Visualization of the nervus intermedius during microvascular decompression in hemifacial spasm: anatomical study.

OBJECTIVE: The surgical anatomy of the nervus intermedius (NI) is highly variable. The aim of this study was to describe the anatomy of the NI during endoscope-assisted microvascular decompression (MVD) in hemifacial spasm (HFS), and the involvement of the nerve in the vascular conflict. METHODS: The authors reviewed a prospectively maintained database for MVDs performed between 2002 and 2022 and extracted clinical data including patient demographics, symptoms, and offending vessel(s). Operative videos and photographs were analyzed retrospectively in an attempt to identify the NI. RESULTS: Endoscopic identification of the NI was possible in 139 of 435 MVDs. The anatomy is very variable. In 79 (56.8%) patients, a single-bundle pattern was detected, whereas a multiple-bundle pattern was identified in 60 (43.2%) patients. Overall the most common pattern was a single-bundle type A (49.7%). In 20.1%, a multiple-bundles type A was identified. In 4.3%, a single-bundle type B was detected. In 2.9% a single-bundle type C was found, and in just 0.7% a multiple-bundles type C was detected. A multiple-origin pattern (type D) was found in 31 patients (22.3%). The NI was frequently involved in the neurovascular conflict (approximately 85%). The type of NI or vascular compression pattern did not affect the results regarding the outcome or recurrence of HFS. CONCLUSIONS: The anatomy of the NI is for the first time evaluated endoscopically in MVD for HFS. The nerve had various anatomical patterns that were clearly identified. Further studies to evaluate the compression patterns in relation to NI neuralgia are warranted.

Machine learning in action: Revolutionizing intracranial hematoma detection and patient transport decision-making.

Objectives: Traumatic intracranial hematomas represent a critical clinical situation where early detection and management are of utmost importance. Machine learning has been recently used in the detection of neuroradiological findings. Hence, it can be used in the detection of intracranial hematomas and furtherly initiate a management cascade of patient transfer, diagnostics, admission, and emergency intervention. We aim, here, to develop a diagnostic tool based on artificial intelligence to detect hematomas instantaneously, and automatically start a cascade of actions that support the management protocol depending on the early diagnosis. Materials and Methods: A plot was designed as a staged model: The first stage of initiating and training the machine with the provisional evaluation of its accuracy and the second stage of supervised use in a tertiary care hospital and a third stage of its generalization in primary and secondary care hospitals. Two datasets were used: CQ500, a public dataset, and our dataset collected retrospectively from our tertiary hospital. Results: A mean dice score of 0.83 was achieved on the validation set of CQ500. Moreover, the detection of intracranial hemorrhage was successful in 94% of cases for the CQ500 test set and 93% for our local institute cases. Poor detection was present in only 6-7% of the total test set. Moderate false-positive results were encountered in 18% and major false positives reached 5% for the total test set. Conclusion: The proposed approach for the early detection of acute intracranial hematomas provides a reliable outset for generating an automatically initiated management cascade in high-flow hospitals.

Preemptive strategies and lessons learned from complications encountered with microvascular decompression for hemifacial spasm.

OBJECTIVE: Microvascular decompression (MVD) is the only curative treatment modality for hemifacial spasm (HFS). Although generally considered to be safe, this surgical procedure is surrounded by many risks and possible complications. The authors present the spectrum of complications that they met in their case series, the possible causes, and the strategies recommended to minimize them. METHODS: The authors reviewed a prospectively maintained database for MVDs performed from 2005 until 2021 and extracted relevant data including patient demographics, offending vessel(s), operative technique, outcome, and different complications. Descriptive statistics with uni- and multivariable analyses for the factors that may influence the seventh, eighth, and lower cranial nerves were performed. RESULTS: Data from 420 patients were obtained. Three hundred seventeen of 344 patients (92.2%) with a minimum follow-up of 12 months had a favorable outcome. The mean follow-up (standard deviation) was 51.3 ± 38.7 months. Immediate complications reached 18.8% (79/420). Complications persisted in only 7.14% of patients (30/420) including persistent hearing deficits (5.95%) and residual facial palsy (0.95%). Temporary complications included CSF leakage (3.10%), lower cranial nerve deficits (3.57%), meningitis (0.71%), and brainstem ischemia (0.24%). One patient died because of herpes encephalitis. Statistical analyses showed that the immediate postoperative disappearance of spasms and male gender are correlated with postoperative facial palsy, whereas combined vessel compressions involving the vertebral artery (VA) and anterior inferior cerebellar artery can predict postoperative hearing deterioration. VA compressions could predict postoperative lower cranial nerve deficits. CONCLUSIONS: MVD is safe and effective for treating HFS with a low rate of permanent morbidity. Proper patient positioning, sharp arachnoid dissection, and endoscopic visualization under facial and auditory neurophysiological monitoring are the key points to minimize the rate of complications in MVD for HFS.

