Application of neuroendoscopic surgical techniques in the assessment and treatment of cerebral ventricular infection.

Cerebral ventricular infection (CVI) is one of the most dangerous complications in neurosurgery because of its high mortality and disability rates. Few studies have examined the application of neuroendoscopic surgical techniques (NESTs) to assess and treat CVI. This multicenter, retrospective study was conducted using clinical data of 32 patients with CVI who were assessed and treated by NESTs in China. The patients included 20 men and 12 women with a mean age of 42.97 years. NESTs were used to obliterate intraventricular debris and pus, fenestrate or incise the intraventricular compartment and reconstruct cerebrospinal fluid circulation, and remove artificial material. Intraventricular irrigation with antibiotic saline was applied after neuroendoscopic surgery (NES). Secondary hydrocephalus was treated by endoscopic third ventriculostomy or a ventriculoperitoneal shunt. Neuroendoscopic findings of CVI were used to classify patients into Grade I (n = 3), Grade II (n = 13), Grade III (n = 10), and Grade IV (n = 6) CVI. The three patients with grade I CVI underwent one NES, the 23 patients with grade II/III CVI underwent two NESs, and patients with grade IV CVI underwent two (n = 3) or three (n = 3) NESs. The imaging features and grades of neuroendoscopy results were positively related to the number of neurosurgical endoscopic procedures. Two patients died of multiple organ failure and the other 30 patients fully recovered. Among the 26 patients with secondary hydrocephalus, 18 received ventriculoperitoneal shunt and 8 underwent endoscopic third ventriculostomy. There were no recurrences of CVI during the 6- to 76-month follow-up after NES. Application of NESTs is an innovative method to assess and treat CVI, and its neuroendoscopic classification provides an objective, comprehensive assessment of CVI. The study trial was approved by the Institutional Review Board of Beijing Shijitan Hospital, Capital Medical University, China.

Surgical Indications of Exploring Optic Canal and Visual Prognostic Factors in Neurosurgical Treatment of Tuberculum Sellae Meningiomas.

BACKGROUND: Tuberculum sellae meningiomas (TSMs) present a special symptom because of the adherence and compression to the optic nerve, optic artery, and the chiasm. A significant number of patients with TSMs appear visual deficits. This study aimed to investigate the surgical indications of exploring the optic canal and visual prognostic factors in the neurosurgical treatment of TSMs. METHODS: Totally 21 patients with TSM, who were operated from September 2007 to August 2011 in the Department of Neurosurgery, Tongren Hospital were enrolled in this study. Results of orbital computed tomography (CT) and magnetic resonance imaging (MRI), visual acuity, Goldmann visual field test, orbital color Doppler flow imaging (CDI) test in these patients were retrospectively analyzed. RESULTS: Visual deficit and optic canal involvement (OCI) were detected in all the 21 patients. Fourteen patients had bone proliferation within the area of the optic canal. After the operation, visual outcomes were improved in 13 patients, unchanged in 7 patients, and deteriorated in 1 patient. All the 21 patients performed orbital CDI test preoperatively, the results showed that if the peak systolic velocity (PSV) of central retinal artery (CRA) value was ≤ 8 cm/s, the visual outcome would be better. CONCLUSIONS: The surgical indications of exploring optic canal in TSM cases included: (1) The neuroimaging evidences of OCI (CT and/or MRI); (2) PSV of CRA in orbital CDI test was ≤ 8 cm/s; (3) visual acuity was below 0.1; (4) visual field deficit. The PSV of CRA in CDI test could be a prognostic factor for visual outcomes of TSMs.

Craniotomy with endoscopic assistance in the treatment of nasopharygeal fibroangioma.

