RESUMEN
OBJECTIVE: In the treatment of skull base chordoma (SBC) surgery is considered the mainstay approach, and gross-total resection has an established relationship with progression-free survival (PFS) and overall survival (OS). However, the tumor's location often interferes with attempts at complete resection. In this case, surgery for maximal resection followed by high-dose radiotherapy has been demonstrated to be the standard treatment. In this context, various modalities are available, yet no consensus exists on the most effective. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of different radiotherapy modalities for SBC. METHODS: Following PRISMA guidelines, the authors systematically searched for the treatment of SBC with radiation modalities in the PubMed, Cochrane, Web of Science, and EMBASE databases. Outcomes assessed for each modality were as follows: OS, PFS, local control (LC), and complications. The random-effects model was adopted. A single-proportion analysis with 95% CI was used to measure the effects in single-arm analysis. For the comparative analysis, the OR with 95% CI was used to compare outcome treatment effects. Heterogeneity was assessed using I2 statistics, and statistical significance was defined as p < 0.05. RESULTS: A total of 32 studies comprising 3663 patients, with 2322 patients who were treated with radiotherapeutic modalities, were included. Regarding 5-year OS findings in each modality study, the findings were as follows: in photon fractionated radiotherapy, an estimated rate of 77% (69%-84%, 568 patients); in conventional fractionated radiotherapy, 76% (65%-87%, 517 cases); in proton-based + carbon ion-based radiotherapy, 85% (82%-88%, 622 cases); and in a comparative analysis of proton-based and carbon ion-based therapy, there was an OR of 1.2 (95% CI 0.59-2.43, 306 cases). Regarding the 5-year PFS estimate, the rates were as follows: 35% (26%-45%, 95 cases) for photon fractionated therapy; 35% (25%-45%, 85 cases) for stereotactic radiotherapy; 77% (50%-100%, 180 cases) for proton-based and carbon ion-based radiotherapy; and 74% (45%-100%, 102 cases) for proton-based radiotherapy. Regarding LC in periods of 3 and 5 years after proton- and carbon ion-based therapy, the overall estimated rates were 84% (78%-90%, 326 cases) and 75% (65%-85%, 448 cases), respectively. For proton-based radiotherapy and carbon ion-based therapy, the 5-year LC rates were 76% (67%-86%, 259 cases) and 75% (59%-91%, 189 cases), respectively. CONCLUSIONS: The analysis highlights the finding that particle-based modalities like proton beam radiotherapy and carbon ion radiotherapy are the most effective radiation therapies available for the treatment of SBC. Furthermore, it reinforces the idea that surgery followed by radiotherapy constitutes the standard treatment.
Asunto(s)
Cordoma , Neoplasias de la Base del Cráneo , Humanos , Neoplasias de la Base del Cráneo/radioterapia , Neoplasias de la Base del Cráneo/cirugía , Cordoma/radioterapia , Cordoma/cirugía , Resultado del Tratamiento , Radiocirugia/métodosRESUMEN
Hearing loss is the most common symptom of vestibular schwannomas (VSs). The management of these lesions includes observation, radiosurgery, and microsurgical resection. Hearing preservation and rehabilitation are the major challenges after the tumor treatment. A 43-year-old man with previous left-sided profound hearing loss and tinnitus presented with a 2-mm left-sided intracanalicular VS. The decision was made to perform a simultaneous cochlear implantation (CI) and microsurgical resection of the tumor. The patient did well postoperatively, with significant improvement of tinnitus, sound localization, and speech recognition in noise. Previous reports of simultaneous CI and VS resection in patients with neurofibromatosis type 2 and sporadic VS in the only hearing ear have been described. The role of CI in patients with VS and normal contralateral hearing has been recently described, showing positive outcomes due to the binaural benefits. Tinnitus also can be treated by the implantation of the cochlear device. The simultaneous microsurgical removal of VS and implantation of a cochlear device is a feasible approach in patients with unilateral hearing loss and severe tinnitus.
