The Use of the Suboccipital Transtentorial Approach to the Posterior Inferior Incisural Space.

Objective To describe our experience with the microsurgical technique of the suboccipital transtentorial (SOTT) approach in the removal of posterior fossa lesions located in the posterior incisural space. Method Between 2002 and 2020 we reviewed all patients who underwent microsurgical resection of lesions of the posterior incisural space at the Department of Neurosurgery, Essex Neuroscience Centre, London, England (eight patients, male to female 3:5, mean age: 51, range 35-69). We describe the preoperative symptoms, radiological findings, surgical techniques, histology and postoperative outcomes in this cohort of patients. Results Eight patients with tumours located in the posterior incisural space underwent surgery during the study period including four meningiomas (50%), two haemangioblastomas (25%), one metastasis (13%) and one giant prolactinoma (13%). Gross or near total resection was achieved in six patients (75%): the giant prolactinoma could not be radically removed and one of the meningiomas required a small fragment to be left in place to protect the Vein of Galen. No patient developed a visual field deficit due to occipital lobe retraction. One patient developed a temporary trochlear nerve palsy (13%). Five patients had mild disability (Glasgow Outcome Scale (GOS) = 5), and four had moderate disability (GOS = 4). Conclusion In our series, the SOTT approach provided excellent access for all cases of tumours in the posterior incisural space. The tumour's size and relationship to the deep venous system contributed to the choice of approach and in one patient who had previously undergone surgery via the supracerebellar route, the SOTT approach enabled the avoidance of gliotic scar tissue. Success is dependent on careful case selection, though from our series of 8 patients, we conclude that this approach allows safe access to the posterior incisural space, with acceptable outcomes with regard to postoperative disability and cranial nerve palsy. As such, the approach should be in the armamentarium of any neurosurgeon who regularly deals with posterior fossa pathology.

The Italian Consensus for the Classification and Reporting of Thyroid Cytology: Cytohistologic and molecular correlations on 37,371 nodules from a single institution.

BACKGROUND: The Italian Consensus for the Classification and Reporting of Thyroid Cytology (ICCRTC) includes six diagnostic categories (TIR 1/1C, TIR 2, TIR 3A, TIR 3B, TIR 4, and TIR 5), each indicating a different risk of malignancy. The objective of this monocentric retrospective study was to evaluate the distribution of the ICCRTC classes at the authors' institution and assess their cytohistologic correlations. METHODS: The authors retrospectively collected 37,371 consecutive cytologic reports of thyroid nodules and described the clinical-pathologic features of the different cytologic categories. The cytologic diagnoses also were compared with histologic outcomes in a subset of patients. RESULTS: The cytologic classes were distributed as follows: nondiagnostic, 15.6%; benign, 66.5%; low-risk indeterminate, 10% (TIR 3A); high-risk indeterminate, 3.5% (TIR 3B); suspicious, 1.7%; and malignant, 2.6%. According to histology, the risk of malignancy was very high in the nondiagnostic category (29.8%), with young male patients more exposed to malignancy, and it was relatively high among benign (7.8%) and indeterminate nodules (32.5% in TIR 3A; 52.1% in TIR 3B), mainly because of the high prevalence of follicular architecture in malignant tumors. On histology, the malignancy rates were 92.4% and 99.3% for the suspicious and malignant categories, respectively; aggressive variants of papillary thyroid carcinoma were mostly diagnosed in these categories. CONCLUSIONS: In this series, nondiagnostic nodules showed high prevalence and, surprisingly, high malignancy rates. Malignant tumors with follicular architecture represented a diagnostic pitfall in benign and indeterminate nodules. The suspicious and malignant categories had high specificity for malignancy. Importantly, the ICCRTC had high reliability for identifying preoperatively aggressive histotypes of thyroid carcinoma.

Down-regulation of miR-7-5p and miR-548ar-5p predicts malignancy in indeterminate thyroid nodules negative for BRAF and RAS mutations.