BACKGROUND: Nasopharygeal fibroangioma (NPF) can be approached through lateral rhinotomy, the middle skull fossa approach and the transcranial-facial combined approach. It is complicated and thus results in more insults, and when adopted, the total resection rate of tumor is still low. The nasal endoscope is minimally invasive, the dead angles of a craniotomy, such as sphenoid sinus, maxillary sinus, and nasopharynx are easily approached by an endoscope. Lateral rhinotomy have to make facial incision and affects maxillary bone development. We combined the craniotomy and endoscopic approach intending to take advantages of the two approaches. METHODS: Twelve NPF patients who underwent craniotomy with endoscopic assistance from March 2002 to July 2008 at the Beijing Tongren Hospital were selected. All patients were male. Their ages ranged from 11 to 33 years. The main symptoms were visual deterioration, exophthalmos, nasal obstruction, epistaxis and pharynx nasalis neoplasm. The diagnosis was based on CT, MRI and digital subtraction angiography (DSA). All patients had intracranial encroachment and all underwent DSA and embolism treatment were taken before surgery. Seven patients had a pterional craniotomy, five had a frontal-temporal-orbital-zygomatic craniotomy. Most of the tumor was resected piecemeal, then removed through the sphenoidal sinus. Finally, using an endoscope in the nasal cavity, tumor in nasal cavity was resected and removed through the sphenoidal sinus, observing the dead angle of the craniotomy and confirming that sinus drainage was unobstructed. RESULTS: The tumor was removed completely in 11 patients and partially resected in one patient because of hemorrhage. One patient had an infection after the operation and one patient had cerebrospinal rhinorrhea 3 years after surgery that was remediated by endoscopic repair. CONCLUSION: Craniotomy with endoscopic assistance in the treatment of NPF was minimally invasive, safe and efficient, and avoided facial incision.

Sphenoid wing meningioma en plaque: report of 37 cases.

BACKGROUND: Sphenoid wing meningioma en plaque is a special morphological subgroup of intracranial meningiomas, defined by a carpet-like, soft tissue component that infiltrates the dura and invades the sphenoid wing and orbit associated with a significant hyperostosis. This report summarized our experiences in 37 patients with sphenoid wing meningioma en plaque who had been treated with transcranio-orbital approach surgery. METHODS: A retrospective study was made on clinical manifestations, neuroradiological features, and operative techniques in 37 patients undergoing transcranio-orbital approach from Sep. 1998 to Apr. 2009. Patients ages: 16 years to 67 years, 45.5 years in average; sex: 15 males, 22 females. Chief complaints were progressive proptosis and visual acuity deficits. All patients were operated on using a fronto-temporal approach with orbital decompression. The extent of tumor resection and postoperative complications were investigated. RESULTS: Simpson grade II resection was achieved in 9 patients, Simpson grade III in 22 patients and Simpson grade IV in 6 patients. Pathological examination showed 27 (73%) patients were meningothelial meningiomas. After surgery, proptosis improved in all patients, visual acuity improved in 18 patients (69%). Temporary ophthalmoplegia was found in 8 patients, cerebrospinal fluid leak was found in 1 patient. Duration of follow up was from 3 months to 9 years, tumor recurred in 7 patients, and 5 patients underwent second surgery, including two trans-nasal endoscopic surgeries to resect sphenoid sinus-involved tumor. There were no operation-related deaths or other significant complications. CONCLUSIONS: Sphenoid wing meningioma en plaque, mainly meningothelial meningiomas, are more likely to produce adjacent hyperostosis and have characteristic radiological appearances. All the hyperostosis bone of the great wing of sphenoid bone should be removed to prevent recurrence. Extensive tumor removal with bony decompression at the orbital apex can produce satisfactory cosmetic and functional outcome. Close co-operation between the neurosurgeons and the ophthalmologists is important.

[Neurosurgical therapy of transorbital intracranial foreign bodies: review of 28 cases].