Asunto(s)
Implantación Coclear/métodos , Pérdida Auditiva/cirugía , Neuroma Acústico/cirugía , Procedimientos Neuroquirúrgicos/métodos , Adulto , Pérdida Auditiva/diagnóstico por imagen , Pérdida Auditiva/etiología , Humanos , Masculino , Neuroma Acústico/complicaciones , Neuroma Acústico/diagnóstico por imagenRESUMEN
Surgical removal of foramen magnum meningiomas poses great challenges due their deep location within the central skull base and their proximity to vital neurovascular structures. This video depicts the operative nuances of surgical management for a 59-year-old female who presented with a right-sided spinocranial meningioma. Simpson Grade I resection was achieved through a right transcondylar approach. The patient's postoperative period was unremarkable, and she was discharged home on postoperative Day 5 for periodic follow-up. The transcondylar approach safely exposes the craniocervical junction at the anterior aspect of the neuraxis and still allows the surgeon to access the tumor through a parallel plane, with minimum morbidity. The video can be found here: https://youtu.be/P0-kXjAkw9U .
Asunto(s)
Foramen Magno/cirugía , Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Canal Medular/cirugía , Femenino , Humanos , Neoplasias Meníngeas/complicaciones , Meningioma/complicaciones , Meningioma/diagnóstico por imagen , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos , Compresión de la Médula Espinal/etiologíaRESUMEN
BACKGROUND: Jugular paragangliomas are highly vascularized tumors that can grow in challenging neurovascular compartments and are particularly challenging to resect. There is still no consensus whether preoperative embolization should be employed to minimize intraoperative morbidity. METHODS: A systematic review and meta-analysis was conducted by searching PubMed, Web of Science, and Embase databases for key terms including "embolization," "jugular paragangliomas," and "surgery." RESULTS: This review included 25 studies with 706 patients and 475 (67%) preoperative embolizations. Polyvinyl alcohol particles were the most common embolic agent (97.8% of all patients who underwent embolization). Complication rate of embolization was 1% (95% confidence interval [CI]: 0%, 2%). Preoperative embolization was significantly associated with less intraoperative estimated blood loss (mean difference of -7.92 dL [95% CI: -9.31 dL, -6.53 dL]), shorter operating room times (mean difference of -55.24 minutes [95% CI: -77.10 minutes, -33.39 minutes]), and less overall tumor recurrence (odds ratio = 0.23 [95% CI: 0.06, 0.91]) compared with resective surgery alone. Preoperative embolization had no impact on the development of postoperative new cranial nerve deficits not associated with embolization (odds ratio = 1.17 [95% CI: 0.47, 2.91]) and achievement of gross total resection (odds ratio = 1.92 [95% CI: 0.67, 5.53]). CONCLUSIONS: Preoperative embolization may provide surgical efficiency with faster surgical times and less bleeding and safety with diminished overall recurrence via safe embolization with minimal risks. These results must be considered taking into account the nonrandomness of studies.
RESUMEN
BACKGROUND: Vestibular schwannomas (VS) are benign tumors arising from vestibular nerve's Schwann cells. Surgical resection via retrosigmoid (RS) or middle fossa (MF) is standard, but the optimal approach remains debated. This meta-analysis evaluated RS and MF approaches for VS management, emphasizing hearing preservation and Cranial nerve seven (CN VII) outcomes stratified by tumor size. METHODS: Systematic searches across PubMed, Cochrane, Web of Science, and Embase identified relevant studies. Hearing and CN VII outcomes were gauged using the American Academy of Otolaryngology-Head and Neck Surgery, Gardner Robertson, and House-Brackmann scores. RESULTS: Among 7228 patients, 56 % underwent RS and 44 % MF. For intracanalicular tumors, MF recorded 38 % hearing loss, compared to RS's 54 %. In small tumors (<1.5 cm), MF showed 41 % hearing loss, contrasting RS's lower 15 %. Medium-sized tumors (1.5 cm-2.9 cm) revealed 68 % hearing loss in MF and 55 % in RS. Large tumors (>3cm) were only reported in RS with a hearing loss rate of 62 %. CONCLUSION: Conclusively, while MF may be preferable for intracanalicular tumors, RS demonstrated superior hearing preservation for small to medium-sized tumors. This research underlines the significance of stratified outcomes by tumor size, guiding surgical decisions and enhancing patient outcomes.