PURPOSE: The value of molecular markers in refining preoperative risk assessment of indeterminate thyroid nodules is being widely investigated. MicroRNAs (miRNA) are emerging as promising biomarkers for diagnostic and prognostic purposes. The aim of this study is to identify miRNAs specifically deregulated in mutation-negative indeterminate thyroid nodules. METHODS: Ninety-eight nodules preoperatively diagnosed as TIR 3A or TIR 3B with available histological diagnosis of follicular adenoma (FA), noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP), and follicular variant papillary thyroid carcinoma (FV-PTC) have been retrospectively selected. Mutations in BRAF and RAS genes have been tested in all samples by real-time PCR; miRNAs were purified from cytology slides of 60 samples; expression analysis of 798 miRNAs was measured by the nCounter system. RESULTS: Point mutations in BRAF and RAS genes were detected in 32 out of 98 nodules (32.7%), the majority of which in FV-PTCs. Differential expression of miRNA in wild-type nodules highlighted that two miRNAs, namely miR-7-5p and miR-548ar-5p, were downregulated in FV-PTCs compared to FAs. The combined expression of these miRNAs, tested by ROC analysis, showed an area under the curve of 0.79. Sensitivity and negative predictive value were high both in wild-type (93% and 92%, respectively) and in mutated nodules (94% and 85%, respectively). CONCLUSION: The analysis of miR-7-5p and miR-548ar-5p expression in indeterminate thyroid nodules demonstrated a promising value in ruling out malignancy.

Women in neurosurgery in the United Kingdom: past, present and future.

Whilst a growing number of women in the United Kingdom (UK) are making a success of a career in medicine as a whole, a considerable gender imbalance persists in neurosurgery. The extent of this disparity and the factors that perpetuate it are difficult to assess. Furthermore, over the 70 years since the first female neurosurgeon in the UK commenced her postgraduate training, it is difficult to gauge the progress that has been made. In this article we present a snapshot of women who have played, and who are playing, a key role in UK neurosurgery, highlighting their diverse career paths. We also present the current training distribution and subspecialties of women in UK neurosurgery. We use these data to reflect upon the possible barriers to completion of neurosurgical training, obtaining a substantive consultant position, and reaching positions of academic and clinical leadership. We discuss potential interventions that may overcome these. Highlighting the role women play in UK neurosurgery's past, present and future should inspire more female neurosurgeons to become leaders in the coming years.

Biographies of international women leaders in neurosurgery.

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as "first" of their country or color or other achievement. All of them are included as outstanding-in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life's work, they chose service, often of the most neglected-those with pain, trauma, and disability. These women inspire and point the way to a time when the term "women leaders" as an exception is unnecessary.-Katharine J. Drummond, MD, on behalf of this month's topic editors.

Digital Gene Expression Analysis on Cytology Smears Can Rule Out Malignancy in Follicular-Patterned Thyroid Tumors.

Patients with indeterminate thyroid nodules (Bethesda III and IV) are often treated with diagnostic lobectomy, which in most cases represents an overtreatment. A reliable rule-out molecular test could spare patients unnecessary surgery. Stained smears of 88 indeterminate thyroid nodules with histologic diagnosis of follicular-patterned tumors were selected: 34 follicular adenomas (FAs), 34 follicular variant papillary thyroid carcinomas (FVPTCs), and 20 noninvasive follicular neoplasms with papillary-like nuclear features (NIFTPs). The expression level of 126 genes was measured by digital counting. Mutation testing was performed for the main gene mutations and fusions. Performance of gene expression and mutation tests was calculated by receiver operating characteristic analysis. The gene expression model showed an area under the curve (AUC) of 88%, with 91% negative predictive value in FAs and FVPTCs only. Part of NIFTPs was labeled as benign, and part was labeled as malignant; thus, the classifier performance worsened. Two FAs (5.9%), eight NIFTPs (40%), and 22 FVPTCs (64.7%) were mutation positive. Mutation testing AUC was 79% in FAs and FVPTCs, and decreased by including NIFTPs. This gene expression-based test was feasible in thyroid-stained smears, showed higher AUC than mutation test, and had a high negative predictive value-making it a good candidate as a rule-out test for indeterminate thyroid cytology. NIFTPs have a heterogeneous phenotype, and their preoperative diagnosis requires further investigation.

