Endoscope-assisted microvascular decompression in hemifacial spasm with a teflon bridge.

BACKGROUND: Microvascular conflicts in hemifacial spasm typically occur at the facial nerve's root exit zone. While a pure microsurgical approach offers only limited orientation, added endoscopy enhances visibility of the relevant structures without the necessity of cerebellar retraction. METHODS: After a retrosigmoid craniotomy, a microsurgical decompression of the facial nerve is performed with a Teflon bridge. Endoscopic inspection prior and after decompression facilitates optimal Teflon bridge positioning. CONCLUSIONS: Endoscope-assisted microsurgery allows a clear visualization and safe manipulation on the facial nerve at its root exit zone.

Patient Satisfaction and Radiologic Assessability After Treatment of Complex Skull Defects With a Custom-Made Cranioplasty From a Thin Titanium Sheet.

OBJECTIVE: The cosmetically good coverage of skull defects is a challenge in neurosurgical clinics. In addition, the skull treated with implants and the underlying structures must remain radiologically assessable. In this examination, the postoperative courses of patients after implantation of CranioTop is described. Digital x-ray, computed tomography, and magnetic resonance images after implantation of CranioTop were evaluated with regard to their assessability. MATERIALS AND METHODS: Between 2018 and 2020, 23 titanium cranioplasties (CranioTop) were implanted to 21 patients. The intraoperative handling, the accuracy of fit, the healing process, the cosmetic result and the physical condition of the patients were examined. In addition, digital x-rays, magnetic resonance imaging, and computed tomography scans of the cranium supplied with CranioTop were examined. RESULTS: The evaluation showed good to very good results regarding patients' satisfaction. There were no severe complications; thirteen patients found the cosmetic result very good; 8 patients assessed the cosmetic result as good. Because of the low thickness and density of the CranioTop plastic there was only low formation of radial stripe artifacts (streaking) and susceptibility artifacts. The assessment of digital x-ray, computed tomography, and magnetic resonance imaging images is possible after implantation of CranioTop. CONCLUSION: The patients treated with CranioTop showed a high level of satisfaction with regard to the cosmetic result and their physical condition. Furthermore, the cranium supplied with CranioTop remains well assessable in radiologic imaging with only slight limitations in magnetic resonance imaging.

Hemopatch® as a primary dural sealant in cranial neurosurgery: Technical note and a retrospective study.

OBJECTIVES: To determine the effectiveness and safety of Hemopatch® as a primary dural sealant in preventing CSF leakage following cranial surgery. Cerebrospinal fluid (CSF) leaks occur in cranial operations and are associated with significant patient burden and expense. The use of Hemopatch® as a dural sealant in cranial neurosurgical procedures is described and analyzed in this study. METHODS: Data were retrospectively collected from all patients who underwent a craniotomy for various neurosurgical indications where Hemopatch® was used as the primary dural sealant between June 2017 and June 2022. Infection and CSF leak were the main indicators evaluated after surgery. RESULTS: A total of 119 consecutive patients met our inclusion criteria. The median was age 41.5 years, and 52.5% were female. The mean follow-up period was 2.3 years (7 months to 6 years). There were 110 (92.44%) supratentorial and 9 (7.56%) infratentorial craniotomies. Postoperative CSF leak was reported in 2 patients (1.68%), one in each cohort. Postoperative infection occurred in one patient (0.84%). CONCLUSION: The results suggest that using Hemopatch® as a dural sealant in cranial surgery is effective and safe. After supra-/infratentorial craniotomies, the rate of postoperative adverse events in our sample was within the range of known surgical revision rates. Future randomized clinical studies are required to confirm our encouraging findings.

[Comparison of polymethyl methacrylate skull implant fixation by three types of titanium fasteners]. / Sravnenie sposobov fiksatsii implantov cherepa iz polimetilmetakrilata tremya vidami titanovykh krepezhei.

