented to the procedure.

[Spinal injury related to alpine winter sports]. / Fractures de la colonne vertébrale lors d'accidents de ski ou autres sports de neige.

Winter sports are the cause of a significant number of spinal injuries in Switzerland. However, the number of patients, the mechanism, the presentation, the diagnosis and the treatment of vertebral fractures have considerably evolved over the last decades. As the hospital of Sion, in Valais, is particularly exposed to these diagnoses, we analyzed two series of prospective cases 30 years apart (1989-1990 and 2019-2020) and propose a review of the main types and mechanisms of fractures, diagnosis, and management for the primary care physician.

Les sports d'hiver sont à l'origine d'un nombre important de lésions de la colonne vertébrale en Suisse. Cependant, le nombre de patients, le mécanisme, la présentation, le diagnostic et le traitement des fractures vertébrales ont considérablement évolué au cours des dernières décennies. L'hôpital de Sion, en Valais, étant particulièrement exposé à ces diagnostics, nous avons analysé deux séries de cas prospectives à 30 ans d'intervalle (1989-1990 et 2019-2020) et proposons une revue des principaux types et mécanismes de fractures, diagnostics, et prises en charge pour le médecin de premier recours.

The interdural hematoma: A subtype of convexity subdural/dural hematoma with specific radioanatomical characteristics.

Background: Rare cases of biconvex hematomas splitting the convexity dura mater were reported and denominated interdural hematoma (IDH). Due to their rarity, little is known about their radiological characteristics, and in most cases, their invasive management with craniotomy and dural membrane excision is unnecessary. Case Description: We report here a case of single burr-hole endoscopic evacuation of an IDH and its complete resolution after the 6-month follow-up imaging. The literature review reveals 11 reported cases of IDH. Most of them are male and the mean age is 65 years (range 51-90). Most of the reported IDHs were misdiagnosed as epidural hematoma or meningioma, and therefore, they have been managed invasively through craniotomy with dural excision. Diagnosis of the interdural nature was confirmed macroscopically during surgery in all cases and histology was reported for 6 cases. Image analysis found a double dural beak sign and biconvex shape on coronal planes, subarachnoid space enlargement at the collection extremities, and irregular thick inner wall as common radiological aspects of the IDH. Conclusion: IDH is a rarely reported and often misdiagnosed dural hematoma subtype. Its invasive treatment through craniotomy is likely related to its unknown radiological characteristics. We review and raise awareness about potentially unique radiological anatomy that could avoid unnecessary invasive treatment. Moreover, we report the first case of endoscopically evacuated IDH with long-term follow-up imaging showing complete resolution.

Traumatic Brain Injury in Alpine Winter Sports: Comparison of Two Case Series from a Swiss Trauma Center 30 Years Apart.

