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To perform an adequate orbitozygomatic craniotomy, it is very important that the bone cut which passes through the body of the zygoma reaches the inferior orbital fissure (IOF). To reach the IOF, two surface landmarks on the body of the zygoma are described: a point located directly superior to the malar eminence and the zygomaticofacial foramen. The article explores the reliability of these landmarks and three other alternative points to reach the IOF. Eighty-three adult skulls were used in this study. The IOF dimensions and the relationship with the malar eminence, the point superior to the malar eminence, the zygomaticofacial foramen, and 3 alternative points (E, C, F) were analyzed. The malar eminence was unacceptable for use as a guide to the IOF. The point superior to the malar eminence was also unacceptable as a guide as only 9.4% and 10.9% were in the projection of the IOF on the right and left, respectively. 59.7% of the total zygomaticofacial foramina fell in the IOF projection. The point F fell in the projection of the IOF in 98.8% and 100.0% on the right and left, respectively. The use of the malar eminence as a guide to reach the IOF is unreliable in one third of cases as it is not easily identified intraoperatively in these cases. The zygomaticofacial foramen cannot be considered a reliable surgical landmark to reach the IOF. The authors recommend using a novel landmark which may be identified as a midpoint between intersections of the anterior and posterior margins of the zygomatic frontal process on a line extending from the inferior margin of the zygomatic arc. This point is reliable in 98.8-100% of cases.
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Órbita , Zigoma , Adulto , Humanos , Órbita/cirurgia , Osteotomia/métodos , Reprodutibilidade dos Testes , Crânio/cirurgia , Zigoma/cirurgiaRESUMO
Ligation of the sphenopalatine and posterior nasal arteries is indicated for posterior epistaxis as initial treatment or when conservative measures fail. In some patients, a transnasal approach or its alternative transantral approach are not possible due to tumor filling the nasal corridor, pterygopalatine fossa, or maxillary sinus. Aim of this study was to evaluate feasibility of endoscopically assisted transoral approach for the ligation of the maxillary artery (MA). Six fresh cadaver specimens (12 sides), previously prepared with intravascular injections of colored latex, were dissected. A combined transnasal and transoral approach exposed the MA from the deep belly of the temporalis muscle laterally to its terminal branches medially. Anatomical relationships of the MA with the deep belly of the temporalis muscle and the lower head of the lateral pterygoid muscle, and feasibility of access to the MA via a transoral approach were assessed. In all specimens, the MA was found at the point where horizontal fibers of the lower head of the lateral pterygoid muscle cross the vertical fibers of the deep belly of the temporalis muscle. In 5 specimens, the artery ran anteriorly and laterally to lower head of the lateral pterygoid muscle, and in 1 specimen, it ran posteriorly and medially to this muscle, diving between its fibers. The modified endoscopically assisted transoral approach is feasible to ligate the MA. It can be used for proximal vascular control in cases when transnasal and transantral approaches are not viable.
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Angiofibroma/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Condrossarcoma/cirurgia , Endoscopia/métodos , Neoplasias de Cabeça e Pescoço/cirurgia , Artéria Maxilar/anatomia & histologia , Artéria Maxilar/cirurgia , Músculos Pterigoides/anatomia & histologia , Músculo Temporal/anatomia & histologia , Adolescente , Pontos de Referência Anatômicos , Cadáver , Estudos de Viabilidade , Feminino , Humanos , Ligadura , Masculino , Pessoa de Meia-Idade , Boca , Fossa PterigopalatinaRESUMO
BACKGROUND: Craniofacial chondroid tumors (CFCTs) constitute less than 1% of all intracranial mass lesions. No protocol for evaluation and management of CFCTs is developed at the moment. MATERIALS AND METHODS: We analyzed 51 patients with CFCTs operated on in Burdenko Neurosurgical Institute from 1980 until 2012, which included chondroma (15), chondroblastoma (3), chondromyxoid fibroma (11), and chondrosarcoma (22). Age varied from 2 to 76 years (mean, 40 y); the series included 23 women and 28 men. All tumors were divided into 4 groups: midline unilateral (8),midline bilateral (21), anterolateral (19), and lateral (3). This division was based on differences in surgical approaches (P = 0.009). RESULTS: All patients underwent surgical treatment. Complete removal was achieved in 20; subtotal, in 21; and partial, in 10. Two patients died, and early complications were observed in 10 cases. Early outcomes correlated with the benign nature of the tumors (P = 0.002). Follow-up data were available in 22 patients. Fifteen of 51 patients were reoperated on because of recurrence (a total of 43 reoperations were performed). The mean recurrence-free period was 45 months. In 3 patients, the tumor metastasized, and malignant transformation was observed in 3 cases. Sixteen patients received postoperative radiation therapy. Delayed sequelae occurred in 5 observations, and 5 patients died during long-term follow-up. Three-year survival in benign and malignant tumors was 87.5% and 55.6%, respectively, and 5-year survival was 83.3% and 40.0%, respectively. CONCLUSION: Surgical resection is the mainstay in treatment of both benign and malignant craniofacial tumors, and adjuvant radiation therapy is mandatory in malignant lesions; however, it should be avoided in benign lesions.
