Combined endovascular and microsurgical management of complex traumatic carotid-cavernous fistula: Three case reports.

Background: With the evolution of the endovascular devices, the management of endovascular interventions has become the current standard therapy for traumatic carotid-cavernous fistula (TCCF). However, only endovascular treatment may not be feasible in some patients with atypical TCCF. Case Description: We described three complex TCCFs that could not be managed by conventional endovascular methods. The first patient had recurrent TCCF previously treated by muscle embolization and ligation of affected carotid arteries 23 years ago. Another two patients had TCCFs association with large pseudoaneurysm within the sphenoid sinus. In each patient, the fistula was successfully closed by trapping procedure using a combination of endovascular and surgical treatment. Conclusion: To reduce costs of treatment, trapping operation by combining surgical and endovascular treatment may be considered as an alternative option for complex TCCF which has some features including chronic stage, preexisting carotid artery ligation, or association with large venous pouch of the cavernous sinus or sphenoid sinus pseudoaneurysm.

Zero-Profile Anchored Spacer (ROI-C) in the Treatment of Cervical Adjacent Segment Disease.

Background Self-locking stand-alone cages have increasingly been used in anterior cervical discectomy and fusion (ACDF) cervical degenerative disc disease. We studied clinical and radiological outcomes of patients who underwent zero-profile anchored spacer (ROI-C)-assisted ACDF without anterior plate fixation in cervical adjacent segment disease. Materials and Methods Fifteen patients suffering from cervical adjacent segment disease with various symptoms, such as radiculopathy, myelopathy, or both, were retrospectively evaluated. The cervical adjacent segment disease was confirmed by plain radiographs and magnetic resonance imaging. The patients underwent radiological evaluation to assess cervical curvature, intervertebral height, fusion, and subsidence. Clinical assessment was graded using a visual analog scale, Modified Japanese Orthopedic Association score, and the Neck Disability Index. Results There were 19 levels of operation. Single-level ACDF was performed in 11 patients and two level in 4 patients. In the postoperative period, our study revealed significant improvement in the clinical outcome. The cervical curvature and intervertebral height were significantly improved at 12-months follow-up ( p < 0.05). The fusion rate was 100%, whereas subsidence occurred in 5.3% but produced no symptoms. Of the 19 operated segment, 2 (5.3%) from 38 VerteBRIDGE plates had breakage. There was only one case of mild dysphagia, which resolved in less than 2 weeks. Conclusion This study indicates that zero-profile anchored spacer (ROI-C) in the treatment of cervical adjacent segment disease provides improvement of clinical outcomes, restoration of lordosis, high fusion rate, and low incidence of dysphagia. However, subsidence and breakage of VerteBRIDGE plate occurred in 5.3% cases, but did not cause clinical symptoms.

Pituitary Hormonal Status after Endoscopic Endonasal Transphenoidal Removal of Nonfunctioning Pituitary Adenoma: 5 years' Experience in a Single Center.

BACKGROUND: This study focuses on hormonal disorder and medical complications postoperative endoscopic endonasal transsphenoidal approach of nonfunctioning adenoma at Prasat Neurological Institute, Bangkok, between January 2013 and December 2017. METHODS AND MATERIAL: Baseline characteristics, clinical complications, and hormonal status data were collected from the patients' medical records and analyzed using the descriptive statistics. RESULTS: There were four surgeons who operated 126 cases, 17 of them were reoperation. The average age of the patients was 49 years old. The average length of stay was 13 days, and average operating time was 134 min. Visual field defect was the most common presenting symptom. Almost all the tumors were classified as pituitary macroadenoma which invaded one or two sellar walls. Total or near total tumor removal was the most extend of resection. There were 61 cases developed early diabetes insipidus (DI), but only 12 cases continue to long-term DI. Seven cases were meningitis. Three cases were death. Out of 83 patients who had preoperative intact hypothalamic-pituitary-adrenal (HPA) axis and hypothalamic pituitary thyroidal (HPT) axis, 2 and 3 of them developed postoperative impair HPA and HPT axis in that order. In addition, among 45 patients who had preoperative impair HPA and HPT axis, 6 of them achieved postoperative endocrinological normalization. CONCLUSION: In preoperative intact pituitary hormone patients, the total or near total tumor removal of non functioning pituitary adenoma may have hypopituitarism during early postoperative period but gradually returned to normal during 4-6 month postoperative period.