OBJECTIVE: To discuss the benefits and complications of the neurosurgical therapy in transorbital intracranial foreign bodies. METHODS: The clinical data of 28 cases of transorbital intracranial foreign bodies, metallic in 13 cases, vegetal 5 cases, and vitreous, plastic and other kinds in 10 cases, were analyzed retrospectively. Optic nerve injury was found in 13 cases, orbital apex syndrome in 11 cases; CSF rhinorrhea in 13 cases, CSF orbital leak in 3 cases, and hemiplegia in 2 cases. All the patients underwent head CT scan, and orbital horizontal and coronal CT scan. The patients with metallic foreign bodies had DSA exams, and the non-metallic cases had MRA scans. 22 cases had orbital-frontal craniotomy and foreign body resection, and 6 cases had direct foreign body extraction. All the cases received antibiotic and nerve nutritional therapy postoperatively. RESULT: The cases in which the foreign bodies came from the orbital roof into the skull recovered well postoperatively; and the cases in which the foreign bodies came from the superior orbital fissure into the skull showed hemiplegia (n = 2) or orbital apex syndrome (n = 6) postoperatively. CONCLUSION: Transorbital intracranial foreign body should be diagnosed in early stage to avoid missed diagnosis. Omission should be avoided during resection of the foreign body. The relationship between the foreign body and internal carotid artery should be examined carefully before the extraction. Direct extraction of foreign body causes less injury, and patients' condition should be followed up.

[Clinical study of lacrimal gland tumor involving anterior and middle cranial fossae].

OBJECTIVE: To investigate the clinical manifestations of lacrimal gland tumor involving the anterior and middle cranial fossae and the effect of transcranial-orbital approach in treatment of such tumor. METHODS: A retrospective study was conducted on the clinical data of 23 cases lacrimal gland tumor involving the anterior and middle cranial fossae confirmed by radiological examination, including 11 cases of adenoid cystic carcinoma, 6 cases of pleomorphic adenocarcinoma (malignant mixed tumor), 2 cases of adenocarcinoma, 1 case of squamous cell carcinoma, 1 case of ductal carcinoma, 1 case of mucoepidermoid carcinoma, and 1 case of benign mixed tumor, 15 males and 8 females, aged 42.5 (2 - 76), with a case history of 43 months (2 months to 27 years), with the chief complaints of progressive proptosis, disgenesia of the eye ball, and orbit pain, all undergoing transcranial-orbital operation from August 1998 to February. 2006. Follow up was conducted for 1 month to 7 years. RESULTS: Postoperatively, ophthalmoplegia was found in 4 cases, and blindness in 1 case. There was no operative death or other significant complication. Recurrence of tumor occurred in 4 cases, and 1 case died from distant metastasis of adenocarcinoma. CONCLUSIONS: Malignant lacrimal gland tumors, mainly adenoid cystic carcinomas, incline to involve the anterior and middle cranial fossae. Adequate orbital apex decompression and exposure of the tumor can result from suitable transcranial-orbital approach. However, complete surgical excision is difficult, and the tumor has a tendency to recur post-operatively. Suitable treatment strategy should by combination of operation with irradiation or chemotherapy. Prognosis is poor.

[Endoscopic decompression of optic canal].

OBJECTIVE: To evaluate the effectiveness of endoscope in the treatment of optic nerve injury. METHODS: Thirteen patients with fracture at the inner and lower walls of optical canal underwent endoscopic decompression. The posterior 1/3 of the middle concha, the posterior ethmoid sinus and sphenoid sinus were opened, chips of bone and old hematocele were scavenged, and the optic ring of the optic canal was polished; however, the sheath of the optic nerve remained intact. In 2 cases with the dura broken at the cranial part of optic nerve, the broken site was covered with mucosa of middle concha, and the sphenoid sinus and the middle nasal meatus were covered with oil ribbon gauze. Three days after the operation, the ribbon gauze was pulled put, however, if cerebro-spinal fluid leakage was suspected, the ribbon gauze was pulled out 7-10 days after. After the operation the visual acuity improvement reaching one grade or more and improvement of visual field were defined as effective. RESULTS: Five of the 6 patients without light perception before the operation showed improvement in visual acuity. The other 7 patients with residual visual acuity all recovered to different extents. CONCLUSION: A mini-invasive surgery, decompression of optic canal with endoscope is effective in decompressing optic nerve, decreasing the injury of optic nerve, and the patients recover quickly after operation.

[Surgical treatment of fibrous dysplasia of the skull with neuro-navagation].

