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BACKGROUND: The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery. METHODS: This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis. RESULTS: Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001). CONCLUSIONS: The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.
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Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagen , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Estudios ProspectivosRESUMEN
PURPOSE: Posterior fossa tumors are the most frequent pediatric solid tumor. Its main treatment is a surgical resection. Being a frequent procedure does not mean that it is exempt from complications, such as surgical site infections (SSI). The main objective of this paper is to study the risk factors associated with SSI following a resection of posterior fossa tumors in a purely pediatric population. METHODS: A retrospective case-control study including all posterior fossa tumor surgeries performed at our hospital between January 2014 and December 2019 was conducted. All patients with a diagnosis of a postoperative SSI have been included as cases, and those who had surgery and no infectious complications have been considered as controls. RESULTS: When analyzing risk factors, we have found that patients with ventriculoperitoneal shunt (VPS) (p = 0.03) or external ventricular drainage (EVD) (p = 0.005) placement had a greater chance of presenting a postoperative surgical site infection. Prolonged operative time (p < 0.001) and cerebrospinal fluid (CSF) leak through the wound (p = 0.002) also caused an increase in the risk of SSI in the postoperative period. A higher hemoglobin value (p = 0.002) would seem to be a preventive factor. CONCLUSIONS: Some strategies that could help to reduce the risk of infections are managing hydrocephalus preferably with endoscopic third ventriculostomy, minimizing the needed operative time to perform the procedure, obtaining an adequate serum hemoglobin level, and avoiding CSF leak through the wound.
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Hidrocefalia , Neoplasias Infratentoriales , Estudios de Casos y Controles , Niño , Humanos , Hidrocefalia/etiología , Hidrocefalia/cirugía , Neoplasias Infratentoriales/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , VentriculostomíaRESUMEN
BACKGROUND: The sellar barrier concept reflects the association between the components of the roof of the pituitary fossa and the risk of intraoperative cerebrospinal fluid (CSF) leak in the surgery of pituitary adenomas. We based our concept in previous reports on the microsurgical anatomy of the pituitary fossa's superior wall. However, proof of the usefulness of this concept in endoscopic approaches is yet missing. The aim of this study was to describe the endoscopic anatomy of the sellar barrier and its subtypes in a laboratory setting and to provide evidence of its clinical usefulness. METHODS: We provided anatomical models in six fresh-frozen head and neck specimens. We performed an endoscopic endonasal approach and recreated a pathological model of each possible subtype of sellar barrier. To demonstrate the usefulness of this model in clinical practice, we conducted a prospective study including all patients with pituitary adenoma operated by an endoscopic approach between June and July 2019. RESULTS: We successfully recreated the models for each subtype of sellar barrier. When analyzing the clinical cases, we found that intraoperatively, 73.69% (14) had a strong sellar barrier; 21.05% (4) had mixed sellar barrier, and 5.26% (1) had weak sellar barrier. We recorded one case of intraoperative CSF leak in a patient with a weak sellar barrier by magnetic resonance imaging. CONCLUSION: We described the endoscopic anatomy of the sellar barrier and we recreated the three subtypes in anatomical models. We also identified these subtypes in a series of clinical cases, proving its clinical usefulness.
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Adenoma/cirugía , Pérdida de Líquido Cefalorraquídeo/prevención & control , Endoscopía , Modelos Anatómicos , Neoplasias Hipofisarias/cirugía , Silla Turca/anatomía & histología , Adulto , Anciano , Cadáver , Femenino , Humanos , Masculino , Persona de Mediana Edad , Quirófanos , Estudios ProspectivosRESUMEN
Primary central nervous system lymphoma (PCNSL) is an infrequent form of non-Hodgkin lymphoma restricted to the CNS. More than 90% are type B and mainly affect patients aged 50-70 years. Immunodeficiency is the most important risk factor. The aim of our study was to evaluate the immune status, clinical presentation and findings in complementary studies of PCNSL patients. A retrospective analysis of 48 cases treated in our center between January 1992 and May 2015 was performed. Median age at diagnosis was 61 years (range 25-84); with male predominance (2.1:1). Forty one cases (85%) were immunocompetent patients. Brain MRI findings showed parenchymal involvement in 45 cases (94%), 43% with frontal lobe and 35% basal ganglia, 4% had meningeal involvement and 2% had ophthalmic involvement at diagnosis. Fifty-five percent had restricted signal on diffusion weighted imaging and contrast enhancement was found in 89%. Pyramidal syndrome was the main initial clinical manifestation (56%). There were abnormal findings in 62% of CSF samples, but in only 11.1% positive cytology results were detected. The most frequent type was diffuse large B-cell lymphoma (83%), being B-cell type the most common form between them (96%). In our series PCNSL was more frequent in immunocompetent elderly male subjects. At initial evaluation, clinical manifestations and MRI findings were variable. The initial suspicion of this entity would allow an early diagnosis, avoiding empirical treatments that may confuse or delay diagnosis.