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Condroblastoma/cirurgia , Condroma/cirurgia , Condrossarcoma/cirurgia , Neoplasias de Cabeça e Pescoço/cirurgia , Adolescente , Adulto , Idoso , Transformação Celular Neoplásica/patologia , Criança , Pré-Escolar , Condroblastoma/secundário , Condrossarcoma/secundário , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Inoculação de Neoplasia , Complicações Pós-Operatórias , Radioterapia Adjuvante , Reoperação , Neoplasias Cranianas/cirurgia , Taxa de Sobrevida , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Adulto JovemRESUMO
Purpose: To report our experience with patient specific implants for one-step orbit reconstruction following hyperostotic SWM removal and to describe the evolution of the technique through three surgical cases. Methods: Three cases of one-step SWM removal and orbit reconstruction are described. All cases are given consecutively to describe the evolution of the technique. Hyperostotic bone resection was facilitated by electromagnetic navigation and cutting guides (templates). Based on a 3D model, silicone molds were made using CAD/CAM. Then PMMA implant was fabricated from these molds. The implant was adjusted and fixed to the cranium with titanium screws after tumor removal. Results: Following steps of the procedure changed over these series: hyperostotic bone resection, implant thickness control, implant overlay features, anatomic adjustments, implant fixation. The proptosis resolved in all cases. In one patient the progressive visual acuity deterioration was recognized during the follow-up. No oculomotor disturbances and no tumor regrowth were found at the follow-up. Conclusion: CAD/CAM technologies enable creation of implants of any size and configuration, and thereby, to increase the extent of bony resection and lower the risk of tumor progression. The procedure is performed in one step which decreases the risk of postoperative morbidity.
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BACKGROUND: One-piece modified orbitozygomatic approach (OZA) is an extended version of the pterional approach that also includes orbital walls and frontal process of the zygomatic bone. For this craniotomy one burr hole must be placed in MacCarty keyhole and another - in the temporal region. OBJECTIVE: To develop a technique of the one-piece modified OZA with single a burr hole in the alternative sphenoid ridge keyhole that allows access to orbit, anterior cranial fossa and middle cranial fossa and apply it intraoperatively. METHODS: A single human head specimen was used. The dissection was performed using standard surgical instruments high-speed Stryker drill. Every stage of the approach was photographed. We also report a surgical case of a patient with orbital cavernous hemangioma that was resected using the described technique. RESULTS: The technique of the one-piece modified OZA with a single burr hole in the alternative sphenoid ridge keyhole is described, and its advantages and limitations are analyzed. The technique is used to totally resect an orbital cavernous hemangioma with good functional and cosmetic result. CONCLUSION: Modified OZA with a single burr hole in the sphenoid ridge keyhole is possible and may be an alternative to the classic technique. The advantages of this variation are the placement of just one burr hole and the preservation of a larger portion of the orbital roof. The latter facilitates better bone reconstruction and better cosmetic outcome. Disadvantages are the difficulty of identifying the location of the sphenoid ridge keyhole and risk of damaging the dura.
