The minipterional approach for ruptured and unruptured anterior circulation aneurysms: Our initial experience.

OBJECTIVE: To report our experience with the minipterional (MPT) craniotomy approach for anterior circulation aneurysms and to discuss the clinical outcomes as well as to evaluate the advantages of this unique approach. MATERIALS AND METHODS: Single-center retrospective review of 57 cases involving anterior circulation aneurysms both ruptured and unruptured aneurysms treated with the MPT. We analyzed the clinical and patient demographic data, aneurysm characteristics, surgical outcomes, and complications in these individuals. RESULTS: Between July 2008 and March 2014, of the 57 patients reviewed: 45 had middle cerebral artery (MCA), 6 had internal carotid artery terminus, and 7 had posterior communicating artery aneurysms. 20 of the 57 patients presented with a ruptured aneurysm. The average aneurysm size was 5.8 mm. The length of hospitalization for unruptured aneurysm cases ranged between 3 and 5 days. The average follow-up for all cases was 21.5 months. Successful clipping of the aneurysms was obtained in all patients. None of the cases required additional skin incisions or craniotomy extensions. The overall surgical outcomes were favorable. There was no postoperative facial nerve damage, temporalis muscle wasting, or symptoms of paresthesias around the incision line. Two patients developed a postoperative stroke manifested as symptoms of unilateral arm and facial weakness, receptive aphasia, and dysarthria. CONCLUSION: The MPT provides a reliable and less invasive alternative to the standard pterional craniotomy. Furthermore, ruptured and unruptured anterior circulation aneurysms can safely and effectively be treated with limited bone removal which provides better cosmetic outcomes and excellent postoperative temporalis muscle function.

Prevalences of skin diseases among primary schoolchildren in Damietta, Egypt.

OBJECTIVES: Information on prevalences of pediatric dermatoses in Egypt is scanty. This study aimed to supplement existing data. METHODS: A cross-sectional study was conducted in Damietta, Egypt between October 2011 and March 2012. It involved 6162 pupils randomly selected from 30 primary schools. The sample was equally divided (3081 pupils/15 schools) between urban and rural areas. Each participant was interviewed for age, gender, residence and complaint. Hygiene status was evaluated and a clinical examination was carried out for skin diseases. Data were coded and analyzed. RESULTS: Although most children revealed more than one dermatosis, the majority (76.2%) had not complained of disease. The most common disease group included benign neoplasms (87.0%), followed by pigmentary disorders (68.3%), infections (50.9%), adnexal disorders (14.1%), hypersensitivity diseases (14.0%), genodermatoses (0.3%) and papulosquamous diseases (0.2%). The most common subgroup of diseases comprised parasitic infections (47.5%), among which pediculosis prevailed (47.5%), followed by dermatitis (10.0%) in which pityriasis alba dominated (6.0%), followed by hair disorders (9.3%), bacterial infections (5.9%), urticaria (4.4%), sebaceous gland disorders (2.7%), sweat gland disorders (2.3%), viral infections (1.6%) and fungal infections (0.7%). The most commonly found diseases included, in descending order, acquired melanocytic nevus, post-inflammatory hyperpigmentation, pediculosis, leukoderma, café au lait spots, atrophic scar, cicatricial alopecia, hypertrophic scar, pityriasis alba, papular urticaria, xerosis and impetigo. CONCLUSIONS: The high prevalence of skin diseases, especially of trauma-related disorders and infections, may be mainly attributable to a lack of appropriate health awareness and care, which has created a tendency within the population to adapt without complaining or seeking medical help. Such circumstances, unfortunately, have resulted in a growing community of silent patients.

Minimally invasive transpalpebral "eyelid" approach to the anterior cranial base.

