A technical guide to robotic-assisted carotid angioplasty and stenting with the Corindus CorPath GRX system.

Robotic-assisted carotid artery angioplasty and stenting is becoming more popular due to its precision and radiation safety. In this video, we present a case using the CorPath GRX Robotic System (Corindus, a Seimens Healthineers Company, Waltham, Massachusetts, USA) with step-by-step procedure process and technical nuances (video 1). We demonstrate that cervical carotid angioplasty and stenting can be safely performed using the robotic system with efficiency and accuracy.

Pterional Craniotomy With Anterior Clinoidectomy for the Resection of a Sphenoid Ridge Meningioma: A Case Report and Two-Dimensional Operative Video.

The pterional craniotomy with anterior clinoidectomy is a surgical technique used to resect sphenoid ridge meningiomas. It involves drilling the bone of the anterior clinoid process to gain access to the skull base, including the cavernous sinus and petrous apex particularly. This approach offers several advantages, including excellent exposure of the surgical site, minimal brain retraction, and the ability to visualize and protect critical neurovascular structures. We present a case of a 59-year-old woman presented with headache, dizziness, blurry vision, and unsteady gait for several months. The brain magnetic resonance imaging with gadolinium contrast showed a large space-occupying homogeneously-enhancing lesion at the left skull base, displacing the surrounding structures, including the frontal lobe, temporal lobe, and brainstem. Herein, we present the intraoperative video on a case in which the pterional craniotomy with anterior clinoidectomy that can allow the exposure and resection of the tumor extending into the posterior fossa was utilized for the resection of a large left sphenoid ridge meningioma with brain stem compression.

Successful Management of Iatrogenic Cranial Pseudomeningocele With Subgaleal Shunt.

Iatrogenic pseudomeningocele is a common complication of cranial surgeries. However, there are no evidence-based guidelines on how to manage this condition. We report two cases of iatrogenic postoperative cranial pseudomeningocele that failed conservative management including compressive head dressing. Subgaleal shunt placement was utilized with successful resolution in both cases. We postulate that subgaleal shunt placement may be an effective method in the management of iatrogenic subgaleal pseudomeningocele.

Mechanical Thrombectomy for Septic Embolism Secondary to Staphylococcus lugdunensis Bacteremia without Infective Endocarditis: A Case Report.

A cerebral large vessel occlusion due to septic embolism with resultant stroke is a known complication of infective endocarditis and can cause severe neurologic disability. However, septic embolism rarely occurs in the absence of infective endocarditis, and emboli due to different organisms may behave differently. As such, it is important to recognize the different pathogens that can cause septic embolism resulting in cerebral large vessel occlusion and to have data on successful treatments. We describe here a case of mechanical thrombectomy for septic embolism secondary to Staphylococcus lugdunensis bacteremia without infective endocarditis.

Cerebrospinal fluid leak management in anterior basal skull fractures secondary to head trauma.

OBJECTIVE: To summarize the presentation, diagnosis, and management of cerebrospinal fluid (CSF) leaks in the setting of traumatic anterior skull base fracture. METHODS: Wide literature research has been performed as well as the authors' own clinical experience has been summarized. RESULTS: Articles from the most recent 30 years have been reviewed and a typical case of our own has been presented. Based on the most updated evidence, a treatment algorithm for CSF leaks has been proposed. CONCLUSION: Anterior skull base fracture accounts for about 4% of all head injuries and CSF leaks is a complication that commonly presents with clear fluid emanating from the nasal passage. A positive beta-2-transferrin study is highly specific for diagnosis, while thin-slice CT scanning and MRI cisternography are also useful tools. The majority of the CSF leaks tend to be resolved spontaneously, and conservative management is attempted first with or without the augmentation of a lumbar drain. Surgical management mainly includes open surgery and endoscopic surgery, which have their own pros and cons.

Open biopsy with posterior instrumentation followed by anterolateral approach for removal of an uncommon tumor in the cervical spine.