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Craniotomia , Hemangioma Cavernoso , Humanos , Craniotomia/métodos , Base do Crânio/cirurgia , Osso Esfenoide/cirurgia , Órbita/cirurgia , Hemangioma Cavernoso/cirurgiaRESUMO
Background: Complex anterior skull base defects produced by resection of mass lesions vary in size and configuration and may be extensive. We analyzed the largest single-center series of midline craniofacial lesions extending intra- and extracranially. The study aims at the development of a predictive model for preoperative measurement of the risk of the postoperative cerebrospinal fluid (CSF) leak based on patients' characteristics and surgical plans. Methods: 166 male and 149 female patients with mean age 40,5 years (1 year and - 81 years) operated for benign and tumor-like midline craniofacial mass lesions were retrospectively analyzed using logistic regression method (Ridge regression algorithm was selected). The overall CSF leak rate was 9.6%. The ROSE algorithm and 'glmnet' software suite in R were used to overcome the cohort's disbalance and avoid overtraining the model. Results: The most influential modifiable negative predictor of the postoperative CSF leak was the use of extracranial and combined approaches. Use of transbasal approaches, gross total resection, utilization of one or two vascularized flaps for skull base reconstruction were the foremost modifiable predictors of a good outcome. Criterium of elevated risk was established at 50% with a specificity of the model as high as 0.83. Conclusions: The performed study has allowed for identifying the most significant predictors of postoperative CSF leak and developing an effective formula to estimate the risk of this complication using data known for each patient. We believe that the suggested web-based online calculator can be helpful for decision making support in off-pattern clinical situations.
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BACKGROUND: Problem of closure of skull base defects after removal of craniobasal lesions, especially, craniofacial, is one of the most challenging in neurosurgery. Persistent skull base defect produces extremely high risk of cerebrospinal fluid leaks and consecutive infectious complications. Local pedicled grafts are the preferred material for plasty. In this study, the authors present original technique of using a pedicled buccal fat pad (BFP) graft. Anatomy and functions of BFP are discussed in details as well as surgical technique illustrated by 2 case reports. METHODS: From 2004 to 2010, 188 patients with anterior and middle skull base mass lesions were operated on in Burdenko Neurosurgical Institute (Moscow, Russia) using BFP as plastic material for closure of different defects (male-female ratio=61:127; mean age was 47 years [range, 10-74 years]). RESULTS: In 93.6% of cases, pedicled BFP flap was applied; in 6.4%, free flap was used. Follow-up period ranged between 1 and 7 years. Only 1 case of postoperative cerebrospinal fluid leak was observed; flap rejection was not registered in the series. CONCLUSIONS: High effectiveness and minimal invasiveness are principal advantages of the described technique, which is applied in neurosurgery for the first time. Other benefits include proximity of donor site and defect, simplicity of surgical technique, minimal postoperative discomfort, and very low risk of benign complications.
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Tecido Adiposo/transplante , Procedimentos de Cirurgia Plástica/métodos , Neoplasias da Base do Crânio/cirurgia , Base do Crânio/cirurgia , Retalhos Cirúrgicos , Tecido Adiposo/anatomia & histologia , Adolescente , Adulto , Idoso , Angiofibroma/cirurgia , Rinorreia de Líquido Cefalorraquidiano/etiologia , Criança , Feminino , Adesivo Tecidual de Fibrina/uso terapêutico , Seguimentos , Retalhos de Tecido Biológico , Sobrevivência de Enxerto , Humanos , Masculino , Meningioma/cirurgia , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Neurofibroma/cirurgia , Complicações Pós-Operatórias , Adesivos Teciduais/uso terapêutico , Adulto JovemRESUMO
BACKGROUND: Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign tumor occurring almost exclusively in adolescent and young adult males. The tumor is characterized by slow progression, aggressive growth, high vascularization, and increased rate of persistence and recurrence. The aim of this study was to describe a case of giant JNA from our practice and discuss the controversies of surgical treatment of advanced JNA. MATERIAL AND METHODS: A series of 29 consecutive male patients with JNA Fisch grade III and IV was surgically treated in Burdenko Neurosurgical Institute from 2000 until 2008. In the vast majority of cases, endovascular embolization and surgical removal via orbitozygomatic approach were applied. RESULTS: Gross total resection was achieved in 24 cases (83%). Complications were encountered in eight cases. No mortality was observed. In three patients, the diseases recurred. An illustrative case is described. CONCLUSION: Surgical treatment is the basic tactics in management of extensive JNA including endovascular embolization and resection of the tumor. We recommend using orbitozygomatic approach or its modifications in JNA. Radiation therapy may be recommended for patients with small residual tumor.