Spinal epidural arteriovenous fistula with intradural venous reflux: The possibility of acquired origin caused by spinal stenosis and/or disc herniation.

BACKGROUND: Spinal epidural arteriovenous fistulas (SEAVFs) are relative rare lesions. The pathogenesis of these fistulas remains unclear. Our aim is to review cases of SEAVFs at our institution. METHODS: We reviewed a consecutive series of spinal vascular disease at our institution and collected all patients harboring SEAVFs. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, previous history of spinal surgery or trauma, treatment methods, and neurological outcome after treatment. All image studies, including plain radiography, spinal MRI, MRA, and angiography were analyzed. RESULTS: We identified 9 cases of lumbosacral SEAVFs with intradural venous reflux treated at our institution from June 2010 to August 2020. Their median age was 67 years, range 52-83 years. Only one patient had a history of trauma. Interestingly, our observations found that all fistulas are associated with spinal stenosis and/or disc herniation. An additional literature search about SEAVFs coexisting with spinal stenosis and/or disc herniation was performed and found another 19 cases with median age 69 years, range 39-83 years. Only 2 patients had a history of previous spinal surgery. The level of shunted pouch in all 28 patients was correlated with the level of spinal canal stenosis and/or disc herniation. CONCLUSIONS: Our study may provide an additional evidence supporting an acquired etiology of SEAVFs, which mainly manifest in late adulthood. It is possible that spinal stenosis and/or disc herniation may result in thrombosis or impairment of venous drainage, causing increased venous pressure, leading to fistulous formation.

Computerized Sunnybrook facial grading scale (SBface) application for facial paralysis evaluation.

BACKGROUND: The Sunnybrook facial grading scale is a comprehensive scale for the evaluation of facial paralysis patients. Its results greatly depend on subjective input. This study aimed to develop and validate an automated Sunnybrook facial grading scale (SBface) to more objectively assess disfigurement due to facial paralysis. METHODS: An application compatible with iOS version 11.0 and up was developed. The software automatically detected facial features in standardized photographs and generated scores following the Sunnybrook facial grading scale. Photographic data from 30 unilateral facial paralysis patients were randomly sampled for validation. Intrarater reliability was tested by conducting two identical tests at a 2-week interval. Interrater reliability was tested between the software and three facial nerve clinicians. RESULTS: A beta version of the SBface application was tested. Intrarater reliability showed excellent congruence between the two tests. Moderate to strong positive correlations were found between the software and an otolaryngologist, including the total scores of the three individual software domains and composite scores. However, 74.4% (29/39) of the subdomain items showed low to zero correlation with the human raters (κ<0.2). The correlations between the human raters showed good congruence for most of the total and composite scores, with 10.3% (4/39) of the subdomain items failing to correspond (κ<0.2). CONCLUSIONS: The SBface application is efficient and accurate for evaluating the degree of facial paralysis based on the Sunnybrook facial grading scale. However, correlations of the software-derived results with those of human raters are limited by the software algorithm and the raters' inconsistency.

Nerve to the Zygomaticus Major Muscle for Facial Reanimation Surgery: A Cadaveric Study for Branching Patterns and Axonal Count.

BACKGROUND: In facial reanimation surgery, higher donor facial nerve axonal load yields a superior outcome. Nerves supplying the zygomaticus major muscle are primary donors for the grafting procedure; however, their topography has not been studied in detail. This study identified potential donor nerves by quantifying axon loads of the zygomaticus major muscle through histological analysis of cadaveric specimens. MATERIALS AND METHODS: Forty-three hemifaces from 26 fresh human cadavers were studied. Branching patterns of nerves were classified according to their shapes. All branches of interest were sectioned and stained for an axon count. The potential donors were mapped into each tributary of nerves supplying the zygomaticus major. RESULTS: Branching patterns were categorized into five types: Y-type (28%), X-type (28%), H-type (19%), E-type (14%), and F-type (11%). The mean number of axons in the most superiorly and proximally located main branches was 1387.33 ± 406.59 in Y-type, 1021.42 ± 187.79 in X-type, 1222.75 ± 193.82 in H-type, 1496.17 ± 364.567 in E-type, and 1353.40 ± 256.07 in F-type (P > 0.05). A topographic relation between facial nerves supplying the zygomaticus major muscle and their mean axonal load was illustrated. The zygomatic/buccal branches were found within 5 mm from Zuker's point in 100% of X-, Y-, H-, and E-type and 75% of F-type specimens. CONCLUSIONS: Most proximal facial nerve branches supplying the zygomaticus major, arising at the anterior border of a parotid gland, contained over 900 axons in all five branching types. The primary subbranches may be used in selected cases if donor weakness is a concern. Further, our study provides evidence that demonstrates the precision of Zuker's point.