Late Frontal Bone Reconstruction Using Three-Dimensional Printed Models for Titanium Mesh Customization: A Case Series.

BACKGROUND: The convex frontal bone is covered by thin skin, rendering its reconstruction cosmetically challenging. Customized alloplastic implants provide better contouring than autologous bone, yet their high cost and availability limit their application. We assess customized titanium mesh implants precontoured using patient-specific three-dimensional (3D) printed models for late frontal cranioplasty. METHODS: We retrospectively analyzed the prospectively collected cases of unilateral frontal titanium mesh cranioplasty with 3D printing-assisted preplanning from 2017 to 2019. We used two 3D-printed patient-specific skull models for preoperative planning: a mirrored normal model for implant contouring and a defect model for edge trimming and fixation planning. The endoscope was used in 4 cases for percutaneous mesh fixation. We documented postoperative complications. We assessed the reconstruction symmetry clinically, and radiologically on postoperative computed tomography. RESULTS: Fifteen patients were included. The duration after previous surgery ranged from 8 to 24 months. Four patients developed complications, which were managed conservatively. Favorable cosmetic outcomes were achieved in all patients. CONCLUSIONS: Precontouring of titanium mesh implants using in-house 3D-printed models could optimize cosmetic and surgical outcomes in late frontal cranioplasty. Preoperative planning could permit minimal access surgery, which could be aided by the endoscope in select cases.

Long-term quality of life after ETV or ETV with consecutive VP shunt placement in hydrocephalic pediatric patients.

PURPOSE: Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting are well-established treatments of obstructive hydrocephalus (HCP) in adult and pediatric patients. However, there is a lack of data with regard to the quality of life (QoL) of these patients during long-term follow-up METHODS: Inclusion criteria were pediatric patients with endoscopic treatment of hydrocephalus at the University Medicine Greifswald between 1993 and 2016. Patients older than 14 years at present were assessed with the Short Form-12 (SF-12) questionnaire. Patients younger than 14 years of age were assessed with the KINDL-R questionnaire that was completed by their parents. Patients' values were compared with the scores of a corresponding age-matched group of the healthy population and with patients who received later shunt treatment. Information about comorbidities, current symptoms, and educational level were gained by an additional part. Comparative analysis between patients with ETV success and failure (defined as shunt implantation after ETV) was performed. RESULTS: A total of 107 patients (53 m, 54f) were included. Fifty-seven/107 patients (53.3%) were considered as ETV success. Mean age at ETV was 6.9 ± 5.9 years. Fifty-four statements of 89 patients that are still alive were gained (response rate 63%). Of these, 49 questionnaires were complete and evaluable (23 m, 26f; mean age 19.8 ± 10.0 years with an average follow-up period of 13.7 ± 7.2 years). Twenty-six/49 patients (53.1%) are considered ETV success. No statistically significant differences could be obtained between patients with ETV success and ETV failure. Patients older 14 years show QoL within normal range, patients younger than 14 years show significantly lower result regarding their environment of peers and social contacts. Patients younger than 6 months at the time of ETV and patients with posthemorrhagic HCP show significantly lower physical QoL. Gait disturbance, fatigue, and seizures are associated with a lower QoL, and educational level is lower than in the normal population. CONCLUSIONS: Patients who underwent ETV in childhood do not have a lower health-related QoL in general. Subsequent insertions of ventriculoperitoneal (vp) shunts do not lower QoL. Certain subgroups of the patients show lower results compared to the healthy population.

Postoperative cerebral infarction after evacuation of traumatic epidural hematoma in children younger than two years: Single-center experience.