Patients with Indeterminate Thyroid Nodules at Cytology and Cancer at Histology Have a More Favorable Outcome Compared with Patients with Suspicious or Malignant Cytology.

BACKGROUND: The outcomes of patients with thyroid cancer proven by histology in patients in whom cytology was Thy 3 (indeterminate; Thy 3 patients in this study) based on the Italian consensus classification compared with those in whom cytology was Thy 4 (suspicious for malignancy) or Thy 5 (indicative for malignancy) (Thy 4-5 patients here) remains unclear. OBJECTIVE: To analyze the outcome of 371 Thy 3 patients versus 269 Thy 4-5 patients homogeneously treated with total thyroidectomy and 131I activity. RESULTS: T1 stage was observed in 46.0% of Thy 3 and in 38.8% of Thy 4-5 patients (p = 0.02), N0 in 95.9% of Thy 3 and in 75.5% of Thy 4-5 patients (p < 0.0001). 35/261 (9.6%) Thy 3 and 85/269 (31.5%) Thy 4-5 patients required >30 mCi of 131I (p < 0.0001). 359/371 (96.8%) Thy 3 and 232/269 (86.2%) Thy 4-5 patients were free of disease at the end of follow-up (p < 0.001). The time required to obtain 50% of patients in remission was 2 years in Thy 3 and 4 years in Thy 4-5 patients (p < 0.001). The most common histological type was the follicular variant of papillary thyroid carcinoma (FV-PTC) in Thy 3 patients (239/371, 64.4%) and the classic variant in Thy 4-5 patients (185/269; 68.8%). The FV-PTC had better prognostic features compared with the other PTC variants: T1 stage was observed in 133/277 (48.0%) FV-PTC patients and in 146/363 (40.0%) patients with the other variants (p < 0.001), N0 was present in 265/277 (96.0%) FV-PTC and in 290/363 (79.8%) patients with the other variants (p < 0.001). Overall, 267/277 FV-PTC patients (96.4%) and 324/363 patients (89.0%) with the other variants were free of disease (p < 0.0008) at the end of follow-up, and the time required to obtain 50% of patients in remission was 2 years in FV-PTC and 4.0 years in the other variants (p < 0.001). CONCLUSION: Patients with Thy 3 cytology have better outcomes of thyroid cancer compared with patients with Thy 4 or Thy 5 cytology, and indeterminate cytology is commonly associated with the less aggressive FV-PTC.

Non-operative meningiomas: long-term follow-up of 136 patients.

BACKGROUND: Improving access to neuroradiology investigations has led to an increased rate of diagnosis of incidental meningiomas. METHOD: A cohort of 136 incidental meningioma patients collected by a single neurosurgeon in a single neurosurgical centre is retrospectively analysed between 2002 and 2016. Demographic data, imaging and clinical features are presented. The radiological factors associated with meningiomas progression are also presented. RESULTS: The mean age at diagnosis was 65 (range, 33-94) years. Univariate analysis showed oedema was most strongly correlated with progression (p = 0.010) followed by hyperintensity in T2-weighted (T2W) MRI (p = 0.029) and in Flair-T2W MRI (p = 0.017). Isointensity in Flair-T2W MRI (0.004) was most strongly correlated with non-progression of the meningioma followed by calcification (p = 0.007), older age (p = 0.087), hypointensity in Flair-T2W MRI (p = 0.014) sequences and in T2W MRI (p = 0.096). In multivariate analysis, the strongest radiological factor predictive of progression was peritumoural oedema (p = 0.016) and that of non-progression was calcification (p = 0.002). At the end of the median follow-up (FU) of 43 (range, 4-150) months, 109 (80%) patients remained clinically stable, 13 (10%) became symptomatic and 14 (10%) showed clinical and radiological progression. CONCLUSIONS: One hundred and nine (80%) patients remained stable at the end of FU. Peritumoural oedema was predictive of meningiomas progression. Further prospective study is needed to identify the combination of factors which can predict the meningioma progression for an early surgery or early discharge.