Filum Terminale Arteriovenous Fistula in Association with Degenerative Lumbosacral Spinal Canal Stenosis: Report of 3 Cases and Review of the Literature.

BACKGROUND: Filum terminale arteriovenous fistulas (FTAVFs) are rare, and the pathogenesis of these fistulas remains unclear. They may be either congenital or acquired in origin. The authors report 3 cases of FTAVFs in association with severe spinal canal stenosis. The authors also review literature of FTAVFs associated with spinal canal stenosis. CASE DESCRIPTION: All 3 cases harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction following long history of back pain, sciatica, and/or intermittent claudication. The fistulas were located around or at the level of spinal canal stenosis and supplied by the anterior spinal and/or lateral sacral arteries with cranial drainage from the dilated vein of the filum terminale to the perimedullary veins. The first and third cases were treated concomitantly by performing instrumented fusion with decompressive laminectomy along with occlusion of the fistula with good results. The second case was unsuccessfully treated by endovascular treatment through the lateral sacral artery and denied further surgical treatment. CONCLUSIONS: Our 3 case reports may provide additional evidence supporting an acquired etiology of FTAVFs, probably secondary to the severe central canal stenosis. From our review, the level of the fistulas in most patients is correlated with the level of spinal canal stenosis. The authors preferred the concomitant surgical treatment by performing decompressive laminectomy and obliteration of the fistula in the same surgical session.

Spinal Sparganosis Coexisting with Acquired Arteriovenous Fistula of the Filum Terminale.

BACKGROUND: Spinal sparganosis associated with filum terminale arteriovenous fistula (FTAVF) has not been reported in the literature. In previous studies, these 2 rare diseases were usually reported separately. We report the first case of spinal sparganosis with concomitant FTAVF. CASE DESCRIPTION: Spinal sparganosis associated with FTAVF manifested in a middle-aged man with progressive back pain and paraparesis. Magnetic resonance imaging of the lumbosacral spine revealed large intradural mass-like lesions involving the conus medullaris and entire cauda equina. Additionally, there was degenerative spinal stenosis at the level of L2-3 to L5-S1. Magnetic resonance imaging of the thoracic spine disclosed abnormal hypersignal intensity extending from the level of the conus medullaris to T7 with tortuous intradural flow voids along the ventral more than dorsal surfaces of the spinal cord. Magnetic resonance angiography and spinal angiography confirmed FTAVF at the level of L3-4. The patient underwent surgical removal of the granulation tissues with lysis adhesions and obliteration of the FTAVF simultaneously in the same surgical session. Histologic findings were consistent with sparganosis. CONCLUSIONS: The formation of FTAVF in the present case may have resulted from severe spinal canal stenosis caused by lumbar spondylosis and spinal sparganosis, inducing chronic inflammation and severe adhesion of spinal nerve roots. This evidence indicates that FTAVF may have been acquired.

Spontaneous Spinal Osseous Epidural Arteriovenous Fistula with Long Segments of Prominent Epidural Venous Drainage Causing Severe Compressive Thoracic Myelopathy Successfully Treated with Combined Endovascular and Surgical Treatments: A Case Report and Review of the Literature.