Asunto(s)
Neuroma Acústico , Procedimientos Neuroquirúrgicos , Humanos , Fosa Craneal Media/cirugía , Nervio Facial/cirugía , Audición/fisiología , Pérdida Auditiva/etiología , Pérdida Auditiva/prevención & control , Pérdida Auditiva/cirugía , Neuroma Acústico/cirugía , Procedimientos Neuroquirúrgicos/métodosRESUMEN
BACKGROUND: Meckel cave tumors are relatively rare, especially trigeminal nerve (TN) schwannomas. These tumors frequently project through the trigeminal pore, occupying the middle and posterior fossae. The most used routes to this region are the suboccipital retrosigmoid intradural approach (SORSA) and the transzygomatic middle fossa approach (TZMFA). Both approaches allow further exposure by adding intraoperative techniques, such as removing the suprameatal tubercle (retrosigmoid intradural suprameatal approach [RISA]) and the petrous apex (TZMFA-PA), respectively. This study aims to understand how TN exposure differs between both surgical approaches and how it increases by adding specific surgical maneuvers to these techniques. METHODS: Five formalin-fixed adult cadaver heads were submitted to high-resolution computed tomography and their images were loaded into the neuronavigation device. Anatomic key points were defined along the outline of the TN, and their three-dimensional spatial locations were collected following each surgical approach. This process allowed the calculation of the TN exposed area obtained through each technique. RESULTS: The mean areas of exposure of the TN were 125.9 mm2 with SORSA and 208.9 mm2 with RISA, which represents an additional mean gain of 61.92% (P = 0.047). Using TZMFA, a mean exposure of 419.24 mm2 was obtained. When TZMFA-PA was used, the mean exposed area was 486.03 mm2, representing a mean gain in the exposure area of 16.81% (P = 0.072). CONCLUSIONS: Our study suggests that TZMFA allows better exposure of TN ganglionic and postganglionic segments, and the removal of the PA adds the preganglionic segment visualization, although with less TN exposed area compared with RISA. With SORSA, the additional suprameatal tubercle removal shows the trigeminal pore and the medial margin of the central portion of the TN ganglionic segment, making it possible to expose the mouth of the Meckel cave and part of its contents.
Asunto(s)
Neoplasias de los Nervios Craneales , Neurilemoma , Adulto , Humanos , Nervio Trigémino/diagnóstico por imagen , Nervio Trigémino/cirugía , Nervio Trigémino/anatomía & histología , Hueso Petroso/cirugía , Neurilemoma/cirugía , Procedimientos Neuroquirúrgicos/métodos , Neoplasias de los Nervios Craneales/cirugía , CadáverRESUMEN
Background: Focal cortical dysplasias (FCD) cause a subgroup of malformations of cortical development that has been closely linked to cause drug intractable epilepsy. Attaining adequate and safe resection of the dysplastic lesion has proved to be a viable option to archive meaningful seizure control. Of the three types of FCD (types I, II, and III), type I has the least detectable architectural and radiological abnormalities. This makes it challenging (preoperatively and intraoperatively) to achieve adequate resection. Intraoperatively, ultrasound navigation has proven an effective tool during the resection of these lesions. We evaluate our institutional experience in surgical management of FCD type I using intraoperative ultrasound (IoUS). Methods: Our work is a retrospective and descriptive study, where we analyzed patients diagnosed with refractory epilepsy who underwent IoUS-guided epileptogenic tissue resection. The surgical cases analyzed were from January 2015 to June 2020 at the Federal Center of Neurosurgery, Tyumen, only patients with histological confirmation of postoperative CDF type I were included in the study. Results: Of the 11 patients with histologically diagnosed FCD type I, 81.8% of the patients postoperatively had a significant reduction in seizure frequency (Engel outcome I-II). Conclusion: IoUS is a critical tool for detecting and delineating FCD type I lesions, which is necessary for effective post-epilepsy surgery results.
