Major Internal Carotid Artery Injury During Endoscopic Skull Base Surgery: Case Report.

Major vascular structures are always at risk during complex skull base surgery, particularly with use of the endoscopic endonasal approach, and intraoperative damage of the internal carotid artery (ICA) can be a devastating complication. Herein, we report a case of a young patient who had a major injury of the left ICA during endoscopic resection of a recurrent petrous bone chordoma. Massive bleeding was controlled by a Foley balloon inserted and kept in the resection area. Urgent angiography revealed a persistent leak from the petrous segment of the left ICA, and the vessel was sacrificed with coiling, since a balloon occlusion test showed good collateral blood flow. The patient woke up from anesthesia without a neurological deficit. Salvage resection of recurrent skull base neoplasms deserves specific attention because of the possibility of major vascular damage. In cases of intraoperative ICA injury, its management requires immediate decisions, and the available possibilities for endovascular therapy should always be considered.

The Quadrangular Space, Endonasal Access to the Meckel Cave: Technical Considerations and Clinical Series.

OBJECTIVE: An anteromedial corridor via an expanded endoscopic endonasal approach to the Meckel cave (MC) was described more than a decade ago. However, few clinical series or endoscopic endonasal technical contributions exist concerning this type of approach to this complex region. METHODS: We present a detailed description of the surgical technique for this approach reviewing the original technique and adding clarifying conceptual notions. We conducted a multicenter retrospective study selecting patients who underwent endonasal endoscopic surgery for lesions exclusively limited to the MC in the past 6 years. Intraoperative and postoperative complications were analyzed. The study of 10 cadaveric specimens provides additional information. RESULTS: We performed a fully endoscopic anteromedial corridor to the MC in 18 patients. The most prevalent pathologic finding was schwannoma of the V nerve in 4 patients. Sixth cranial nerve palsy (13 patients) and trigeminal dysfunction (10 patients) were the predominant preoperative clinical signs. There were no remarkable intraoperative complications. Corneal keratopathy caused by dry eye syndrome affected 3 patients and V2 residual neuralgia appeared postoperatively in 2 patients. Six patients recovered from sixth cranial nerve palsy, and 2 showed improvement in preoperatively referred facial pain. CONCLUSIONS: The front door to the MC via the endonasal anteromedial corridor could be a good option. Understanding of the anatomy and the concept of the quadrangular space is crucial to performing this technique safely, which has few complications in experienced hands. Recovery from sixth nerve palsy is possible with this approach. Corneal keratopathy in these patients is a potential complication.

Graphene Oxide and Reduced Derivatives, as Powder or Film Scaffolds, Differentially Promote Dopaminergic Neuron Differentiation and Survival.

Emerging scaffold structures made of carbon nanomaterials, such as graphene oxide (GO) have shown efficient bioconjugation with common biomolecules. Previous studies described that GO promotes the differentiation of neural stem cells and may be useful for neural regeneration. In this study, we examined the capacity of GO, full reduced (FRGO), and partially reduced (PRGO) powder and film to support survival, proliferation, differentiation, maturation, and bioenergetic function of a dopaminergic (DA) cell line derived from the mouse substantia nigra (SN4741). Our results show that the morphology of the film and the species of graphene (GO, PRGO, or FRGO) influences the behavior and function of these neurons. In general, we found better biocompatibility of the film species than that of the powder. Analysis of cell viability and cytotoxicity showed good cell survival, a lack of cell death in all GO forms and its derivatives, a decreased proliferation, and increased differentiation over time. Neuronal maturation of SN4741 in all GO forms, and its derivatives were assessed by increased protein levels of tyrosine hydroxylase (TH), dopamine transporter (DAT), the glutamate inward rectifying potassium channel 2 (GIRK2), and of synaptic proteins, such as synaptobrevin and synaptophysin. Notably, PRGO-film increased the levels of Tuj1 and the expression of transcription factors specific for midbrain DA neurons, such as Pitx3, Lmx1a, and Lmx1b. Bioenergetics and mitochondrial dysfunction were evaluated by measuring oxygen consumption modified by distinct GO species and were different between powder and film for the same GO species. Our results indicate that PRGO-film was the best GO species at maintaining mitochondrial function compared to control. Finally, different GO forms, and particularly PRGO-film was also found to prevent the loss of DA cells and the decrease of the α-synuclein (α-syn) in a molecular environment where oxidative stress has been induced to model Parkinson's disease. In conclusion, PRGO-film is the most efficient graphene species at promoting DA differentiation and preventing DA cell loss, thus becoming a suitable scaffold to test new drugs or develop constructs for Parkinson's disease cell replacement therapy.

Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change.