Spontaneous shrinkage of vestibular schwannoma.

BACKGROUND: "Watch, wait, and rescan" (WWR) has an established place as a successful management option for a significant proportion of vestibular schwannomas (VS) as an alternative to microsurgical removal or stereotactic radiotherapy. VS may grow slowly and continuously, followed by stagnation or even shrinkage. We present two case reports of spontaneous shrinkage of VS along with a review of the literature. CASE DESCRIPTION: A 29-year-old female presented with a progressive history of visual blurring and intermittent diplopia over 2 months. A 29 mm of maximum intracranial diameter (ICD) VS with secondary obstructive hydrocephalus was diagnosed. The patient underwent a ventriculo-peritoneal shunt with resolution of her symptoms and opted for initial WWR management. Interval scanning between 2007 and 2014 showed progressive reduction in the maximum ICD together with reduction in the degree of central tumor enhancement. Maximum ICD at most recent follow up was 22 mm. A 28-year-old female was referred with right sensorineural deafness. A right VS of maximum ICD of 27 mm was diagnosed. Initial WWR management was planned after discussion. Serial imaging showed an initial increase in the size of the tumor followed by progressive reduction in size. The most recent follow up showed a maximum ICD of 20 mm. CONCLUSION: Early WWR management can be associated with spontaneous shrinkage of VS over time. Prospective clinical study of larger numbers of such cases using the UK VS database may help to identify predictive factors for the spontaneous regression of VS.

Diffusion tensor magnetic resonance imaging for predicting the consistency of intracranial meningiomas.

BACKGROUND: The ability of preoperative MRI-sequences to predict the consistency of intracranial meningiomas has not yet been clearly defined. We aim to demonstrate that diffusion tensor imaging (DTI) improves the prediction of intracranial meningiomas consistency. METHODS: We prospectively studied 110 meningioma patients operated on in a single center from March 1st to the 25th of May 2012. Demographic data, location and size of the tumor, peritumoral edema, T1WI, T2WI, proton density weighted (PDWI), fluid-attenuated inversion recover (FLAIR) sequences, and arterial spin labeling (ASL) perfusion were studied and compared with the gray matter signal to predict meningioma consistency. Diffusion tensor imaging (DTI) with fractional anisotropy (FA) and mean diffusivity (MD) maps were included in the preoperative MRI. Meningioma consistency was evaluated by the operating surgeon who was unaware of the neuroradiological findings. RESULTS: In univariate analysis, meningioma size (diameter > 2 cm) and supratentorial or sphenoidal wing location were more frequently associated with hard-consistency meningiomas (p < 0.05). In addition, isointense signal on MD maps (p = 0.009), hyperintense signal on FA maps, and FA value > 0.3 (p = 0.00001) were associated with hard-consistency tumors. Age and sex, T1WI, T2WI, PDWI, FLAIR, or ASL perfusion sequences and peritumoral edema were not significantly associated with meningioma consistency. In logistic regression analysis, the most accurate model (AUC: 0.9459) for predicting a hard-consistency meningioma shows that an isointense signal in MD-maps, a hyperintense signal in FA-maps, and an FA value of more than 0.3 have a significant predictive value. CONCLUSIONS: FA value and MD and FA maps are useful for prediction of meningioma consistency and, therefore, may be considered in the preoperative routine MRI examination of all patients with intracranial meningiomas.

Molecular characterization of 54 cases of false-negative fine-needle aspiration among 1347 papillary thyroid carcinomas.