RESUMEN
Given the difficulty and importance of achieving maximal resection in chordomas and chondrosarcomas, all available tools offered by modern neurosurgery are to be deployed for planning and resection of these complex lesions. As demonstrated by the review of our series of skull base chordoma and chondrosarcoma resections in the Advanced Multimodality Image-Guided Operating (AMIGO) suite, as well as by the recently published literature, we describe the use of advanced multimodality intraoperative imaging and neuronavigation as pivotal to successful radical resection of these skull base lesions while preventing and managing eventual complications.
RESUMEN
Olfactory neuroblastoma, or esthesioneuroblastoma, is an uncommon malignant tumor originating from the neural crest that commonly occurs in the upper nasal cavity. Its ectopic origin is extremely rare, especially when located in the optical pathways. This paper reports the case of a giant ectopic esthesioneuroblastoma of the optic pathways that were surgically treated through a cranio-orbital-zygomatic (COZ) craniotomy with extensive resection, in addition to a literature review. The patient is a 46-year-old female presenting with a 4-month history of visual loss in the left eye. Since she was previously blind in the right eye from a traumatic injury, it was evolving to loss of bilateral vision. Imaging depicted an expansive infiltrating lesion involving the entire path of the right optic nerve, extending to the optic chiasm, cisternal portion of the left optic nerve, bilateral optic tract, and hypothalamus. Investigation of pituitary function was unremarkable. Esthesioneuroblastoma is a rare tumor with poorly defined standard clinical management. Its ectopic presentation makes the diagnosis even more challenging, making it difficult to manage these cases properly. Surgeons should be aware of this rare possibility, as early aggressive treatment is likely to be associated with better results.
RESUMEN
OBJECTIVES: A thorough understanding of cerebellum anatomy is essential in 4th ventricle approaches (more frequent in pediatric neurosurgery), avoiding relevant complications such as cerebellar mutism. The aim of the present work is to show the feasibility of a didactic dissection of human cerebellum focusing on cerebellar peduncles and dentate nucleus (DN), which are structures at high risk during these surgical procedures. MATERIAL AND METHODS: The cerebellum was dissected according to the Klingler method for white matter, using standard and specific microsurgery tools. Surgical microscope magnification (×6-×40) provided by a D.F. Vasconcellos M900 was required. A Canon EOS T7 18-55â¯mm digital camera was used and Adobe Lightroom Classic CC and Keynote were selected as photo enhancing software. Special methods such as LED light endoscopic transillumination were used for photographical reasons. RESULTS: DN dissection was successfully achieved and the relations between these nucleus and the cerebellar peduncles, inferior vermis and medullary velums were described. Through this three steps dissection guide (1. tentorial surface; 2. suboccipital surface; 3. 4th ventricle structures), the most relevant anatomical structures were shown and its implications in different 4th ventricle approaches were characterised. CONCLUSION: 3 D perspective provided by real specimen anatomical dissection is critical for learning neuroanatomy. LED transillumination was shown as a useful technique for the 4th ventricle structures photographic documentation which improves spatial recognition. This benefit can be applied for the study of the relations between the medullary velums and the rhomboid fossa foramina, which are permeable to light. The proposed three-steps dissection guide helps to a better understanding of human cerebellum and to gain self-confidence, allowing safer practice for neurosurgeons in all stages of their career.