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Neoplasias del Sistema Nervioso Central , Linfoma , Adulto , Anciano , Anciano de 80 o más Años , Biopsia , Neoplasias del Sistema Nervioso Central/complicaciones , Neoplasias del Sistema Nervioso Central/diagnóstico , Neoplasias del Sistema Nervioso Central/inmunología , Femenino , Humanos , Linfoma/complicaciones , Linfoma/diagnóstico , Linfoma/inmunología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Distribución por SexoRESUMEN
The coincidence in a patient of Hemifacial Spasm and Trigeminal Neuralgia is not frequent. A case is presented with the objective of showing this association due to the abnormal activation of the Trigemino-Facial Reflex. A 55-year-old woman with an 8-year history of left-sided hemifacial spasm and typical trigeminal pain in the ipsilateral V1 and V2 territory. The physical examination shows spasms in the left hemiface, with reproduction of intense pain upon sensory stimulation of the skin on the forehead and upper dental arch. The MRI showed a vessel in intimate contact with the entrance area of ââthe left trigeminal nerve. A left retrosigmoid approach was performed. First, the entrance area of ââthe trigeminal nerve was accessed, finding a clear vascular conflict, which was isolated with Teflon. Then, the trajectory was changed and the exit zone of the facial nerve was accessed, and no type of vascular conflict was identified. The patient presented complete resolution of the Hemifacial Spasm and the associated trigeminal pain. The analysis of this case allows us to conclude that during microvascular decompression of the Facial Nerve, if frank proximal compression is not evident, the Trigeminofacial structural relationship must be taken into account, making it necessary to explore the Trigeminal Nerve.
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Large meningiomas extending through the middle cranial fossa, posterior fossa, and foramen magnum (FM) represent a surgical challenge even for experienced skull base surgeons.1 Although decompression may be necessary for offering clinical improvement, surgical risks may involve cranial nerves and vascular injury. We present a case of a sphenocavernopetroclival-FM meningioma, with our surgical plan extending through the sphenoid region, FM, and posterior fossa to the anterior arch of C1. We designed a 2-day, 3-stage surgical strategy to achieve complete surgical resection for offering better long-term prognosis and satisfactory postoperative neurological outcome.2 The surgical plan was completed in 2 days of surgery: the first day the extradural part for achieving optimal tumor exposure and the second day the intradural part to tackle tumor resection in a 3-stage fashion. The first stage consisted in a far lateral approach to access the lower portion of the tumor extending from the FM to the spinal region; the second stage focused on the portion of the tumor extending through the inferior clivus and the petroclival region; and the third stage consisted in resecting the tumor extending from the petroclival region to the sphenoid region.3 A near-total resection was achieved, with a very small tumor remnant observed at the level of the tentorium on postoperative MRI, which was treated with radiosurgery owing to the young age of the patient. This is a 3-dimensional operative video showing the surgical steps of the tumor resection. The patient consented to the procedure and to the publication of her image.