BACKGROUND: Between 3 and 15% of winter sports-related injuries are related to head injuries, which are the primary cause of mortality and disability among skiers. Despite the widespread adoption of helmets in winter sports, which has reduced the incidence of direct head injury, there is a paradoxical trend of an increasing number of individuals wearing helmets sustaining diffuse axonal injuries (DAI), which can result in severe neurologic sequelae. METHODS: We retrospectively reviewed 100 cases collected by the senior author of this work from 13 full winter seasons during the period from 1981 to 1993 and compared them with 17 patients admitted during the more shortened 2019 to 2020 ski season due to COVID-19. All data analyzed come from a single institution. Population characteristics, mechanism of injury, helmet use, need for surgical treatment, diagnosis, and outcome were collected. Descriptive statistics were used to compare the two databases. RESULTS: From February 1981 to January 2020, most skiers with head injuries were men (76% for the 1981-1993 and 85% for 2020). The proportion of patients aged over 50 increased from <20% in 1981 to 65% in 2020 (p < 0.01), with a median age of 60 years (range: 22-83 years). Low- to medium-velocity injuries were identified in 76% (13) of cases during the 2019 to 2020 season against 38% (28/74) during the 1981 to 1993 seasons (p < 0.01). All injured patients during the 2020 season wore a helmet, whereas none of the patients between 1981 and 1993 wore one (p < 0.01). DAI was observed in six cases (35%) for the 2019 to 2020 season against nine cases (9%) for the 1981 to 1993 season (p < 0.01). Thirty-four percent (34) of patients during the 1981 to 1993 seasons and 18% (3) of patients during the 2019 to 2020 season suffered skeletal fractures (p = 0.02). Among the 100 patients of the 1981 to 1993 seasons, 13 (13%) died against 1 (6%) from the recent season during care at the hospital (p = 0.15). Neurosurgical intervention was performed in 30 (30%) and 2 (12%) patients for the 1981 to 1993 and 2019 to 2020 seasons, respectively (p = 0.003). Neuropsychological sequelae were reported in 17% (7/42) of patients from the 1981 to 1993 seasons and cognitive evaluation before discharge detected significant impairments in 24% (4/17) of the patients from the 2019 to 2020 season (p = 0.29). CONCLUSION: Helmet use among skiers sustaining head trauma has increased from none in the period from 1981 to 1993 to 100% during the 2019 to 2020 season, resulting in a reduction in the number of skull fractures and deaths. However, our observations suggest a marked shift in the type of intracranial injuries sustained, including a rise in the number of skiers experiencing DAI, sometimes with severe neurologic outcomes. The reasons for this paradoxical trend can only be speculated upon, leading to the question of whether the perceived benefits of helmet use in winter sports are actually misinterpreted.

Impact of Subjective Evaluations in Predicting Response to Ventriculoperitoneal Shunt for Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: Cerebrospinal fluid tap test is a common procedure to predict the efficacy of ventriculoperitoneal shunt for idiopathic normal pressure hydrocephalus. Objective tests after cerebrospinal fluid tap test are used to establish the surgical indication, but subjective improvements may also be important in selection of surgical candidates. The aim of this study was to evaluate surgical outcomes of patients with ventriculoperitoneal shunt for idiopathic normal pressure hydrocephalus, comparing patients showing objective improvement with patients improving only on subjective assessments. METHODS: In this retrospective analysis, patients were divided into 2 groups: group 1 included patients with improvement on objective evaluation after cerebrospinal fluid tap test; group 2 included patients who showed only subjective improvement. The surgical outcomes of the 2 groups were compared. RESULTS: Of 28 included patients, 17 were objective responders (group 1), and 11 were subjective responders (group 2). Clinical and radiological characteristics were similar. The only significant difference was the baseline Berg Balance Scale, which was lower in objective responders (P = 0.0015). At 3 months after surgery and at last follow-up, there was no difference in surgical outcomes between the 2 groups. However, in the group of subjective responders, a continuous improvement for incontinence and gait was more frequently observed (P = 0.04 and P < 0.001, respectively). CONCLUSIONS: Surgical outcomes after ventriculoperitoneal shunt were similar between the 2 groups, with a more favorable trend in terms of symptom improvement for subjective responders. Subjective assessment seems to be an important factor to consider in preoperative evaluation.

Occipito-transtentorial approach for falcotentorial meningiomas: how I do it.

BACKGROUND: Falcotentorial meningiomas are rare tumors that arise at the junction of the dural folds of the tentorium and falx cerebri, at the junction of the vein of Galen with the straight sinus with possible extensions along the course of the straight sinus. Surgery of falcotentorial meningiomas remains challenging due to the intimate neurovascular relationships in the posterior incisural space. METHODS: We describe the key steps of the occipito-transtentorial approach for falcotentorial meningiomas with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. CONCLUSION: The occipito-transtentorial approach offers good surgical exposure and outcomes in carefully selected patients harboring falcotentorial meningiomas. Precise understanding of the relationship between the tumor and the internal cerebral veins, basal veins, and vein of Galen should be thoroughly analyzed as these structures may be infiltrated or displaced.

Endoscope-Assisted Extreme Lateral Supracerebellar Infratentorial Approach for Resection of Superior Cerebellar Peduncle Pilocytic Astrocytoma: Technical Note.

