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BACKGROUND: Gamma Knife Radiosurgery (GKRS) is an effective treatment option for medically refractory trigeminal neuralgia (TN). This study examines GKRS outcome in a large cohort of TN patients and highlights pretreatment factors associated with pain relief. METHODS: This is a single-center retrospective analysis of patients treated with GKRS for TN between 2011 and 2019. Pain relief was assessed at 1 year, and 2-3 years following GKRS. Multivariable analysis identified several factors that predicted pain relief. These predicting factors were applied to establish a pain relief scoring system. RESULTS: A total of 162 patients met inclusion criteria. At 1 year post-GKRS, the breakdown of Barrow Neurological Institute (BNI) score for pain relief was as follows: 77 (48%) score of I, 13 (8%) score of II, 37 (23%) score of III, 22 (14%) score of IV, and 13 (8%) score of V. Factors that were significantly associated with pain-free outcome at 1 year were: Typical form of TN (OR = 2.2 [1.1, 4.9], p = 0.049), No previous microvascular decompression (OR = 4.4 [1.6, 12.5], p = 0.005), Response to medical therapy (OR = 2.7 [1.1, 6.1], p = 0.018), and Seniority > 60 years (OR = 2.8 [1.4, 5.5], p = 0.003). The term "Trigeminal Neuralgia-RadioSurgery" was used to create the TN-RS acronym representing the significant factors. A stepwise increase in the median predicted probability of pain-free outcome at 1 year from 3% for patients with a score of 0 to 69% for patients with a maximum score of 4. CONCLUSION: The TN-RS scoring system can assist clinicians in identifying patients that may benefit from GNRS for TN by predicting 1-year pain-free outcomes.
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Radiocirugia , Neuralgia del Trigémino , Humanos , Neuralgia del Trigémino/radioterapia , Neuralgia del Trigémino/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Dolor/cirugía , Estudios de SeguimientoRESUMEN
PURPOSE: To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach. METHODS: PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance. RESULTS: Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases. CONCLUSIONS: Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.
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Lesiones del Sistema Vascular , Aorta Abdominal , Humanos , Enfermedad Iatrogénica/epidemiología , Incidencia , Vértebras Lumbares/cirugía , Lesiones del Sistema Vascular/epidemiología , Lesiones del Sistema Vascular/etiología , Lesiones del Sistema Vascular/cirugíaRESUMEN
Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.
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Traumatismos Craneocerebrales/complicaciones , Inhibidores del Factor Xa/uso terapéutico , Hemorragias Intracraneales/etnología , Vitamina K/antagonistas & inhibidores , Anciano , Anciano de 80 o más Años , Traumatismos Craneocerebrales/epidemiología , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Inhibidores del Factor Xa/farmacología , Femenino , Humanos , Hemorragias Intracraneales/epidemiología , Masculino , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodos , Vitamina K/uso terapéuticoRESUMEN
INTRODUCTION AND CLINICAL PRESENTATION: The authors report a case of a 5-year-old boy presenting with vision loss, right-sided hearing loss, and facial paralysis secondary to hydrocephalus causing brainstem herniation into the internal auditory canal (IAC) following cerebrospinal fluid (CSF) otorrhea. MANAGEMENT AND OUTCOME: After placement of a ventriculo-peritoneal shunt (VP shunt), the vision and facial palsy improved whilst hearing loss persisted. Imaging demonstrated partial reduction of the herniated brainstem and resolution of hydrocephalus. To our knowledge, this is the first case reported of brainstem herniation into the internal auditory canal.
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Tronco Encefálico/diagnóstico por imagen , Otorrea de Líquido Cefalorraquídeo/diagnóstico por imagen , Conducto Auditivo Externo/diagnóstico por imagen , Encefalocele/diagnóstico por imagen , Hidrocefalia/diagnóstico por imagen , Tronco Encefálico/cirugía , Otorrea de Líquido Cefalorraquídeo/complicaciones , Otorrea de Líquido Cefalorraquídeo/cirugía , Preescolar , Conducto Auditivo Externo/cirugía , Encefalocele/etiología , Encefalocele/cirugía , Pérdida Auditiva/diagnóstico por imagen , Pérdida Auditiva/etiología , Pérdida Auditiva/cirugía , Humanos , Hidrocefalia/complicaciones , Hidrocefalia/cirugía , Masculino , Derivación VentriculoperitonealRESUMEN
The Myriad is an innovative, high precision tool for tumor resection, designed to work within narrow endoscopic corridors. Due to its application in technically demanding situations, the learning curve associated with its use might be extremely challenging and time-consuming.The authors describe the application of an already validated training model, the skull base injectable tumor model (ITM), to allow trainees to practice with the use of the Myriad during endoscopic skull base procedures.A formalin embalmed cadaveric head was used for technical assessment. Stratathane resin ST-504 derived polymer was injected to mimic skull base tumors and Myriad was used for tumor resection during different endoscopic procedures.An endoscopic endonasal transsphenoidal, a trans-planum trans-tuberculum, and a trans-clival approach have been performed after ITM injection. The Myriad was used for tumor debulking and blunt manipulation, qualitatively evaluating the technical challenges in performing the surgical dissection.Injectable tumor model demonstrates to be a valuable educational tool to train surgeons in the use of Myriad, potentially speeding up the learning curve in the acquirement of necessary technical skills in manipulating the instrument, even in case of demanding surgical situation.