OBJECTIVE: To evaluate mechanical strength of three methods of polymethyl methacrylate skull implant fixation in two experimental models. MATERIAL AND METHODS: The first experiment was performed on a plastic model that was as close as possible to bone in structural characteristics. The second experiment was performed on a biological specimen (a ram's head). We assessed the quality of implant fixation to bone window edges by craniofixes, ties and microscrews and lateral intercortical screws. RESULTS: Craniofixes are feasible for small flat flaps, but not advisable for wide highly curved implants. They are also the most expensive method of fixation. Implant fixation by ties and microscrews is a universal method comparable in price to craniofix. Lateral intercortical fixation is effective both for small flat implants and wide implants with large curvature. However, this method is not always applicable. CONCLUSION: Combined fixation by lateral intercortical screws and ties allows for the most effective fixation while reducing the overall price of consumables.

Craniotomy Burr Hole Covers: A Comparative Study of Biomechanical, Radiological, and Aesthetic Outcomes Using 3 Different Plug Materials.

Burr holes in the cranial vault are usually made during trephination for craniotomy or drainage of chronic subdural hematomas. The resulting cranial defect might bring to unsatisfactory esthetic outcome. In the current study the authors report clinical data regarding a cohort of patients who were treated with 3 different types of burr hole covers; autologous bone dust from skull trephination, and 2 different types of cylindric plug made out of porous hydroxyapatite in order to evaluate medium and long-term esthetic and radiological outcomes. Twenty patients were consecutively enrolled in the study and in each patient all 3 types of materials were used to cover different holes. Clinical and radiological outcomes at 6 and 12 months, were analyzed for all 3 types of plugs in terms of thickness of the graft coaptation of margins, remodeling, fractures, mobilization, and contour irregularities. In all craniotomy holes filled with autologous bone dust the authors have observed partial or complete bone reabsorption at 1 year and in 60% of the cases a visible and palpable cranial vault contour irregularity was reported. Both types of bone substitutes gave satisfactory results, comparable to autologous bone dust at 6 months and superior at 12 months, especially in terms of thickness and esthetic appearance. Hydroxyapatite plugs have shown better esthetic and biomechanical results and higher patients' satisfaction compared to autologous bone dust while not giving any additional complications.

Infants With Trigonocephaly Treated With Fronto-Orbital Remodelling and Endocortical Positioning of Resorbable Plates-A Retrospective Cohort Study Including 101 Patients.

PURPOSE: Fronto-orbital remodeling is the gold standard for surgical treatment of metopic synostosis in many craniofacial centers. For fixation, resorbable materials are widely used. Because of swelling during resorption, the positioning of the plates can be relevant. Therefore, the goal of this study was to investigate whether there are limitations to endocortical positioning of resorbable plates. METHODS: In this retrospective study, all patients with metopic craniosynostosis resulting in trigonocephaly, who were treated with a standardized fronto-orbital remodeling and endocortical positioning of resorbable plates, between February 2012 and December 2019 were included. The endpoint of this study was the postoperative complications that can be attributed to the material used. RESULTS: A total of 101 patients, who were treated at our unit, could be included with a male predominance, 81 (80.2%) boys versus 20 (19.8%) girls. Surgery was performed at a median age of 9 months (±2.56). No complications were seen related to resorbable plates. All patients of our study population were categorized as Whitaker classification I and II. CONCLUSION: This study shows that the risk level in using endocortical resorbable plates positioned on the inner surface of the bone is low. From an aesthetic point of view, we could not detect any disadvantage.

Methylmetacrylate (PMMA) cranioplasty technique: Technical interest of intraoperative modeling and review of the literature.

Reconstruction of bone loss in the cranial vault may be necessary for functional or aesthetic reasons following trauma, decompression craniectomy, or craniofacial malformations. Many techniques have been described in the literature, using various materials, each with its own advantages and drawbacks. Reconstruction with polymethylmetacrylate cement has the advantage of a durable result and relative ease of use. In this article we present our cement cranioplasty technique through 4 clinical cases of cranial vault reconstruction, by direct intraoperative modeling on the bone defect. This accessible, effective method, applicable to all sizes of defect, remains an attractive option in the arsenal of techniques available today.

Mastication after craniotomy: pilot assessment of postoperative oral health-related quality of life.