The conventional treatment for the resection of cervical spinal tumors comprises anterior, posterior, and combined surgical approaches. However, these approaches have certain limitations when tumors invade the vertebrae, vertebral artery, or spinal nerves. Herein, we report an interesting case where a 45-year-old patient was admitted for neck pain. An invasive cervical spinal tumor was discovered and approached in two stages: stage 1 was open biopsy with posterior instrumentation, which was followed by stage 2 with an anterolateral approach for definitive surgical resection. A series of preoperative tests including angiography as well as a balloon occlusion test of the vertebral artery facilitated stage 2 surgical planning for gross total resection of the tumor while minimizing surgical complications.

Intraoperative utilization of Microvascular Doppler for the detection of intracranial venous structures during tumor resection - A technical note.

BACKGROUND: Microvascular Doppler (MVD) has been widely used for the detection of arterial blood flow in the brain, especially during aneurysm clipping, vascular malformation resection, or bypass surgeries. However, the benefits obtained from early identification of intracranial sinuses and deep draining veins during tumor resection has not been reported. METHODS: We reviewed the clinical data and imaging from our cases and conducted a systemic review of the medical literature using PubMed and keywords. Bibliographies of each result were evaluated to determine if additional reports describing the use of MVD during tumor resection could be found. RESULTS: No reports were found in the literature where MVD was specifically used for venous identification during the resection of deep-seated brain tumors. In our patient cohort, MVD was used successfully to detect and ultimately allow immediate protection of large dural venous sinuses as well as smaller deep cerebral veins during tumor resection. Each patient developed no new venous infarcts and made a satisfactory recovery with no new postoperative neurological deficits. CONCLUSION: MVD is a reliable tool for the intraoperative detection of intracranial venous blood flow to allow for quick identification and protection of venous structures. MVD is an additional safety measure for the patient as its accuracy in detecting venous structures is less susceptible to many of the inherent weaknesses of stereotactic neuro-navigation including the accompanying brain shift or anatomical distortion produced by long duration deep seated brain tumor resection.

Novel Decompressive Hemicraniectomy Technique for Traumatic Brain Injury: Technical Note.

BACKGROUND: Traumatic brain injury (TBI) is a significant cause of morbidity and mortality across all age groups. Decompressive hemicraniectomy is the treatment for TBI-related refractory intracranial hypertension. The traditional technique for this procedure can result in wound complications due to injury of the scalp flap's vascular supply, namely the superficial temporal and postauricular arteries. METHODS: In this technical note we describe our experience using a novel technique that preserves both vascular territories by placing the inferior aspect of the incision posterior to the ear as opposed to anterior to it. This modification has the potential to reduce wound healing complications, especially in those at higher risk, while also reducing operative time by avoiding temporalis muscle incision and closure during procedure. RESULTS: After performing hospital chart review, a total of 7 patients were found who underwent this hemicraniectomy technique for severe TBI. Of these, 5 patients had this performed on the left side, and 2 patients had this performed on the right side. Six of the patients had an accompanying subdural hematoma, whereas 1 patient had no intracranial hemorrhage present. CONCLUSIONS: In each case, both the superficial temporal and postauricular arteries were preserved, and rapid healing of the scalp flap occurred. In addition to providing a large bone window to allow the brain to swell, this technique has the potential to reduce complications of wound healing by preserving the vascular supply of the scalp flap and reduce operative times by minimizing temporalis muscle dissection.

Safely performing neurosurgical procedures during COVID-19 pandemic.