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Modelos Anatómicos , Neuroendoscopía/educación , Neuroendoscopía/instrumentación , Entrenamiento Simulado , Neoplasias de la Base del Cráneo/cirugía , Base del Cráneo/cirugía , Humanos , Curva de Aprendizaje , Neuroendoscopía/métodos , PolímerosRESUMEN
BACKGROUND: The posterior fusiform gyrus lies in a surgically challenging region. Several approaches have been described to access this anatomical area. The paramedian supracerebellar transtentorial (SCTT) approach benefits from minimal disruption of normal neurovascular tissue. The aim of this study was to demonstrate its application to access the posterior fusiform gyrus. METHODS: Three brains and six cadaveric heads were examined. A stepwise dissection of the SCTT approach to the posterior fusiform gyrus was performed. Local cortical anatomy was studied. The operability score was applied for comparative analysis on surgical anatomy. RESULTS: The major posterior landmark used to identify the fusiform gyrus with respect to the medial occipitotemporal gyrus was the collateral sulcus, which commonly bifurcated at its caudal extent. Compared with other surgical approaches addressed to access the region, SCTT demonstrated the best operability in terms of maneuverability arc. Favorable tentorial anatomy is the only limiting factor. CONCLUSIONS: The supracerebellar transtentorial approach is able to provide access to the posterior fusiform gyrus via a minimally disruptive, anatomic, microsurgical corridor.
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Neoplasias Encefálicas/cirugía , Procedimientos Neuroquirúrgicos/métodos , Lóbulo Occipital/cirugía , Lóbulo Temporal/cirugía , Disección , HumanosRESUMEN
BACKGROUND: When performing a transplanum transtuberculum approach, dealing with the anterior communicating artery (ACoA) complex is inevitable. The aim of this study is to provide quantitative anatomical information regarding the ACoA complex and its bony and neural relationships, when exposed through this approach. METHOD: The endoscopic endonasal transplanum transtuberculum approach was performed on ten human cadaver heads. In each specimen, radiological studies were performed. A three-dimensional model of the approach was reconstructed. Measured parameters were: exposure of the vessels; distance between the proximal anterior cerebral artery (A1) and the optic chiasm; dimension of the bone opening. The feasibility to perform clip placement was graded as "possible" or "not possible". RESULTS: Dimension of bone opening varied from 88 to 53 mm(2). The ACoA was exposed for 3 mm ± 2 mm, A1 for 17 mm ± 9 mm, the distal anterior cerebral artery (A2) for 12 mm ± 3 mm, the recurrent artery of Heubner (RAH) for 16 mm ± 4 mm. Clip placement was possible on the ACoA, A2, and distal segment of A1 in all cases, and on the proximal segment of A1 in one instance. The distance between A1 and the optic chiasm measured 9 mm ± 2 mm. CONCLUSIONS: The ACoA, A2, and the distal segment of A1 can be visualized and controlled through the transplanum transtuberculum approach. The relationship between A1, gyrus rectus, and optic chiasm is the main determinant for the exposure and control of the vessel. The olfactory nerve can represent a surgical landmark for the identification of the A1 origin. The whole course of the RAH can be visualized trough this approach.