BACKGROUND: Neurosurgical approaches to the brain often require the mobilization of the temporal muscle. Many patients complain of postoperative pain, atrophy, reduced mouth opening, and masticatory problems. Although the pterional, frontolateral-extended-pterional, and temporal craniotomies are the most frequently used approaches in neurosurgery, a systematic assessment of the postoperative oral health-related quality of life has never been performed so far. This study evaluates the oral health-related quality of life of patients after pterional, frontolateral-extended-pterional, or temporal craniotomy using a validated and standardized dental questionnaire, compares the results with the normal values of the general population, and investigates whether this questionnaire is sensitive to changes caused by surgical manipulation of the temporal muscle. METHODS: The "Oral Health Impact Profile" (OHIP14) is a validated questionnaire to assess the oral health-related quality of life. It asks the patients to assess their oral health situation within the past 7 days in 14 questions. Possible answers range from 0 (never) to 4 (very often). Sixty patients with benign intracranial processes operated through a lateral cranial approach were included. The questionnaire was answered before surgery (baseline) and 3 months and 15 months after surgery. RESULTS: Overall, postoperative OHIP scores increase significantly after 3 months and decrease after 15 months, but not to preoperative values. No factors can be identified which show a considerable relationship with the postoperative OHIP score. CONCLUSIONS: Postoperative impairment of mouth opening and pain during mastication can be observed 3 to 15 months after surgery and sometimes cause feedback from patients and their dentists. However, in line with existing literature, these complaints decrease with time. The study shows that the OHIP questionnaire is sensitive to changes caused by surgical manipulation of the temporal muscle and can therefore be used to investigate the influence of surgical techniques on postoperative complaints. Postoperatively, patients show worse OHIP scores than the general population, demonstrating that neurosurgical cranial approaches negatively influence the patient's oral health-related wellbeing. Larger studies using the OHIP questionnaire should evaluate if postoperative physical therapy, speech therapy, or specialized rehabilitation devices can improve the masticatory impairment after craniotomy. TRIAL REGISTRATION: Clinical trial register: DRKS00011096.

A novel omnidirectional tin-alloyed ring retractor for craniotomy in neurosurgery: technical note.

In neurosurgical operations, proper craniotomy using retractors is necessary. Various surgical instruments are used for this purpose, including standard retractors and multipurpose head frame retractor systems. However, the conventional multipurpose head frame system is often not optimal for use in some craniotomies and postures because of its size and complexity of setting. We have invented a new omnidirectional tin-alloyed (ODT) ring retractor for craniotomy with malleability and shape memory characteristics to resolve these issues. It is principally elliptical in shape, approximately 30 × 20 cm in diameter, and sufficiently firm. Accordingly, this ODT ring can retract the surgical field in all directions. Here, we report our experiences of 281 neurosurgical craniotomies using this ODT ring retractor system in various craniotomy sites and postures. Our novel ODT ring retractor is useful because of its low profile, multidirectional retractability, and less obstructiveness with its malleability. It could be used with pediatric patients where strong traction is not desirable.

GAPO syndrome with craniosynostosis and intracranial hypertension.

BACKGROUND: GAPO (growth retardation, alopecia, pseudoanodontia, and optic atrophy) as a rare genetic disorder includes growth retardation, alopecia, pseudoanodontia, and optic atrophy. It was reported to be associated with craniosynostosis and intracranial hypertension. CASE REPORT: A patient with such a rare disorder associated with multisuture craniosynostosis and headache is presented. Surgery has been done due to intracranial hypertension. CONCLUSIONS: Abnormal intraoperative findings including sever pericranium and dural adhesions and extraordinary bleeding related to this syndrome are described.

Orbital Roof Reconstruction Using Nylon Foil Implants.

PURPOSE: To describe a surgical technique of orbital roof reconstruction with a thin nylon foil implant. METHODS: This study is a description of a surgical technique with a retrospective chart review of 3 consecutive patients treated with a nylon foil implant for a complete superior orbital defect after meningioma resection via craniotomy approach. RESULTS: The nylon foil reconstruction achieved an anatomically stable orbit without globe dystopia, pulsatile proptosis, cerebrospinal fluid leak, or other serious cranio-orbital problems, in all cases. Postoperative visual acuity, pain, extraocular motility, proptosis, and globe position remained stable or improved in each case. There were no complications related to the orbital roof reconstruction. CONCLUSIONS: Nylon foil implantation was an effective and inexpensive surgical technique for orbital roof reconstruction after tumor resection in this small series.

Paediatric brain abscesses: a single centre experience.