BACKGROUND: Supra orbital frontal minicraniotomy is one of the most commonly used minimally invasive approaches for anterior cranial fossa lesions. OBJECTIVE: To describe our experience with the transpalpebral "eyelid" incision to obtain access to the anterior cranial fossa. METHODS: We describe the approach and technique of the transpalpebral eyelid incision in a step-by-step fashion and discuss the results of 40 cases for which the eyelid incision was used. We retrospectively reviewed the charts of these patients to analyze outcomes with regard to opening and closing time, length of hospital stay, residual aneurysm or Simpson grade for resection, complications, and cosmetic result. RESULTS: We treated 31 anterior circulation aneurysms (28 unruptured and 3 ruptured), 7 anterior skull base meningiomas, 1 frontal low-grade glioma, and 1 frontal cavernoma using the transpalpebral incision. Opening time was about 45 to 60 minutes, and closure time from dura to skin was about 45 to 60 minutes. The hospital length of stay was similar to that in our open craniotomy cases. No residual aneurysm was demonstrated in the follow-up studies of all 31 aneurysms. Simpson grade I resection was achieved in 6 meningiomas. Complications included 1 postoperative eyelid hematoma, 2 postoperative infections, and a subclinical stroke discovered on postoperative imaging. Excellent cosmetic outcome was accomplished in 39 of 40 patients. CONCLUSION: The transpalpebral approach provides dissection in natural anatomical planes, affords preservation of the frontalis muscle, avoids injury to nerve VII branches, and results in an excellent cosmetic outcome.

Microvascular decompression in patients with isolated maxillary division trigeminal neuralgia, with particular attention to venous pathology.

OBJECT: The authors have the clinical impression that patients with isolated V2, or maxillary division, trigeminal neuralgia (TN) are most often women of a younger age with atypical pain features and a predominance of venous compression as the pathology. The aim of this study was to evaluate a specific subgroup of patients with V2 TN. METHODS: Among 120 patients who underwent microvascular decompression (MVD) for TN in 2007, data were available for 114; 6 patients were lost to follow-up. Patients were stratified according to typical (Burchiel Type 1), mixed (Burchiel Type 2a), or atypical (Burchiel Type 2b) TN. A pain-free status without medication was used to determine the efficacy of MVD. All patients were contacted in June 2008 and again in January 2009 at 12-24 months after surgery (median 18.4 months) and asked to rate their response to MVD as excellent (complete pain relief without medication), fair (complete pain relief with medication or some relief with or without medication), or poor (continued pain despite medication; that is, no change from their preoperative baseline pain status. RESULTS: Of 114 patients, 14 (12%) had isolated V2 TN. Among these 14 were 2 typical (14%), 1 mixed (7%), and 11 atypical cases (79%) of TN. Among the remaining 100 cases were 37 typical (37%), 14 mixed (14%), and 49 atypical cases (49%) of TN. In the isolated V2 TN group, all patients were women as compared with 72% of women in the larger group of 100 patients (p = 0.05, chi-square test). The average age in the isolated V2 TN group was 51.2 years (median 48.1 years) versus 54.2 years (median 54.0 years) in the remainder of the group (p = NS, unpaired Student t-test). In the isolated V2 TN group, there was a predominance of atypical pain cases (79%) versus 49% in the remainder of the group, and this finding trended toward statistical significance (p = 0.07, chi-square test). Venous contact or compression (partly or wholly) was noted in 93% of the patients with isolated V2 versus 69% of the remainder of the group (p = 0.13, chi-square test). The likelihood of excellent outcomes in the patients with V2 TN (71%) was compared with that in typical pain cases (79%) among patients in the rest of the group (that is, the bestoutcome group), and no difference was found between the 2 groups (p = 0.8, chi-square test). CONCLUSIONS: The authors confirmed that patients with isolated V2 TN were more likely to be female, tended toward an atypical pain classification with venous pathology at surgery, and fared just as well as those presenting with typical pain.

Microsurgical and endoscopic anatomy of Liliequist's membrane: a complex and variable structure of the basal cisterns.

OBJECTIVE: Descriptions of Liliequist's membrane, as reported in the literature, vary considerably. In our cadaveric study of Liliequist's membrane, we attempted to clarify and define its anatomic features and boundaries, as well as its relationship with surrounding neurovascular structures. We describe the embryology of this membrane as a remnant of the primary tentorium. The clinical significance of our findings is discussed with respect to third ventriculostomy and surgical approaches to basilar tip aneurysms, suprasellar arachnoid cysts, and perimesencephalic hemorrhage. METHODS: Thirteen formalin-fixed adult cadaveric heads were injected with colored silicone. After endoscopic exploration of Liliequist's membrane, a bilateral frontal craniotomy was performed, and the frontal lobes were removed to fully expose Liliequist's membrane. RESULTS: Liliequist's membrane is a complex and highly variable structure that is composed of either a single membrane or two leaves. The membrane was absent in two specimens without any clear demarcation between the interpeduncular, prepontine, and chiasmatic cisterns. CONCLUSION: Understanding the variable anatomy of Liliequist's membrane is important, particularly to improve current and forthcoming microsurgical and endoscopic neurosurgical procedures. It is important as a surgical landmark in various neurosurgical operations and in the physiopathology of several pathological processes (suprasellar arachnoid cysts and perimesencephalic hemorrhage).

