Potential reasons for failure and recurrence in microvascular decompression for hemifacial spasm.

BACKGROUND: To examine the factors contributing to persistent and recurrent hemifacial spasms (HFS) following a microvascular decompression (MVD) procedure and to suggest technical improvements to prevent such failures. METHODS: A retrospective review was conducted on fifty-two cases of repeat surgery. The extent of the previous craniotomy and the location of neurovascular compression (NVC) were investigated. The operative findings were categorized into two groups: "Missing Compression" and "Teflon Contact". The analysis included long-term outcomes and operative complications after repeat MVD procedures. RESULTS: Missing compression was identified in 29 patients (56%), while Teflon contact was observed in 23 patients (44%). Patients with missing compression were more likely to experience improper craniotomy (66%) compared to those with Teflon contact (48%). Medially located NVC was a frequent finding in both groups, mainly due to compression by the anterior inferior cerebellar artery. In the missing compression group, during the repeat MVD, Teflon sling retraction was utilized in 79% of cases, while in the Teflon contact group, the most common procedure involved removing the Teflon in contact (65%). After the repeat MVD procedure, immediate spasm relief was achieved in 42 patients (81%), with six (12%) experiencing delayed relief. After a median follow-up of 54 months, 96% of patients were free from spasms. Delayed facial palsy, facial weakness, and hearing impairment were more frequently observed in the Teflon contact group. CONCLUSIONS: A proper craniotomy that provides adequate exposure around the REZ is crucial to prevent missing the culprit vessel during the initial MVD procedure. Teflon contact on the REZ should be avoided, as it poses a potential risk of procedure failure and recurrence.

Preauricular retromandibular trans tympanic plate and styloid process keyhole approach to parapharyngeal lesions: a laboratory study.

BACKGROUND: The surgical removal of the infratemporal parapharyngeal lesions (IPL) is challenging due to its anatomical complexity. Previous surgical approaches have often been too invasive and necessitated sacrifice of normal function and anatomical structures, particularly in the retromandibular nerve region. Therefore, we sought to identify an approach corridor to this area that requires less sacrifice and report an innovative approach through a retromandibular fossa route to the IPL. METHODS: Five cadaveric specimens were dissected bilaterally with a trans-tympanic plate and styloid process approach. These specimens were investigated microanatomically and morphometrically to examine the extent of the approach in the parapharyngeal space. The clinical application of this approach was compared to previous approaches to the IPL used in our clinical series of 20 cases. RESULTS: Using this novel approach, the inferior alveolar nerve was identified in all specimens, while the chorda tympani and lingual nerve were identified in 6 (60%) and 4 (40%) dissections, respectively. In all specimens, the petrous portion of the internal carotid artery and the exit of the lower cranial nerve were identified. The average length of the exposed lower cranial nerves was 16.6 ± 3.8 mm (range: 11-25 mm). CONCLUSIONS: The described approach is feasible for accessing the IPL at the retromandibular nerve and is less invasive than conventionally used approaches.

Introduction of Triptycene with a Particular Substitution Pattern into Polymer Chains Can Dramatically Improve the Structural and Rheological Properties.

Although a large number of polymers that contain triptycene units in the main chains have been developed, no polymer design using 1,8-substituted triptycene has been reported to date. In this study, we investigated the properties of linear homo- and copolymers obtained by ring-opening polymerization of a triptycene monomer bearing a macrocyclic olefin linked at its 1,8-position and its copolymerization with cyclooctene, respectively. We found that the introduction of triptycene with this substitution pattern leads to nanoscale molecular ordering, thereby greatly improving the physical properties of the polymers. The key to this remarkable behavior of 1,8-substituted triptycene-containing polymers is the formation of a particular two-dimensional assembly of the triptycene units by nested hexagonal packing, which aligns one-dimensionally while folding the polymer chains into a well-defined layered structure. The polymer design using 1,8-substituted triptycene can be applied to other polymers, unless their main chain contains functional groups capable of a strong intermolecular interaction such as hydrogen bonding.

Skull base training and education using an artificial skull model created by selective laser sintering.