Introduction: Brain parenchymal abscesses are relatively infrequent but potentially serious infections in the paediatric population. Surgical intervention in addition to a prolonged administration of antibiotics is generally appropriate management. This study presents our centre's experience of managing such patients in the context of relevant literature. Method: A single-centre retrospective case note review was conducted over a 15 year period (2003-2017). Patients were selected from electronic hospital records using ICD10 code G06.0. Patients < 18 years of age with a confirmed intra-parenchymal abscess were included. Patient records were reviewed for abscess location, microbiology results, surgical intervention, and outcome using the Glasgow Outcome Score at 3 months. Results: Twenty-four patients were identified (mean age: 7.4 ± 5.3 years, male n = 11). Twelve (50.0%) patients had an abscess in the frontal lobe and Streptococcus was the most common causative microorganism (n = 15). Nineteen patients (79.2%) had an identifiable source which included: ENT infections, congenital cardiac malformations, recent dental surgery and meningitis. All 24 patients underwent surgery with 20 patients having a total of 32 aspirations between them and the other 4 having craniotomy and excision. Twenty patients had 3 month follow-up data of which 18 patients scored GOS: 5, one was GOS: 4 and one was GOS: 3. Conclusions: Brain parenchymal abscess remains an uncommon pathology in the paediatric population. The majority of patients have a preceding infection with Streptococcus as the most common causative organism. Antimicrobial therapy should be selected accordingly. All of our patients underwent surgical intervention and received intravenous antibiotics with favourable outcome and no mortality.

Cost-Effective Technique of Fabrication of Polymethyl Methacrylate Based Cranial Implant Using Three-Dimensional Printed Moulds and Wax Elimination Technique.

OBJECTIVE: Cranioplasty is one of the oldest known neurosurgical procedure performed. Many materials have been used for cranioplasty since ages. Polymethyl methacrylate (PMMA) has become the workhorse for fabrication of cranial implants since World War II in cases where autologous bone is not available or cannot be harvested. The aim of the present study is to present author's experience in the management of cranioplasty using acrylic implants fabricated using 2 different techniques. METHODS: The author conducted a retrospective analysis of patients with extensive skull defects undergoing acrylic cranioplasties between October 2016 and January 2018. The surgical results were classified based on surgical time, blood loss, and the 3 scales of patient satisfaction, improvement of facial symmetry, and need for additional surgery along with the rate of wound complications. RESULTS: Thirty patients underwent cranioplasty with PMMA-based implants, whether fabricated using alginate impression technique (56.67%) or fabricated using 3-dimensional (3D) printed patient-specific moulds (43.33%). Complications included infection (13.3%). The authors considered the craniofacial aesthetics based on patient satisfaction excellent (69%) with the degree of improvement of craniofacial symmetry satisfactory (92.3%), and 1 patient requiring resurgery in alginate impression technique fabricated implants. CONCLUSION: The author recommends a unique technique for fabrication of PMMA-based implants using 3D printed moulds to achieve a better fitting implant and highly cosmetic outcome for cranioplasty at affordable cost.

Review of the Use of Stainless Wires in Craniosynostosis Surgery.

BACKGROUND: Controversy exists as to the ideal form of bone fixation in craniosynostosis surgery with the use of resorbable plates predominating in most craniofacial units. However, the use of stainless steel wires has been the preferred fixation method at the Oxford Craniofacial Unit (OCU) since its establishment. Wires have the advantage of being malleable, inexpensive, and quick and easy to use. METHODS: A retrospective review of all patients who underwent craniosynostosis surgery at the OCU between February 1995 and February 2017 was undertaken. Average follow-up period was 141 months (11.7 years), with a minimum of 6 months. RESULTS: A total number of 1226 craniosynostosis procedures were performed. A minimum of 16,160 wires were inserted. No complications were identified resulting from transdural migration of wires. One hundred fifty-six wires were removed in 92 patients during 109 general anesthetic day-care procedures. This was due to discomfort on palpation in the majority of cases. The average time from primary surgery to removal of wires was 37 months (3.1 years). The most common site for wire removal was in the supraorbital and lateral forehead regions, and occurred most frequently in children who had undergone fronto-orbital advancement and remodeling. CONCLUSION: The use of wires in craniofacial surgery is safe. One percent of all wires that were inserted had to be removed. Children undergoing primary craniosynostosis surgery have a 9% chance of needing a subsequent day-care procedure to have a wire removed. Taking into account the cost of this additional surgical procedure, the primary use of wires in craniosynostosis surgery is still significantly cheaper than the use of resorbable plates.