Asunto(s)
Neuroanatomía , Sustancia Blanca , Cerebelo/anatomía & histología , Cerebelo/cirugía , Niño , Cuarto Ventrículo/cirugía , Humanos , Microcirugia/métodos , Neuroanatomía/educación , Sustancia Blanca/anatomía & histología , Sustancia Blanca/diagnóstico por imagen , Sustancia Blanca/cirugíaRESUMEN
OBJECTIVE: Congenital arachnoid cysts in the middle fossa accounts for 50% of all intracranial arachnoid cysts. Several management options have been described; however, no single technique has been universally adopted. We describe a series of pediatric patients with middle cranial fossa arachnoid cyst that were treated through an innovative minimally invasive endoscopic technique, along with their clinical aspects and surgical outcomes. METHODS: Data from 65 patients operated between 2012 and 2018 were retrospectively analyzed. Follow-up ranged from 12 to 96 months. Clinical presentation and surgical outcomes were collected. Endoscopic cystocisternostomy was performed in all patients using a mini endoscope. RESULTS: There were 41 male and 24 female patients, with a mean age of 5.3 years at the time of treatment. Except for 4 patients, all presented with 1 or more symptoms, and the most frequent were intracranial hypertension signs. All patients were treated with the same surgical technique, with an efficacy of 81.5%. CONCLUSIONS: Using a mini endoscope allow us to perform multiple fenestrations along the arachnoid and deeply inspect the basal cisterns, achieving a much wider communication between the cyst and subarachnoid space with a high success rate and minimal invasiveness.
Asunto(s)
Quistes Aracnoideos , Quistes Aracnoideos/diagnóstico por imagen , Quistes Aracnoideos/cirugía , Niño , Preescolar , Fosa Craneal Media/cirugía , Endoscopía/métodos , Femenino , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Ventriculostomía/métodosRESUMEN
Ischemia of the optic nerve (ON) is an important cause of visual field deficit provoked by tuberculum sellae (TS) meningiomas. Indocyanine green (ICG) videoangiography could provide prognostic information. Moreover, it allows new insight into the pathophysiology of visual disturbance. The authors present the case of a 48-year-old woman with visual field impairment. Magnetic resonance imaging (MRI) depicted a lesion highly suggestive of a TS meningioma. Following microsurgical resection, ICG videoangiography demonstrated improvement of right ON pial blood supply. In this case, there was one lesion causing visual impairment through both direct compression over the left ON and ischemia to the right nerve. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21155.
RESUMEN
Even though intracranial meningiomas commonly invade the optic canals, true optic nerve sheath meningiomas are extremely rare. They are insidious lesions that frequently grow in 4 stages, leading to progressive visual loss.1-4 Frequently, management includes observation for asymptomatic patients, and fractioned stereotactic radiotherapy with progressive visual loss.1,3 However, surgery is avoided due to the risk of perioperative visual loss.2-4 However, many of these cases present in the early stage of tumor growth, where an arachnoidal plane is still present, and vision can be saved by microsurgical tumor resection.2 Here we present the case of a 33-yr-old female presenting with a 3-wk history of blurred vision. Neuroimaging depicted an enhancing lesion along both optic nerves consistent with bilateral optic nerve sheath meningioma. Neuroophthalmological examination showed inferior cut of visual field bilaterally, more extensive on the left eye. Acuity was 20/20 on both eyes. Microsurgical resection of the tumor was performed through left supraorbital craniotomy, with the goal of eliminating intracranial extension and stabilizing visual function.5 The optic canal was unroofed with diamond bit drill under copious irrigation. A remarkable improvement of her visual field was observed with maintenance of acuity at 20/20 on follow-up. As the patient is attempting pregnancy, she is closely monitored without radiation. Surgery can be offered as a primary treatment of optic nerve sheath meningiomas, especially in early stages, with likely preservation and, in some cases, improvement of visual function.6 The patient consented to the procedure and the use of image. Images at 1:46 and 3:48 reprinted from Al-Mefty O, Operative Atlas of Meningiomas. 1998: Raven Press; Philadelphia, PA, with permission from LWW. Image at 2:57 reprinted from Rassi et al2; © Anil Can, 2018, used with permission. Image at 9:27 in public domain/age.