Exposure of the distal cervical segment of the internal carotid artery using the trans-spinosum corridor: cadaveric study of surgical anatomy.

BACKGROUND: Exposure of the most distal portion of the cervical segment of the internal carotid artery (ICA) is technically challenging. Previous descriptions of cranial base approaches to expose this segment noted facial nerve manipulation, resection of the glenoid fossa, and significant retraction or resection of the condyle. We propose a new approach using the frontotemporal orbitozygomatic approach to expose the distal portion of the cervical segment of the ICA via the trans-spinosum corridor. METHODS: Six formalin-fixed injected heads were used for cadaveric dissection. Two blocs containing the carotid canal and surrounding region were used for histological examination. RESULTS: The ICA lies immediately medial to the vaginal process. The carotid sheath attaches laterally to the vaginal process. With use of the trans-spinosum corridor, the surgeon's line of sight courses in front of the temporomandibular joint, through the foramen spinosum, spine of the sphenoid, and vaginal process. Removal of the vaginal process exposes the vertical portion of the petrous segment of the ICA. The loose connective tissue space between the adventitia and the carotid sheath is easily entered from above. Incision of the carotid sheath exposes the ICA without disruption of the temporomandibular joint. CONCLUSION: Control of the cervical segment of the ICA can be critical when dealing with cranial base tumors that invade or surround the petrous segment of the ICA. This novel technique through the trans-spinosum corridor can effectively expose the distal portion of the cervical segment of the ICA without causing manipulation of the facial nerve and while maintaining the integrity of the temporomandibular joint.

Large sphenoid wing meningiomas involving the cavernous sinus: conservative surgical strategies for better functional outcomes.

OBJECTIVE: The ability to resect meningiomas that involve the medial and anterior compartments of the cavernous sinus has been refuted. In this retrospective study, we determined the efficacy of total resection of meningiomas that invade the cavernous sinus but are restricted to the lateral compartment. METHODS: We reviewed the charts of 38 consecutive patients with sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous meningiomas who underwent surgical treatment. We assessed early and late cranial nerve morbidity, extent of resection, and long-term outcome (mean, 96 mo). RESULTS: In all patients, tumors exceeded 3 cm diameter. In 22 of 24 patients, total microscopic excision was achieved in tumors that involved only the lateral compartment of the cavernous sinus and touched or partially encased the cavernous internal carotid artery (i.e., modified Hirsch Grades 0 and 1, respectively). In 2 of 24 patients, remaining tumor infiltrated the superior orbital fissure. All 14 patients who had tumors that encased (with or without narrowing) the cavernous segment of the internal carotid artery (Hirsch Grades 2-4) underwent incomplete resection. Among 38 patients, mortality was 0%, late cranial nerve deficits remained in 6 (16%), and late Karnofsky Performance Scale scores exceeded 90 in 34 patients (90%). Four patients (10.5%) developed a recurrence or regrowth. Of 20 patients who were treated with either linear accelerator-based stereotactic radiosurgery or fractionated conformal radiotherapy, 11 had residual tumor and a moderate to high proliferative index, 4 had atypical tumors and 1 had angioblastic meningioma after total excision, 2 had regrowth, and 2 had recurrent tumors. In 18 (90%) of the 20 patients who underwent radiation, tumor size was reduced or controlled. CONCLUSION: On the basis of this study and a review of the literature, we demonstrate that sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous meningiomas of Hirsch Grades 0 and 1 can be excised from the lateral compartment of the cavernous sinus without postoperative mortality and with acceptable rates of morbidity. Residual tumor in the medial compartment (Hirsch Grades 2-4) may be treated with some form of radiation therapy or observation.

The carotid-oculomotor window in exposure of upper basilar artery aneurysms: a cadaveric morphometric study.

