Expert Consensus on Procedures and Operations of Navigation-guided Needle Biopsy Techniques for Skull Base Tumours.

Skull base surgery is an interdisciplinary subject. The anatomical structures in the skull base related to oral and maxillofacial surgery include the parapharyngeal space, the pterygopalatine fossa and the infratemporal space. This operative area is one of the most challenging surgical areas in oral and maxillofacial surgery due to its deep site, complex anatomy and high risk. Obtaining pathological information of the tumour preoperatively may help surgeons optimise their treatment plan. Needle biopsy is one of the major minimally invasive techniques that allows preoperative pathological results to be obtained. The navigation technology, which is developing rapidly nowadays, provides a reliable assistance for deep tissue biopsy surgery. Experts from the Society of Oral and Maxillofacial Surgery, Chinese Stomatological Association formulated an expert consensus on the procedures and operations of navigation-guided needle biopsy techniques for skull base tumours, so as to standardise and promote the application and operation of navigation-guided needle biopsy for skull base tumours.

Evolution of transmaxillary approach to tumors in pterygopalatine fossa and infratemporal fossa: anatomic simulation and clinical practice.

BACKGROUND: The endoscopic transnasal approach has been proven to have advantages on the removal of the tumors in pterygopalatine fossa (PPF) and infratemporal fossa (ITF). Herein, this study aimed to describe a modified approach for resection of the tumors in these areas, both in cadaveric specimen and clinical patients. METHODS: The 20 adult cadaveric specimens and five patients with tumors in PPF and ITF were enrolled in this study. For the cadaveric specimens, ten were simulated anterior transmaxillary approach and ten were performed modified endoscopic transnasal transmaxillary approach. The exposure areas were compared between two groups and main anatomic structure were measured. Surgery was operated in the five patients with tumors of PPF and ITF to verify the experience from the anatomy. Perioperative management, intraoperative findings and postoperative complications were recorded and analyzed. RESULTS: The modified endoscopic transnasal transmaxillary approach provided as enough surgical exposure and high operability to the PPF and ITF as the anterior transmaxillary approach did. The diameter of maxillary artery in the PPF was 3.77 ±â€Š0.78 mm (range: 2.06-4.82 mm), the diameter of middle meningeal artery in the ITF was 2.79 ±â€Š0.61 mm (range: 1.54-3.78 mm). Four patients who suffered schwannoma got total removal and one of adenocystic carcinoma got subtotal removal. The main complications were facial numbness and pericoronitis of the wisdom tooth. No permanent complication was found. CONCLUSIONS: With the widespread use of neuroendoscopy, the modified endoscopic transnasal transmaxillary approach is feasible and effective for the resection of tumors located in PPF and ITF, which has significant advantages on less trauma and complications to the patients.

[Surgical treatment of paraclinoid aneurysms].

OBJECTIVE: To explore the surgical treatment of paraclinoid aneurysms and evaluate the safety and efficacy of microsurgical clip and endovascular embolization of paraclinoid aneurysms. METHODS: The data of 28 patients with 30 paraclinoid aneurysms receiving surgical treatment were retrospectively analyzed. According to Barami classification, 4 aneurysms were type Ia, 5 aneurysms type Ib, 13 aneurysms type II, 4 aneurysms type IIIa, 1 aneurysm type IIIb, and 3 aneurysms type IV. In the study, 15 cases with 17 paraclinoid aneurysms received microsurgical treatment, of which 3 cases underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass firstly and then aneurysms were trapped. The other 13 cases received endovascular embolism, in which balloon assistant technology was performed in 3 cases and stent assistant technology in another 3 cases. RESULTS: All the 30 paraclinoid aneurysms were treated. One patient with bilateral paraclinoid aneurysms became blind after bilateral microsurgical procedures and another patient was unexceptedly dead 10 d after operation. Vasospasm resulting with cerebral infarction occurred in one case who received endovascular embolism, while two patients suffered from hydrocephalus. Ten cases of microsurgical group and 9 cases of interventional group were followed up with digital subtraction angiography, which disclosed that 9 cases of microsurgical group were clipped completely, while 7 aneurysms of interventional group were completely embolised. One aneurysm recurred and enlarged 12 months after stent assistant embolism, and after STA-MCA bypass and bilateral anterior cerebral artery anastomy and aneurysm insulation, the patient recovered well. When the patients were discharged, their Glasgow outcome scales showed that 18 cases were with 5, 8 with 4, 1 with 3 and 1 with 0. CONCLUSION: According to the classification, and with appropriate treatment, the patients with paraclinoid aneurysms will get good outcomes both with microsurgical clipping and with endovascular embolization.

[Application of superficial temporal artery to middle cerebral artery bypass in treatment of cerebral artery steno-occlusive disease].