INTRODUCTION: The novel coronavirus disease (COVID-19) pandemic poses a substantial threat to the health of healthcare personnel on the front line of caring for COVID-19 patients. The Centers for Medicare and Medicaid Services previously announced that all non-essential planned surgeries and procedures should be postponed until further notice and only urgent procedures should proceed. METHODS: We share our experiences with safely performing neurosurgical procedures on confirmed and suspected COVID-19 patients, to aide other neurosurgical teams in preparing for these high-risk cases, especially for neurosurgical interventions which are essential at saving a life or preserving functioning of the central nervous system that cannot be delayed. Perioperative and intraoperative strategies, considerations, as well as challenges arisen under the specific circumstance have been discussed: the hospital should be equipped with negative pressure areas and multiple areas to quarantine positive patients; the operating rooms should be negative pressure or have HEPA-filtration systems in place; all healthcare personnel who immediately participate in neurosurgical interventions for confirmed and suspected COVID-19 patients should take airborne precautions and wear enhanced personal protective equipment. RESULTS: Successful management of neurosurgical emergencies without healthcare personnel infection has been achieved during this pandemic crisis. CONCLUSION: Following the proposed guidance, urgent neurosurgical surgeries and procedures can be safely performed for the benefit of critical patients with or suspected for COVID-19.

Lessons from China When Performing Neurosurgical Procedures During the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: The novel coronavirus disease 2019 (COVID-19) pandemic poses a substantial threat to the health of health care personnel on the front line of caring for patients with COVID-19. The Centers for Medicare and Medicaid Services have announced that all nonessential planned surgeries and procedures should be postponed until further notice and only urgent procedures should proceed. Neurologic surgeries and procedures should not be delayed under the circumstance in which it is essential at saving a life or preserving functioning of the central nervous system. METHODS: With the intent to advise the neurosurgery team on how to adequately prepare and safely perform neurosurgical procedures on confirmed and suspected patients with COVID-19, we discuss considerations and recommendations based on the lessons and experience shared by neurosurgeons in China. RESULTS: Perioperative and intraoperative strategies, considerations, as well as challenges arisen under the specific circumstance have been discussed. In addition, a case of a ruptured aneurysm in a suspected patient with COVID-19 is reported. It is advised that all health care personnel who immediately participate in neurosurgical surgeries and procedures for confirmed and suspected patients with COVID-19 should take airborne precautions and wear enhanced personal protective equipment. CONCLUSIONS: Following the proposed guidance, urgent neurosurgical surgeries and procedures can be safely performed for the benefit of critical patients with or suspected for COVID-19.

"Plugged" Anterior Inferior Cerebellar Artery Aneurysm Causing Facial Palsy, Hearing Loss, and Subarachnoid Hemorrhage Treated by a Translabyrinthine Approach.

Anterior inferior cerebellar artery (AICA) aneurysms are rare, less than 1%-2% of all intracranial aneurysms. Aneurysms of the distal AICA are even less common and can present with hearing loss and facial paralysis because of their relationship with the internal auditory canal (IAC). A 65-year-old male was followed for fluctuating left facial weakness and left-sided hearing loss for over a year. Serial magnetic resonance imaging (MRI) scans showed a mass near the left IAC, thought to be a vestibular schwannoma. Just prior to his next clinic visit, the patient deteriorated suddenly from a subarachnoid hemorrhage. Cerebral angiography revealed a 5.5 mm saccular aneurysm at the distal left AICA, which was clip ligated via a translabyrinthine (TL) approach. The patient had a good functional outcome (modified Rankin Scale [mRS] 1) after 30 days despite persistent left facial weakness. Stable obliteration of the aneurysm was demonstrated by cerebral angiography postoperatively. Distal AICA aneurysms are rare and can have a similar presentation to tumors in the cerebellar pontine angle. Because of the unique anatomy of the distal AICA, open clip ligation via a TL approach is an effective method to secure these aneurysms.

Off-Label Application of Pipeline Embolization Device for Intracranial Aneurysms.