INTRODUCTION: Practicing skull base approaches on cadavers affords the surgeon a chance to learn complex anatomical relationships and to practice surgical skills. However, there are ethical or legal problems in obtaining cadaver material in some countries. In addition, there is always risk of transmitting infections with cadaveric material. In order to get around these problems, we created a whole skull model which reproduces the detailed anatomy within the skull base using a selective laser sintering (SLS) technique. MATERIALS AND METHODS: The first author's head was scanned using multidetector-row computed tomography. The data were reconstructed and converted into the standard triangulation language file system. Powdered material comprised of polyamide nylon and glass beads was laser-sintered in accord with the data derived from the head CT. The model was dissected under a surgical microscope using a high-speed drill, suction, and other surgical instruments. RESULTS AND DISCUSSION: The appearance of both inner and outer cranial surfaces, including sutures, foramens, fissures, and protrusions, were clearly demonstrated. The artificial mastoid did not melt from the heat of the drill when a mastoidectomy was performed. The anatomical structures inside the mastoid and of paranasal sinuses were accurately reproduced in the model. CONCLUSION: The model created using SLS should be very useful for the teaching skull base approaches avoiding the ethical, legal, and infection problems inherent in cadavers.

Simple identification of the third segment of the extracranial vertebral artery by extreme lateral inferior transcondylar-transtubercular exposure (ELITE).

PURPOSE: The exposure of the third segment of the extracranial vertebral artery (V3) is an important step in the extreme lateral inferior transcondylar-transtubercular exposure (ELITE) approach. The muscular suboccipital triangle provides one of the landmarks to identify the V3 segment; however, identification of this triangle and dissection of the V3 segment is not always straightforward in the actual surgery. Blind dissection below the level of the foramen magnum can lead to vertebral artery injury. While the surgeon may be able to readily define the V3 segment of the vertebral artery by feeling its pulse, it is important to have a safe systematic approach to finding the V3 segment when the vessel is illusive. We propose a simple method to identify the V3 segment avoiding accidental injury of the vertebral artery. METHODS: Sixteen cadaver heads (using both sides) were prepared by injecting red- or blue-coloured silicone into their arteries and veins, respectively. We performed an ELITE bilaterally on each cadaver head following four key bony landmarks. A postauricular lazy S-shaped skin incision was made centered just behind the mastoid tip. The posterior neck muscles were cut along the line of the skin incision behind the attachment of the sternocleidomastoid muscle to expose the occipital bone. All the incised muscles were reflected anteriorly as the ELITE is a dorsolateral approach. A suboccipital craniotomy was made exposing the posterior half of the sigmoid sinus up to the inferior retrosigmoid point (point A). The foramen magnum was opened after the craniotomy was completed. The dura on the foramen magnum was followed posteriorly in order to identify the occipital midline dural point (point B) that is identified by the bony ridge at the junction of the posterior fossa dura on the foramen magnum and the posterior most aspect of the spinal dura. The posterior tubercle of C1 (point C) was identified directly inferior to Point B. The posterior arch of C1 was followed anteriorly from the tubercle to find the "J-groove", which cradles the vertebral artery (point D). The V3 segment lies above this groove, covering the paravertebral venous plexus. We measured the distances between the landmarks introduced above after completion of the exposure. RESULTS: The distance between points A and B was 30.5 +/- 5.6 mm, points B-C was 10.4 +/- 2.3 mm, points C-D was 19.1 +/- 3.8 mm. The V3 segment was identified using the anatomical relationships described above in all heads. In no cadaver specimen was the artery injured. CONCLUSIONS: Identification of the V3 segment of the vertebral artery by systematically detecting the four anatomical points defined above is simple and much safer than a direct dissection below the foramen magnum.

Visualization of Dark Side of Skull Base with Surgical Navigation and Endoscopic Assistance: Extended Petrous Rhomboid and Rhomboid with Maxillary Nerve-Mandibular Nerve Vidian Corridor.

