Endonasal endoscopic or endoscopic-assisted transcranial surgery of Rathke's cleft cysts: does the approach and surgical technique influence the radicality and recurrence rate?

OBJECTIVE: Resections of symptomatic Rathke's cleft cysts (RCCs) are mainly performed via an endonasal transsphenoidal approach. However, there is a lack of equivalent data in current literature concerning transcranial keyhole approach in the treatment of RCCs. In order to find general recommendations for the surgical treatment of RCCs also with regard to recurrence, the object of this study is the analysis and comparison of both techniques. METHODS: Twenty-nine patients having been surgically treated between January 2004 and August 2019 were retrospectively analysed. The transsphenoidal approach was chosen in 16 cases and the transcranial keyhole approach in 13 cases. Both surgical techniques were analyzed and compared concerning preoperative symptoms and cyst characteristics, complications, surgical radicality, endocrinological and ophthalmological outcome and recurrences in patients´ follow up. RESULTS: The postoperative outcome of both techniques was identic and showed highly satisfying success rates with 92% for neurological deficits, 82% for endocrinological dysfunctions and 86% for visual deficits. In contrast, momentous postoperative complications were significantly more likely after transsphenoidal operations. After a mean follow-up time of 5.7 years, the recurrence rates of both cohorts were the same with 0% each. CONCLUSIONS: Regarding its equal outcome with its lower complication rate, the authors suggest using the supraorbital keyhole approach for RCCs whose anatomical configuration allow both techniques. Yet, the decision should always consider the surgeon's personal experience and other individual patient characteristics. Further studies with higher numbers of cases and longer follow-up periods are necessary to analyse the effect of the selected approach on recurrence.

Endoscope-assisted resection of brainstem cavernous malformations.

Targeted surgical precision and minimally invasive techniques are of utmost importance for resectioning cavernous malformations involving the brainstem region. Minimisation of the surgical corridor is desirable but should not compromise the extent of resection. This study provides detailed information on the role of endoscopy in this challenging surgical task. A retrospective analysis of medical documentation, radiologic studies and detailed intraoperative video documentation was performed for all consecutive patients who underwent surgical resection of brainstem cavernous malformations between 2010 and 2020 at the authors' institution. A case-based volumetry of the corticotomy was performed and compared to cavernoma dimensions. A total of 20 procedures have been performed in 19 patients. Neuroendoscopy was implemented in all cases. The mean size of the lesion was 5.4 (± 5) mm3. The average size of the brainstem corticotomy was 4.5 × 3.7 (± 1.0 × 1.1) mm, with a median relation to the cavernoma's dimension of 9.99% (1.2-31.39%). Endoscopic 360° inspection of the resection cavity was feasible in all cases. There were no endoscopy-related complications. Mean follow-up was 27.8 (12-89) months. Gross-total resection was achieved in all but one case (95%). Sixteen procedures (80%) resulted in an improved or stable medical condition. Eleven patients (61.1%) showed further improvement 12 months after the initial surgery. With the experience provided, endoscopic techniques can be safely implemented in surgery for BSCM. A combination of neuroendoscopic visualisation and neuronavigation might enable a targeted size of brainstem corticotomy. Endoscopy can currently be considered a valuable additive tool to facilitate the preparation and resection of BSCM.

Management of severe intraoperative hemorrhage during intraventricular neuroendoscopic procedures: the dry field technique.

OBJECTIVE: Neuroendoscopic procedures inside the ventricular system always bear the risk for an unexpected intraoperative hemorrhage with potentially devastating consequences. The authors present here their experience, and a stage-to-stage guide for the endoscopic management of intraoperative hemorrhages. METHODS: A step-by-step guide for the management to gain control of and stop the bleeding is described including a grading system. More advanced techniques are presented in cases examples. CONCLUSION: Most of intraoperative hemorrhages can be controlled by constant irrigation and coagulation. More advanced techniques can be applied quickly and easily to ensure control of the hemorrhages and avoid the need for a microsurgical conversion.