BACKGROUND: Fine-needle aspiration (FNA) has been widely accepted as the most crucial step in the preoperative assessment of thyroid nodules, but the false-negative rates are generally reported to be between 3.6% and 10.2%. To lower the overall incidence of this false-negative testing, new reporting systems encourage the molecular testing of thyroid nodules. However, to the authors' knowledge, the role of molecular testing in false-negative FNA has not yet been evaluated. METHODS: In total, 1347 consecutive papillary thyroid carcinomas (PTCs) with both cytological and histological diagnoses were collected from the same center. A blinded revision of the false-negative cases was performed. An analysis of the BRAF and Ras genes in the false-negative cases was then performed. RESULTS: The false-negative rate at the time of primary FNA diagnosis was 4.8% (65 of 1347 cases). False-negative cases were 15 follicular variant PTCs, 2 classical variant, and 1 solid variant that lacked peculiar PTC cytomorphological features. Adequate cellular material for molecular analysis was available only in 54 of the 65 false-negative cases. Mutations were found in 6 cases (11%), and Ras alterations were present in 16 cases (29.6%). The addition of molecular analysis decreased the false-negative rate to 0.4% (5 of 1347 cases). CONCLUSIONS: The results of the current study confirm the feasibility of BRAF and Ras analysis in routine FNA. However, when the false-negative FNA rate is low, the cost-benefit analysis of the detection of BRAF and Ras mutations should be carefully evaluated. Consequently, the authors suggest that preoperative molecular assessment could be helpful for benign nodules, but only in the presence of clinical suspicion of malignancy.

The large majority of 1520 patients with indeterminate thyroid nodule at cytology have a favorable outcome, and a clinical risk score has a high negative predictive value for a more cumbersome cancer disease.

CONTEXT: Clinical management of patients with thyroid nodules indeterminate at fine-needle aspiration (FNA) cytology is still unsettled. OBJECTIVE: Our objective was to establish the clinical outcome of patients with thyroid nodules indeterminate at cytology and to identify the features associated with malignancy. DESIGN AND PATIENTS: This was a retrospective evaluation of 1520 consecutive patients with indeterminate cytology among 100 065 patients who underwent FNA between January 2000 and December 2010. RESULTS: Of 1520 patients, 371 (24.4 %) had thyroid cancer at histology, the follicular variant of papillary cancer being the most frequent histotype, and 342 patients with cancer were free of disease after thyroidectomy and (131)I remnant ablation, whereas 29 needed further treatment because of persistent disease. Among them, only 12 had persistence of disease at the end of follow-up. Atypias at cytology (P = .001), blurred nodule margins (P = .005), and spot microcalcifications (P = .003) at thyroid ultrasound (US) were significantly associated with malignancy. A clinical score including cytology and US characteristics was calculated; the lowest value showed a high negative predictive value (83.9%) for the presence of malignancy and even higher (99.5%) for the presence of a more cumbersome cancer disease, and only 4 of the 29 patients who needed further treatment were included in the group with the lowest risk score. CONCLUSIONS: Patients with Thy 3 cytology and histology of thyroid cancer had an overall good prognosis. A clinical risk score including the results of cytology and US features is helpful in the management of patients with indeterminate thyroid nodules.

Revascularización indirecta de la pialsinangiosis en enfermedadcerebrovascular oclusiva en adultos. Informe de Caso / Indirect Revascularization by Pial Synangiosis in Cerebrovascular Occlusive Disease in Adults: Case Report

Muchos estudios demuestran la eficacia del tratamiento de la enfermedad de Moyamoya mediante técnicas de revascularizaciónindirecta, y en nuestro medio la técnica más usada y con mejores resultados es la pialsinangiosis, principalmente para casospediátricos con dicha patología. Si bien no existía evidencia en cuanto al uso de estas técnicas en un adulto con una insuficienciacirculatoria cerebral localizada causada por una enfermedad oclusiva de varias arterias cerebrales IC de origen ateromatoso,juzgamos válido intentar realizar la misma técnica de pialsinangiosis. Como resultado del procedimiento, pudimos observar unamejoría en la revascularización cerebral y una disminución objetiva del área cerebral comprometida, además de que la pacientepermanece asintomática luego de un extenso seguimiento.

Are risk factors common to thyroid cancer and nodule? A forty years observational time-trend study.