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Angiofibroma/cirurgia , Neoplasias Nasofaríngeas/cirurgia , Adolescente , Adulto , Angiofibroma/irrigação sanguínea , Angiofibroma/diagnóstico , Angiofibroma/patologia , Angiografia , Vazamento de Líquido Cefalorraquidiano , Rinorreia de Líquido Cefalorraquidiano/etiologia , Rinorreia de Líquido Cefalorraquidiano/cirurgia , Criança , Embolização Terapêutica , Humanos , Masculino , Moscou , Neoplasias Nasofaríngeas/irrigação sanguínea , Neoplasias Nasofaríngeas/diagnóstico , Neoplasias Nasofaríngeas/patologia , Invasividade Neoplásica , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Cuidados Pré-Operatórios , Reoperação , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
Objective: This study is to analyze fluorescence sensitivity in the diagnosis of brain and spinal cord tumors. Material and methods: The authors conducted a multicenter retrospective analysis of data on 653 cases in 641 patients: 553 of them had brain tumors and 88 spinal cord tumors. Brain tumor resection was performed in 523 patients, of whom 484 were adults and 39 children. The analyzed series was presented by 320 gliomas, 101 meningiomas, and 72 metastases. A stereotactic biopsy was performed in 20 patients and endoscopic surgery in 10 patients. In all cases, 20 mg/kg of 5-Aminolaevulinic acid was administered orally 2-h before surgery. All surgical interventions were performed with a microscope BLUE 400 to visualize fluorescence, while endoscopic surgery-with an endoscope equipped with a fluorescent module. Fluorescence spectroscopy was conducted in 20 cases of stereotactic biopsies and in 88 cases of spinal cord tumors. Results: Among adult brain tumors operated by microsurgical techniques, meningiomas showed the highest 5-ALA fluorescence sensitivity 94% (n = 95/101), brain metastases 84.7% (n = 61/72), low-grade gliomas 46.4% (n = 26/56), and high-grade gliomas 90.2% (n = 238/264). In children the highest 5-ALA visible fluorescence was observed in anaplastic astrocytomas 100% (n = 4/4) and in anaplastic ependymomas 100% (n = 4/4); in low-grade gliomas it made up 31.8% (n = 7/22). As for the spinal cord tumors in adults, the highest sensitivity was demonstrated by glioblastomas 100% (n = 4/4) and by meningiomas 100% (n = 4/4); Fluorescence was not found in gemangioblastomas (n = 0/6) and neurinomas (n = 0/4). Fluorescence intensity reached 60% (n = 6/10) in endoscopic surgery and 90% (n = 18/20) in stereotactic biopsy. Conclusion: 5-ALA fluorescence diagnosis proved to be most sensitive in surgery of HGG and meningioma (90.2 and 94.1%, respectively). Sensitivity in surgery of intracranial metastases and spinal cord tumors was slightly lower (84.7 and 63.6%, correspondingly). The lowest fluorescence sensitivity was marked in pediatric tumors and LGG (50 and 46.4%, correspondingly). Fluorescence diagnosis can also be used in transnasal endoscopic surgery of skull base tumors and in stereotactic biopsy.
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Background The aim of the project was to show the peculiarities of manipulations in two-dimensional (2D) visualization and to enlighten young neurosurgical residents for further independent training of their manual skills in the anatomic lab. The course followed a step-by-step training program starting with artificial models in a static 2D exoscopic view field with subsequent transition to cadaveric animal models and the use of dynamic four-hand techniques and endoscopy. Materials and methods Since 2015, two 2-day workshops and four 1-day workshops have been organized. All courses consisted of short theoretical and prevailing hands-on practical part and were designed mainly for manual skills training. For optimal practical training, each pair of trainees were engaged with a separate working place equipped with a video system, exoscope, drill, suction, and a set of microsurgical and endoscopic instruments. A total of 48 trainees, including residents of the Nikolay Nilovich (NN) Burdenko National Medical Research Center of Neurosurgery (NMRCN), the Russian Medical Academy of Continuous Postgraduate Education, and other institutions from different regions of Russia, completed the program. Analysis of evaluation sheets revealed that over 90% of trainees were under the age of 30. Results The key idea - accommodation to endoscopy through a series of microsurgical exercises in 2D visualization - has been successfully actualized and met with interest. After analyzing the questionnaires, we found that an overall satisfaction rate was high. The vast majority of trainees intended to gain further experience and apply new techniques in their clinical neurosurgical and microsurgical practice. The number of practiced techniques and the quality of the provided equipment were considered by the participants as good or very good. The highly individualized training course with a participant/tutor ratio of 4:1 and the use of tissue models (no sacrifice of living animals) was well appreciated. Conclusion The demand for a workshop indicates a lack of such training activities for young professionals, such as the one we presented herein. Evaluation of the courses by the trainees showed that the contents of workshops corresponded to their tasks and expectations, regardless of their previous experience. The workshop was not only the 'stepping stone' from which the path of practical self-development should begin but also initiated the development of a whole series of specially focused training workshops on microsurgery and endoscopy for neurosurgeons.