The authors describe an extremely rare case of spinal osseous epidural arteriovenous fistulas (SOEAVFs) with unique characteristic features. A 25-year-old man presented with progressive weakness and paresthesia of the lower extremities for 1 month. Magnetic resonance imaging of the thoracic spine showed an extradural dilated vascular flow void structure extending from T4 to T8 levels with abnormal hyperintense T2 signal from T6 to T8 levels. Magnetic resonance angiography and spinal angiography revealed unique features of SOEAVF supplied by multiple small arterial feeders of intercostal arteries converging into a dilated round venous sac corresponding to a bony defect of T7 lamina and spinous process. The venous drainage directly drained into prominent epidural venous plexus extending from the level of T4 to T8 without intradural venous drainage, causing severe compressive myelopathy. Transarterial embolization was performed using N-butyl cyanoacrylate through the main feeder. Subsequently, he successfully underwent laminectomy and total excision of the fistula and large epidural draining venous plexus. Histopathology confirmed spinal vascular malformations with evidence of previous embolization. He gradually improved until being ability to walk independently 3 months later. Follow-up spinal angiography confirmed complete resection of SOEAVF. The patient has remained clinically asymptomatic 5 years after operation.

Spontaneous resolution of direct carotid-cavernous fistulas: case series and literature review.

Spontaneous regression of direct carotid-cavernous fistulas (CCFs) is extremely rare. Most of the patients with direct CCFs are usually treated using endovascular techniques. Spontaneous obliteration of the direct fistulas probably results from thrombosis of the venous drainage and/or cavernous sinus. We report spontaneous closure of nine direct CCFs in nine patients. From literature review, we found another 37 patients with 43 fistulas due to spontaneous obliteration of bilateral lesions in six cases. There was no spontaneous closure in large-sized fistula. The factors associated with spontaneous thrombosis of the fistulas may be low-flow and small-sized fistula, hypotension, severe ocular manifestations, dissections or spasm of carotid artery, and increased intracranial pressure. Spontaneous healing of direct traumatic CCFs should be confirmed with cerebral angiography. Conservative treatment of direct CCFs should be carefully restricted in patients with normal vision or minimal visual impairment, and the patients must be monitored closely for any changes in visual function. Prompt endovascular treatment for complete obliteration of the fistula should be performed in patients with rapidly progressive visual loss. Venous thrombosis can still effect vision and rerouting towards cortical veins remains a concern. Because spontaneous resolution cannot be reliably predicted, the fistula then should be treated rather than waiting for spontaneous thrombosis.

Do Asians have Higher Carotid Bifurcation? A Computed Tomographic Angiogram Study of the Common Carotid Artery Bifurcation and External Carotid Artery Branching Patterns.

INTRODUCTION: Carotid endarterectomy is a major treatment modality for high-grade carotid stenosis. Preoperative identification of the level of the carotid bifurcation and its branching pattern is important in planning for adequate exposure and cross-clamping to achieve hemostasis during the procedure. Most of the previous studies on carotid arteries were performed in cadavers. METHODS: We studied levels of carotid bifurcation compared relatively with the level of the vertebral body and ipsilateral angle of the mandible and its branching pattern using computed tomographic angiogram (CTA) carotid with multiplanar reconstruction and three-dimensional imaging in 100 CTA studies. RESULTS: Most of the carotid bifurcations were located at the level of C3-C4 vertebral body and 12% were considered to be high bifurcation. Carotid bifurcations were located below the angle of the mandible in 83.5%. The superior thyroid, facial, and lingual arteries arose from separate branches of external carotid arteries in 67.7% of samples. Facial arteries arose in common trunk with lingual arteries in 29.2%, much more common than previous cadaveric studies. The lingual arteries arose with superior thyroid arteries in 2%, while occipital arteries had high variations in their branching patterns. CONCLUSIONS: CTA is an effective and reliable modality for preoperative evaluation of the carotid system in patients undergoing carotid endarterectomy and other carotid procedures. Higher percentage of high carotid bifurcation was found in our study, concordant with other Asian cadaveric studies. We assumed that carotid bifurcation of Asian tends to be located slightly higher than those of the Caucasian population.

Cysteinyl Leukotriene Receptor Antagonists Inhibit Migration, Invasion, and Expression of MMP-2/9 in Human Glioblastoma.