Asunto(s)
Meningioma , Neoplasias del Nervio Óptico , Femenino , Humanos , Meningioma/diagnóstico por imagen , Meningioma/radioterapia , Meningioma/cirugía , Nervio Óptico/diagnóstico por imagen , Nervio Óptico/cirugía , Neoplasias del Nervio Óptico/diagnóstico por imagen , Neoplasias del Nervio Óptico/radioterapia , Neoplasias del Nervio Óptico/cirugía , Resultado del Tratamiento , Trastornos de la Visión/etiologíaRESUMEN
OBJECTIVES: A thorough understanding of cerebellum anatomy is essential in 4th ventricle approaches (more frequent in pediatric neurosurgery), avoiding relevant complications such as cerebellar mutism. The aim of the present work is to show the feasibility of a didactic dissection of human cerebellum focusing on cerebellar peduncles and dentate nucleus (DN), which are structures at high risk during these surgical procedures. MATERIAL AND METHODS: The cerebellum was dissected according to the Klingler method for white matter, using standard and specific microsurgery tools. Surgical microscope magnification (x6-x40) provided by a D.F. Vasconcellos M900 was required. A Canon EOS T7 18-55 mm digital camera was used and Adobe Lightroom Classic CC and Keynote were selected as photo enhancing software. Special methods such as LED light endoscopic transillumination were used for photographical reasons. RESULTS: DN dissection was successfully achieved and the relations between these nucleus and the cerebellar peduncles, inferior vermis and medullary velums were described. Through this three steps dissection guide (1. tentorial surface; 2. suboccipital surface; 3. 4th ventricle structures), the most relevant anatomical structures were shown and its implications in different 4th ventricle approaches were characterised. CONCLUSION: 3 D perspective provided by real specimen anatomical dissection is critical for learning neuroanatomy. LED transillumination was shown as a useful technique for the 4th ventricle structures photographic documentation which improves spatial recognition. This benefit can be applied for the study of the relations between the medullary velums and the rhomboid fossa foramina, which are permeable to light. The proposed three-steps dissection guide helps to a better understanding of human cerebellum and to gain self-confidence, allowing safer practice for neurosurgeons in all stages of their career.
RESUMEN
As with other meningiomas, the goal of petroclival meningioma treatment should be curative total removal by achieving a Simpson I resection of the tumor, dura, and bone. Petroclival meningiomas particularly pose a great technical challenge because of their deep location and intimate relation with vital neurovascular structures. They require adequate exposure and trajectory to achieve total removal while minimizing the manipulation and risk to critical neurovascular structures, such as the vertebrobasilar system, the brainstem, and the cranial nerves. Here, we describe the indications and technical nuances of the posterior and combined posterior-anterior petrosal approaches for petroclival meningiomas.
Asunto(s)
Fosa Craneal Posterior/cirugía , Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Procedimientos Neuroquirúrgicos/métodos , Neoplasias de la Base del Cráneo/cirugía , Fosa Craneal Posterior/patología , Humanos , Neoplasias Meníngeas/patología , Meningioma/patología , Neoplasias de la Base del Cráneo/patologíaRESUMEN
Brainstem cavernous malformations are challenging lesions considering the numerous eloquent structures frequently related. Surgical resection is the preferred treatment if the patient is symptomatic and the lesion can be safely resected. We present the case of a right-handed 38-yr-old female, presenting with progressive impairment of her handwriting. Physical examination showed a right-sided grade 4/5 hemiparesis. Preoperative imaging was suggestive of a left cerebral peduncle cavernous malformation with a recent area of hemorrhage. The most superficial portion of the lesion was on the surface of the brainstem in the supratrigeminal safe entry zone of the pons. A frontotemporal craniotomy was performed, followed by a pretemporal transtentorial approach. Prior to performing brainstem incision, the area was stimulated, and no motor evoked potential was recorded. The hematoma was then evacuated, and the cavernous malformation was dissected and removed. The capsule was also dissected and removed, using neurophysiological monitoring to guide this procedure. The lesion was completely resected, and the patient was discharged on postoperative day 7 with a right-sided hemiparesis grade 3/5, which improved to grade 5/5 after 4 mo. The patient presented an improvement of her symptoms, with no new neurological deficits. Brainstem cavernomas can be safely removed in selected cases, using the adequate safe entry zone and the appropriate surgical approach. The pretemporal route can be used to reach the anterolateral aspect of the upper part of the brainstem, as it combines the advantages of both transsylvian and subtemporal approaches. An informed consent was obtained from the patient for publication of this operative video.