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Arteria Cerebral Anterior/cirugía , Cirugía Endoscópica por Orificios Naturales/métodos , Procedimientos Neuroquirúrgicos/métodos , Arteria Cerebral Anterior/anatomía & histología , HumanosRESUMEN
OBJECTIVE: To describe the imaging and histopathological findings and provide an overview of a recently described and rare cause of bone sclerosis. MATERIALS AND METHODS: Five cases of intra-osseous hibernoma of bone that presented over the last year. The imaging and histopathology is reviewed. RESULTS: All cases were identified in asymptomatic middle-aged to elderly adults as incidental findings with bone sclerosis in the axial skeleton. MRI showed lesions that were T1 hypointense to subcutaneous fat and hyperintense to skeletal muscle and one showed contrast enhancement. Glucose avidity was demonstrated on FDGPET in both cases tested and isotope bone scan performed in three cases showed strong positivity in two, but uptake was inconspicuous in one case. CONCLUSIONS: Intra-osseous hibernoma is a rare cause of sclerotic bone lesions, predominating in the axial skeleton of middle-aged and elderly adults. They have a non-aggressive appearance on CT and on MRI are T1 hypointense to subcutaneous fat and hyperintense to skeletal muscle. They are usually T2 hyperintense and may show peripheral contrast enhancement. They may show increased glucose avidity on FDGPET and may or may not be positive on isotope bone scans. We suspect that with ever-increasing use of a variety of imaging techniques, particularly in a setting of staging for malignant disease, more such cases will come to light. This diagnosis should be added to the differential diagnosis of sclerotic bone lesions.
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Neoplasias Óseas/diagnóstico , Fluorodesoxiglucosa F18 , Lipoma/diagnóstico , Imagen por Resonancia Magnética/métodos , Tomografía de Emisión de Positrones/métodos , Anciano , Anciano de 80 o más Años , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , RadiofármacosRESUMEN
PURPOSE: The sulcal and gyral anatomy of the basal occipital-temporal lobe is highly variable and detailed descriptions of this region are limited and often inconsistent. The aim of this study was to describe the salient features of the sulcal and gyral anatomy of the basal occipital-temporal lobe. METHODS: We studied the sulcal and gyral patterns of 30 formalin-fixed cerebral hemispheres. RESULTS: The major landmarks are the collateral sulcus (separated into the rhinal, proper, and caudal segments) and occipitotemporal sulcus (often interrupted), which were always present in this study. The bifurcation of the caudal collateral sulcus is a useful landmark. In relation to these sulci, we have described the surface anatomy and nominated landmarks of the medial (parahippocampal and lingual) and lateral (fusiform) occipitotemporal gyri. CONCLUSIONS: Understanding of the sulcal and gyral patterns of the basal occipital-temporal lobe may provide valuable information in its radiological and intraoperative interpretation.
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Lóbulo Occipital/anatomía & histología , Lóbulo Temporal/anatomía & histología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Background: Intradural, extramedullary capillary hemangiomas of the cauda equina are exceedingly rare malformations arising from the endothelial cells of the nervous system vasculature. Roughly 20 cases have been reported in the literature, with the youngest and only pediatric case being in a 17-year-old patient. We report the youngest case of intradural extramedullary capillary hemangioma of the cauda equina in a 14-year-old patient. Case Description: A 14-year-old female presented with two-month history of low back pain with bilateral leg pain and numbness. Magnetic resonance imaging (MRI) revealed an L2 well-defined homogenous contrast-enhancing intradural, extramedullary mass causing severe spinal canal stenosis. Patient underwent laminoplasty for resection of an intradural tumor. Intraoperative hemostasis was readily achieved via early identification and coagulation of the predominate feeding vessel. Postoperatively, the patient awoke with no deficits and resolved leg pain. A 3-month postoperative MRI revealed no tumor recurrence and fully healed lamina. Conclusions: Given the benign nature, the operative goal is complete excision of the tumor without damage to surrounding neural structures. Postoperatively the goal is relief of pain and improvement in neurologic function. To our knowledge we report the first case in which laminoplasty is utilized for the treatment of this pathology in a pediatric patient. Evidence for laminoplasty in this patient population is sparse and future studies are still needed. In any case, reconstruction of the surgical site in a manner that returns the patient's normal anatomy should be strongly considered especially in younger patients.
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Lateral interbody cages have proven useful in lumbar fusion surgery. Spanning both lateral cortical rims while sparing the anterior longitudinal ligament, they restore disc height, improve coronal balance and add stability. The standard approach to their insertion is 90 degrees lateral transpsoas which is bloodless compared to other techniques of interbody cage insertion but requires neuro-monitoring and at L4/5 can be difficult because of iliac crest obstruction or an anterior plexus position. The oblique muscle-splitting approach with the patient in a lateral position, remains retroperitoneal, and on the left side enters the disc space through a window between psoas and the common iliac vein. Reports of this approach are few and none previously have described how to use the large lateral-type cages so effective at restoring spinal alignment. In this video we demonstrate our technique of anterior to psoas fusion of the lumbar spine with a retroperitoneal approach and gentle retraction of the psoas muscle. The video can be found here: http://youtu.be/OS2vNcX9JMA.