Glioblastoma is one of the most malignant and aggressive types of brain tumors. 5-lipoxygenase and cysteinyl leukotriene receptor 1 (CysLT1) play a role in human carcinogenesis. Leukotriene receptor antagonists (LTRAs), anti-asthmatic drugs with mild side effects, have anti-metastatic activity in epidermoid carcinoma, lung carcinoma, and colon cancers as well as neuroprotective effects. Herein, anti-migratory effects of two LTRAs, montelukast and zafirlukast, were investigated in glioblastoma cells. The level of CysLT1 in A172 cells was increased by 3.13 folds after IL-1ß treatment. The median toxic concentration of LTRAs in A172, U373, and primary astrocytes ranged from 7.17 to 26.28 µM at 24-h post-exposure. Both LTRAs inhibited migration and invasion of glioma. Additionally, both drugs significantly inhibited the expression and activities of MMP-2 and MMP-9 in A172 and U373 glioblastoma cells and primary human astrocytes, suggesting that CysLT1 plays a role in migration and invasion of glioma, and LTRAs are potential drugs to reduce migration and invasion.

The Possible Role of Mast Cells and VEGF in Peritumoural Oedema of Secretory Meningioma.

Objective: Secretory meningiomas constitute a relatively rare subtype of meningiomas and present often with massive peritumoural oedema. From our previous report, a high number of mast cells were demonstrable in this subtype of meningiomas. The present study aimed to obtain more information about mast cell derived progangiogenic factors and mediators as well as VEGF receptors in secretory meningioma. Additionally, the correlation of histological factors such as the presence of mast cells and the radiological evidence of surrounding tumour oedema was analysed. Material and Method: Sixteen cases of secretory meningioma were examined. Relevant clinical information was obtained from the patient files. The peritumoural oedema was determined either by CT or MRI scans and graded as mild, moderate and severe. Immunohistochemical studies of histamine, substance P, serotonin, VEGF and VEGF receptors were performed. A double-blind quantitative evaluation of mast cells staining positively for VEGF in a comparison with total mast cells in secretory meningiomas was made by two histopathologists. Results: There was no immunoreactivity against histamine or substance P within the tumour tissue or in mast cells. Fine granules of serotonin were demonstrated within the mast cells and a coarse granular expression of VEGF was found within the mast cells. Our preliminary data demonstrated that tumours with moderate to severe degree of peritumoural oedema usually contained more than 50% of VEGF-staining positive mast cells. Conclusion: Secretory meningiomas are characterized by a significantly increased number of mast cells. VEGF and serotonin might be involved in the pathophysiological process of this vasogenic brain oedema. The preliminary data demonstrated the potential relation between the radiological evidence of increasing oedema and the high numbers of mast cell staining positively for VEGF.

Lumbar Drainage and Low Rate of Permanent Shunt Insertion after Treating Aneurysmal Subarachnoid Hemorrhage.

Objective: This study investigated the predictive factors contributing to shunt-dependent hydrocephalus and the rate of shunt requirement in a ruptured aneurysmal subarachnoid hemorrhage. The factors related to short-term clinical outcomes were also determined. Material and Method: A retrospective review was conducted of 200 patients who underwent surgical clipping of ruptured aneurysmal subarachnoid hemorrhage based on protocols of CSF drainage at Prasat Neurological Institute (PNI) between January 2008 and February 2010. Patient demographic, Glasgow Coma Score (GCS), Hunt and Hess (H&H) grade, Fisher's grade and Glasgow Outcome Scale (GOS) were evaluated. The rate of shunt requirement was analyzed. PNI score was designed for predicting shunt requirement. Results: Two hundred patients who underwent surgical clipping aneurysm consisted of 86 males and 114 females aged ranging from 34-78 years (Mean 56 years). The patients were divided into two groups by treatment protocols; 164 patients (82%) in the first group were operated using supraorbital craniotomy (SOC) with a pre-operative spinal drain. Thirty-six patients (18%) in the second group were operated using mini-open craniotomy and without pre-operative spinal drain. Three patients (1.5%) required a permanent shunts and all of them had full PNI Score (PNI score = 7) (p<0.001). In all, 189 patients (94.5%) with high preoperative GCS 9 (p<0.001) had satisfactory surgical outcomes (GOS 4&5). Conclusion: This study demonstrated the decreased rate of permanent shunts in patients with ruptured aneurysmal SAH who were treated under the PNI protocol. A factor that effectively predicted shunt-dependency was the PNI score equivalent to 7.

Outcomes of Surgical Treatment and Radiation Therapy in En Plaque Sphenoid Wing Meningioma.