(1) Background: Superior cerebellar peduncle (SCP) lesions are sparsely reported in the literature. The surgical approaches to the cerebello-mesencephalic region remain challenging. In this article, we present the extreme lateral supracerebellar infratentorial (ELSI) approach to treat a large hemorrhagic pilocytic astrocytoma of the SCP. (2) Methods: An 11-year-old boy, known for neurofibromatosis Type I, presented to the emergency department of our institution with symptoms and signs of intracranial hypertension. The cerebral magnetic resonance imaging (MRI) revealed a large hemorrhagic lesion centered on the SCP provoking obstructive hydrocephalus. Following an emergency endoscopic third ventriculocisternostomy (ETV), he underwent a tumor resection via an endoscope-assisted ELSI approach. (3) Results: ELSI approach allows for a wide exposure with direct access to lesions of the SCP. The post-operative course was uneventful, and the patient was discharged home on post-operative day 5. Post-operative MRI revealed a near total resection with a small residual tumor within the mesencephalon. (4) Conclusion: ELSI approach offers an excellent exposure with the surgical angles necessary for median and paramedian lesions. The park-bench position with appropriate head flexion and rotation offers a gravity-assisted relaxation of the tentorial and petrosal cerebellar surfaces. The endoscope can be an adjunct to illuminate the blind areas of the surgical corridor for an improved tumor resection without significant cerebellar retraction.

Late metachronous cerebral metastasis of pancreatic adenocarcinoma of the tail of the pancreas: a case report.

BACKGROUND: Pancreatic cancer is one of the leading causes of cancer mortality and one of the most lethal malignant neoplasms worldwide. It is known for its local tumor extension to the liver; other common sites include the lung, distant lymph nodes, and bone. Brain metastases are extremely rare and represent less than 0.6% of all brain metastases. CASE REPORT: We report the case of a 66-year-old Caucasian female known to have adenocarcinoma of the tail of the pancreas treated with chemotherapy. During follow-up, thoracoabdominal computed tomography scans did not reveal any residual tumor or any metastasis. Moreover, tumor markers were within normal limits. She presented to the emergency department of our institution following an episode of a generalized tonic-clonic seizure 5 years following the initial diagnosis. Brain magnetic resonance imaging revealed an expansive left frontal intraaxial lesion compatible with high-grade glioma. The patient underwent surgical treatment. Histological examination revealed pancreatic metastasis. CONCLUSIONS: Thought to be rare, metachronous cerebral pancreatic metastasis should be kept in mind in patients with pancreatic cancer. Early diagnosis and complete surgical resection play a key role in the survival of these patients.

Radiosurgery for Benign Vertebral Body Hemangiomas of the Spine: A Systematic Review and Meta-Analysis.

OBJECTIVE: Spinal vertebral hemangiomas (SVHs) are the most common benign tumors of the spine. We performed a systematic review and meta-analysis of radiosurgery (RS) for SVHs. METHODS: We reviewed articles published between January 1990 and December 2020 on PubMed. Tumor control, pain relief, and damage to surrounding tissues were evaluated with separate meta-analyses. This study was performed in accordance with the published Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 23 patients with 24 SVHs were reported in 3 studies. RESULTS: Follow-up time was 7.3-84 months. The vast majority of lesions were located at dorsal level (n = 18; 75%). In 20 (83.3%) patients, pain was the initial clinical presentation. Complete, partial, and stable responses after radiation were reported in 45.7% (P < 0.001), 23.6% (P = 0.02), and 37.2% (P = 0.7) of cases. Overall response was reported in 94.1% (P = 0.7). No progressive disease was reported. Pain relief was achieved in 87.5% of patients (P = 0.2). Damage to surrounding tissue caused by irradiation was reported in 22.3% (P = 0.02) of cases in 1 study, in which higher doses of radiation were delivered. CONCLUSIONS: Radiosurgery is safe and effective for SVHs. Pain relief after RS in symptomatic patients was extremely high, while no progressive disease was reported. Damage to surrounding tissues was reported in only 1 series and included osteitis, osteonecrosis, or soft tissue injury after higher radiation doses.

Extreme lateral supracerebellar infratentorial approach for tentorial arteriovenous fistula associated with a giant venous ectasia: how I do it.