PURPOSE: The Pipeline embolization device (PED) is approved in the USA for treating giant and large aneurysms arising from the petrous to superior hypophyseal segments of the internal carotid artery in patients older than 21 years of age. This study investigates off-label PED results in a large cohort. MATERIALS AND METHODS: Retrospective, single-center review of all patients who had off-label PED surgery. RESULTS: Sixty-two aneurysms (48 patients) underwent off-label PED treatment from 2012- 2017. There were 44 females and four males (age 21 to 75 years; mean/median, 54.3/55.0 years). The most common presenting symptom was headache (47/62, 75.8%). All aneurysms were in the anterior circulation. Aneurysm size ranged from 1.4 to 25.0 mm (mean/median, 7.6/6.9 mm). Fifty-two aneurysms had post-operative imaging with total/near-complete occlusion of 84.6% (44/52). Aneurysm-based operative near-term complication rate was 9.7% while there were no permanent complications. For aneurysms and headache, 86.7% improved/resolved after embo-surgery, and were four times more likely to have a better clinical outcome (resolved or improved symptoms) after surgery (odds ratio [OR], 4.333; P=0.0325). Left-sided aneurysms had a higher occlusion rate (OR, 20; P=0.0073). Hypertension (OR, 4.2; P=0.0332) and smoking (OR, 7; P=0.0155) were more prone towards aneurysm occlusion. Patients without a family history were 14 times more likely to have favorable imaging outcome (P=0.0405). There is no difference of occlusion rates between untreated and previously treated aneurysms (P=0.6894). Overall, occlusion rate decreased by 14% with an increase of aneurysm size by 1 mm (P=0.0283). CONCLUSION: For anterior circulation aneurysms, the off-label application of PED is as effective and safe as reported for on-label intracranial aneurysms.

Triple-drug Therapy With Bevacizumab, Irinotecan, and Temozolomide Plus Tumor Treating Fields for Recurrent Glioblastoma: A Retrospective Study.

Clinical studies treating pediatric and adult solid tumors, such as glioblastoma (GBM), with a triple-drug regimen of temozolomide (TMZ), bevacizumab (BEV), and irinotecan (IRI) [TBI] have demonstrated various efficacies, but with no unexpected toxicities. The TBI regimen has never been studied in recurrent GBM (rGBM) patients. In this retrospective study, we investigated the outcomes and side effects of rGBM patients who had received the TBI regimen. We identified 48 adult rGBM patients with a median age of 56 years (range: 26-76), who received Tumor Treating Fields (TTFields) treatment for 30 days or longer, and concurrent salvage chemotherapies. The patients were classified into two groups based on chemotherapies received: TBI with TTFields (TBI+T, N = 18) vs. bevacizumab (BEV)-based chemotherapies with TTFields (BBC+T, N = 30). BBC regimens were either BEV monotherapy, BEV+IRI or BEV+CCNU. Patients in TBI+T group received on average 19 cycles of TMZ, 26 and 21 times infusions with BEV and IRI, respectively. Median overall survival (OS) and progression-free survival (PFS) for rGBM (OS-R and PFS-R) patients who received TBI+T were 18.9 and 10.7 months, respectively. In comparison, patients who received BBC+T treatment had OS-R and PFS-R of 11.8 (P > 0.05) and 4.7 (P < 0.05) months, respectively. Although the median PFS results were significantly different by 1.5 months (6.6 vs. 5.1) between TBI+T and BBC+T groups, the median OS difference of 14.7 months (32.5 vs. 17.8) was more pronounced, P < 0.05. Patients tolerated TBI+T or BBC+T treatments well and there were no unexpected toxicities. The most common side effects from TBI+T treatment included grade III hypertension (38.9%) and leukopenia (22.2%). In conclusion, the TBI regimen might play a role in the improvement of PFS-R and OS-R among rGBM patients. Prospective studies with a larger sample size are warranted to study the efficacy and toxicity of TBI+T regimen for rGBM.

What is the advance of extent of resection in glioblastoma surgical treatment-a systematic review.

Glioblastoma multiform (GBM) is the most common malignant brain tumor characterized by poor prognosis, increased invasiveness, and high relapse rates. The relative survival estimates are quite low in spite of the standard treatment for GBM in recent years. Now, it has been gradually accepted that the amount of tumor mass removed correlates with longer survival rates. Although new technique advances allowing intraoperative analysis of tumor and normal brain tissue and functional paradigms based on stimulation techniques to map eloquent areas have been used for GBM resection, visual identification of tumor margins still remains a challenge for neurosurgeons. This article attempts to review and summarize the evolution of surgical resection for glioblastomas.