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OBJECTIVE: The pterional approach is the workhorse of skull-base neurosurgery, which allows virtual access to any intracranial lesion around the circle of Willis. Preserving the frontotemporal branch of the facial nerve and conserving the temporal muscle's symmetry are fundamental objectives besides the access that can be obtained through this versatile neurosurgical technique. This manuscript proposes a subgaleal preinterfascial dissection, a novel hybrid technique that provides advantages of previously described temporal muscle dissection techniques while preserving the integrity of facial nerve branches and the unobstructed broad pterional region. We describe the subgaleal preinterfascial dissection as a safe and simple to technique to achieve preservation of the facial nerve frontal branches during anterolateral approaches. METHODS: Two cadaveric heads were skillfully dissected and studied to perform a proper subgaleal preinterfascial dissection on both sides of each cadaver. Afterward, the same technique was employed in 108 patients during a pterional approach for different neurosurgical diseases, with a postoperative follow-up of 6 months. RESULTS: None of the 108 patients presented postoperative frontotemporal branch palsy during postoperative follow-up. Likewise, no complications related to the proposed technique were present. CONCLUSIONS: The subgaleal preinterfascial dissection is a reliable, safe technique that may be employed during a pterional approach with an unobstructed surgical view and excellent cosmetic and functional results, preserving the frontotemporal branch of the facial nerve.
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Craneotomía , Nervio Facial , Humanos , Nervio Facial/cirugía , Nervio Facial/anatomía & histología , Craneotomía/métodos , Cabeza/cirugía , Procedimientos Neuroquirúrgicos , Disección , CadáverRESUMEN
BACKGROUND: The therapeutic and diagnostic approach in deep vein thrombosis (DVT) has changed enormously in the last two decades with the introduction of ultrasound, low-molecular-weight heparin (LMWH), and premature motion. The aim of this study is to evaluate these changes and analyze their clinical and economic aspects. METHODS: We registered all inpatients with a diagnosis of DVT during 1994 (n=110) and 2009 (n=75) and their sociodemographic and clinical features in a descriptive observational design. We performed a comparison of diagnostic techniques, length of stay, inpatient complications, and costs thus derived for both series, based on 2009 prices, so that we could get comparable results. RESULTS: Ninety-one percent of inpatients in 1994 were diagnosed by venography, whereas, in 2009, the diagnosis was based on clinical features, D-dimer, and ultrasound in 100% of patients. Inpatient treatment went from 7% LMWH in 1994 to 96% in 2009, and as outpatient from 82% acenocumarol to 90.6% LMWH. Complications decreased by 13.3%. Length of stay was 2.7 higher in 1994. Globally, the cost per patient decreased by 63.39%, based primarily on reduced length of stay. CONCLUSIONS: The current diagnostic and therapeutic approach in DVT allows for effective treatment, fewer complications, and a drastic reduction in inpatient costs.
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Anticoagulantes , Heparina de Bajo-Peso-Molecular , Costos de Hospital , Pacientes Internos , Tromboembolia Venosa , Adulto , Anciano , Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Biomarcadores/sangre , Ahorro de Costo , Análisis Costo-Beneficio , Costos de los Medicamentos , Femenino , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Heparina de Bajo-Peso-Molecular/economía , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Modelos Económicos , Flebografía/economía , Valor Predictivo de las Pruebas , Sistema de Registros , Factores de Tiempo , Resultado del Tratamiento , Tromboembolia Venosa/sangre , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/economía , Tromboembolia Venosa/terapiaRESUMEN
BACKGROUND AND OBJECTIVES: Volumetric analysis of the working corridors of the interdural approach to the Meckel cave may lead to a selection of routes which are anatomically more advantageous for trigeminal schwannoma resection. The herein-reported anatomic study quantitively compares the infratrochlear (IT) transcavernous, anteromedial (AM), and anterolateral (AL) corridors, highlighting their feasibility, indications, advantages, and limitations. METHODS: Anatomic boundaries and depth of Meckel cave, porus trigeminus, IT transcavernous, AM, and AL corridors were identified in 20 formalin-fixed latex-injected cadaveric heads and were subsequently measured. The corridor areas and volumes were derived accordingly. Each opening angle was also calculated. Angles and volumes were compared using analysis of variance. Statistical significance was set at a P -value <.05. RESULTS: The IT transcavernous corridor volume was greater than that of the AM and AL. The opening angle of the AM middle fossa triangle was wider than the other 2. CONCLUSION: The IT corridor can be advantageous for Meckel cave schwannomas invading the cavernous sinus and those with a notable extension into the posterior fossa because the transcavernous approach maximizes the working space into the retrosellar area. The AM middle fossa corridor is strategic in schwannomas confined to the Meckel cave with a minor extension into the posterior fossa. It raises the chance of total resection with a single approach involving the porus trigeminus opening.
