Intrasylvian Retraction Technique to Facilitate the Sylvian Fissure Dissection: A Clinical Study of 125 Cases.

Although many authors have recommended the retractorless technique to avoid retractor-induced brain injury, others usually use brain retractors with a meticulous technique to facilitate the surgery, especially for sylvian fissure dissection. The intrasylvian retraction technique was described for sylvian fissure opening, but no clinical evidence was found. We evaluate the efficacy and safety of this technique for the distal transsylvian approach. We reviewed the video records of clinical cases where the distal transsylvian approach was performed using the intrasylvian retraction technique for aneurysm treatment and middle cerebral artery (MCA) bypass between September 2018 and August 2022. Operative techniques are described. The efficacy and safety of the technique were assessed by full exposure of the sylvian fissure and new postoperative perisylvian hematoma, respectively. One hundred twenty-five cases were included and had an average age of 53.5 (range 16-85) years. Women comprised 73.6%. Aneurysm surgery, pure MCA revascularization, and aneurysm surgery with MCA revascularization were 106 (84.8%), 12 (9.6%), and 7 cases (5.6%), respectively. The most common aneurysm location was the internal carotid artery-posterior communicating artery junction in 37 cases (34.9%), followed by the anterior communicating artery in 27 (25.5%). Full exposure of the Sylvian fissure was achieved in all cases. No perisylvian hematoma was detected by immediate postoperative computed tomography in any patient. Using an appropriate technique for brain retractor application, sylvian fissure dissection was safely performed. The intrasylvian retraction technique effectively facilitated sylvian fissure dissection and provided wide exposure for the distal transsylvian approach.

Training in Sylvian Arachnoid Dissection: The Art of Using Kamiyama Scissors and a Simple Novel Model for Practice Sylvian Arachnoid Dissection Using Cotton Fiber with Brain Model.

Background Transsylvian approach is one of the main approaches for a variety of vascular, tumor, and skull-base lesions. Sylvian fissure harbors a lot of critical structures including the middle cerebral artery and many venous structures. If not done properly, the transsylvian approach could cause several complications. Up to now, there is no simple training model for practicing Sylvian fissure dissection. In this article, we describe the technique of using microscissors for the sharp dissection of arachnoid trabeculae. We also propose a new model for practicing Sylvian arachnoid dissection using a three-dimensional (3D) brain model with cotton fiber. Materials and Method We inserted cotton fiber into the Sylvian fissure of the brain model (aneurysm box from UpsurgeOn) and covered the Sylvian fissure with a cotton sheet, then sprayed the water over it. We dissected this model under a microscope by using Kamiyama scissors in the right hand and suction in the left hand. Result Under the microscope, our model appears comparable with the real Sylvian fissure. We can use this model for practicing arachnoid dissection with Kamiyama scissors. Conclusion The arachnoid dissection model by using a 3D brain model with cotton fiber is a simplified and novel approach for practicing the Sylvian fissure dissection.

Frontal sinus reconstruction with overlapping sinus mucosa and vascularized pericranial flap Coverage after modified transbasal bifrontal craniotomy: Novel technique and clinical outcomes.

Background: The modified transbasal bifrontal craniotomy is a variant of the bifrontal craniotomy with a wider surgical corridor than the standard approach. There are several methods for frontal sinus repair in bifrontal craniotomy. This study reports a novel method for frontal sinus repair in the modified transbasal interhemispheric approach by precisely overlapping the frontal sinus mucosa margin (without frontal sinus mucosa exenteration) with packing the frontal sinus with povidone-soaked gel foam and covering it with a vascularized pericranial flap. Methods: In this case series, we retrospectively collected the clinical outcomes regarding cerebrospinal fluid (CSF) leakage, meningitis, and mucocele formation of patients who underwent modified transbasal bifrontal craniotomy at Vara Hospital. Results: From January 2016 to December 2021, 65 patients with anterior skull-base lesions were treated with a modified transbasal interhemispheric approach with frontal sinus repair by overlapping frontal sinus mucosa with gel foam packing and vascularized pericranium flap covering. There was no case of postoperative CSF leakage, meningitis, or mucocele formation during the follow-up period of 19.2 months (min 1, max 73). Conclusions: We demonstrated that the modified transbasal interhemispheric approach with frontal sinus repair using gel foam packing and pericranial flap is effective in preventing postoperative CSF leakage and meningitis.

Antiplatelet Treatment in Moyamoya Disease: A Systematic Review.