BACKGROUND: Lesions located at the petrous apex, cavernous sinus, clivus, medial aspect of the jugular foramen, or condylar regions are still difficult to fully expose using the operating microscope. Although approaches to this region through the middle cranial fossa have been previously described, these approaches afford only limited visualization. We have confirmed a transcranial infratemporal fossa combined microsurgical and endoscopic access to the petrous apex, clivus, medial aspect of the jugular foramen, and occipital condyle. We have presented the results of a micro-anatomical cadaver dissection study and its clinical application. METHODS: Ten latex-injected cadaveric specimens (20 twenty sides) underwent dissection with navigational guidance to achieve an extended anterior petrosal approach combined with a far vidian corridor approach (between the foramen rotundum and foramen ovale). We performed anatomical dissections to confirm the surgical anatomy and the feasibility and limitations of this approach. Anatomical dissections were performed in the skull base laboratory of Lariboisière Hospital and Duke University Medical Center. This approach was then applied to some clinical cases. RESULTS: The combination of the microscope and endoscope, aided by surgical navigation, was extremely effective and provided a wide view of the petrous rhomboid, the entire clivus, and the medial condylar regions. The extended extradural anterior petrosal approach provided a large corridor to petrous and clival lesions. Endoscopic assistance allows for wide and deep exposure of the middle to lower clivus, epipharyngeal space, and bilateral condylar regions. This approach successfully provided adequate surgical access for resection of tumors located in these regions. The depth of the medial aspect of the jugular foramen was 16.3 ± 1.2 mm deep from the geniculate ganglion. The emerging point of the inferior petrosal sinus in the jugular foramen was 16.5 ± 1.8 mm deep from the geniculate ganglion. The hypoglossal canal was 21.6 ± 2.2 mm deep from the geniculate ganglion. The foramen magnum was located 31.5 ± 2.4 mm deep from the gasserian ganglion. The inferior petrosal sinus was found to be a reliable landmark to identify the medial portion of the jugular bulb. The introduction of the endoscope through the middle fossa rhomboid enabled visualization of the medial aspect of the jugular bulb, which otherwise would be hampered by the internal auditory canal under the microscope. CONCLUSION: After microscopic exposure of the middle fossa rhomboid, neuronavigational endoscopic assistance facilitated visualization of the ventral cavernous region, petrous apex, retropharyngeal space, and middle and inferior clivus down to the medial aspect of the jugular bulb and condyle regions. Additional maxillary nerve-mandibular nerve vidian corridor visualization provides a lateral transsphenoidal approach to upper clivus lesions.

Extended middle fossa approach to lateralized pontine cavernomas in children.

OBJECTIVE Treatment of hemorrhagic cavernous malformations within the lateral pontine region demands meticulous surgical planning and execution to maximize resection while minimizing morbidity. The authors report a single institution's experience using the extended middle fossa rhomboid approach for the safe resection of hemorrhagic cavernomas involving the lateral pons. METHODS A retrospective chart review was performed to identify and review the surgical outcomes of patients who underwent an extended middle fossa rhomboid approach for the resection of hemorrhagic cavernomas involving the lateral pons during a 10-year period at Rady Children's Hospital of San Diego. Surgical landmarks for this extradural approach were based on the Fukushima dual-fan model, which defines the rhomboid based on the following anatomical structures: 1) the junction of the greater superficial petrosal nerve (GSPN) and mandibular branch of the trigeminal nerve; 2) the lateral edge of the porus trigeminus; 3) the intersection of the petrous ridge and arcuate eminence; and 4) the intersection of the GSPN, geniculate ganglion, and arcuate eminence. The boundaries of maximal bony removal for this approach are the clivus inferiorly below the inferior petrosal sinus; unroofing of the internal auditory canal posteriorly; skeletonizing the geniculate ganglion, GSPN, and internal carotid artery laterally; and drilling under the Gasserian ganglion anteriorly. This extradural petrosectomy allowed for an approach to all lesions from an area posterolateral to the basilar artery near its junction with cranial nerve (CN) VI, superior to the anterior inferior cerebellar artery and lateral to the origin of CN V. Retraction of the mandibular branch of the trigeminal nerve during this approach allowed avoidance of the region involving CN IV and the superior cerebellar artery. RESULTS Eight pediatric patients (4 girls and 4 boys, mean age of 13.2 ± 4.6 years) with hemorrhagic cavernomas involving the lateral pons and extension to the pial surface were treated using the surgical approach described above. Seven cavernomas were completely resected. In the eighth patient, a second peripheral lesion was not resected with the primary lesion. One patient had a transient CN VI palsy, and 2 patients had transient trigeminal hypesthesia/dysesthesia. One patient experienced a CSF leak that was successfully treated by oversewing the wound. CONCLUSIONS The extended middle fossa approach can be used for resection of lateral pontine hemorrhagic cavernomas with minimal morbidity in the pediatric population.

Dramatic effect of dispersed carbon nanotubes on the mechanical and electroconductive properties of polymers derived from ionic liquids.