BACKGROUND: Surgery of tentorial dural arteriovenous fistulas (DAVF) associated with large ectatic vein remains challenging due to the intimate neurovascular relationships in the incisural space. Interruption of the arterialized vein requires a good knowledge of the regional anatomy and a precise preoperative evaluation. METHODS: We describe the key steps extreme lateral supracerebellar infratentorial (ELSI) approach for tentorial DAVF with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. CONCLUSIONS: In cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers good surgical exposure and outcomes.

Feeding artery aneurysms associated with large meningiomas: case report and review of the literature.

Though brain tumors and intracranial aneurysms co-exist, the occurrence of feeding artery aneurysms with meningiomas are unusual. We describe here a large falcine meningioma that was associated with three feeding artery aneurysms of the anterior circulation. These aneurysms can be treated either by pre-operative endovascular therapy or during the meningioma surgery. The management strategy for these patients will depend on the clinical presentation, morphology and localization of these aneurysms with respect to the tumor.

Banking Brain Tumor Specimens Using a University Core Facility.

Within the past three decades, the significance of banking human cancer tissue for the advancement of cancer research has grown exponentially. The purpose of this article is to detail our experience in collecting brain tumor specimens in collaboration with the University of Miami/Sylvester Tissue Bank Core Facility (UM-TBCF), to ensure the availability of high-quality samples of central nervous system tumor tissue for research. Successful tissue collection begins with obtaining informed consent from patients following institutional IRB and federal HIPAA guidelines, and it needs a well-trained professional staff and continued maintenance of high ethical standards and record keeping. Since starting in 2011, we have successfully banked 225 brain tumor specimens for research. Thus far, the most common tumor histology identified among those specimens has been glioblastoma (22.1%), followed by meningioma (18.1%). The majority of patients were White, non-Hispanics accounting for 45.1% of the patient population; Hispanic/Latinos accounted for 23%, and Black/African Americans accounted for 14%, which represent the particular population of the State of Florida according to the 2010 census data. The most common tumors found in each subgroup were as follows: Black/African American, glioblastoma and meningioma; Hispanic, metastasis and glioblastoma; White, glioblastoma and meningioma. The UM-TBCF is a valuable repository, offering high-quality tumor samples from a unique patient population.

Surgical anatomy of the diaphragm in the anterolateral approach to the spine: a cadaveric study.

STUDY DESIGN: Laboratory cadaveric study. OBJECTIVE: To delineate the pertinent surgical anatomy of the diaphragm during access to the anterolateral thoracolumbar junction. SUMMARY OF BACKGROUND DATA: The general anatomy of the thoracic diaphragm is well described. The specific surgical anatomy as it pertains to the lateral and thoracoabdominal approaches to the thoracolumbar junction is not well described. METHODS: Dissections were performed on adult fresh cadaveric specimens. Special attention was paid to the diaphragmatic attachments to the lower rib cage and to the spinal thoracolumbar junction. RESULTS: The pertinent diaphragmatic attachments to the rib cage are at the 11th and 12th ribs. Whether the diaphragm is incised or mobilized ventrally, the pertinent spinal attachments are the lateral and medial arcuate ligaments. Identifying and sectioning these structures allows for direct access to the thoracolumbar junction, particularly the L1 vertebral body. CONCLUSIONS: An understanding of the diaphragmatic-costal and diaphragmatic-spinal attachments is key for the safe and effective implementation of diaphragm mobilization during the lateral and thoracoabdominal approaches to the spine.

The minipterional craniotomy for anterior circulation aneurysms: initial experience with 72 patients.