Pott's puffy tumor: a need for interdisciplinary diagnosis and treatment.

Pott's puffy tumor (PPT) is an infection of the frontal sinus with subperiosteal and intracranial abscess formation and one of the rare entities in pediatrics. We present a series of four cases of PPT that occurred in two children (6 and 9 years) and in two young adults (17 and 19 years). All patients were treated by an interdisciplinary team of pediatric, neurosurgical, ENT, radiological, and neuroradiological specialists. Antibiotic treatment was combined with single endoscopic surgery in one case and combined endoscopic sinus surgery with an open transcranial approach to drain intracranial abscess formation in three cases. It is important to be aware that PPT occurs in children with the finding of intracranial abscess formation. Therefore, a close interdisciplinary cooperation for successful treatment is needed in this rare disease.

[Pott's Puffy Tumor: a need for interdisciplinary diagnosis and treatment. German Version]. / Pott-Puffy-Tumor: die Notwendigkeit einer interdisziplinären Diagnostik und Behandlung.

Pott's puffy tumor (PPT) is an infection of the frontal sinus with subperiosteal and intracranial abscess formation and one of the rare entities in pediatrics. We present a series of four cases of PPT that occurred in two children (6 and 9 years) and in two young adults (17 and 19 years). All patients were treated by an interdisciplinary team of pediatric, neurosurgical, ENT, radiological, and neuroradiological specialists. Antibiotic treatment was combined with single endoscopic surgery in one case and combined endoscopic sinus surgery with an open transcranial approach to drain intracranial abscess formation in three cases. It is important to be aware that PPT occurs in children with the finding of intracranial abscess formation. Therefore, a close interdisciplinary cooperation for successful treatment is needed in this rare disease.

Distended abdomen due to a pseudocyst around a ventriculoperitoneal shunt.

Described herein is a case of distended abdomen in a 4-year-old boy with a ventriculoperitoneal (VP) shunt due to bilateral intraventricular hemorrhage following premature birth. Physical examination and laboratory tests revealed tenderness in the lower quadrants, with mild leukocytosis and normal C­reactive protein levels. X­ray demonstrated an intact VP shunt catheter but cranial displacement of the large intestine. Ultrasonography confirmed a large pseudocyst around the VP shunt, with extension from the symphysis to the sternum. The distal part of the VP shunt was surgically revised and 2.5 l of cerebrospinal fluid were evacuated. The boy made a full clinical recovery. Conventional X­rays, routinely used to confirm or exclude VP shunt continuity, may provide important clues regarding to the etiology of VP shunt dysfunction.

[Neurosurgical treatment of cervical spine injuries]. / Neurochirurgische Eingriffe bei Traumata der Halswirbelsäule.

BACKGROUND: Injuries of the cervical spine are quite common with an incidence of more than 3% in trauma patients. The incidence is even higher in elderly patients. Cervical spine injuries might induce severe neurological deficits. Therefore, they must be quickly and adequately diagnosed and treated. Depending on the pattern of injury, conservative or surgical treatment is indicated. OBJECTIVE: The authors describe the different surgical strategies and treatment options based on the pattern of injury. Typical surgical methods are illustrated by case presentations. CONCLUSION: Cervical spine injuries should be treated in a trauma centre with extensive expertise in spine surgery. The immobilisation and gentle transportation is important already at the scene of the accident. Nowadays, there are excellent surgical options and strategies available as well as excellent intensive care therapy. These possibilities lead to rapid and good stabilisation of cervical spine injuries and the posttraumatic morbidity and mortality can be reduced significantly especially in elderly patients.

The extended endoscopic approach to perisellar and skull base lesions: is one nostril enough?