Objective: En plaque sphenoid wing meningioma is a rare tumor. Complete surgical resection is difficult. Role of adjuvant radiation therapy in treatment of meningiomas is still controversial. This present study aimed to examine the clinical outcomes and to evaluate the role of adjuvant radiation for the residual tumors. Material and Method: A retrospective study was performed in 26 patients with en plaque sphenoid wing meningioma, who underwent operation at Prasat Neurological Institution between January 2008 and December 2012. Presenting symptoms, location of tumor, surgical approach, postoperative outcomes, and adjuvant radiation were reviewed and analyzed. Results: Among the 26 patients, their ages ranged from 31 to 57 years. All tumors were removed by transcranial approach. Eleven of the patients underwent adjuvant radiation therapy and post-radiation imaging revealed tumors being stable in size. Nine patients that had regrowth tumors were not radiated. Mean followed-up time was 51.77 months (range 18-96 months). Conclusion: Proptosis, visual acuity and cosmetic problems can be improved by surgery. Postoperative adjuvant radiation therapy may be an option for residual en plaque sphenoid wing meningioma.

Pre-operative Embolization of Intracranial and Extracranial Tumors: A Review of 37 Cases

Objective: To examine the safety and efficacy of pre-operative embolization of intra-and extracranial tumors and determine the selection criteria of patients for this procedure. Material and Method: Between June 2008 and August 2012, 37 patients (17 males, 20 females; mean age, 44.2+14.2years), underwent pre-operative embolization of intra- and extracranial tumors, were retrospectively reviewed. Tumor characteristics (type, location, volume, percentage of supplying artery, presence of an early draining vein), angiographic extent of tumor devascularization, timing between embolization and surgery, estimated blood loss, and complication related embolization were evaluated. Results: There were 37 tumors (mean volume, 90.9+83.6 cm3) composed of 18 meningiomas, six hemangioblastomas, six hemangiopericytomas, one metastasis, one osteoblastoma, one osteosacroma, one neurofibroma, one central neurocytoma, one glomus jugulare, one mixed oligoastrocytoma, and one glioblastoma multiforme. Early of draining veins were visualized in 24 patients (64.9%). Failure of pre-operative embolization occurred in four patients. Median time to surgery after embolization was seven days (ranged 1-171 days). There was statistically significant difference between grading of angiographic devascularization and estimated blood loss (p = 0.009, Kruskal-Wallis test). Two patients (5.4%) had embolization-related complications, including hemorrhage during sub-selective catheterization and postoperative scalp necrosis. Conclusion: Although pre-operative embolization of intra- and extracranial tumors was safe, only extensive or complete angiographic devascularization has been effective in less intra-operative blood loss. From this present study, indications regarding when to perform pre-operative embolization include history of excessive bleeding from previous surgery, known hypervascular tumor types (e.g., hemangiopericytoma, hemangioblastoma, paraganglioma), the presence of multiple flow voids on MRI, hypervascular tumors of skull or scalp, deep-seated tumors (e.g., cranial base tumor, intraventricular tumor) with difficulty in early surgical access of the main feeding vessels, and tumors associated with intratumoral aneurysm.

Comparison of Quality-of-Life after the Three Different Techniques of Transpedicular Screw Fixation (TPSF) in Lumbar Spondylolisthesis (LS): Results of a Therapeutic Cohort Study.

Background: Transpedicular screw fixation in lumbar spondylolisthesis remains debatable for which aspects that provide better quality of life outcomes such as procedure of convention, navigation-assisted or mini-open technique. Objective: To analyze the clinical outcomes and assess pre-operative versus postoperative quality-of-life outcomes of patients diagnosed with LS who underwent three different techniques of spinal fusion. Material and Method: A prospective cohort study was conducted with 60 patients with LS who received conventional TPSF or navigation-assisted TPSF or mini-open TPSF at Prasat Neurological Institute between 2010 and 2012. The 12-month follow-up patients were recruited for a structured interview regarding social life, mental health, functional capacity or an independent living status. The quality-of-life measurement was determined using Oswestry Disability Index (ODI) and the Short Form-36 Health Survey (SF-36). Results: Comparisons of quality of life outcomes declared significant differences through the 12-month follow-up evaluation. According to ODI, navigation-assisted group presented with significant level of faster recovery than conventional and miniopen groups at one week (p = 0.031) and one month (p = 0.008) after surgery. At one year follow-up, the navigation-assisted technique was noted to have a significant better improvement (p = 0.033 and mean ODI scores = 5.8) compared with conventional and mini-open techniques (mean ODI scores = 8.7 and 10.6, respectively). Moreover, SF36 assessment indicated considerably improvement at 12 months after surgery. In addition, the finding reveals no statistically significant differences among three techniques. Conclusion: Overall, three different techniques provide the positive outcomes of quality of life. The 12-month follow-up of quality of life measures based on ODI suggest that the navigation-assisted technique was significantly associated with wellrecovered at one week and one month after surgery. However, in terms of clinical outcomes, they do not make any considerable differences to patient care within the 12-month follow-up period.