OBJECTIVE: The carotid-oculomotor window remains the traditional deep window in the exposure of aneurysms of the upper basilar artery. Although several techniques have been described to expand this window, few morphometric studies document either the degree of its expansion or its contribution to the exposure of the basilar artery. We review the microsurgical anatomy of the carotid-oculomotor window, describe expansion techniques, and analyze morphometrically the contribution of each step (i.e., extradural anterior clinoidectomy, mobilization of the internal carotid artery [ICA], and posterior clinoidectomy) to the expansion of the window and/or exposure of the artery. METHODS: Ten formalin-fixed, alcohol-preserved, cadaver heads injected with pigmented silicone were prepared for bilateral dissection. The vertebrobasilar system was injected with pigmented silicone mixed with barium (1:1), rendering it radiopaque. After completing a frontotemporal-orbitozygomatic craniotomy, we performed dissection in two stages: Stage I consisted of a conventional transsylvian exposure of the upper basilar artery through the carotid-oculomotor window; and Stage II added anterior clinoidectomy, ICA mobilization, and posterior clinoidectomy. A clip was applied to the lowest accessible point of the basilar trunk at each stage. Measurements obtained during each stage included: 1). the transverse carotid-oculomotor distance, that is, anteriorly between the oculomotor foramen and ICA, and posteriorly between the oculomotor nerve and ICA; and 2). the exposed length of the basilar artery, as seen under the microscope and on angiograms. RESULTS: Measurements were obtained before and after the addition of anterior clinoidectomy, mobilization of the ICA, and posterior clinoidectomy. Increases in expansion of the window and exposure of the upper basilar artery were documented as percentages of the control values. The anterior carotid-oculomotor distance averaged 7.1 mm (range, 5-10 mm) and 10.1 mm (range, 7-15 mm) before and after the additional surgical steps to expand the window, respectively. The posterior carotid-oculomotor distance averaged 12.7 mm (range, 9-18 mm) and 16.1 mm (range, 11-22 mm) before and after the additional surgical steps to expand the window, respectively. The exposed length of the basilar artery from the bifurcation to the clip was 4.2 mm (range, 1-13 mm) before expansion and 7 mm (range, 3-15 mm) after expansion. CONCLUSION: Anterior clinoidectomy and ICA mobilization increased the carotid-oculomotor space 44% anteriorly and 28% posteriorly. Posterior clinoidectomy increased the exposed length of the basilar artery by 69%. Superficial wide field exposure, expansion of the carotid-oculomotor window, and increased exposure of the upper basilar artery facilitate both visualization of the aneurysm for clip application and the use of proximal vascular control as an adjunct to basilar aneurysm surgery.

Subtonsillar approach to the foramen of Luschka: an anatomic and clinical study.

OBJECTIVE: Conventional approaches to tumors of the foramen of Luschka are limited because the foramen is viewed from either the fourth ventricle laterally (transvermian approach) or the cerebellopontine angle medially (suboccipital approach). The definitive approach is subtonsillar, because the foramen of Luschka is actually the end of the natural cleavage plane between the cerebellar tonsil and the medulla. We describe the microsurgical anatomic features of the foramen of Luschka region and the operative technique for the subtonsillar approach to this region. METHODS: In the anatomic study, five formalin-fixed, silicone-injected, cadaveric heads were used. In the clinical study, the records for five patients treated via the subtonsillar approach were examined; several illustrative cases are presented. RESULTS: The foramen of Luschka is formed by the tela choroidea and the rhomboid lip and exists at the lateral end of the cerebellomedullary fissure, which is a natural cleavage plane between the cerebellar tonsil and the medulla. The subtonsillar approach is performed via a suboccipital craniotomy; the patient is positioned in the lateral decubitus position, with the tumor side down. After the cerebellar tonsil is freed from arachnoid adhesions, it can be retracted rostrodorsally from the medulla, to expose the cerebellomedullary fissure. Clinically, the tela choroidea and rhomboid lip are significantly attenuated by tumor expansion. Therefore, by dissecting in a subtonsillar manner around the tumor, one can reach the foramen of Luschka without traversing any neural tissue. CONCLUSION: The subtonsillar approach yields a panoramic view to the foramen of Luschka laterally and up to the middle cerebellar peduncle superiorly. This approach minimizes the distance between the tumor and the surgeon, while maximizing neural preservation. We think this is the definitive approach to this difficult region of the posterior fossa.