The extended endonasal endoscopic approach to the skull base is still under investigation. The main advantage of using this technique is to approach lesions in a minimally invasive manner resulting without brain retraction. Here, the authors present the results of extended endonasal endoscopic surgery via one nostril. All skull base procedures performed via an endonasal approach at the author's Department between January 2011 and May 2017 were analysed prospectively. Special attention was paid to complications, radicality, advantages and disadvantages of the endoscopic technique. Additionally, the application of various telescopes and the technique of dural closure were analysed. Sixty-two patients were operated on various pathologies of the skull base via an extended endonasal approach. Seven pathologies were resected via binostril technique. All other pathologies could be exposed by the mononostril technique. In 2 of 62 cases, the authors had to switch to binostril technique. MRI revealed radical gross total resection in 93% of all cases when intended. Overall complication rate was 16% (9/55) in the mononostril and 57% (4/7) in the binostril cohort. Seven patients in the mononostril cohort (13%) versus three patients in the binostril cohort (43%) complained of postoperative nasal congestion. This clinical report shows that many extended skull base lesions can be treated by a mononostril endonasal approach. In selected cases, this technique might represent an alternative to the binostril approach. Nevertheless, the binostril technique offers a better range of manipulation and exposure and should be preferred in difficult and very extended cases.

Nusinersen Administration Via an Intrathecal Port in a 16-Year-Old Spinal Muscular Atrophy Patient with Profound Scoliosis.

INTRODUCTION: Spinal muscular atrophy (SMA) is a genetic disease affecting the second motor neuron, causing progressive muscle atrophy and weakness due to decreased expression of the survival motor neuron. Different subtypes exist, type 2 being one of the most frequent ones. These patients show a high incidence of scoliosis requiring surgery. In 2016 and 2017, the Federal Drug Administration and European Medical Agency approved nusinersen for all types of SMA. It is a splicing modifier that enhances the expression of survival motor neuron and it has to be administered intrathecally. In patients with profound scoliosis, intrathecal administration can be challenging. Here, we present our experience with the implantation of an intrathecal port in a patient with SMA type 2. CASE PRESENTATION: A 16-year-old girl with SMA type 2 was referred for intrathecal nusinersen therapy. Because of severe scoliosis, spondylodesis of the segments TH7-S1 was performed at 14 years of age. The first two loading doses were given by spinal tap under sedation and computed tomography guidance, but we were unable to administer the following dose because of severe scoliotic spinal deformation. To ensure further drug therapy, an intrathecal port catheter (Celsite® Safety; Braun, Germany) was implanted via microsurgical hemilaminectomy L4. Further intrathecal nusinersen administration was uneventful. CONCLUSION: We conclude that the implantation of an intrathecal port system in patients with SMA and profound scoliosis is a safe and feasible procedure and allows the administration of nusi-nersen while reducing the need for sedation and exposure to radiation.

Cerebral vasospasm after endoscopic fenestration of a temporal arachnoid cyst in a child-a case report and review of the literature.

INTRODUCTION: Intracranial arachnoid cysts (ACs) represent rare extra-axial CSF-containing lesions. Surgical management mainly depends on the cyst location and its size. Nevertheless, pure endoscopic fenestration represents a relatively straightforward and safe technique, and-in most cases-the treatment of choice for symptomatic intracranial ACs. The postoperative complication rate of the procedure is low including subdural hematomas, hygromas, and intraparenchymal hemorrhages. Symptomatic cerebral vasospasm after endoscopic treatment of ACs is a very uncommon event. CASE REPORT/RESULTS: To the authors' knowledge, this adverse event in children has not yet been reported in the literature yet. The authors present a case of a 9-year-old child developing an early symptomatic cerebral vasospasm with an insignificant secondary ischemia following endoscopic fenestration of a large temporal arachnoid cyst. DISCUSSION: The clinical approach, possible pathogenesis, and the therapeutic strategy is discussed particularly with regard to the literature.

Fluorescence imaging of meningioma cells with somatostatin receptor ligands: an in vitro study.