Reoperation for growth hormone-secreting pituitary adenomas: report on an endonasal endoscopic series with a systematic review and meta-analysis of the literature.

OBJECTIVE Surgery is generally the first-line therapy for acromegaly. For patients with residual or recurrent tumors, several treatment options exist, including repeat surgery, medical therapy, and radiation. Reoperation for recurrent acromegaly has been associated with poor results, with hormonal control usually achieved in fewer than 50% of cases. Extended endonasal endoscopic approaches (EEAs) may potentially improve the results of reoperation for acromegaly by providing increased visibility and maneuverability in parasellar areas. METHODS A database of all patients treated in the authors' center between July 2004 and February 2016 was reviewed. Cases involving patients with acromegaly secondary to growth hormone (GH)-secreting adenomas who underwent EEA were selected for chart review and divided into 2 groups: first-time surgery and reoperation. Disease control was defined by 2010 guidelines. Clinical and radiological characteristics and outcome data were extracted. A systematic review was done through a MEDLINE database search (2000-2016) to identify studies on the surgical treatment of acromegaly. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the included studies were reviewed for surgical approach, tumor size, cavernous sinus invasion, disease control, and complications. Cases were divided into reoperation or first-time surgery for comparative analysis. RESULTS A total of 44 patients from the authors' institution were included in this study. Of these patients, 2 underwent both first-time surgery and reoperation during the study period and were therefore included in both groups. Thus data from 46 surgical cases were analyzed (35 first-time operations and 11 reoperations). The mean length of follow-up was 70 months (range 6-150 months). The mean size of the reoperated tumors was 14.8 ± 10.0 mm (5 micro- and 6 macroadenomas). The patients' mean age at the time of surgery was younger in the reoperation group than in the first-time surgery group (34.3 ± 12.8 years vs 49.1 ± 15.7 years, p = 0.007) and the mean preoperative GH level was also lower (7.7 ± 13.1 µg/L vs 25.6 ± 36.8 µg/L, p = 0.04). There was no statistically significant difference in disease control rates between the reoperation (7 [63.6%] of 11) and first-time surgery (25 [71.4%] of 33) groups (p = 0.71). Univariate analysis showed that older age, smaller tumor size, lower preoperative GH level, lower preoperative IGF-I level, and absence of cavernous sinus invasion were associated with higher chances of disease control in the first-time surgery group, whereas only absence of cavernous sinus invasion was associated with disease control in the reoperation group (p = 0.01). There was 1 case (9%) of transient diabetes insipidus and hypogonadism and 1 (9%) postoperative nasal infection after reoperation. The systematic review retrieved 29 papers with 161 reoperation and 2189 first-time surgery cases. Overall disease control for reoperation was 46.8% (95% CI 20%-74%) versus 56.4% (95% CI 49%-63%) for first-time operation. Reoperation and first-time surgery had similar control rates for microadenomas (73.6% [95% CI 32%-98%] vs 77.6% [95% CI 68%-85%]); however, reoperation was associated with substantially lower control rates for macroadenomas (27.5% [95% CI 5%-57%] vs 54.3% [95% CI 45%-62%]) and tumors invading the cavernous sinus (14.7% [95% CI 4%-29%] vs 38.5% [95% CI 27%-50%]). CONCLUSIONS Reoperative EEA for acromegaly had results similar to those for first-time surgery and rates of control for macroadenomas that were better than historical rates. Cavernous sinus invasion continues to be a negative prognostic indicator for disease control; however, results with EEA show improvement compared with results reported in the prior literature.

Transorbital endoscopic eyelid approach for resection of sphenoorbital meningiomas with predominant hyperostosis: report of 2 cases.