Background: Epidural hematoma (EDH) forms about 2-3% of all head injuries in the pediatric population. We evaluated clinical data and risk factors for postoperative infarction in children younger than 2 years presented with traumatic EDH. Methods: We retrospectively reviewed and analyzed the data of 28 children with traumatic EDH operated in our institute during a period of 26 months (from December 2016 to Febuary 2019). Results: Nineteen children were boys (68%) and nine were girls (32%), the mean age was 15 months (range from 5 to 24 months). Postoperative cerebral infarction was detected in seven cases (25%). Factors could be linked to postoperative cerebral: preoperative pediatric Glasgow Coma Scale (P = 0.036), neurological deficit on admission (P = 0.023), size of hematoma (P < 0.001), time between trauma and surgery (P = 0.004), midline shift (MLS) (P = 0.001), and basal cistern compression (P = 0.004). Conclusion: Traumatic EDH in young children represents a neurosurgical challenge that needs rapid surgical intervention for the best surgical outcome. Delay in the time of surgery for more than 6 h, large hematoma volume >100 ml3, MLS >10 mm, and basal cisterns compression will push the intracranial pressure to the point of decompensation and the resultant ischemic sequel occurs.

An eye on the future for defeating hydrocephalus, ciliary dyskinesia-related hydrocephalus: review article.

Congenital hydrocephalus affects approximately one in 1000 newborn children and is fatal in approximately 50% of untreated cases. The currently known management protocols usually necessitate multiple interventions and long-term use of healthcare resources due to a relatively high incidence of complications, and many of them mostly provide a treatment of the effect rather than the cause of cerebrospinal fluid flow reduction or outflow obstruction. Future studies discussing etiology specific hydrocephalus alternative treatments are needed. We systematically reviewed the available literature on the effect of ciliary abnormality on congenital hydrocephalus pathogenesis, to open a discussion on the feasibility of factoring ciliary abnormality in future research on hydrocephalus treatment modalities. Although there are different forms of ciliopathies, we focused in this review on primary ciliary dyskinesia. There is growing evidence of association of other ciliary syndromes and hydrocephalus, such as the reduced generation of multiple motile cilia, which is distinct from primary ciliary dyskinesia. Data for this review were identified by searching PubMed using the search terms 'hydrocephalus,' 'Kartagener syndrome,' 'primary ciliary dyskinesia,' and 'immotile cilia syndrome.' Only articles published in English and reporting human patients were included. Seven studies met our inclusion criteria, reporting 12 cases of hydrocephalus associated with primary ciliary dyskinesia. The patients had variable clinical presentations, genetic backgrounds, and ciliary defects. The ependymal water propelling cilia differ in structure and function from the mucus propelling cilia, and there is a possibility of isolated non-syndromic ependymal ciliopathy causing only hydrocephalus with growing evidence in the literature for the association ependymal ciliary abnormality and hydrocephalus. Abdominal and thoracic situs in children with hydrocephalus can be evaluated, and secondary damage of ependymal cilia causing hydrocephalus in cases with generalized ciliary abnormality can be considered.

Value of Endoscopic Visualization During the Sling-Transposition Technique for Microvascular Decompression of the Facial Nerve in a Case with Hemifacial Spasm.

Endoscopic visualization during microvascular decompression for hemifacial spasm enables better identification of compression areas along the facial nerve, which is especially important in cases with complex compression and enlarged vessels obscuring the compression site. A 40-year-old man presented with a 10-year history of left hemifacial spasm. Magnetic resonance imaging showed a deep compression site with multiple vessels. Within the narrow space, the compression area was clearly visualized using an angled endoscope. Arterial transposition was performed using a polytetrafluoroethylene (Teflon) sling, which was fixed to the nearby dura using an aneurysm clip. Decompression was visually confirmed using the angled endoscope. The patient was free of spasms directly after surgery with no further complications and no recurrence of spasm during 6-month follow-up (Video 1).

Endoscopic Transcortical-Transventricular Approach in Treating Third Ventricular Craniopharyngiomas-Case Series With Technical Note and Literature Review.