BACKGROUND: The use of five-aminolevulinic acid (5-ALA) in the staining of malignant glioma cells has significantly improved intraoperative radicality in the resection of gliomas in the last decade. Currently, there is no comparable selective fluorescent substance available for meningiomas. There is however a demand for intraoperative fluorescent identification of, e.g., invasive skull base meningiomas to help improve safe radical resection. Meningiomas show high expression of the somatostatin receptor type 2, offering the possibility of receptor-targeted imaging. The authors used a somatostatin receptor-labeled fluorescence dye in the identification of meningiomas in vitro. The aim of this study was to evaluate the possibility of selective identification of meningioma cells with fluorescent techniques. METHODS: Twenty-four primary human meningioma cell cultures were analyzed. The tumor cells were incubated with FAM-TOC (5,6-Carboxyfluoresceine-Tyr3-Octreotide). As a negative control, four human dura tissues were cultured as well as a mixed cell culture in vitro and incubated with the same somatostatin receptor-labeled fluorescence substance. After incubation, fluorescence signal and intensity in all cell cultures were analyzed at three different time points using a fluorescence microscope with 488 nm epi-illumination. RESULTS: Sixteen WHO I, six WHO II, two WHO III meningioma primary cell cultures, and four dura cell cultures were analyzed. Fluorescence was detected in all meningioma cell cultures (22 cell culture stained strongly, 2 cell cultures moderately) directly after incubation up until 4 h later. There were no differences in the quality and quantity of fluorescence signal between the various meningioma grades. The fluorescence signal persisted unchanged during the analyzed period. In the negative control, dura cell cultures remained unstained. CONCLUSIONS: This study demonstrates the use of FAM-TOC in the selective fluorescent identification of meningioma cells in vitro. Further evaluation of the chemical kinetics of the applied somatostatin receptor ligand and fluorescence dye is warranted. As a next step, an experimental animal model is needed to evaluate these promising results in vivo.

Perioperative olfactory dysfunction in patients with meningiomas of the anteromedial skull base.

Olfactory dysfunction represents a main symptom in olfactory groove meningiomas (OGM). Besides this, olfactory function has been sparsely investigated in patients suffering from supratentorial meningiomas. Here, the authors explore pre- and postoperative variables associated with olfactory dysfunction in supratentorial meningioma patients. This is a retrospective study on supratentorial meningioma patients who underwent meningioma resection between January 2015 and January 2016. Preoperative and postoperative olfactory performance was quantified using a lateralized sniffin' stick odor identification test. Meningiomas affecting the olfactory system (n = 23) were compared to meningiomas in other locations among the control group (n = 40). Meningiomas that affected the olfactory system had odds of 3.6 and 3.7 in being associated with ipsilateral (lesional) and bilateral anosmia, respectively. Subgroup analysis revealed that meningiomas causing a midline shift across the frontal base and older age represented risk factors for preoperative anosmia. The odds of experiencing acquired postoperative ipsilateral anosmia were significantly increased in olfactory system affecting meningiomas (OR 11.1). Subgroup analysis highlighted OGMs to represent the predominant location associated with deterioration. General surgical complications predisposed patients to loss of contralateral (OR 12.3) and bilateral olfactory function (OR 27.8). Older age and meningiomas causing a midline shift across the frontal base predispose patients to preoperative olfactory dysfunction. Resection of OGMs and surgical complications are risk factors for postoperative olfactory deterioration to anosmia. Likely, olfactory dysfunction is underrecognized even in OGMs. In OGM surgery, however, preoperative lateralized testing might be critical to selecting an appropriate surgical route to preserve olfactory function. Clin. Anat. 32:524-533, 2019. © 2019 Wiley Periodicals, Inc.

Clinical practice audit concerning antimicrobial prophylaxis in paediatric neurosurgery: results from a German paediatric oncology unit.