Sphenoorbital meningiomas (SOMs) are slow-growing tumors that originate from the sphenoidal wing and are associated with visual deterioration, extrinsic ocular movement disorders, and proptosis caused by hyperostosis of the lateral wall of the orbit. In some cases, the intracranial component is quite small or "en plaque," and the majority of the symptoms arise from adjacent hyperostosis. Craniotomy has traditionally been the standard of care, but new minimally invasive multiportal endoscopic approaches offer an alternative. In the current study, the authors to present their experience with the transorbital endoscopic eyelid approach for the treatment of 2 patients with SOMs and sphenoid wing hyperostosis. Clinical and radiological data for patients with SOMs who underwent a transorbital endoscopic eyelid approach were retrospectively reviewed. Surgical technique and clinical and radiographic outcomes were analyzed. The authors report the cases of 2 patients with SOMs and proptosis due to sphenoid wing hyperostosis. One patient underwent prior craniotomy to debulk the intracranial portion of the tumor, and the other had a minimal intracranial component. Both patients were discharged 2 days after surgery. MR images and CT scans demonstrated a large debulking of the hyperostotic bone. Postoperative measurement of the proptosis with the aid of an exophthalmometer demonstrated significant reduction of the proptosis in one of the cases. Persistence of intraconal tumor in the orbital apex limited the efficacy of the procedure in the other case. A review of the literature revealed 1 publication with 3 reports of the transorbital eyelid approach for SOMs. No measure of relief of proptosis after this surgery had been previously reported. The transorbital endoscopic approach, combined with endonasal decompression of the medial orbit, may be a useful minimally invasive alternative to craniotomy in a subset of SOMs with a predominantly hyperostotic orbital wall and minimal intracranial bulky or merely en plaque disease. In these cases, relief of proptosis and optic nerve compression are the primary goals of surgery, rather than gross-total resection, which may have high morbidity or be unachievable. In cases with significant residual intraconal tumor, orbital bone removal alone may not be sufficient to reduce proptosis.

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

OBJECTIVE Craniopharyngiomas arise from the pituitary stalk, and in adults they are generally located posterior to the chiasm extending up into the third ventricle. The extended endonasal approach (EEA) can provide an ideal corridor between the bottom of the optic chiasm and the top of the pituitary gland (chiasm-pituitary corridor [CPC]) for their removal. A narrow CPC in patients with a prefixed chiasm and a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and subtotal resection. METHODS A database of all patients treated in the authors' center (Weill Cornell Medical College, NewYork-Presbyterian Hospital) between July 2004 and August 2016 was reviewed. Patients with craniopharyngiomas who underwent EEA with the goal of gross-total resection (GTR) were included in the study. Patients with postfixed chiasm or limited available preoperative imaging were excluded. Using preoperative contrast-enhanced T1-weighted sagittal midline MR images, the authors calculated the CPC as well as the distance from the chiasm to the top of the tumor (CTOT). From these numbers, they calculated a ratio of the CPC to the CTOT as a measure of difficulty in removing the tumors through the EEA and called this ratio the corridor index (CI). The relationship between the CI and the ability to achieve GTR and visual outcome were measured. RESULTS Thirty-four patients were included in the study. The mean CPC was 10.1 mm (range 5.2-19.1 mm). The mean CTOT was 12.8 mm (range 0-28.3 mm). The median CI was 0.8; the CI ranged from 0.4 to infinity (for tumors with a CTOT of 0). Thirty-two patients had GTR (94.1%) and 2 had subtotal resection. The CPC value had no relationship with our ability to achieve GTR and no effect on visual or endocrine outcome. CONCLUSIONS EEA for craniopharyngioma is generally considered the first-line surgical approach. Although a narrow corridor between the top of the pituitary gland and the bottom of the chiasm may seem to be a relative contraindication to surgery for larger tumors, the authors' data do not bear this out. EEA appears to be a successful technique for the majority of midline craniopharyngiomas.

Surgical Management and Outcome Experience of 53 Cerebellopontine Angle Meningiomas.