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Seno Cavernoso , Neoplasias de los Nervios Craneales , Neurilemoma , Humanos , Procedimientos Neuroquirúrgicos , Seno Cavernoso/cirugía , Neurilemoma/diagnóstico por imagen , Neurilemoma/cirugía , Neoplasias de los Nervios Craneales/diagnóstico por imagen , Neoplasias de los Nervios Craneales/cirugíaRESUMEN
Background: Most neurosurgical photographs are limited to two-dimensional (2D), in this sense, most teaching and learning of neuroanatomical structures occur without an appreciation of depth. The objective of this article is to describe a simple technique for obtaining right and left 2D endoscopic images with manual angulation of the optic. Methods: The implementation of a three-dimensional (3D) endoscopic image technique is reported. We first describe the background and core principles related to the methods employed. Photographs are taken demonstrating the principles and also during an endoscopic endonasal approach, illustrating the technique. Later, we divide our process into two sections containing explanations, illustrations, and descriptions. Results: The results of taking a photograph with an endoscope and its assembly to a 3D image has been divided into two parts: Photo acquisition and image processing. Conclusion: We conclude that the proposed method is successful in producing 3D endoscopic images.
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Introduction: Since the introduction of the endoscopic endonasal approach (EEA) to skull base, the nasal phase has been a true challenge as it represents the moment of definition of the corridor, thus defining the instruments maneuverability at tumor removal phase. The longstanding cooperation between ENT and neurosurgeons have provided the possibility of creating adequate corridor with maximal respect toward nasal structures and mucosa. This sparked the idea of entering the sella as thieves, so we named "Guanti Bianchi" technique a lesser invasive variation of the approach for the removal of selected pituitary adenoma. Research Question: The purpose of this study is to present the preliminary results of "Guanti Bianchi" technique. Material and Methods: Data from 17 patients undergoing "Guanti Bianchi" technique (out of 235 standard EEA) at our center, were retrospectively analysed. ASK Nasal-12, a quality-of-life instrument developed specifically to assess patient perception of nasal morbidity, was administered pre- and postoperatively. Results: 10 (59%) patients were men and 7 (41%) women. The mean age was 67.7 (range 35-88). The average duration of the surgical procedure was 71.17 minutes (range 45-100). GTR was achieved in all patients, no postoperative complications were observed. Baseline ASK Nasal-12 was near normal in all patients, 3/17 (17,6%) experienced transitory very mild symptoms without any worsening at 3 and 6 months. Discussion and Conclusions: This minimally invasive technique does not require turbinectomy or carving of the nasoseptal flap, it alters the nasal mucosa as little as necessary, and it is quick and easy to perform.
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INTRODUCTION: The most frequent pathology of the fifth cranial nerve is trigeminal neuralgia (TN), characterized by unilateral orofacial pain, of a paroxysmal nature, with distribution in one or more divisions of the trigeminal nerve. The main objective of this work is to demonstrate the efficacy and safety of neurovascular decompressive surgery (NVD). METHODS: Retrospective analytical study, patients operated on for NVD by TN (n: 155), from January 2006 - 2022, using a retrosigmoid approach and clinicalradiological follow-up, whose intraoperative recording was in 3D system (n: 42). RESULTS: 83.3% (n=35) presented classic NT and 16.7% (n = 7) idiopathic. The right side prevailed with 59.5% (n = 25) and paroxysmal pain with 81% (n=34) of representation in the entire series. Compression of arterial origin represented 76.2% (n: 32) of the cases, the superior cerebellar artery represented the first cause of neurovascular compression (NVC) in 52.4% (n: 22) in the exit zone of the trigeminal nerve. The validity of the magnetic resonance imaging (MRI) protocol selected for this series was analyzed; evidencing a high sensitivity of MRI with 97%, and a specificity of 86%. CONCLUSION: The sensitivity and specificity of highdefinition MRI studies and with special protocols for the evaluation of TN, as gold standard paraclinical, were presented. The DNV offered safe results, a high percentage of the patients were described as successful. The 3D recording allowed retrospective analysis with a vision identical to that of the surgeon during the intraoperative period, the type of NVC.