OBJECTIVE: To evaluate the role and effect of neuro-navagation in the surgical treatment of fibrous dysplasia of the skull and to discuss the indication and advantages of transcranial optic nerve decompression are discussed. METHODS: Fifteen patients with fibrous dysplasia of skull, 6 males and 9 females, aged 10.3 (5 approximately 21), were surgically treated by transcranial approach. The location of lesion, symptoms and signs, CT characteristics, surgical approaches, and outcomes were analyzed. The postoperative outcomes of visual acuity were grouped into 5 categories: blindness, light perception, hand motion, counting fingers, and recognizing acuity chart. Improvement of visual acuity of one grade or more or increase of 0.1 by acuity chart, and improvement of visual field were defined as effective. RESULTS: Fibrous dysplasia of skull in children most often involved the frontal, sphenoid, and ethmoid bones and resulted in stenosis of optic canal and superior optic fissure. The most common symptoms were decreased vision, proptosis and facial asymmetry. 13 patients underwent decompression of optic canal in lateral side, and two patients in both side. All the cases had pathological diagnosis of Fibrous dysplasia of the skull. After 3-to-25-month follow-up, improvement was found in 11 eyes (65%), and no improvement was found in 6 eyes (35%). Decreased vision was not seen. CONCLUSION: Transcranial optic nerve decompression is an effective treatment for decreased vision induced by Fibrous dysplasia of the skull.

[Transcranial optic nerve decompression for optic nerve injury].

OBJECTIVE: To discuss the operative indications and advantages of transcranial optic nerve decompression in treatment of optic nerve injury resulted from skull base fracture. METHODS: The data, such as the site of impact, vision, ocular movement, characteristic of CT, and pathologic changes during operation, and the extent of operative decompression of 118 patients with optic nerve injury. According the site of impact on the head, 87 of lateral superciliary arch type, 18 of medial superciliary arch type, and 13 of zygomatic type, undergoing transcranial optic nerve decompression were analyzed retrospectively. The patients were followed up for 6 months after operation. For the purpose of evaluation, the postoperative outcome of visual acuity was classified into five grades: blindness, hand movement, finger count, light perception and visual acuity > 0.05. The visual acuity improvement reaching one grade or more was defined as effective. The improvement of visual field was also considered effective. RESULTS: After follow-up of 6 months, effect was shown in 35 out of the 72 patients with pre-operative blindness (48.6%), and all the 46 patients with residual vision (100%). The total effective rate was 68.6%. The post-operative effective rate was 64.4% in patients with lateral superciliary arch type, 83.3% in patients with medial superciliary arch type injury and 76.9% in patients with zygomatic type injury. CONCLUSIONS: Transcranial optic nerve decompression is worthy recommending to the patients with traumatic optic neuropathy. The operative indications include patients with residual vision; patients with bilateral optic nerve injury; and patients with blindness less than 3 days.

[Traumatic Rollel's syndrome treated with decompression of orbital apex].

OBJECTIVE: To observe the efficiency of decompression of orbital apex operation for the treatment of traumatic Rollel's syndrome. METHODS: Eleven patients with Rollel's syndrome were operated using two different approaches of decompression of orbital apex according to the location of the lesion. Five cases were treated by trans-frontal approach and 6 cases by trans-pterion approach. For the purpose of evaluation, the postoperative outcome of visual acuity was classified into five grades: Non-light perception, light perception, hand motion, finger counter and acuity chart. The visual acuity improvement reaching 1 grade or more was defined as effective and less than 1 grade as inefficient. The improvement of nerve injuries in superior orbital fissure was also evaluated, patients with recover of 2 or more nerves was defined as effective. RESULTS: Visual acuity: 3 cases (50%) were classified as effective in non-light perception group, the remaining 5 cases who had residual vision before operation all improved to various extents. The eye position in cases with exophthalmos was return to normal after operation. Injured nerves were recovered in all 11 cases. CONCLUSIONS: Decompression of orbital apex is an effective treatment for patients with Rollel's syndrome and the craniotomy approach can treat the combined brain injury. The recovery after operation is correlated with the timing of surgery, the approach of the operation and also related with the severity of the nerve injury.