BACKGROUND: A paradigm shift toward less radicality in the treatment of craniopharyngioma (CP) has increasingly gained recognition. In selected patients, a less invasive approach aiming at cyst decompression may be suitable. OBJECTIVE: To present our experience with the endoscopic transcortical-transventricular approach (ETTA) for the treatment of CP located in the third ventricle, describe our surgical technique, and explore the results reported in the literature. METHODS: Data for third ventricular CPs treated using ETTA in 2 tertiary medical centers between 2006 and 2020 were retrospectively reviewed. Cystic, mixed lesion, new, and recurrent cases were included. ETTA aimed at cyst fenestration, subtotal or partial tumor resection, managing the hydrocephalus, or a combination of these modalities. Fractionated radiotherapy (RT) was performed (54 Gy in 30 fractions). RESULTS: The described approach was performed in 13 patients with a mean age of 30.2 years. Tumor excision was attempted in 10 patients. Cystic fenestration alone was conducted in 3 patients, followed by intracystic catheter implantation in 2 patients. Permanent diabetes insipidus developed in 3 patients, and 1 patient experienced a surgical site infection. The recurrence rate for ETTA + RT (pre-ETTA in 33.3%) was 2/9 (22.2%) after a mean follow-up of 21.3 months. Four patients did not undergo RT after ETTA, and all these patients experienced recurrences after a mean follow-up of 15.5 months. Hydrocephalus resolved in all 6 patients who presented with accompanying hydrocephalus. CONCLUSION: ETTA combined with adjuvant RT is a safe and effective option in the management of cystic or predominantly cystic CP extending into the third ventricle. This procedure also effectively treats the accompanying hydrocephalus.

Outcome of Endoscope-Assisted Microvascular Decompression in Patients With Hemifacial Spasm Caused by Severe Indentation of the Brain Stem at the Pontomedullary Sulcus by the Posterior Inferior Cerebellar Artery.

BACKGROUND: Microvascular decompression (MVD) is the most effective treatment option for hemifacial spasm (HFS). However, deeply located forms of compression would require proper identification to allow for adequate decompression. OBJECTIVE: To describe the usefulness of endoscopic visualization in one of the most challenging compression patterns in HFS, where the posterior inferior cerebellar artery (PICA) loop is severely indenting the brain stem at the proximal root exit zone of facial nerve along the pontomedullary sulcus. METHODS: Radiological and operative data were checked for all patients in whom severe indentation of the brainstem by PICA at pontomedullary sulcus was recorded and endoscope-assisted MVD was performed. Clinical correlation and outcome were analyzed. RESULTS: A total of 58 patients with HFS were identified with radiological and surgical evidence proving brainstem indentation at the VII transitional zone. In 31 patients, PICA was the offending vessel to the facial nerve. In 3 patients, the PICA loop was mobilized under visualization of a 45° endoscope. A total of 31 patients had a mean follow-up duration of 52.1 mo. The mean duration between start of complaints and surgery was 7.2 yr. In the last follow-up, all patients had remarkable spasm improvement. A total of 5 patients had more than 90% disappearance of spasms and 26 patients experienced spasm-free outcome. CONCLUSION: Although severe indentation of brain stem implies morphological damage, outcome after MVD is excellent. A 45° endoscope is extremely helpful to identify compression down at the pontomedullary sulcus. Deeply located compression site can easily be missed with microscopic inspection alone.

Endoscopic Fenestration of Arachnoid Cysts Through Lateral Pontomesencephalic Membranotomy: Technical Note and Case Series.

BACKGROUND: The ideal treatment method for cranial arachnoid cysts stills controversial, each of endoscopic and microscopic techniques has its pros and cons. METHODS: We described cystocisternostomy technique for arachnoid cysts through fenestration medial to the edge of tentorium through lateral pontomesencephalic membrane and illustrated it's outcomes. We performed endoscopic lateral pontomesencephalic membranotomy in nine children with zero angled rigid endoscope (STORZ).The age ranged from eight months up to nine years. The cysts were Galassi type III in eight cases (five of them giant hemispheric) and Galassi type II in one case. Clinical presentations were delay in milestones, seizures, loss of consciousness, unsteady gait, and persistent headache. RESULTS: The cysts decreased in size in five cases after three months and nearly disappeared after three and 15 months in two cases, and in 18 months in the other two. Preoperative symptoms improved in all cases. Insignificant subdural hygroma was found in five cases, one case developed hydrocephalus four months later treated with a ventriculoperitoneal shunt; contralateral massive subdural hematoma occurred in one case four months after surgery evacuated with two burr holes with good clinical outcome. There was neither cerebrospinal fluid leakage, cranial nerve palsy nor mortality. CONCLUSIONS: The fenestration through the lateral pontomesencephalic membrane created a shortcut of cerebrospinal fluid flow to the basal cisterns especially cerebellopontine cistern and represents a reliable option with an acceptable success rate. It creates a good drainage to the large cysts.