Pre-operative Embolization of Intracranial and Extracranial Tumors: A Review of 37 Cases.

Objective: To examine the safety and efficacy of pre-operative embolization of intra-and extracranial tumors and determine the selection criteria of patients for this procedure. Material and Method: Between June 2008 and August 2012, 37 patients (17 males, 20 females; mean age, 44.2+14.2years), underwent pre-operative embolization of intra- and extracranial tumors, were retrospectively reviewed. Tumor characteristics (type, location, volume, percentage of supplying artery, presence of an early draining vein), angiographic extent of tumor devascularization, timing between embolization and surgery, estimated blood loss, and complication related embolization were evaluated. Results: There were 37 tumors (mean volume, 90.9+83.6 cm3) composed of 18 meningiomas, six hemangioblastomas, six hemangiopericytomas, one metastasis, one osteoblastoma, one osteosacroma, one neurofibroma, one central neurocytoma, one glomus jugulare, one mixed oligoastrocytoma, and one glioblastoma multiforme. Early of draining veins were visualized in 24 patients (64.9%). Failure of pre-operative embolization occurred in four patients. Median time to surgery after embolization was seven days (ranged 1-171 days). There was statistically significant difference between grading of angiographic devascularization and estimated blood loss (p = 0.009, Kruskal-Wallis test). Two patients (5.4%) had embolization-related complications, including hemorrhage during sub-selective catheterization and postoperative scalp necrosis. Conclusion: Although pre-operative embolization of intra- and extracranial tumors was safe, only extensive or complete angiographic devascularization has been effective in less intra-operative blood loss. From this present study, indications regarding when to perform pre-operative embolization include history of excessive bleeding from previous surgery, known hypervascular tumor types (e.g., hemangiopericytoma, hemangioblastoma, paraganglioma), the presence of multiple flow voids on MRI, hypervascular tumors of skull or scalp, deep-seated tumors (e.g., cranial base tumor, intraventricular tumor) with difficulty in early surgical access of the main feeding vessels, and tumors associated with intratumoral aneurysm.

Endoscopic Optic Nerve Sheath Fenestration for Treatment of Papilledema Secondary to Intracranial Venous Hypertension: Report of Two Cases.

Objective: To determine the safety and efficacy of endoscopic optic nerve sheath fenestration (ONSF) for the reversal of papilledema in intracranial venous hypertension. Material and Method: A retrospective chart review was performed on two consecutive patients who underwent endoscopic ONSF. Presenting symptoms, neuro-ophthalmological work-ups, including visual acuity (VA), visual field charting (VF), optical coherence tomography (OCT) and MRI as well as magnetic resonance venography (MRV) were recorded. Cerebrospinal fluid pressure was also measured preoperatively in both individuals. Visual improvement was assessed by comparing with preoperative ophthalmological findings. Results: This report is the first endoscopic ONSF study focusing on treatment of papilledema resulting from intracranial venous hypertension (tumor compressing transverse sigmoid junction in the first patient and venous sinus stenosis in the second patient). ONSF was performed on both sides of the first patient and on the right optic nerve of the second patient with showing reduction of papilledema on both eyes. Papilledema was improved in both individuals. Vision improved more in the first patient than in the second whom had pre-existing optic nerve atrophy. Conclusion: Endoscopic optic nerve sheath fenestration is an effective and safe procedure to revert visual loss or to stabilize vision in patients presenting with visual loss caused by intracranial venous hypertension.