Introducción: La afección más frecuente del V nervio craneal es la neuralgia del trigémino (NT), se caracteriza por dolor orofacial unilateral, paroxístico, distribuyéndose en una o más divisiones del nervio trigémino. El objetivo de presente trabajo es demostrar la eficacia y seguridad de la cirugía descompresiva neurovascular (DNV). Métodos: Estudio analítico retrospectivo, pacientes intervenidos para DNV por NT (n: 155), desde enero de 2006 - 2022, mediante un abordaje retrosigmoideo y seguimiento clínico-radiológico, cuyo registro intraoperatorio fue en sistema 3D (n: 42). Resultados: 83.3% (n=35) presentó NT clásica y 16.7% (n = 7) idiopática. La mayoría con afectación del lado derecho 59.5% (n = 25) y el dolor paroxístico con 81% (n = 34). La compresión de origen arterial representó 76.2% (n: 32) de los casos, la arteria cerebelosa superior representó la primera causa de compresión neurovascular (CNV) en un 52.4% (n:22) en la zona de salida del nervio trigémino. Se analizó la validez del protocolo de resonancia magnética (RM) seleccionado para esta serie; evidenciando una alta sensibilidad de la RM con 97%, y una especificidad del 86%. Conclusión: Se demostró la sensibilidad y especificidad de los estudios de resonancia magnética (RM) de alta definición y con protocolos especiales para la evaluación de la NT, como paraclínico estándar de oro. La DNV ofreció resultados seguros, un alto porcentaje de los pacientes se calificaron como exitosos. El registro 3D permitió analizar en retrospectiva con una visión idéntica a la del cirujano durante el intraoperatorio, el tipo de CNV.
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Neuralgia del Trigémino , Humanos , Neuralgia del Trigémino/diagnóstico por imagen , Neuralgia del Trigémino/cirugía , Neuralgia del Trigémino/etiología , Estudios Retrospectivos , Nervio Trigémino/cirugía , Nervio Trigémino/patología , Imagen por Resonancia Magnética/métodos , Descompresión/efectos adversosRESUMEN
There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.
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AIM: To weight the benefits and limitations of intraoperative use of micromirrors in neurosurgery. MATERIAL AND METHODS: Surgical cases where micromirrors were employed were retrospectively selected from the surgical database of five different surgeons in different hospitals. Complications directly attributable to the micromirrors were assessed intraoperatively and confirmed with postoperative neuroimaging studies. RESULTS: Fourteen patients were selected. The site of the lesion was as follows: posterior fossa (43%), frontal lobe (22%), temporal lobe (14%), parietal lobe (7%), insula (7%), and basal ganglia (7%). Five tumors (35%) were gliomas, 3 (21%) epidermoid, and 3 (21 %) supratentorial metastases. Two patients underwent microvascular decompression for neurovascular conflict, and 1 harbored a brain arteriovenous malformation. A gross total resection was achieved in all the tumors and the AVM, while an effective decompression was successfully performed in both patients with conflict. No complications directly attributable to the use of the micromirror occurred. A relatively easy learning curve was noted. CONCLUSION: Micromirrors proved to be useful in enhancing the visualization of neurovascular structures and pathology residuals within deep-seated surgical fields without the need for fixed brain retraction. Their cost-effectiveness and easy learning curve constitute solid reasons for advocating a revitalization of this ?old but gold? tool in neurosurgery.