Quality of life and olfactory function after suprasellar craniopharyngioma surgery-a single-center experience comparing transcranial and endoscopic endonasal approaches.

The endoscopic endonasal approach to suprasellar craniopharyngiomas has become popular as alternative to transcranial approaches. However, the literature lacks data regarding quality of life and olfactory function. The assessment of the long-term quality of life and olfactory function of all patients harboring a suprasellar craniopharyngioma who underwent surgery in our department has been done. Patient characteristics and perioperative data were gathered in a prospectively maintained database. At the last follow-up visit, the olfactory function and the quality of life (ASBQ, SNOT-22) as well as visual and pituitary function were assessed. Thirteen and 17 patients underwent surgery via a transcranial (T) and endonasal (E) route, respectively. No differences were seen in ASBQ, SNOT-22, and olfactory function between T and E, but in E were more full-time worker and less obesity. CSF leaks occurred in 15% of T and 29% of E (p = 0.43). Patients from group E had a superior visual outcome which was most pronounced in the visual field. The degree of new anterior and posterior pituitary gland deficiency after surgery and in the follow-up was lower in group E. The general and sinonasal quality of life and the olfactory function are equal in E and T. E is associated with a superior visual outcome, lower rates of diabetes insipidus, and lower rates of obesity, but has a higher risk for postoperative CSF leaks.

Outcome improvement in cerebral ventriculitis after ventricular irrigation: a prospective controlled study.

OBJECTIVE: Cerebral ventriculitis remains one of the most challenging neurosurgical conditions, with poor outcome and a long course of treatment and duration of hospital stay. Despite the current conventional management plans, i.e., using antibiotics in addition to CSF drainage, the outcome remains unsatisfactory in some cases, with no definitive therapeutic guidelines. This study aims to compare the outcome of ventricular irrigation/lavage (endoscopic irrigation or the double-drain technique) to conventional currently accepted therapy using just drainage and antibiotics. METHODS: The authors conducted a prospective controlled study in 33 patients with cerebral ventriculitis in which most of the cases were complications of CSF shunt operations. Patients were divided into two groups. Removal of the ventricular catheter whenever present was performed in both groups. The first group was managed by ventricular lavage/irrigation, while the other group was managed using conventional therapy by inserting an external ventricular drain. Both systemic and intraventricular antibiotics were used in both groups. The outcomes were compared regarding mortality rate, modified Rankin Scale (mRS) score, and duration of hospital stay. RESULTS: The mean age of the study population was 5.98 ± 7.02 years. The mean follow-up duration was 7.6 ± 3.2 months in the conventional group and 5.7 ± 3.4 months in the lavage group. The mortality rate was 25% (4/16) in the lavage group and 52.9% (9/17) in the nonlavage group (p = 0.1). The mRS score was less than 3 (good outcome) in 68.8% (11/16) of the lavage group cases and in 23.5% (4/17) of the conventional group (p < 0.05). The mean hospital stay duration was 20.5 ± 14.2 days in the lavage group, whereas it was 39.7 ± 16.9 days in the conventional group (p < 0.05). CONCLUSIONS: Ventricular lavage or irrigation together with antibiotics is useful in the management of cerebral ventriculitis and associated with a better outcome and shorter hospital stay duration compared to current conventional lines of treatment.

Visual changes after space flight: is it really caused by increased intracranial tension? A systematic review.