OBJECTIVE: Worldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand. METHODS: Results from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity. RESULTS: Every year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases-all in low- and middle-income countries-that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia. CONCLUSIONS: Each year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease.

Shunt overdrainage syndrome: review of the literature.

Shunt overdrainage in patients with hydrocephalus still represents a challenge for neurosurgeons, in part due to the lack of agreement or uniformity concerning the entity. Important problems exist relating to the real incidence of the entity, its definition, classification, and the pathophysiological theories behind the various treatment strategies proposed. Recent reports have suggested that the evidence about overdrainage and its consequences is not so robust as presumed. Consequently, the topic requires more detailed examination. In this review, we comment on all the main facets related with shunt overdrainage.

Gangliocitoma selar asociado a adenoma hipofisario productor de hormona de crecimiento. Caso clínico / No disponible

Introducción Los gangliocitomas intraselares son entidades poco frecuentes que en raras ocasiones pueden encontrarse asociados a adenomas funcionantes. Caso clínico Mujer de 49 años estudiada por acromegalia, con lesión selar que se reseca por vía transesfenoidal endoscópica. El resultado histopatológico es de gangliocitoma con adenoma somatotrófico asociado. Discusión Encontramos descritos en la literatura 85 casos de gangliocitomas intraselares asociados con adenomas hipofisarios funcionantes, de los cuales podemos distinguir: 50 productores de hormona de crecimiento (GH) (59%), 15 mixtos (productores de GH y prolactina) (17%), 11 productores de prolactina (13%), 7 productores de hormona adrenocorticotropa (ACTH) (8%) y 2 productores de hormona liberadora de corticotropina (CRH) (2%).Conclusiones En estas entidades es más común la asociación a secreción de GH y la presentación en mujeres de edad media. El diagnóstico es histopatológico. Es importante el conocimiento de esta entidad, por la posible limitación de respuesta terapéutica en la resección incompleta (AU)

[Intrasellar gangliocytoma associated with growth hormone-producing pituitary adenoma. Case report]. / Gangliocitoma selar asociado a adenoma hipofisario productor de hormona de crecimiento. Caso clínico.

INTRODUCTION: Intrasellar gangliocytomas are uncommon entities which, unusually, may be found in association with hormone-releasing pituitary adenomas. CASE REPORT: The patient was a 49-year-old female who presented a sellar lesion with associated acromegaly. A trans-sphenoidal tumour was removed, with no medical improvement. Histopathological analysis revealed a gangliocytoma with an associated somatotroph adenoma. DISCUSSION: We found 85 cases of intrasellar gangliocytomas with associated hormone-releasing pituitary adenomas reported in the literature, with the following distribution: 50 growth hormone-releasing (GH) cases (59%), 15 mixed (GH and prolactin-releasing) cases (17%), 11 prolactin-releasing cases (13%), 7 adrenocorticotropic hormone-releasing (ACTH) cases (8%) and 2 corticotropin hormone-releasing (CRH) cases (2%). CONCLUSIONS: Mixed gangliocytomas-adenomas are uncommon entities. Association with growth hormone-releasing cases is more frequent and the most common presentation is among middle-aged females. Diagnosis is histopathological. Identification of this entity is important because it may lead to a limitation in therapeutic response in incomplete resections.

Success criteria in pediatric neuroendoscopic procedures. Proposal for classification of results after 67 operations.

PURPOSE: Controversial issues exist concerning criteria for patient selection and long-term success in pediatric neuroendoscopic procedures. We designed a classification of success grades applicable to high-pressure and chronic hydrocephalus and also to those cases in which different endoscopic maneuvers are performed during the same procedure. We then evaluated the success rate and complications in our series. METHODS: A total of 59 patients underwent 67 neuroendoscopic procedures between January 2003 and January 2011. A retrospective study was made of the preoperative history, operative reports, and postoperative imaging findings and medical records. A 5-grade scale was developed to assess the type of success depending on clinical and radiological data. Complications related to the surgical procedure were also recorded. RESULTS: Two patients were excluded from the success analysis due to insufficient follow-up time. The final results for the first procedures in 57 patients were complete and permanent success (grade I) in 49.1%, complete but transitory success (grade II) in 10.5%, partial success (grade III) in 12.3%, doubtful success (grade IV) in 5.3%, and failure (grade V) in 22.8%. In eight cases a second procedure followed the failure of the first: grade I success was achieved in seven cases (87.5%) and grade V in one case (12.5%). The highest success rates were achieved in cases of hydrocephalus caused by tumors or arachnoid cysts and the lowest in slit ventricle syndrome. CONCLUSIONS: A common classification of degrees of success, such as that proposed here, would aid the development of comparative and cooperative studies.