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Malformaciones Arteriovenosas , Neurocirugia , Humanos , Estudios Retrospectivos , Procedimientos Neuroquirúrgicos/métodos , EncéfaloRESUMEN
OBJECTIVE: To analyze and find risk factors associated with developing transient diabetes insipidus (DI) using a multicenter case series after trans-sphenoidal surgery. METHODS: Medical records of patients who underwent trans-sphenoidal surgery for pituitary adenoma resection between 2010 and 2021 at 3 different neurosurgical centers by 4 experienced neurosurgeons were retrospectively analyzed. The patients were divided into 2 groups (DI group or control group). Logistic regression analysis was conducted to identify risk factors associated with postoperative DI. Univariate logistic regression was performed to identify variables of interest. Covariates with a P value <0.05 were incorporated into multivariate logistic regression models to identify independently associated risk factors for DI. All statistical tests were conducted using RStudio. RESULTS: A total of 344 patients were included; 68% were women, the mean age was 46.5 years, and nonfunctioning adenomas were the most frequent (171, 49.7%). The mean tumor size was 20.3 mm. Covariates associated with postoperative DI were age, female gender, and gross total resection. The multivariable model showed that age (odds ratio [OR] 0.97, CI 0.95-0.99, P = 0.017) and female gender (OR 2.92, CI 1.50-6.03, P = 0.002) remained significant predictors of DI development. Gross total resection was no longer a significant predictor of DI in the multivariable model (OR 1.86, CI 0.99-3.71, P = 0.063), suggesting that this variable may be confounded by other factors. CONCLUSIONS: The independent risk factors for the development of transient DI were female and young patients.
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Adenoma , Diabetes Insípida , Diabetes Mellitus , Neoplasias Hipofisarias , Humanos , Femenino , Persona de Mediana Edad , Masculino , Neoplasias Hipofisarias/patología , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Adenoma/patología , Diabetes Insípida/epidemiología , Diabetes Insípida/etiología , Factores de Riesgo , Resultado del TratamientoRESUMEN
The temporomesial region is a frequent site of neurosurgical lesions such as tumors, cavernomas, or arteriovenous malformations. This region has been divided into 3 regions: anterior, middle, and posterior.1-4 The objective of Video 1 is to present the case of a posterior temporomesial cavernoma resection through a supracerebellar transtentorial approach, highlighting the surgical technique. The case is a 50-year-old female with history of temporomesial bleeding, headaches, and seizures refractory to medical treatment. In the neuroimaging studies a posterior temporomesial image was diagnosed. We selected a paramedian supracerebellar transtentorial approach in semisitting position for the surgery. With the use of neuronavigation guidance, the cavernoma was located and removed in 1 piece. The patient evolved favorably, without neurologic deficit, improving the symptoms after surgery. The approach is an excellent alternative for exposing the temporomesial region, and the semisitting position facilitates the retraction by gravity of the cerebellum, maintaining a clean surgical field during the microsurgical procedure.3-5.
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Hemangioma Cavernoso , Procedimientos Neuroquirúrgicos , Cerebelo/cirugía , Femenino , Hemangioma Cavernoso/cirugía , Humanos , Microcirugia/métodos , Persona de Mediana Edad , Neuronavegación , Procedimientos Neuroquirúrgicos/métodosRESUMEN
Intracranial trigeminal schwannomas are rare tumors that may extend into multiple cranial compartments and may emerge from the root, ganglion, or intracranial portion of any of its branches.1-6 The aim of this 3-dimensional operative video is to present a single-stage complete removal of a dumbbell-shaped trigeminal schwannoma through a pretemporal approach (Video 1). Informed consent was given by the patient for use of images and the surgical video. We describe the case of a 43-year-old female presenting with chronic headaches and left facial pain in the trigeminal territory of V2 and V3. Magnetic resonance imaging showed a tumoral lesion located within the cerebellopontine angle, petroclival region, and middle fossa. Due to the patient's symptoms, tumor size, and growth on sequential imaging, single-stage surgical removal was determined through a frontotemporal approach. There were no adverse outcomes posterior to the surgery, and the patient evolved favorably without neurologic deficits. Postoperative imaging showed complete resection of the tumoral lesion. Presurgical planning is essential for an effective and safe surgical strategy. For cases of trigeminal schwannomas with extension to the middle and posterior fossa, single-stage surgery is feasible for complete and safe removal.
