Temporal aneurysmal bone cyst: cost-effective method to achieve gross total resection.

Aneurysmal bone cyst (ABC) is a vascular benign bony expansile lesion. The treatment is gross total resection. Surgery for a skull base aneurysmal bone cyst poses a significant challenge because of its vascularity and the adjacent neurovascular structures. We present the case of a young male with a temporal aneurysmal bone cyst who underwent gross total resection of the lesion. The external carotid artery (ECA) was temporarily clamped to cut off the vascular supply. There was no intraoperative event, and the patient made a good postoperative clinical recovery. This technique was used as an alternative to subselective endovascular embolization of the ECA branches. This case represents a simple yet cost-effective surgical technique to control bleeding for a highly vascular lesion such as ABCs, especially in resource-deficient countries.

Are C2 pars-pedicle screws alone for type II Hangman's fracture overrated?

BACKGROUND/OBJECT: The recent trend for treatment of certain cases of type II Hangman's fracture has been towards motion preserving surgery. This is claimed to be achieved with placement of pedicle screws across the fracture fragments. However, the long term outcome in clinical scenario is not yet clear, neither are the factors determining suitability of such a technique. MATERIALS AND METHODS: We have retrospectively analyzed the results of 11 patients of type II Hangman's fracture, according to the extent of translation. Nine patients underwent stabilization of fracture with C2 pedicle screws and 2 were managed with halo immobilization. The conservative management failed in one and this patient underwent internal fixation using pars-pedicle screw as well. The long term clinical and radiological (CT and dynamic X-rays) outcome was analyzed. RESULTS: All patients including the one with halo immobilization, showed solid fusion across the fracture fragments. With the exception of one patient none had any clinical symptoms. This lone patient complained of restricted neck movements. Three different types of radiological results were observed. Two patients with translation >8mm showed C2-3 body fusion. Three of 6 patients with minimal translational (3-4mm) showed facet fusion. Three patients with moderate translational dislocation (4.5-5.5mm) showed persisting C2-3 angular instability. CONCLUSIONS: The C2 pedicle screw is a good technique for osteosynthesis. However, the claimed long term advantage of motion segment preservation with this technique remains doubtful. It may be suitable for those fractures with minimal translation (<4mm), where the superiority of surgery, itself, over external immobilization is questionable. C2-3 fusion is preferable for those fractures with translation >4mm as these are unstable and C2 pedicle screws alone are likely to have less desirable results.

Is ligation and division of anterior third of superior sagittal sinus really safe?

BACKGROUND/OBJECT: Ligation and division of anterior third (AT) of superior sagittal sinus (SSS) is presumed to be safe and is commonly used for approaching anterior skull base tumors and distal anterior cerebral artery aneurysms (DACA). Contrary to this belief we found complications secondary to this procedure more often than described and we have described them along with probable etiology. MATERIALS AND METHODS: A total of 62 patients who underwent bifrontal or extended bifrontal craniotomies with ligation and division of the proximal end of SSS were studied retrospectively. The clinical profiles and postoperative CT scans were studied to look for venous edema and hemorrhages. Venogram (digital subtraction) was done in one of the patients who had developed this complication. RESULTS: Five patients developed bifrontal venous hemorrhagic infarcts (4 patients with anterior skull base tumors and 1 with DACA aneurysm). These patients had a morbid postoperative hospital stay with memory disturbances and urinary incontinence in the follow up period. Two patients died. The venogram done in one patient revealed complete occlusion of the AT-SSS. The morbidity and mortality that can be attributed to ligation of AT-SSS was 8.06% and 1.6% respectively. CONCLUSIONS: The safety of ligation and division of the AT-SSS is questionable, contrary to traditional teaching. Though only the proximal end of SSS is ligated, the occlusion extends upto the distal craniotomy edge possibly due to reflection of the dural leaf with AT-SSS that causes kinking and thrombosis. It is more often seen in patients with anterior skull base lesions, probably because of already compromised basal venous drainage. A preoperative venogram could possibly predict the safety of this procedure.