Asunto(s)
Pedúnculo Cerebral , Hemangioma Cavernoso del Sistema Nervioso Central , Adulto , Tronco Encefálico/diagnóstico por imagen , Tronco Encefálico/cirugía , Craneotomía , Femenino , Hemangioma Cavernoso del Sistema Nervioso Central/diagnóstico por imagen , Hemangioma Cavernoso del Sistema Nervioso Central/cirugía , Humanos , PuenteRESUMEN
Trigeminal schwannomas are benign lesions arising from the Schwann cells of the trigeminal nerve. This is an unusual tumor that accounts for less than 0.4% of intracranial pathologies, even though they are the second most frequent schwannoma after the vestibular schwannoma. The tumor spreads along the natural course of the V nerve at its cisternal portion, along the ganglion inside Meckel's cave or through its peripheral division. Even though the tumor can reach great size and become multicompartmental. We present a 51-yr-old woman, with an history of 3 mo of incapacitating facial pain, that was found on examination to be on the territory of the third division of the trigeminal nerve on the right side. The MRI depicted a large homogeneous enhancing lesion at the base of the right middle fossa with extension through the petrous apex to the most superior and medial part of the posterior fossa. The patient was operated by the senior author, through a middle fossa approach, dissecting between the two layers of the middle fossa dura (the apparent inner and the true outer layer of the cavernous sinus), the so called middle fossa "peeling". We achieved total resection of the tumor, but the patient presented after surgery with facial nerve paresis. This is thought to be related to geniculate ganglion manipulation, as it was unprotect by bone at the middle fossa and the patient maintained lacrimal function (post-geniculate alteration). It resolved completely after 6 mo. The patient consented to publication of her images.
RESUMEN
Tentorial meningiomas are challenging tumors because of its complex relationship with vital neurovascular structures. We present the case of a 41-yr-old female with a history of right-sided facial numbness associated with pain around the ear. Magnetic resonance imaging demonstrated a lesion in the right tentorium edge closely related with the porus trigeminus, suggestive of a meningioma. Because of worsening of symptoms the patient underwent surgery for tumor removal. A standard temporo-zygomatic craniotomy was performed, followed by an extradural peeling of the middle fossa; the petrous apex was drilled allowing access to the posterior fossa dura. Dural opening was carried connecting the temporal and posterior fossa, and the tentorium was then cut to the incisura. The tumor was identified and completely removed reaching Simpson grade I resection. Postoperatively, the patient presented a right dry eye in the first days that fully improved, and also a right-sided facial paralysis (House-Brackmann grade IV) and diplopia, both recovered completely after 4 mo. We believe that facial paralysis was the result of an undesired traction of the geniculate ganglion, or upon the nerve itself. To avoid such complication, dissection over the GSPN must be carried parallel to that nerve. Facial numbness and pain improved with no neurological other deficits. Tentorial meningiomas are complex deep-seated lesions that can be successfully approached through an anterior transpetrosal route in selected cases. Informed consent was obtained from the patient for publication of this operative video. Anatomical images were a courtesy of the Rhoton Collection, American Association of Neurological Surgeons/Neurosurgical Research and Education Foundation.