INTRODUCTION: Moyamoya disease (MMD) is an uncommon cause of stroke. Antiplatelet treatment is commonly prescribed for patients with MMD despite the lack of strong evidence supporting its efficacy. We conducted a systematic review to evaluate evidence of antiplatelet treatment and clinical outcomes among patients with MMD. METHODS: A systematic literature search was performed to identify studies that evaluated the association between antiplatelet treatment and clinical outcomes, including ischemic stroke, hemorrhagic stroke, functional outcome, survival, and bypass patency, in patients with MMD. The following databases were searched: PubMed, Embase, Scopus, and the Cochrane Library, from the inception date to February 2022. RESULTS: Eight studies were included in this systematic review. Six studies evaluated antiplatelet treatment and ischemic stroke. Most studies did not demonstrate a protective effect of antiplatelet treatment against ischemic stroke. Five studies evaluated antiplatelet treatment and hemorrhagic stroke. All of them did not demonstrate an increased risk of hemorrhagic stroke. One study found the benefit of antiplatelet treatment in terms of survival. Regarding the effect of antiplatelet treatment on functional outcome and patency of surgical bypass, the results were inconclusive. CONCLUSION: Current evidence suggests that antiplatelet treatment in patients with MMD did not demonstrate a protective effect against ischemic stroke. However, antiplatelet treatment did not increase the risk of hemorrhagic stroke in patients with MMD. The well-designed randomized controlled trial should be highlighted.

Microsurgical partial trapping for the treatment of unclippable vertebral artery aneurysms: Experience from 27 patients and review of literature.

BACKGROUND: The efficacy and safety of partial trapping for the treatment of unclippable vertebral artery aneurysms (UVAs) are still questionable. The partial trapping method (proximal or distal occlusion) was used in the treatment of aneurysms to simplify the surgical procedure and avoid postoperative complications. METHODS: This study included 27 patients with UVAs who underwent microsurgical partial trapping between January 2015 and August 2022, and their postoperative outcomes and complications were retrospectively reviewed and evaluated. RESULTS: Ruptured UVAs were detected in 25 (92.6%) patients, and 13 (48.1%) patients had poor-grade status. Fusiform dissection, dissecting, and fusiform aneurysms were observed in 17 (63%), 7 (25.9%), and 3 (11.1%) patients, respectively. By location, preposterior inferior cerebellar artery (PICA), PICA, post- PICA, and non-PICA types were noted in 7 (25.9%), 9 (33.3%), 6 (22.2%), and 5 (18.5%) patients, respectively. Microsurgical partial trapping was performed in all patients (blind-alley formation in 96.3%). Complete aneurysm obliteration was achieved in 26 (96.3%) patients. Immediate complete obliteration was achieved in 21 (77.8%) patients, delayed thrombosis within 7 days in 5 (18.5%), and nearly complete obliteration in 1 (3.7%). No re-bleeding was detected in all patients. Favorable outcomes 3 months after the operation were achieved by 92.9% of the patients in the good-grade group and 85.2% overall. CONCLUSIONS: Microsurgical partial trapping, especially the blind-alley formation technique, was a safe and effective treatment of UVAs with high rates of aneurysm thrombosis. The appropriate sites for clip occlusion were dependent on the angioarchitecture of UVAs.

Far-lateral approach without C1 laminectomy for microsurgical treatment of vertebral artery and proximal posterior inferior cerebellar artery aneurysms: Experience from 48 patients.

Background: In the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes. Methods: Forty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated. Results: Most patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA-PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively. Conclusions: Microsurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum.

Course of the V3 segment of the vertebral artery relative to the suboccipital triangle as an anatomical marker for a safe far lateral approach: A retrospective clinical study.

Background: The third segment of the vertebral artery (V3) is vulnerable during far lateral and retrosigmoid approaches. Although the suboccipital triangle (SOT) is a useful anatomical landmark, the relationship between V3 and the muscles forming the triangle is not well-described. We aimed to demonstrate the relationship between the V3, surrounding muscles, and SOT in clinical cases. Methods: Operative videos of patients with the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms treated with occipital artery-PICA bypass through the far lateral approach were examined. Videos from January 2015 to October 2021 were retrospectively reviewed to determine anatomy of the V3 and the SOT. Results: Fourteen patients were included in this study. The ipsilateral V3 was identified without injury in all patients using the bipolar cutting technique. The lateral 68.2% of the horizontal V3 segment, including the V3 bulge, was covered by the inferomedial part of the superior oblique muscle (SO). The medial 23.9% was covered by the inferolateral part of the rectus capitis posterior major muscle. The inferomedial part of the horizontal V3 segment is located within the SOT. Conclusion: Most of the V3, including the V3 bulge, were located beneath the SO and the inferomedial part of V3 located within the SOT. Elevation of the SO should be performed carefully using the bipolar cutting technique to avoid injury to the V3. To the best of our knowledge, this is the first description of the V3 relative to the SOT in the clinical setting.