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Neoplasias de los Nervios Craneales , Neurilemoma , Femenino , Humanos , Adulto , Neoplasias de los Nervios Craneales/diagnóstico por imagen , Neoplasias de los Nervios Craneales/cirugía , Neurilemoma/diagnóstico por imagen , Neurilemoma/cirugía , Procedimientos Neuroquirúrgicos/métodos , Imagen por Resonancia MagnéticaRESUMEN
Background: Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare and have characteristics differentiating them from other intracranial aneurysms. Their microsurgical management is challenging and requires different strategies. In this article, we review the surgical anatomy of the A1 segment of the ACA with cadaveric dissections and describe the microsurgical management of complex A1 aneurysms with illustrative cases. Methods: A right pterional craniotomy and Sylvian dissection were performed on a formalin-fixed and silicone-injected cadaver head to depict the key anatomic structures and surgical corridors for microsurgical clipping of A1 segment aneurysms. The microneurosurgical management of ruptured and unruptured aneurysms of the A1 segment of the ACA is described with case illustrations. Results: The A1 segment of the ACA can be subdivided into proximal, middle, and distal subsegments, the former having abundant perforating branches. Both patients treated with microsurgical clipping had excellent and durable outcomes and postoperative cerebral angiograms showed complete aneurysm occlusion. Conclusion: Small A1 aneurysms may require early treatment as their rupture risk appears to be higher. A1 aneurysms are usually embedded in perforators, especially those arising from the proximal A1 subsegment, and require careful distal to proximal microdissection and strategic placement of the aneurysm clip blades. The approach, arachnoid dissection, and angles of attack are carefully planned after accounting for the aneurysm dome projection, precise location of the aneurysm neck and perforators, and the presence or absence of subarachnoid hemorrhage.
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OBJECTIVES: The risks and benefits of coagulating intradural venous elements during a retrosigmoid approach for trigeminal neurovascular decompression has not been accurately established. The objectives of this study were to identify the veins that drain into the superior petrosal sinus, classify them in relation to the suprameatal tubercle, and determine the implication of their coagulation. METHODS: A retrospective study of 3-dimensional surgical videos of retrosigmoid approaches for trigeminal neurovascular decompression from the Laboratory of Neurosurgical Innovations of Tucumán (LINT) digital archive was carried out. The veins encountered were classified into 3 groups: retromeatal, meatal and premeatal. The neurosurgical postoperative complication scale proposed by Landriel et al. was utilized to assess complications from venous coagulation. A grade 0 was added for patients without complications. The STATA 14 program was utilized for statistical analysis. RESULTS: The pontocerebellar-petrosal veins of 28 patients who underwent trigeminal decompressive surgery were analyzed. In 7 cases these were found in the retromeatal region; 100% were sacrificed. Eleven cases revealed veins within the meatal region; 90.91% were coagulated. Veins in the premeatal region were found in 14 cases; 57.14% were sacrificed. In the postoperative follow-up, 27 patients were grade 0 and 1 patient developed postoperative meningitis (grade Ib complication). No patient suffered vascular complications. CONCLUSIONS: The venous elements identified in trigeminal neurovascular decompressive surgery are variable. We propose classifying them into retromeatal, meatal, and premeatal groups. Retromeatal and meatal veins can be safely sacrificed for appropriate visualization of the neurovascular conflict. The premeatal venous elements should be coagulated only in justified cases.
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Venas Cerebrales , Cirugía para Descompresión Microvascular , Neuralgia del Trigémino , Venas Cerebrales/diagnóstico por imagen , Venas Cerebrales/cirugía , Drenaje , Humanos , Cirugía para Descompresión Microvascular/métodos , Estudios Retrospectivos , Neuralgia del Trigémino/cirugíaRESUMEN
In certain cases, the closing force of a single vascular clip is not sufficient for complete aneurysmal occlusion, and the use of multiple clips, or clip stacking, is required. Many stacking techniques have been described in the literature, such as in tandem stacking and overstacking. However, these may not be feasible during procedures with limited exposure or narrow corridors. Clip reinforcement with a second high-pressure booster clip, also known as the piggyback technique, is an alternative for these cases along with anatomically complex aneurysms or aneurysms demonstrating atypical morphological features. Although this technique has been cited as a potential resource for certain aneurysms, descriptions of its characteristics and advantages are scarce. The purpose of this technical note was to discuss our experience with the piggyback clipping technique and use of a booster clip for a partially embolized and recanalized saccular posterior communicating artery aneurysm in a 50 year-old patient.