Asunto(s)
Neoplasias Meníngeas , Meningioma , Adulto , Duramadre/diagnóstico por imagen , Duramadre/cirugía , Femenino , Humanos , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Meningioma/diagnóstico por imagen , Meningioma/cirugía , Procedimientos Neuroquirúrgicos , Hueso Petroso/diagnóstico por imagen , Hueso Petroso/cirugíaRESUMEN
Brainstem cavernous malformations are frequently surrounded by vital structures, which often makes surgical treatment a challenging task even to the most skilled surgeon. Accordingly, microsurgical excision is preferably offered to symptomatic patients and superficial lesions.1-3 We present the case of a 41-yr-old male presenting with progressive dizziness and diplopia. Neurological examination showed horizontal nystagmus, dysmetria, and unbalance. Preoperative magnetic resonance imaging (MRI) suggested a cavernous malformation in the right middle cerebellar peduncle. A telovelar approach was employed with the guidance of intraoperative neurophysiological monitoring. An exophytic lesion was identified in the right middle cerebellar peduncle and a clear cleavage plane was obtained allowing circumferential dissection around the capsule. The lesion was removed en bloc. Postoperative MRI confirmed a complete excision of the malformation. The patient presented an improvement in his initial symptoms, with no new neurological deficit. Cavernous malformations related with the fourth ventricle can be successfully resected through a telovelar approach in select cases, especially when exophytic, where the surgeon might take advantage of the path created by the lesion. Informed consent was obtained from the patient for the procedure and publication of this operative video. Anatomic images were a courtesy of the Rhoton Collection, American Association of Neurological Surgeons (AANS)/Neurosurgical Research and Education Foundation (NREF).
Asunto(s)
Hemangioma Cavernoso del Sistema Nervioso Central , Pedúnculo Cerebeloso Medio , Adulto , Cuarto Ventrículo , Hemangioma Cavernoso del Sistema Nervioso Central/diagnóstico por imagen , Hemangioma Cavernoso del Sistema Nervioso Central/cirugía , Humanos , Imagen por Resonancia Magnética , Masculino , Procedimientos NeuroquirúrgicosRESUMEN
OBJECT: Intracranial aneurysms may grow closer to anterior optic pathways, causing mass effect over these anatomical structures, including visual deficit. The authors retrospectively reviewed a series of aneurysms in patients presenting with visual field deficit caused by mass effect, to analyze the aneurysm's characteristics, the neurosurgical management of these aneurysms, as well as their clinical, visual, and radiological outcomes. METHODS: The authors reviewed the medical charts, neuroimaging examination results, and surgical videos of 15 patients presenting with visual symptoms caused by an aneurysm's mass effect over the anterior optic pathways. These patients were treated at the Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, Brazil. Statistical analysis was performed to identify the variables related to partial or total recovery of the visual symptoms. RESULTS: All patients underwent microsurgical clip placement and emptying of their aneurysms. After a mean follow-up of 38.5 months, the mean postoperative Glasgow Outcome Scale score was 4.33, and the visual outcomes were as follows: 1 patient (6.6%) unchanged, 7 (46.6%) improved, and 7 (46.6%) experienced complete recovery from visual deficits. The variables that influenced the visual outcomes were the size of the aneurysm (p = 0.039), duration of the visual symptoms (p = 0.002), aneurysm wall calcification (p = 0.010), and intraluminal thrombosis (p = 0.007). Postoperative examination using digital subtraction angiography showed complete aneurysm occlusion in 14 (93.3%) of the 15 patients. CONCLUSIONS: Intracranial aneurysms causing mass effect over the anterior optic pathways usually present with complex features. The best treatment option must include not only the aneurysm occlusion but also relief of the mass effect. Microsurgical clip placement with reduction of aneurysmal mass effect achieved improvement in visual ability or recovery from visual impairment, as well as total aneurysm occlusion, in 93.3% of the study group. Therefore, this option is well supported as the first choice of treatment for intracranial aneurysms presenting with mass effect over the anterior visual pathways.