OBJECTIVE: To explore the effect of superficial temporal artery to middle cerebral artery(STA-MCA) bypass in treatment of cerebrovascular disease. METHODS: Fifty-two patients with atherosclerotic carotid artery occlusion or middle cerebral artery occlusion or moyamoya disease were included in this study. There were both clinical ischemic manifestation and hemodynamic dysfunction detected by perfusion CT in all the patients. DSA and perfusion CT (PCT) were conducted before and after STA-MCA bypass in order to evaluate the change of hemodynamics and the state of anastomotic astium. The patients were followed-up to know if there was any complication or recurrent stroke. Modified Rankin scale (mRS) was used in assessing the state of neurological function. RESULTS: STA-MCA bypass was performed successfully in 50 patients, while anastomotic astium was found to be obstructed in 2 patients during operation and temporalis attachment was conducted immediately. Complications occurred in 4 patients, 2 with subdural hematoma, 1 with hematoma in contralateral basal ganglia, and 1 with poor wound healing. Postoperative DSA showed that anastomotic astium was opened well in 48 patients, while PCT displayed a significant improvement in both relative cerebral blood flow [rCBF,(37.79±9.76)mL/(min×100 g)vs.( 33.71±7.92)mL/(min×100 g),P<0.05] and the relative mean transmit time [rMTT,(8.49±1.97)s vs. (11.06±3.00)s,P<0.01]. mRS improved significantly in both the 3 month and 12 month follow-ups(1.37±0.66 vs. 1.58±0.64, 0.84±0.57 vs. 1.51±0.67,P<0.05). There was no ipsilateral stroke during the follow-up. CONCLUSION: STA-MCA bypass may improve the hemodynamic and neurological condition and prevent the recurrence of ischemic stroke in patients combined with occlusive cerebrovascular disease and hemodynamic disturbance.

Virtual reality system for diagnosis and therapeutic planning of cerebral aneurysms.

BACKGROUND: The virtual reality (VR) system can provide the neurosurgeon to intuitively interact with and manipulate the three dimensional (3-D) image similarly to manipulate a real object. It was seldom reported that the system was used in diagnosis and treatment of cerebral aneurysms. This study aimed to investigate the application of VR system in diagnosis and therapeutic planning of cerebral aneurysms. METHODS: A total of 24 cases of cerebral aneurysms were enrolled in this study from 2006 to 2008, which diagnosed by 3-D digital subtraction angiography (3D-DSA) or VR-based computed tomography angiographies (CTA). The VR system and 3D-DSA system were used to observe and measure aneurysms and the adjacent vessels. The data of observation and measurements were compared between VR image and 3D-DSA image. All the patients underwent surgical plan and simulated neurosurgical procedures in the VR system. RESULTS: There were 28 aneurysms detected in VR system and 3D-DSA system. The VR system generated clear and vivid 3-D virtual images which clearly displayed the location and size of the aneurysms and their precise anatomical spatial relations to the parent arteries and skull. The location, size and shape of the aneurysms and their anatomical relationship with the adjacent vessels were similar between 3-D virtual image and 3D-DSA, but the spatial relationship between aneurysms and skull only been displayed by VR system. This VR system also could simulate simple surgical procedures and surgical environments. CONCLUSIONS: The VR system can provide a highly effective way to provide precise imaging details as same as 3D-DSA system and assist the diagnosis of cerebral aneurysms with virtual 3-D data based on CTA. It significantly enhances the chosen therapeutic strategy of cerebral aneurysms.

[A case report of squamous cell carcinoma arising in a patient with meningomyelocele].

Meningomyelocele combined with squamous cell carcinoma is rare in literature. In this article, we report the clinical and treatment of a patient with meningomyelocele and squamous cell carcinoma and discuss its mechanism, clinical feature, therapy and prognosis.The patient was a 11-year-old Chinese boy.At the time of his birth he was noted to have a lumbosacral meningomyelocele, which was disrupted and the cerebral spinal fluid flew out when the child was six.The wound surface abrased and exudated repeatedly.Two months before admission,the meningomyelocele was disrupted again and the condition got worse.Inspection showed a meningomyelocele in the lower lumbar region 10 cm in diameter,consisting of a cauliflower-shaped swelling and a central crater containing black slough.The area smelled foul and was constantly draining serosanguineous fluid.Magnetic resonance imaging showed meningomyelocele associated with spinal dysraphism and tethered cord syndrome.After thorough preparation, operation was undertaken.A perpendicular skin incision,which was carried down to the lumbar aponeurosis,allowed the main bulk of the tumour to be undercut and removed.The quick frozen pathological examination confirmed that it was squamous cell carcinoma.The skin and subcutaneous tissue were further resected and the vertebral canal explored until frozen section showed the excision edge was clear.Skin closure was achieved by a bipedicle advancement flap,some 10 cm wide and the secondary defect was closed with a thigh skin graft.Histological examination showed that the massive outgrowth was a well-differentiated squamous cell carcinoma.The postoperative recovery was uneventful and the wounds healed by primary intention.Although meningomyelocele combined with squamous cell carcinoma is rare in literature,the possibility of cancerization should be considered when there is a long-term and non-healing ulcer (Marjolin ulcer) with foul smell in a meningomyelocele patient.

[Congenital bilateral perisylvian syndrome: a case report].

Congenital bilateral perisylvian syndrome (CBPS) is rare in literature, especially in China. In this article, we report the clinical and treatment of a patient with CBPS and discuss its mechanism, clinical features and therapy. This patient was a 28-year-old man. His main clinical features were pseudobulbar palsy, cognitive deficits and intractable epilepsy. MRI shows bilateral thickening of the cortex around the sylvian fissures which were deeper than normal and polymicrogyria. The electroencephalogram demonstrated slow spike in right temporal lobe and left frontal lobe. Rhythmal 4 Hz theta waves exist in left frontal and parietal lobe. As the epilepsy was poorly controlled by antiepileptic, section of the corpus callosum was carried out. After callosotomy, there was pronounced seizure reduction and intelligence development improvement. CBPS is characterized by pseudobulbar palsy, cognitive deficits, and bilateral perisylvian abnormalities in imaging studies. If intractable epilepsy is combined, callosotomy may be effective.