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Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Músculos Psoas/cirugía , Fusión Vertebral/métodos , Humanos , Disco Intervertebral/patología , Vértebras Lumbares/patología , Músculos Psoas/patología , Espacio Retroperitoneal/patología , Espacio Retroperitoneal/cirugía , Grabación en Video/métodosRESUMEN
The authors describe the extradural subtemporal transzygomatic (ESTZ) approach and its variants to expose the clival and paraclival areas. A microanatomical study was conducted to quantify the clival and paraclival exposure and the maneuverability areas obtained by microscope and endoscope using the ESTZ approach. Section versus preservation of the third trigeminal branch (V3) and petrous apicectomy to obtain a wider clival exposure and a better internal carotid artery control are discussed. Eight cadaveric specimens were dissected to obtain morphometric measurements after performing the ESTZ approach and its variants. Anatomic areas exposed by the approaches were calculated using the ImageJ 1.37a software. The ESTZ approach performed with sectioning of V3 and petrous apicectomy allowed for a mean incremental exposed area of 1.8 cm2 (range, 1.24-2.43 cm2). The mean amount of additional anatomic areas visualized after the ESTZ approach with petrous apicectomy if compared with the ESTZ approach without petrous apicectomy was 24% (range, 14.4%-37.5%). The mean percentage increase of maneuverability area after petrous apicectomy was 69.9% (range, 43.8%-96.6%). The ESTZ approach is suitable when dealing with extradural tumors of the middle-upper clivus extending into the ipsilateral paraclival area. V3 section and petrous apicectomy increase the operability, the surgical exposure, and the maneuverability area and improve vascular control on the internal carotid artery. Application of endoscopy does not impact on the maneuverability area but enhances the visualization of blind corners; endoscopic surgical view without drilling the petrous apex is comparable to that obtained by the microscope after petrous apicectomy.
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Fosa Craneal Posterior/anatomía & histología , Craneotomía/métodos , Hueso Petroso/anatomía & histología , Cigoma/anatomía & histología , Cadáver , Fosa Craneal Posterior/cirugía , Endoscopía , Humanos , Osteotomía/métodos , Hueso Petroso/cirugía , Base del Cráneo/anatomía & histología , Base del Cráneo/cirugía , Cigoma/cirugíaRESUMEN
Background: C7 instrumentation during posterior cervicothoracic fusion can be challenging because it requires additional work of either placing side connectors to a single rod or placing two rods. Our clinical observations suggested that skipping instrumentation at C7 in a multi-level posterior cervicothoracic fusion will result in minimal intraoperative complications and decreased blood-loss while still maintaining sagittal balance parameters of cervical fusion. The objective of this study is to determine the clinical and radiographic outcomes of skipping C7 instrumentation compared to instrumenting the C7 vertebra in posterior cervicothoracic fusion. Methods: This is a retrospective chart review of 314 consecutive patients who underwent multilevel posterior cervical fusion (PCF) at our institution. Out of 314 patients, 19 were instrumented at C7 serving as the control group, while the remaining 295 patients were not. Evaluation of efficacy was based on intraoperative complications, operative time, estimated blood loss (EBL), significant long-term complications, and radiographic evidence of fusion. Results: Skipping the C7 level resulted in a significant reduction in EBL (488±576 vs. 822±1,137; P=0.007); however, operative time was similar between groups (174±95 vs. 184±86 minutes; P=0.844). Complications were minimal in both groups and not statistically significant. Radiographic analysis revealed C7 bridge patients had a significantly increased postoperative sagittal vertical axis (SVA) (29.3±13.1 vs. 20.2±3.1 mm; P=0.008); however, there was no significant difference between groups in SVA correction (-0.3±16.2 vs. -16.1±16.0 mm; P=0.867), T1 slope correction (3.4°±9.9° vs. 3.2°±5.5°; P=0.127), or cervical cobb angle correction (-5.7°±14.2° vs. -7.0°±12.2°; P=0.519). There were no significant long-term complications in either group. Conclusions: Skipping instrumentation at C7 in a multilevel posterior cervicothoracic fusion is associated with significantly reduced operative blood loss without loss of radiographic correction. This study demonstrates the clinical benefits of skipping C7 instrumentation in posterior cervicothoracic fusion with maintenance of radiographic correction parameters.