BACKGROUND: The pterional craniotomy is well established for microsurgical clipping of most anterior circulation aneurysms. The incision and temporalis muscle dissection impacts postoperative recovery and cosmetic outcomes. The minipterional (MPT) craniotomy offers similar microsurgical corridors, with a substantially shorter incision, less muscle dissection, and a smaller craniotomy flap. OBJECTIVE: To report our experience with the MPT craniotomy in select unruptured anterior circulation aneurysms. METHODS: From January 2009 to July 2013, 82 unruptured aneurysms were treated in 72 patients, with 74 MPT craniotomies. Seven patients had multiple aneurysms treated with a single MPT craniotomy. The average patient age was 56 years (range: 24-87). Aneurysms were located along the middle cerebral artery (n = 36), posterior communicating (n = 22), paraophthalmic (n = 22), choroidal (n = 1), and dorsal ICA segments (n = 1). The MPT craniotomy utilized an incision just posterior to the hairline and a single myocutaneous flap. RESULTS: The average aneurysm size was 5.45 mm (range: 1-14). There were no instances of compromised operative corridors requiring craniotomy extension. Three significant early postoperative complications included epidural and subdural hematomas requiring evacuation, and a middle cerebral artery infarction. Average length of hospitalization was 3.96 days (range: 2-20). Two patients required reoperation for wound infections. Average follow-up was 421 days (range: 5-1618). Minimal to no temporalis muscle wasting was noted in 96% of patients. CONCLUSION: The MPT craniotomy is a worthwhile alternative to the standard pterional craniotomy. There were no instances of suboptimal operative corridors and clip applications when the MPT craniotomy was utilized in the treatment of unruptured middle cerebral artery and supraclinoid internal carotid artery aneurysms proximal to the terminal internal carotid artery bifurcation.

Extracranial glioblastoma in transplant recipients.

PURPOSE: Traditionally, gliomas are considered to be confined to the central nervous system. The shortage of solid donor organs resulted in consideration of organs from patients with primary malignancy such as glioblastoma multiforme (GBM) for transplantation into patients suffering from end-stage organ disease. METHODS: We performed a PubMed search including all studies that documented patient demographics, pre- and post-transplantation conditions as well as time to metastasis and overall survival in recipients of organ transplants from donors suffering from GBM. RESULTS: A total of 11 studies with 11 patients were included in this review. Three patients had liver, three had kidney, and five had lung transplantation. For kidney transplants, average time to metastasis was 17.3 months post-surgery. The average follow-up time was 32.3 months, and all patients were doing well. All liver transplant recipients succumbed due to GBM metastasis. The average survival was 7 months for all three patients. For lung-receiving patients, two patients died at an average of 9.5 months post-transplantation, with a mean time to metastasis of 9 months. Two patients were doing well at 17- and 20-month follow-up. One patient was diagnosed with metastasis 12 months after transplantation, but no follow-up data were provided. CONCLUSIONS: These studies emphasize the disadvantage of transplanting an organ of an individual with GBM. However, it should be noted that these cases do not make up a large percentage of overall transplantations, and donors with primary central nervous system malignancies also do not represent the whole pool of organs available.

The rib head as a landmark in the anterolateral approach to the thoracic spine: a computed tomography-based morphometric study.

OBJECT: The rib head is an important landmark in the anterolateral approach to the thoracic spine. Resection of the rib head is typically the first step in gaining access to the underlying pedicle and ultimately the spinal canal. The goal of this work is to quantify the relationship of the rib head to the spinal canal and adjacent aorta at each thoracic level using CT-based morphometric measurements. METHODS: One hundred thoracic spine CT scans (obtained in 50 male and 50 female subjects) were evaluated in this study. The width and depth of each vertebra body were measured from T-1 to T-12. In addition, the distance of each rib head to the spinal canal was determined by drawing a line connecting the rib heads bilaterally and measuring the distance to this line from the most ventral aspect of the spinal canal. Finally, the distance of the left rib head to the thoracic aorta was measured at each thoracic level below the aortic arch. RESULTS: The vertebral body depth progressively increased in a rostral to caudal direction. The vertebral body width was at its minimum at T-4 and progressively increased to T-12. The rib head extended beyond the spinal canal maximally at T-1. This distance incrementally decreased toward the caudal levels, with the tip of the rib head lying approximately even with the ventral canal at T-11 and T-12. The distance between the aorta and the left rib head increased in a rostral to caudal direction as well. CONCLUSIONS: The rib head is an important landmark in the anterolateral approach to the thoracic spine. At more cephalad levels, a larger portion of rib head requires resection to gain access to the spinal canal. At more caudad levels, there is a safer working distance between the rib head and aorta.