Transcranioplasty Ultrasound Through a Sonolucent Cranial Implant Made of Polymethyl Methacrylate: Phantom Study Comparing Ultrasound, Computed Tomography, and Magnetic Resonance Imaging.

BACKGROUND: Current methods of transcranial diagnostic ultrasound imaging are limited by the skull's acoustic properties. Craniotomy, craniectomy, and cranioplasty procedures present opportunities to circumvent these limitations by substituting autologous bone with synthetic cranial implants composed of sonolucent biomaterials. OBJECTIVE: This study examined the potential to image the brain using transcranioplasty ultrasound (TCU) through a sonolucent cranial implant. MATERIALS AND METHODS: A validated adult brain phantom was imaged using computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound without an implant. Next, for experimental comparison, TCU was performed through a sonolucent implant composed of clear polymethyl methacrylate. RESULTS: All imaging modalities successfully revealed elements of the brain phantom, including the bilateral ventricular system, the falx cerebri, and a deep hyperdense mass representing a brain tumor or hematoma. In addition, ultrasound images were captured which closely resembled axial images obtained with both CT and MRI. CONCLUSION: The results obtained in this first-ever, preclinical, phantom study suggest TCU is now a viable immediate and long-term diagnostic imaging modality deserving of further clinical investigation.

Cranioplasty Using Polymethylmethacrylate Cement Following Retrosigmoid Craniectomy Decreases the Rate of Cerebrospinal Fluid Leak and Pseudomeningocele.

OBJECTIVE: Cerebrospinal fluid (CSF) leak frequently occurs after retrosigmoid craniectomy. The present study investigated the effects of cranioplasty using polymethylmethacrylate (PMMA) cement to reduce the incidence of CSF leak following retrosigmoid craniectomy as compared with the autologous bone flap combined with titanium plates. METHODS: Two hundred forty-three patients underwent surgeries via retrosigmoid approach for microvascular decompression or tumor resection. Of these, 107 patients underwent craniotomy, and incomplete cranioplasty was performed with autologous bone flap fixed with titanium plates, while 136 patients underwent craniectomy and complete cranioplasty was performed with PMMA cement. Variables including the incidence of CSF leak, pseudomeningocele formation, wound infection, rejection reaction were compared retrospectively based on the clinical data between the 2 groups. RESULTS: In the autologous bone group, 9 patients had postoperative CSF leaks, and 11 patients had pseudomeningoceles, while 3 CSF leaks and 2 pseudomeningoceles were found in the PMMA group. Statistical analysis showed that PMMA significantly decreased the incidence of postoperative CSF leaks (P = 0.03) and pseudomeningocele formation (P = 0.002). Wound infections were observed in 2 and 1 patients between the autologous bone and PMMA group, respectively, which did not differ significantly (P = 0.58). None of the patients in both groups developed a rejection reaction of artificial materials. CONCLUSIONS: Complete cranioplasty with PMMA cement following retrosigmoid craniectomy could decrease the incidence of CSF leak and pseudomeningocele formation as compared with the autologous bone flap combined with titanium plates. Thus, PMMA cement is preferable for bone reconstruction with excellent biocompatibility and without increasing the rate of wound infection.

Cranioplasty With Mandibular Outer Cortex Bone Grafts.

BACKGROUND: Autologous bone grafts are still the best materials for calvarial reconstruction. In the past, rib, iliac crest, and cranial bone have been used for the reconstruction of the calvarial defects. However, the use of mandibular outer cortex bone graft in calvarial defects reconstruction is poorly reported in literature. This study focused on using the mandibular outer cortex bone grafts for calvarial defects. METHODS: From October 2004 to July 2016, there were a total of 13 patients in this study who underwent cranioplasty with mandibular outer cortex bone grafts to reconstruction calvarial defects. All the patients were followed up for at least 6 months. RESULTS: The majority of the patients were satisfied with the reconstructive outcome. CONCLUSION: The authors consider the mandibular outer cortex bone graft can achieve excellent esthetic results in selected cranioplasty reconstructions.

Ring graft technique for microvascular decompression.