A progressive increase in the incidence of thyroid cancer (TC) has been reported over the last few decades. This either reflects the increased number of newly discovered and accurately selected thyroid nodules with more sensitive technologies and a relative more potent carcinogenic effect of pathogenetic factors in malignant, but not benign nodules. This observational time-trend study addresses this issue by analysing the proportion of TC within 8411 consecutive thyroid nodule (TN) patients evaluated in Pisa by the same pathology Department and individual clinician over a four-decade period. From 1972 to 1979 surgery was used to detect TC among the TN patients: 1140 TN patients were operated on and 35 cancers were detected (3.1% of all the TN patients). Subsequently, needle aspiration techniques were used to select TN for surgery. From 1980 to 1992, 5403 TN patients were examined, 483 were selected for surgery, and 150 cancers were found (2.8% of all the TN patients). From 1993 to 2010, 1568 TN patients were examined, 143 were selected for surgery, and 46 cancers were found (2.9% of all the TN patients). Therefore, in the University Hospital of Pisa, and independent of preoperative TN selection protocols, these proportions of TN eventually found to harbor TC remained statistically unchanged over 40 years (p = 0.810). This finding suggests that pathogenic risk factors and more sensitive diagnostic technologies did not differentially affect the incidence of TN and TC.

Thromboelastometry during intraoperative transfusion of fresh frozen plasma in pediatric neurosurgery.

Normal blood coagulation is essential in pediatric neurosurgery because of the risk of abundant bleeding, and therefore it is important to avoid transfusion of fluids that might interfere negatively with the coagulation process. There is a lack of transfusion guidelines in massive bleeding with pediatric neurosurgical patients, and early use of blood compounds is partly controversial. We describe two pediatric patients for whom fresh frozen plasma (FFP) infusion was started at the early phase of brain tumor surgery to prevent intraoperative coagulopathy and hypovolemia. In addition to the traditional laboratory testing, modified thromboelastometry analyses were used to detect possible disturbances in coagulation. Early transfusion of FFP and red blood cells preserved the whole blood coagulation capacity. Even with continuous FFP infusion, fibrin clot firmness was near to critical value at the end of surgery despite increased preoperative values. By using FFP instead of large amounts of crystalloids and colloids when major blood loss is expected, blood coagulation is probably less likely to be impaired. Our results indicate, however, that the capacity of FFP to correct fibrinogen deficit is limited.

Lateral supraorbital approach applied to tuberculum sellae meningiomas: experience with 52 consecutive patients.

BACKGROUND: Various surgical approaches for the removal of tuberculum sellae meningiomas (TSMs) have previously been described. OBJECTIVE: To assess the reliability and safety of the lateral supraorbital (LSO) approach to remove TSMs. METHODS: We identified all TSM patients operated on at the Department of Neurosurgery at Helsinki University Central Hospital, Finland, by the senior author (J.H.) using the LSO approach between September 1997 and August 2010. We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients and discuss the operative technique. RESULTS: Apparent complete tumor removal was achieved in 45 patients (87%). Of 42 patients, preexisting visual deficit improved in 22, remained the same in 13, and worsened in 7, and de novo visual deficit occurred in 1 patient. At 3 months post-discharge, 47 patients (90%) had a good recovery, 4 (8%) were moderately disabled, and 1 (2%) died 40 days after surgery of unexplained cardiac arrest. Seven patients (13%) had minimal residual tumors, 2 of which required reoperation. During the median follow-up of 59 months (range, 1-133 months), tumor recurred in 1 of the patients who had undergone a second operation. CONCLUSION: TSMs of all sizes can be removed via the LSO approach with minimal morbidity and mortality. Low-power or no coagulation is recommended near the optic nerves and the optic chiasm to preserve their vascular support from the internal carotid artery perforators. Our results are comparable to those obtained using more extensive and time-consuming approaches. We recommend the LSO approach to remove TSMs.

Complications of anterior clinoidectomy through lateral supraorbital approach.