BACKGROUND: Perioperative antimicrobial prophylaxis (PAP) has been identified as an important target for internal audits, concerning the judicious use of antibiotics. Paediatric oncology patients with brain tumours face an increased risk of surgical site infection (SSI) after neurosurgery and receive routine PAP in this setting. PATIENTS AND METHODS: All patients younger than 18 years admitted to the paediatric oncology centre (POC) with a neurosurgical intervention. Systematic audit of routine clinical data is divided in two groups: retrospective (Jan 01, 2012-March 31, 2014) and prospective (April 01, 2014-March 31, 2015) referring to an internal PAP guideline, invented in Jan. 2014). Surveillance of SSI up to 30 days after the operation with standard criteria (Centres for Disease Control and Prevention, USA). RESULTS: In total, 53 neurosurgical operations were analysed in 33 paediatric oncology patients. Twelve patients received more than one operation. The detailed analysis of PAP revealed prophylactic cefuroxim doses about 30 mg/kg instead of 50 mg/kg and no repeated dosing in operations lasting longer than 4 h. In addition, Cefotaxim, which is not indicated as PAP in neurosurgery, was used instead of Cefuroxim (or Ampicillin-Sulbactam) in 23 % of all cases in the retrospective and 18 % of all cases in the prospective audit. PAP for more than 3 doses (>24 h) was administered in 66 % in the retrospective group and in 60 % in the prospective group (p = n.s.). In both groups, no SSI was detected. DISCUSSION: This first comprehensive audit of PAP in paediatric oncology patients undergoing neurosurgery outlines significant opportunities to improve clinical practice in terms of correct dosing, the correct choice of the antibiotic, a correct timing schedule and a shorter duration of PAP. In addition, our results illustrate in detail the challenges in clinical practice when an evidence-based approach to improve a standard workflow has to be implemented.

Intra-catheter endoscopy for various shunting procedures-a retrospective analysis on surgical practicability, catheter placement, and failure rates.

BACKGROUND: The long-term function of a cerebral shunt is directly influenced by the placement of the ventricle catheter. In this work, an intra-luminal endoscope for best possible catheter positioning was used. Practicability, postoperative imaging, and shunt failure rates were retrospectively evaluated. METHODS: Between January 2012 and June 2016, an intra-catheter endoscope was applied in 71 procedures. Endoscopic technique was used for catheter placement in first-time shunting or cerebrospinal fluid reservoir insertion (n = 38), revision surgery in proximal shunt failure (n = 13), and various intraventricular stenting procedures (n = 20). Catheter positioning was graded on postoperative imaging using a four-point scale. All patients were regularly followed up (mean, 31.6 months) to recognize shunt failures. RESULTS: Endoscopic application could be completed as intended in 68 of 71 procedures. Postoperative imaging could exclude complete misplacement of all catheters, but optimal positioning was only achieved in 64.7% (44/68 cases). Four catheters had to be revised due to malfunction (failure rate, 5.8%). Another five catheters had to be removed due to infectious complications or wound-healing disorders. Direct correlations between catheter complications and suboptimal catheter positioning were not seen. Slit or distorted ventricles also did not prove to be a risk factor for the observed complications. CONCLUSIONS: Versatile application possibilities of the intra-catheter endoscope reflect the advantages of the technique. Independent of the performed procedure, unintended positionings or even complete catheter misplacements could be avoided. However, in more than one-third of all cases, suboptimal catheter placements became obvious. Interestingly, negative influences on later shunt failures were not seen.

An unusual cause of vertigo and headache in childhood.

Spinal perimedullary arteriovenous fistulas (PMAVFs) are rare entities among vascular malformations of the spinal cord. Due to progressive myelopathy, spastic paresis, sensory disturbance, and bowl and bladder dysfunction can be the presenting symptoms. Cervical spinal arteriovenous fistulas (AVFs) are even rarer. These lesions differ from the ones in the thoracolumbar region and have an even wider mode of presentation. We report on a 9-year-old boy with a cervical PMAVF manifesting with headache and vertigo.

Aqueductal stenting with an intra-catheter endoscope--a technical note.