Free-radical polymerization of an imidazolium ion-based ionic liquid bearing a methacrylate group, gelling with single-walled carbon nanotubes (SWNTs), allows fabrication of a mechanically reinforced, electroconductive soft material (bucky plastic). A film sample of this material displays an excellent conductivity of 1 S cm(-1) and a 120-fold enhancement of the Young's modulus at a 7 wt % content of SWNTs. The conductivity is temperature-dependent in the range 5-300 K, suggesting that the conductive process involves carrier hopping. Scanning electron and atomic force micrographs of a bucky plastic film display the presence of crosslinked networks consisting of finely dispersed SWNTs. Such nanotube networks, developed in the polymer matrix, likely suppress slipping of entrapped polymer molecules via a strong interfacial interaction and also facilitate intertubular carrier transport. Although a bucky plastic derived from a vinylimidazolium ion-based ionic liquid monomer shows a comparable conductivity to that of the methacrylate version, the film is brittle irrespective of the presence or absence of SWNTs.

Bioinspired design of a polymer gel sensor for the realization of extracellular Ca(2+) imaging.

Although the role of extracellular Ca(2+) draws increasing attention as a messenger in intercellular communications, there is currently no tool available for imaging Ca(2+) dynamics in extracellular regions. Here we report the first solid-state fluorescent Ca(2+) sensor that fulfills the essential requirements for realizing extracellular Ca(2+) imaging. Inspired by natural extracellular Ca(2+)-sensing receptors, we designed a particular type of chemically-crosslinked polyacrylic acid gel, which can undergo single-chain aggregation in the presence of Ca(2+). By attaching aggregation-induced emission luminogen to the polyacrylic acid as a pendant, the conformational state of the main chain at a given Ca(2+) concentration is successfully translated into fluorescence property. The Ca(2+) sensor has a millimolar-order apparent dissociation constant compatible with extracellular Ca(2+) concentrations, and exhibits sufficient dynamic range and excellent selectivity in the presence of physiological concentrations of biologically relevant ions, thus enabling monitoring of submillimolar fluctuations of Ca(2+) in flowing analytes containing millimolar Ca(2+) concentrations.

Ultraflexible organic amplifier with biocompatible gel electrodes.

In vivo electronic monitoring systems are promising technology to obtain biosignals with high spatiotemporal resolution and sensitivity. Here we demonstrate the fabrication of a biocompatible highly conductive gel composite comprising multi-walled carbon nanotube-dispersed sheet with an aqueous hydrogel. This gel composite exhibits admittance of 100 mS cm(-2) and maintains high admittance even in a low-frequency range. On implantation into a living hypodermal tissue for 4 weeks, it showed a small foreign-body reaction compared with widely used metal electrodes. Capitalizing on the multi-functional gel composite, we fabricated an ultrathin and mechanically flexible organic active matrix amplifier on a 1.2-µm-thick polyethylene-naphthalate film to amplify (amplification factor: ∼200) weak biosignals. The composite was integrated to the amplifier to realize a direct lead epicardial electrocardiography that is easily spread over an uneven heart tissue.

Midsubtemporal ridge as a predictor of the lateral loop formed by the maxillary nerve and mandibular nerve: a cadaveric morphological study.

BACKGROUND: The lateral loop formed by the maxillary nerve (V2) and the mandibular nerve (V3) consists of a part of the far lateral triangle of the cavernous sinus. Because this triangle becomes a surgical corridor of the preauricular infratemporal fossa approach and a landmark of the extradural approach for the ganglion-type trigeminal schwannomas, identification of the lateral loop has important implications at the early stage of middle cranial base surgery. We realized that a bony ridge usually existed just lateral to the lateral loop. OBJECTIVE: To nominate midsubtemporal ridge (MSR) as the name for this anatomically unnamed bony ridge and to clarify its features. METHODS: Using 35 cadaver heads, we measured the shape of the MSR on both sides and the distance between the MSR and the adjacent structures. RESULTS: The MSR was recognized in 60 of 70 specimens (85.7%). The bony protrusion was 2.9 ± 1.1 mm in height, 6.0 ± 2.1 mm in width, and 9.1 ± 3.2 mm in length. A single peak with anteroposterior length was common in 47 of 60 specimens (78.3%). The MSR was located at the midpoint of the V2 and V3 in 28 specimens (46.7%) and existed 10.7 ± 3.6 mm lateral from the line that bound the foramen rotundum and the foramen ovale. CONCLUSION: We demonstrate morphological characteristics of the MSR. These data on the MSR will assist the surgeon in identifying the lateral loop as a surgical landmark during middle cranial base surgery.