Background Meningiomas follow schwannomas as the second most common cerebellopontine angle (CPA) tumors. We investigate the diagnosis, management, and prognosis of this disease. Methods We reviewed the cases with the CPA meningiomas in our institution in Shaanxi, China from January 2012 to December 2015. Charts were retrospectively examined and patients were divided into two groups: 1) surgical treatment with a retrosigmoid approach for tumor resection and 2) stereotactic radiosurgery treatment only. Patients were followed up and outpatient records were also reviewed. Results Forty-nine patients underwent surgical resection via the retrosigmoid approach, while the other four underwent Gamma Knife® stereotactic radiosurgery (Elekta AB, Stockholm, Sweden) only. The most common presenting symptoms included hearing loss/tinnitus, vertigo, and headache; only 8.2% were asymptomatic. The largest diameter and base of each tumor varied from 4.0 to 5.5 cm and 3.0 to 5.0 cm, respectively. The tumors extended into different directions, mainly towards the tentorium and internal acoustic meatus (IAM). Eighty-three percent of surgical patients had a gross total resection. One death occurred due to pulmonary inflammation. Tumor recurrence was noted in 6.1% of patients. Postoperative trigeminal disturbance, facial nerve palsy, and hearing deterioration or loss were the most common immediate and delayed postoperative complications; most patients partially or completely recovered after hospital discharge. Intraoperative neuro-electrophysiological monitoring, complete resection, and postoperative radiation were key factors for reducing complications and recurrence. Conclusions The retrosigmoid approach offers an ideal visual field for exposing and resecting CPA meningiomas in a large series of cases. In our experience, it is one of the most useful and commonly used surgical approaches for removing meningiomas of this region.

Limitations of the endonasal endoscopic approach in treating olfactory groove meningiomas. A systematic review.

OBJECTIVE: To review current management strategies for olfactory groove meningioma (OGM)s and the recent literature comparing endoscopic endonasal (EEA) with traditional transcranial (TCA) approaches. METHODS: A PubMed search of the recent literature (2011-2016) was performed to examine outcomes following EEA and TCA for OGM. The extent of resection, visual outcome, postoperative complications and recurrence rates were analyzed using percentages and proportions, the Fischer exact test and the Student's t-test using Graphpad PRISM 7.0Aa (San Diego, CA) software. RESULTS: There were 444 patients in the TCA group with a mean diameter of 4.61 (±1.17) cm and 101 patients in the EEA group with a mean diameter of 3.55 (± 0.58) cm (p = 0.0589). GTR was achieved in 90.9% (404/444) in the TCA group and 70.2% (71/101) in the EEA group (p < 0.0001). Of the patients with preoperative visual disturbances, 80.7% (21/26) of patients in the EEA cohort had an improvement in vision compared to 12.83%(29/226) in the TCA group (p < 0.0001). Olfaction was lost in 61% of TCA and in 100% of EEA patients. CSF leaks and meningitis occurred in 25.7% and 4.95% of EEA patients and 6.3% and 1.12% of TCA patients, respectively (p < 0.0001; p = 0.023). CONCLUSIONS: Our updated literature review demonstrates that despite more experience with endoscopic resection and skull base reconstruction, the literature still supports TCA over EEA with respect to the extent of resection and complications. EEA may be an option in selected cases where visual improvement is the main goal of surgery and postoperative anosmia is acceptable to the patient or in medium-sized tumors with existing preoperative anosmia. Nevertheless, based on our results, it seems more prudent at this time to use TCA for the majority of OGMs.

Transtubular excisional biopsy as a rescue for a non-diagnostic stereotactic needle biopsy-case report and literature review.

Stereotactic needle biopsy, a standard of care for acquiring deep-seated pathology, has limitations and risks in some situations. We present an uncommon case with basal ganglia dematiaceous mycetoma. Due to the firm consistency of the lesion, the initial stereotactic needle biopsy failed to provide a diagnosis. In a second operation, transtubular excisional biopsy was successfully performed to remove the entire mycetoma. We reviewed recent case series of transtubular approaches to deep-seated brain lesions and suggest this method could be a rescue for a non-diagnostic stereotactic needle biopsy and even may be the approach of choice in some cases.