INTRODUCTION: Various nerve compression syndromes, such as trigeminal neuralgia (TN), glossopharyngeal neuralgia (GN), and hemifacial spasm (HFS), are caused by compression of the concerned nerve by the adjacent vessel. Patients who do not respond to medical management are usually treated by "microvascular decompression (MVD) of the nerve." Teflon patch graft is the most commonly used material for MVD. This graft has been used in various shapes like a patch, in the shredded form, or as a sling. This is done to prevent recurrence because of graft failure. We used a teflon ring graft to perform a successful MVD in 10 patients. MATERIAL AND METHODS: Out of 10 cases, 6 cases were of TN, 2 of HFS, 1 of GN, and 1 case was of cochleovestibular nerve compression syndrome (CNCS). After MVD, every patient underwent a follow up assessment for 5 years. RESULTS: There was no major postoperative complication, except in the patient with CNCS who suffered from a temporary episode of facial palsy. All cases were symptom free at a follow-up duration of equal to or more than 5 years. CONCLUSION: Ring teflon graft may be used as an alternative as well as a safe method to perform MVD and has a good success rate.

Evaluation of locally manufactured patient-specific custom made implants for cranial defects using a silicone mould.

BACKGROUND: Cranial vault defects can pose a significant problem for neurosurgeons where autologous bone is no longer available for cranioplasty. Numerous materials exist to create implants which include polymethyl methacrylate (PMMA) and titanium. A technique using 3-dimensional CT scan reconstruction of a cranial defect and creating a silicon mould which can be autoclaved in theatre to create a PMMA implant was developed. OBJECTIVE: The aim of this study is to evaluate the efficacy, cosmetic result, safety and cost-effectiveness of this procedure and compare this to existing techniques. METHOD: An ambispective study was performed in patients requiring cranioplasty with a custom made implant. Patients were assessed for risk factors and cosmetic outcome, surgical technique was described and complications and cost compared to existing literature between 2010 and 2016. RESULTS: Thirty retrospective and 30 consecutive prospective patients were recruited into the study. Overall sepsis rate was 8.3%. All septic cases had superficial sepsis of which 2 grafts were removed due to cerebrospinal fluid leakage resulting in wound breakdown. A 100% accurate implant to defect ratio was achieved leading to a high satisfaction rate. Average cost was 5 times cheaper than the closest market related product. CONCLUSION: Patient specific moulds using PMMA to create custom implants are safe, have excellent cosmetic results and are a very cost-effective option to manage cranial defects. Accurate planning strategies for large craniotomies, where bone will potentially be discarded, add to surgical effectiveness and cost-saving to the patient.

Long-Term Outcomes of Pediatric Cranial Reconstruction Using Resorbable Plating Systems for the Treatment of Craniosynostosis.

BACKGROUND: Resorbable plating in cranial reconstruction for craniosynostosis has fewer reported complications than rigid hardware. Few long-term outcome studies exist for pediatric patients treated with this technology for cranial vault reconstruction. METHODS: A retrospective review was performed on pediatric patients undergoing cranial vault reconstruction for craniosynostosis by 3 surgeons over a 15-year period. MacroPore (Cytori Therapeutics, San Diego, CA) or Lactosorb (Walter Lorenz Surgical Inc, Jacksonville, FL), composed of polyglycolic and polylactic acids, was used for resorbable plate fixation. RESULTS: A total of 203 patients underwent resorbable plate fixation with a mean age of 15.8 months at surgery. Mean length of follow-up was 6.4 years. Lactosorb plating system was used in the majority of patients (74%) compared with MacroPore plating system (26%). Overall, unplanned reoperations were required in 5.4% of patients. Palpable hardware was noticed in 10.3% of patients. Only 3 patients (1.5%) developed exposure of the resorbable hardware requiring removal, all MacroPore plates. Four patients (2%) developed surgical site infection and 3 patients (1.5%) developed a seroma. There were 15.8% requiring later surgical revision with cranial vault expansion or cranioplasty with grafts for residual cranial defects. The majority of revisional reoperations (81%) occurred in the first half of the study before the addition of Allogenix. CONCLUSIONS: Resorbable plating systems, specifically Lactosorb, for cranial reconstruction are a safe, reproducible, inexpensive modality with very low complication rates. They have 3-dimensional stability, rigid fixation without causing growth restriction, and lower likelihood of need for removal.