OBJECTIVE: We reviewed the surgical complications from our recent experience in vascular and tumor patients who underwent anterior clinoidectomy through the lateral supraorbital (LSO) approach. METHODS: Between June 2007 and January 2011, a total of 82 patients with neoplastic and vascular lesions underwent anterior clinoidectomy by the senior author (J.H.) through the LSO approach. We analyzed the operative videos paying particular attention to the surgical technique used for removal of the anterior clinoid process (ACP) and compared the microsurgical nuances to postoperative complications related to anterior clinoidectomy. RESULTS: Forty-five patients were treated for aneurysms; 35 patients for intraorbital, parasellar, and suprasellar tumors; and 2 patients for carotid-cavernous fistulas. Intradural anterior clinoidectomy was performed in 67 (82%) cases; in 15 (18%) cases an extradural approach was used. In 51 (62%) cases, ACP was removed completely, whereas in the remaining 31 (38%) a tailored anterior clinoidectomy was performed. Four (5%) patients had new postoperative visual deficits and 3 (4%) experienced a worsening of preoperative visual deficits. Twelve (15%) patients improved their preoperative visual deficits after intradural anterior clinoidectomy. Ultrasonic bone device is a useful tool but may damage the optic nerve when performing anterior clinoidectomy. There was no mortality in our series. CONCLUSION: Anterior clinoidectomy can be performed through an LSO approach with a safety profile that is comparable to other approaches. Ultrasonic bone dissector is a useful tool but may lead to injury of the optic nerve and should be used very carefully in its vicinity.

Tailored anterior clinoidectomy through the lateral supraorbital approach: experience with 82 consecutive patients.

OBJECTIVE: To demonstrate that anterior clinoidectomy is possible through the lateral supraorbital (LSO) approach, and that extent of the clinoidectomy is tailored according to the lesion. We reviewed our recent experience on patients with vascular and tumor who underwent anterior clinoidectomy through the LSO approach. METHODS: Between June 2007 and January 2011, 82 patients with neoplastic and vascular lesions underwent anterior clinoidectomy by the senior author (J.H.) with the LSO approach. We retrospectively analyzed the surgical videos and the microsurgical techniques of anterior clinoidectomy. RESULTS: Forty-five patients were treated for aneurysms, 35 patients for intraorbital, parasellar and suprasellar tumors, and 2 patients presented with carotid-cavernous fistula. Intradural anterior clinoidectomy was performed in 67 patients (82%); in 15 patients (18%) extradural anterior clinoidectomy was used. A minimal removal of the anterior clinoid process (ACP) was performed in 5 patients, in 8 patients a partial clinoidectomy was performed, in 18 patients a subtotal removal of the ACP was needed, and in 51 patients, the entire ACP was removed. There was no operation-related mortality in the series. CONCLUSIONS: A tailored anterior clinoidectomy is useful and can be performed through the LSO approach. Intradural visualization of the internal carotid artery and optic nerve is mandatory for the exact anatomic orientation and safe anterior clinoidectomy. We recommend intradural anterior clinoidectomy for all vascular and most neoplastic lesions.

Benefits of early aneurysm surgery: Southern Iran experience.

BACKGROUND: Neurovascular surgery has been practiced in Shiraz, the main referral center of the Southern Iran, for over 30 years; however, the trend has accelerated tremendously in recent years following subspecialization of neurovascular surgery in Shiraz, Department of Neurosurgery. Over 100 patients are operated each year, and nearly all are addressed during the first 72 hours after presentation. METHODS: In this paper, we focus on the description of techniques we apply for early clipping of ruptured intracranial aneurysms in the anterior circulation. Improvements in outcome, mortality, and rebleeding rates are also discussed. RESULTS: Mortality and rebleeding rates have declined significantly since the institution of new techniques. CONCLUSION: The establishment of early surgery for ruptured anterior circulation aneurysms through the lateral supraorbital approach along with specific anesthetic protocol has resulted in significant improvement of morbidity, mortality, and rebleeding rates at our department.