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BACKGROUND: Whether or not the laparoscopic technique has substantial advantages over the mini-laparotomy one for ventriculoperitoneal shunt is still controversial. The present study is a literature review and a meta-analysis about this topic, focused on the duration of surgery, length of stay (LOS), infection rate and rate of distal catheter failure. METHODS: An extensive online literature search was performed, followed by a meta-analysis implemented with RevMan 5.0 Cochrane software. For laparoscopy and mini-laparotomy group, odds ratio (OR) and 95% confidence interval (CI) was calculated for distal catheter malposition/obstruction and infection rate. Mean difference was considered for duration of surgery and LOS. Fixed-effect model with a significance < 0.05 was employed. A t-test (p< 0.05) between the groups, also including the non-comparative cohort studies, was performed for each primary endpoint. RESULTS: 18 studies, involving 3361 patients, were selected. Average level of evidence was 3.2 ± 0.7. Primary shunts were 93 % in laparoscopy group and 87 % in mini-laparotomy one (p=0.626). A previous abdominal surgery was present in 37.5 % and 33.7% of laparoscopy and laparotomy group, respectively (p=0.449). Laparoscopy had a lower incidence of distal catheter failure (OR 0.52, 95% CI 0.38-0.72; p<0.001). No differences were revealed about the duration of surgery, LOS and infection rate. CONCLUSION: Laparoscopic technique has a lower risk of distal catheter failure in ventriculoperitoneal shunt for the treatment of hydrocephalus. Duration of surgery, LOS and infection rate are independent by the surgical technique. The overall level of evidence is low, and no absolute conclusions can be drawn. KEY WORDS: Hand-Assisted Laparoscopy, Hydrocephalus, Meta-Analysis, Mini-Laparotomy, Shunt Failure, Shunt Malfunction, Ventriculoperitoneal Shunt.
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Laparoscópía Mano-Asistida , Laparoscopía , Humanos , Hidrocefalia/cirugía , Laparotomía , Estudios Retrospectivos , Derivación VentriculoperitonealRESUMEN
OBJECTIVE: Evaluation of lumbar canal dimensions in a Chicago population born in 2 different decades. METHODS: This is a retrospective chart review analyzing computed tomography reconstruction from patients born between 1940 and 1949 (older group) and 1970 and 1979 (younger group). The cross-sectional area (CSA) and anterior-posterior diameter (APD) of the lumbar bony canal was measured at each lumbar level at the level of the pedicle. RESULTS: Our study includes 918 patients, 372 in the young group and 546 in the older group. Older patients have significantly larger CSA and APD at all lumbar levels compared with younger patients. Further, CSA and APD comparisons between ethnicities demonstrate significant differences between individuals of Caucasian, Asian, Hispanic, African American, and Other ethnicities. Lastly, there were no differences in CSA or APD compared with factors known to affect bone health (smoking, steroid use, osteoporosis, cancer history). CONCLUSIONS: As seen in European cohorts, our data suggest that patients born in the 1940s have both larger canal area and larger anterior-posterior diameter compared with the younger generation. These data suggest that significant differences exist between ethnicities. These differences highlight the importance of studying normal anatomical dimensions within different geographical populations and the importance of studying non-modifiable factors as they relate to spinal dimensions and spine patients. Furthermore, spinal canal growth seems to be negatively influenced in younger generations, a rather unexpected but worrying finding.
