Neuronavigated percutaneous gasserian radiofrequency thermorhizotomy for trigeminal neuralgia: how I do it.

BACKGROUND: Radiofrequency thermorhizotomy (TRZ) is an established treatment for trigeminal neuralgia (TN). TRZ can result risky and painful in a consistent subset of patients, due to the need to perform multiple trajectories, before a successful foramen ovale cannulation. Moreover, intraoperative x-rays are required. METHOD: TRZ has been performed by using a neuronavigated stylet, before trajectory planning on a dedicated workstation. CONCLUSION: Navigated-TRZ (N-TRZ) meets the expectations of a safer and more tolerable procedure due to the use of a single trajectory, avoiding critical structures. Moreover, N-TRZ is x-ray free. Efficacy outcomes are similar to those reported in literature.

Perioperative ROTEM® evaluation in a patient affected by severe VII factor deficiency undergoing microvascular decompression craniotomy for hemifacial spasm.

The potential use of TEG/ROTEM® in evaluating the bleeding risk for rare coagulation disorders needs to be assessed, considering the common mismatch among laboratory tests and the clinical manifestations. As a result, there is currently no published data on the use of viscoelastic tests to assess coagulation in FVII deficient patients undergoing elective neurosurgery. We describe the case of a patient affected by severe FVII deficiency who underwent microvascular decompression (MVD) craniotomy for hemifacial spasm (HFS). The ROTEM® did not show a significant coagulopathy according to the normal ranges, before and after the preoperative administration of the recombinant activated FVII, but a substantial reduction in EXTEM and FIBTEM Clotting Times was noted. The values of coagulation in standard tests, on the contrary, were indicative of a coagulopathy, which was corrected by the administration of replacement therapy. Whether this difference between ROTEM® and standard tests is due to the inadequacy of thromboelastographic normal ranges in this setting, or to the absence of clinically significant coagulopathy, has yet to be clarified. Neurosurgery is a typical high bleeding risk surgery; additional data is required to clarify the potential role for thromboelastographic tests in the perioperative evaluation of the FVII deficient neurosurgical patients.

Incidental discovery of ano-rectal disease during transrectal ultrasound performed for prostatic disease.

Transrectal ultrasound (US) has long been a routine investigation for the study of various diseases of the prostate. The use of 360 degrees transverse scanning probes and recently, of 3D probes, has been proposed as a suitable means of studying the rectal wall. Between January 1997 and February 2004, 3758 subjects suffering from lower urinary tract symptoms associated with micturition disturbances underwent transrectal ultrasound (TRUS) with a multiplane probe having a variable frequency ranging up to 7.5 MHz and, in the later period, with a transrectal 3D volumetric probe. In 489 patients (13%) TRUS yielded suspicious images of the rectal wall. This finding was verified by a proctologic and rectoscopic examination. In 132 cases (27%) it was shown to be a false positive, mainly due to imperfect cleansing of the anal canal; in 284 cases (58%) benign disease was demonstrated (hemorrhoids in 192 patients, abscesses in 21, perianal fistulas in 18, inflamed lymph nodes in 27, polyps in 16). In 34 patients (7%) a malignant tumor was found (infiltration of the anterior rectal wall by a prostatic adenocarcinoma in 13, and a primitive adenocarcinoma of rectal origin in the remaining 21). It can be concluded that transrectal US does not permit a certain diagnosis of the nature of rectal disease, but does raise a diagnostic suspicion that can orient the surgeon to schedule more invasive diagnostic investigations.