INTRODUCTION: Aqueductoplasty as well as aqueductal stenting is an accepted therapy option in short-segment aqueductal stenosis and isolated fourth ventricle. Over the years, different techniques with only slight modifications by using a conventional neuroendoscope with a working sheath to introduce different instruments have been presented. In summary, the use of Fogarty balloon catheters or flexible endoscopes to pass the narrowed aqueduct is recommended. METHODS: This technical report describes a substantially new technique for this purpose. Six patients underwent aqueductal stenting with a new intracatheter endoscope. RESULTS: Aqueductal stenting was possible in 4 out of 6 cases. No complications occurred. Handling of this new technique was good and easy without a prolonged learning curve. All four stents did work appropriately, and the procedure was considered to be successful. Of the two failures, the technique was abandoned and endoscopic third ventriculostomy (ETV) was performed in one. In the other case, suboccipital shunting was done. CONCLUSION: This technical report describes a substantially new technique for aqueductal stenting. The combination of an intracatheter miniature endoscope and a prepared ventricular catheter enables careful and elegant aqueductal stenting. Large or flexible endoscopes, balloons, or special instruments to place a stent have become completely obsolete in selected cases.

Mononostril endoscopic transsphenoidal approach to sellar and peri-sellar lesions: Personal experience and literature review.

OBJECTIVE: The endonasal endoscopic approach to skull base is still under investigation. The main goal is the minimal invasive approach to pathologies with a better rate of resection without retraction of the brain tissue. Here, the authors report their technique of transnasal endoscopic neurosurgery using a mononostril approach and its development. METHODS: The supplementary video demonstrates the different steps of the mononostril approach and resection of a pituitary adenoma. All video-recorded procedures that were carried out between 2000 and 2013 using this technique were analysed. The patients were followed prospectively. RESULTS: Visualization and handling were good in 246/251 (98%). In three cases, we had to switch to microscopy because of severe bleeding of the cavernous sinus. On follow-up, magnetic resonance imaging revealed radical tumour resection in 92% of all cases when intended. There was no mortality, and the low complication rate was remarkable. CONCLUSION: Our mononostril approach of transnasal transsphenoidal surgery shows better results compared with previously published reports in regards to radicality, low cerebrospinal fluid leaks and morbidity. The very low rate of nasal complains is particularly remarkable.

Endoscopic-Assisted Microsurgical Meningioma Resection in the Skull Base via Minicraniotomy: Is There a Difference in Radicality and Outcome between Anterior Skull Base and Posterior Fossa?

Background: Keyhole-based approaches are being explored for skull base tumor surgery; aiming for reduced complications while maintaining resection success rates. This study evaluates skull base meningiomas resected using an endoscopic-assisted microsurgical keyhole approach, comparing outcomes with standard procedures. Methods: Between 2013 and 2019; 71 out of 89 patients were treated using an endoscopic-assisted microsurgical procedure. A total of 42 meningiomas were localized at the anterior skull base and 29 in the posterior fossa. The surgical techniques and use of an endoscope were analyzed and compared in terms of complications, surgical radicality, outcome, and recurrences in the patients' follow-up. Results: The two different cohorts yielded similar rates of GTR (anterior skull base: 80% versus posterior fossa: 82%). The complication rate was 31% for the posterior fossa and 16% for the anterior skull base. An endoscope was used in 79% of all cases. Tumor remnants were detected by means of endoscopic visualization in 58.6% of posterior fossa and 33% of anterior skull base meningiomas. The statistical analysis revealed significantly higher benefits from endoscope use in the posterior fossa cohort (p < 0.05). Conclusions: The results revealed that endoscopy was beneficial in both locations. The identification of remnant tumor tissue and the benefit of endoscopy were clearly higher in the posterior fossa. Endoscopic assistance is a very helpful tool for increasing radicality, providing a better anatomical overview during surgery, and better identifying remnant tumor tissue in skull base meningioma surgery.