Redox-responsive molecular helices with highly condensed π-clouds.

Helices have long attracted the attention of chemists, both for their inherent chiral structure and their potential for applications such as the separation of chiral compounds or the construction of molecular machines. As a result of steric forces, polymeric o-phenylenes adopt a tight helical conformation in which the densely packed phenylene units create a highly condensed π-cloud. Here, we show an oligomeric o-phenylene that undergoes a redox-responsive dynamic motion. In solution, the helices undergo a rapid inversion. During crystallization, however, a chiral symmetry-breaking phenomenon is observed in which each crystal contains only one enantiomeric form. Crystals of both handedness are obtained, but in a non-racemic mixture. Furthermore, in solution, the dynamic motion of the helical oligomer is dramatically suppressed by one-electron oxidation. X-ray crystallography of both the neutral and oxidized forms indicated that a hole, generated upon oxidation, is shared by the repeating o-phenylene units. This enables conformational locking of the helix, and represents a long-lasting chiroptical memory.

Fractionated stereotactic radiotherapy as a boost treatment for tumors in the head and neck region.

The objective of this retrospective study was to report initial results of CyberKnife stereotactic radiotherapy (SRT) boost for tumors in the head and neck area. Between March 2008 and August 2009, 10 patients were treated with SRT boost using CyberKnife system due mainly to unfavorable condition such as tumors in close proximity to serial organs or former radiotherapy fields. Treatment sites were the external auditory canal in two, the nasopharynx in one, the oropharynx in three, the nasal cavity in one, the maxillary sinus in two, and the oligometastatic cervical lymph node in one. All patients underwent preceding conventional radiotherapy of 40 to 60 Gy. Dose and fractionation scheme of the Cyberknife SRT boost was individualized, and prescribed dose ranged from 9 Gy to 16 Gy in 3 to 4 fractions. Among four patients for whom dose to the optic pathway was concerned, the maximum dose was only about 3 Gy for three patients whereas 9.6 Gy in the remaining one patient. The maximum dose for the mandible in one of three patients with oropharyngeal cancer was 19.7 Gy, whereas majority of the bone can be spared by using non-isocentric conformal beams. For a patient with nasopharyngeal cancer, the highest dose in the brain stem was 15 Gy. However, majority of the brain stem received less than 40% of the maximum dose. Although a small volume high dose area within the normal structure could be observed in several patients, results of the present study showed potential benefits of the CyberKnife SRT boost.

Formation of water-dispersible nanotubular graphitic assembly decorated with isothiouronium ion groups and its supramolecular functionalization.

A newly designed Gemini-shaped hexabenzocoronene amphiphile (1), carrying an isothiouronium ion-appended side chain, self-assembles in CH2Cl2 to form a nanotubular object, whose graphitic wall is densely covered by a positively charged molecular layer of isothiouronium ion pendants. The graphitic nanotube can be dispersed uniformly in aqueous media owing to effective hydration as well as electrostatic repulsion. Post-supramolecular functionalization of the nanotube surface is possible, without disruption of the tubular morphology, by taking advantage of a specific interaction of the isothiouronium ion pendants with oxoanion guests. Mixing with sodium poly(4-styrenesulfonate) results in wrapping of the nanotube, while complexation with an electron-accepting oxoanion such as anthraquinone carboxylate allows photoinduced electron transfer from the graphitic wall to the bound guest molecules.

Stabilization of a kinetically favored nanostructure: surface ROMP of self-assembled conductive nanocoils from a norbornene-appended hexa-peri-hexabenzocoronene.

Newly designed norbornene-appended hexabenzocoronene 1 self-assembles, upon diffusion of an Et(2)O vapor into its CH(2)Cl(2) solution, to form either graphitic nanocoils or nanotubes, depending on the self-assembling conditions. The coiled assembly, selectively formed at 15 degrees C, is a kinetic intermediate for the tubular assembly and transforms into nanotubes on standing at 25 degrees C. However, post-ring-opening metathesis polymerization of the norbornene pendants of 1 enhances the thermal stability of the coiled assembly as well as the tubular one and disables a thermodynamic coil-to-tube transition. The polymerized nanocoils show an electroconductivity of 1 x 10(-)(4) S cm(-)(1) upon doping with I(2), while the nonpolymerized nanocoils are disrupted upon being doped.