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Nasal chondromesenchymal hamartoma (NCMH) is a rare benign tumor of the sinonasal tract in children with possible orbit and skull base involvement. We present the 57th published observation of this kind of tumor. A 25-month-old female patient presented with recurrent mass lesion of the sinonasal tract. According to her history, she had feeding difficulties and nasal obstruction since birth. She underwent partial resection at eight months of age via transfacial approach in the local hospital. Due to progression of tumor remnants, a second surgery was performed using an endoscopic endonasal approach resulting in subtotal resection. At 12 months of follow-up, a good postoperative result was observed with no signs of tumor progression despite incomplete resection. Histological and immunohistochemical examination of the biopsy specimens is presented. Comparison of specimens obtained from each of the two surgeries showed a difference in histological patterns. Endoscopic endonasal approach is the mainstay of surgical management. In case of incomplete resection, careful follow-up MRI studies should be recommended.
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Objectives To evaluate the efficacy and safety of using a buccal fat pad for endoscopic skull base defect reconstruction. Design Descriptive anatomical study with an illustrative case presentation. Setting Anatomical study was performed on 12 fresh human cadaver specimens with injected arteries (24 sides). Internal carotid artery was exposed in the coronal plane via the endoscopic transpterygoid approach. The pedicled buccal fat pad was used for reconstruction. Participants: 12 human cadaver head specimens; one patient operated using the proposed technique. Main outcome measures: Proximity of the buccal fat pad flap to the defect, compliance of the flap, comfort and safety of harvesting procedure, and compatibility with the Hadad-Bassagasteguy nasoseptal flap. Results: Harvesting procedure was performed using anterior transmaxillary corridor. The pedicled buccal fat pad flap can be used to pack the sphenoid sinus or cover the internal carotid artery from cavernous to upper parapharyngeal segment. Conclusion The buccal fat pad can be safely harvested through the same approach without external incisions and is compliant enough to conform to the skull base defect. The proposed pedicled flap can replace free abdominal fat in central skull base reconstruction. The volume of the buccal fat pad allows obliteration of the sphenoid sinus or upper parapharyngeal space.
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INTRODUCTION: Preoperative stereotactic radiosurgery (pre-SRS) is a recent advancement in the strategy for brain metastasis (BM) management, and available data demonstrate the advantages of pre-SRS before postoperative radiation treatment, including lower rates of local toxicity, leptomeningeal progression, and a high percentage of local control. The authors presented the results of pre-SRS in patients with BM. MATERIALS AND METHODS: Nineteen patients with BM (11 female and eight male) have been treated at N.N. Burdenko Medical Research Center for Neurosurgery (Moscow, Russia) and Gamma-Knife Center (Moscow, Russia) using pre-SRS. A total of 22 symptomatic metastatic lesions were preoperatively irradiated in the series. Eight patients had multiple BM (number of metastases ranged between two and seven). The median target volume for combined treatment was 14.131 cc (volumes varied between 2.995 and 57.098 cc; mean - 19.986 cc). The median of the mean target dose was 18 Gy, ranging between 12.58 and 24.36 Gy. Results: All patients tolerated pre-SRS well, without any neurological deterioration, and surgical treatment was performed as scheduled. The median follow-up period was 6.3 months (ranging between five weeks and 22.9 months). In 17 out of 19 patients, follow-up magnetic resonance (MR) images obtained two or three months after the combined treatment demonstrated the postoperative cavity without any signs of postradiation alterations in the perifocal tissues. In two observations, peritumoral edema was present. Local recurrences were found in two cases, 5.5 and 17.4 months after treatment. Radionecrosis was present in one observation after 4.6 months of follow-up. Two patients died of disease progression and are presented as illustrative cases. CONCLUSION: The combined treatment of secondary brain tumors has proved to be the best treatment option. Preoperative stereotactic radiosurgery may decrease radiation-induced toxicity and rates of local tumor progression. The potential hazards of pre-SRS associated with the postoperative healing of irradiated soft tissues of the head were not confirmed in our study. The decision of pre-SRS should be made by the tumor board, including specialists in neurosurgery, neuro-oncology, and radiation oncology, if the diagnosis of BM is based on oncological history and visualization data.