INTRODUCTION: Spaceflight-Associated Neuro-ocular Syndrome (SANS) was linked to increased intracranial pressure (ICP) attributable to the combined effects of microgravity and environmental conditions encountered during spaceflight. Microgravity countermeasures as lower body negative pressure (LBNP) are potential interventions for SANS. Our aim is to provide a comprehensive qualitative analysis of literature contrasting simulation and spaceflight studies, focusing on the pathophysiology of SANS, and highlighting gaps in current knowledge. EVIDENCE ACQUISITION: We systematically searched PubMed electronic database for English primary research published until February 2019 discussing intracranial changes in spaceflight or simulated microgravity, excluding animal and experimental studies. Two authors screened all the abstracts with a third author resolving disagreements. The full-text manuscripts were analyzed in pilot-tested tables. EVIDENCE SYNTHESIS: Nineteen studies were reviewed; 13 simulation, and two out of six spaceflight studies were prospective. ICP changes were investigated in 11 simulation studies, where eight demonstrated a significant increase in ICP after variable periods of head-down tilt. three showed a significant increase in intraocular pressure (IOP) in conjunction with ICP elevation. With increasing ambient CO2: one showed an increase in IOP without further increase in ICP, while another showed a slight further decrease in ICP. LBNP demonstrated no significant effect on ICP in one and a decrease thereof in another study. After spaceflight, increased ICP on lumbar puncture was demonstrated in five studies. CONCLUSIONS: Exposure to microgravity increases ICP possibly precipitating ocular changes. Whether other factors come into play is the subject of investigation. Further randomized studies and methods of direct ICP measurement during spaceflight are needed.

ETV in infancy and childhood below 2 years of age for treatment of hydrocephalus.

PURPOSE: Age and etiology play a crucial role in success of endoscopic third ventriculostomy (ETV) as a treatment of obstructive hydrocephalus. Outcome is worse in infants, and controversies still exist whether ETV is superior to shunt placement. We retrospectively analyzed 70 patients below 2 years from 4 different centers treated with ETV and assessed success. METHODS: Children < 2 years who received an ETV within 1994-2018 were included. Patients were classified according to age and etiology; < 3, 4-12, and 13-24 months, etiologically; aqueductal stenosis, post-hemorrhagic-hydrocephalus (PHH), tumor-related, fourth ventricle outflow obstruction, with Chiari-type II and following CSF infection. We investigated statistically the predictors for ETV success through computing Kaplan-Meier estimates using patient's follow-up time and time to ETV failure. RESULTS: We collected 70 patients. ETV success rate was 41.4%. The highest rate was in tumor-related hydrocephalus and fourth ventricle outlet obstruction (62.5%, 60%) and the lowest rate was in Chiari-type II and following infection (16.7%, 0%). The below 3 months age group showed relatively lower success rate (33.3%) in comparison to older groups which showed similar results (46.4%, 46.6%). Statistically, a previous VP shunt was a predictor for failure (p value < 0.05). CONCLUSION: Factors suggesting a high possibility of failure were age < 3 months and etiology such as Chiari-type II or following infection. Altered CSF dynamics in patients with PHH and under-developed arachnoid villi may play a role in ETV failure. We do not recommend ETV as first line in children < 3 months of age or in case of Chiari II or following infection.

Arachnoid bands and venous compression as rare causes of hemifacial spasm: analysis of etiology in 353 patients.

BACKGROUND: Hemifacial spasm is usually caused by arterial compression at the root exit zone of the facial nerve. However, other etiologies have been reported. The aim of this study was to analyze the frequency of other causes of hemifacial spasm. METHODS: Our prospectively maintained hemifacial spasm database containing all patients who underwent microvascular decompression (MVD) for hemifacial spasm from 2002 to 2018 was reviewed. All offending structures were identified and recorded by the surgeon at the time of surgery. Additionally, the operative videos were analyzed retrospectively. RESULTS: MVD was performed in 353 patients. Arterial compression was the main cause of hemifacial spasm in 341 (96.9%) patients. Combined venous-arterial compression was seen in 7 (2.0%) patients. In one patient, the compression was from a large vein. In two patients, no compression was found. One patient who suffered from Bell's palsy many years previously had severe synkinesis and the other had facial tics. In two patients, the spasm was caused due to strangulation of the facial nerve by arachnoid bands. Long-term follow-up of more than 18 months was available in 249 patients with total resolution or near total resolution of spasms in 89.96% of patients. CONCLUSIONS: In most patients with hemifacial spasm, arterial vessels are involved in compressing the facial nerve. Purely venous compression is rarely encountered. We report for the very first time arachnoid bands strangulating the nerve as a cause for hemifacial spasm without involvement of any vessel.