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Vértebras Lumbares/anatomía & histología , Canal Medular/anatomía & histología , Adulto , Negro o Afroamericano , Anciano , Asiático , Efecto de Cohortes , Femenino , Glucocorticoides/uso terapéutico , Hispánicos o Latinos , Humanos , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Neoplasias/epidemiología , Tamaño de los Órganos , Osteoporosis/epidemiología , Valores de Referencia , Fumar/epidemiología , Canal Medular/diagnóstico por imagen , Estados Unidos , Población BlancaRESUMEN
BACKGROUND: Pathophysiological mechanisms underlying the syringomyelia associated with Chiari I malformation (CM-1) are still not completely understood, and reliable predictors of the outcome of posterior fossa decompression (PFD) are lacking accordingly. The reported prospective case-series study aimed to prove the existence of a pulsatile, biphasic systolic-diastolic cerebrospinal fluid (CSF) dynamics inside the syrinx associated with CM-1 and to assess its predictive value of patients' outcome after PFD. Insights into the syringogenesis are also reported. METHODS: Fourteen patients with symptomatic CM-1 syringomyelia underwent to a preoperative neuroimaging study protocol involving conventional T1/T2 and cardiac-gated cine phase-contrast magnetic resonance imaging sequences. Peak systolic and diastolic velocities were acquired at four regions of interest (ROIs): syrinx, ventral, and dorsal cervical subarachnoid space and foramen magnum region. Data were reported as mean ± standard deviation. After PFD, the patients underwent a scheduled follow-up lasting 3 years. One-way analysis of variance with Bonferroni Post hoc test of multiple comparisons was performed P was <0.001. RESULTS: All symptoms but atrophy and spasticity improved. PFD caused a significant velocity changing of each ROI. Syrinx and premedullary cistern velocities were found to be decreased within the 1st month after PFD (<0.001). A caudad and cephalad CSF jet flow was found inside the syrinx during systole and diastole, respectively. CONCLUSION: Syrinx and premedullary cistern velocities are related to an early improvement of symptoms in patients with CM-1 syringomyelia who underwent PFD. The existence of a biphasic pulsatile systolic-diastolic CSF pattern inside the syrinx validates the "transmedullary" theory about the syringogenesis.
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OBJECTIVES: To report the results of a retrospective series and a technical note about the anterolateral approach for the treatment of the rotational occlusion syndrome (ROS) involving the subaxial V2 segment of the vertebral artery (VA). METHODS: We retrospectively reviewed the data of a cohort of patients that underwent an anterolateral approach to decompress the VA as they suffered from ROS secondary to a subaxial compression. A dynamic study with ultrasonography, CT, MRI, and catheter-based angiography were obtained in all cases. Severe symptomatology and cerebellar-brainstem strokes were indications for surgery. The anterolateral approach involved a pre-sternocleidomastoid precarotid exposure. The retro-longus colli and pre-scalenic corridors were used to access the C5-C6 and C3-C4 segment, respectively, and to perform the decompression. RESULTS: Twelve patients were treated. Recurrent drop attacks were present in all cases. Osteophytes at C5 and C6 were the most common causes of subaxial VA compression. Anterior decompression stand-alone was performed in all but 1 patient. A recurrent laryngeal nerve palsy and a numbness of the C5 nerve root were the only complications observed, both transient. A satisfactory untethering of the VA with a complete recovery was achieved in all patients, apart from those with severe infratentorial strokes. DISCUSSION READ: Anterolateral approach allows for an effective and safe treatment of the ROS involving the subaxial portion of the VA. Retro-longus colli and pre-scalenic corridors, developed through a precarotid exposure, have an anatomical rationale in decreasing the risks of complications. Decompression stand-alone is adequate in almost the totality of cases.
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Descompresión Quirúrgica/métodos , Arteria Vertebral/cirugía , Insuficiencia Vertebrobasilar/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.
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Pituitary surgery exemplifies the continuous refinement of surgical techniques. The transsphenoidal approach is the approach of choice to treat most pituitary adenomas. We report here, as a technical note, an operative nuance that represents an encompassment of various technical steps that we utilize in our current surgery, including the corroboration of navigation system on a free head with combined use of endoscope and microscope techniques.
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Adenoma/cirugía , Microscopía , Cavidad Nasal/cirugía , Neuroendoscopía/métodos , Neuronavegación , Neoplasias Hipofisarias/cirugía , Adenoma/diagnóstico , Cadáver , Diseño de Equipo , Humanos , Imagen por Resonancia Magnética , Neuronavegación/instrumentación , Neoplasias Hipofisarias/diagnóstico , Seno Esfenoidal/cirugíaRESUMEN
The data presented in this brief paper aims to summarize the overall results of 82 consecutive patients surgically treated over 20 years for a giant intracranial aneurysm (GIA) in the context of the endovascular era. Data were retrospectively collected from the database of two different tertiary referral Italian hospitals. A retrospective analysis of the patients' cohort was performed. Data are presented as they relate to the demographic and clinical aspects, the prevalence of GIAs according to anterior and posterior circulation, aneurysm angioarchitectural features, surgical treatment options, complications, outcome, and main microneurosurgical techniques required explicitly for GIAs, namely temporary clipping, aneurysm remodeling, thrombectomy, fragmentation, and bypass. Furthermore, data about the effects of implementing the flow-diverter/flow-disruptor on the surgical case volume over the years are also reported. The data presented herein are related to our previously published research article titled "Surgical Management of Giant Intracranial Aneurysms: Overall Results of a Large Series" (2020) [1].