Anatomical partition of the clival region and adjacent structures via extended endoscopic endonasal approach.

OBJECTIVES: To explore the anatomy of the ventral clivus and adjacent structure in the endoscopic surgery through the anterior approach, particularly in accurate locating lesions in transnasal endoscopic surgery. PATIENTS AND METHODS: A total of 9 formalin-fixed adult cadaver heads were injected with red and blue latex to observe the arteries and veins, respectively. The relationships between various parts of internal carotid artery (ICA) and anatomic structures of clivus were investigated, followed by the measurement of the posterior pharyngeal wall, anterior wall and posterior wall of clivus, cerebral dura mater, subdural space and adjacent regions to determine their correlations, as well as the clivus and adjacent structures. RESULTS: The clivus structure was divided into the bone segment, the ICA segment and subdural segment for anatomic division according to the anatomic landmarks in the anatomic process. The clivus can be classified in a shape of '' with the ICA, including the middle superior region, middle inferior region, bilateral lateral superior and lateral inferior regions. CONCLUSION: The ICA is closely related to the ventral clivus and adjacent structure, which can be used as the basis of anatomic division via anterior approach.

Endoscopic approach to the trigeminal nerve: an anatomic study.

OBJECTIVE: To describe an endoscopic perspective of the surgical anatomy of the trigeminal nerve. METHODS: Nine adult cadaveric heads were dissected endoscopically. RESULTS: Opening the pterygopalatine fossa is important because many key anatomical structures (V2, pterygopalatine ganglion, vidian nerve) can be identified and traced to other areas of the trigeminal nerve. From the pterygopalatine ganglion, the maxillary nerve and vidian nerve can be identified, and they can be traced to the gasserian ganglion and internal carotid artery. An anteromedial maxillectomy increases the angle of approach from the contralateral nares due to an increase in diameter of the piriform aperture, and provides excellent access to the mandibular nerve, the petrous carotid, and the cochlea. CONCLUSIONS: Identification of key anatomical structures in the pterygopalatine fossa can be used to identify other areas of the trigeminal nerve, and an anteromedial maxillectomy is necessary to expose the ipsilateral mandibular nerve and contralateral cranial level of the trigeminal nerve.

[Application of neuroendoscope in the treatment of skull base chordoma].

OBJECTIVE: To further explore the application, approach, indication and prognosis of neuroendoscope treatment for skull base chordoma. METHODS: A total of 101 patients of skull base chordoma were admitted at our hospital from May 2000 to April 2010. There were 59 males and 42 females. Their major clinical manifestations included headache, cranial nerve damage and dyspnea. They were classified according to the patterns of tumor growth: Type I (n = 13): tumor location at a single component of skull base, i. e. clivus or sphenoid sinus with intact cranial dura; Type II (n = 56): tumor involving more than two components of skull e. g clivus, sphenoid and nasal/oral cavity, etc. But there was no intracranial invasion; Type III (n = 32) : tumor extending widely and intradurally forming compression of brain stems and multiple cranial nerves. Based on the types of chordoma, different endoscopic approaches were employed, viz. transnasal, transoral, trans-subtemporal fossa and plus microsurgical craniotomy for staging in some complex cases. RESULTS: Among all patients, total resection was achieved (n = 19), subtotal (n = 58) and partial (n = 24). In partial resection cases, 16 cases were considered to be subtotal due to a second-stage operation. Most cases had conspicuous clinical improvements. Self-care recovery within one week post-operation accounted for 58.4%, two weeks 30.7%, one month 6.9% and more than one month 1.9%. Postoperative complications occurred in 13 cases (12.8%) and included CSF leakage (n = 4) cranial nerve palsy (n = 5), hemorrhagic nasal wounds (n = 3) and delayed intracranial hemorrhage (n = 1). All of these were cured or improved after an appropriate treatment. A follow-up of 6 - 60 months was conducted in 56 cases. CONCLUSION: Early detection and early treatment are crucial for achieving a better outcome in chordoma. Neuroendoscopic treatment plays an important role in managing those complicated cases. Precise endoscopic techniques plus different surgical approaches and staging procedures are required to improve the post-operative quality of life for patients.

Suprasellar cysts: clinical presentation, surgical indications, and optimal surgical treatment.

BACKGROUND: To describe the clinical presentation of suprasellar cysts (SSCs) and surgical indications, and compare the treatment methods of endoscopic ventriculocystostomy (VC) and ventriculocystocisternotomy (VCC). METHODS: We retrospectively reviewed the records of 73 consecutive patients with SSC who were treated between June 2002 and September 2009. Twenty-two patients were treated with VC and 51 with VCC. Outcome was assessed by clinical examination and magnetic resonance imaging. RESULTS: The patients were divided into five groups based on age at presentation: age less than 1 year (n = 6), 1-5 years (n = 36), 6-10 years (n = 15), 11-20 years (n = 11), and 21-53 years (n = 5). The main clinical presentations were macrocrania (100%), motor deficits (50%), and gaze disturbance (33.3%) in the age less than 1 year group; macrocrania (75%), motor deficits (63.9%), and gaze disturbance (27.8%) in the 1-5 years group; macrocrania (46.7%), symptoms of raised intracranial pressure (ICP) (40.0%), endocrine dysfunction (40%), and seizures (33.3%) in the 6-10 years group; symptoms of raised ICP (54.5%), endocrine dysfunction (54.5%), and reduced visual field or acuity (36.4%) in the 11-20 years group; and symptoms of raised ICP (80.0%) and reduced visual field or acuity (40.0%) in the 21-53 years group. The overall success rate of endoscopic fenestration was 90.4%. A Kaplan-Meier curve for long-term efficacy of the two treatment modalities showed better results for VCC than for VC (p = 0.008). CONCLUSIONS: Different age groups with SSCs have different main clinical presentations. VCC appears to be more efficacious than VC.

Assessment of endoscopic treatment for middle cranial fossa arachnoid cysts.

BACKGROUND: Endoscopic cystocisternotomy is one of three surgical methods used to treat middle cranial fossa arachnoid cysts. There is debate about which method is the best. OBJECTIVE: The aim of this study is to evaluate the effectiveness and safety of endoscopic cystocisternotomy for treatment of arachnoid cysts of the middle cranial fossa. METHODS: Thirty-two patients with arachnoid cysts of the middle cranial fossa who had undergone endoscopic cystocisternal fenestration between 2004 and 2009 were studied retrospectively. Data were obtained on clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and the results of clinical and neuroradiological follow-up. RESULTS: Among the 27 patients with symptoms before surgery, 8 had disappearance of symptoms and 17 had improvement of symptoms. The cyst was reduced in size or it completely disappeared in 24 (75%) patients. The incidence rate of complications was 18.8%. CONCLUSIONS: Endoscopic cystocisternal fenestration is an effective treatment for symptomatic arachnoid cysts of the middle cranial fossa and should be the initial surgical procedure.

[Endoscopic treatment of middle fossa arachnoid cysts].

OBJECTIVE: To investigate and evaluate the effectiveness of neuroendoscopic therapy for arachnoid cysts of middle cranial fossa. METHODS: From January 2004 to June 2009, 32 patients with arachnoid cysts of middle cranial fossa who were treated with endoscopic cystocisternal fenestration were retrospectively analyzed. There were 21 male patients and 11 female patients, aged from 6 months to 39 years. The clinical and neuroradiological presentation, indications, surgical technique, complications, and clinical and neuroradiological follow-up were analyzed. RESULTS: The cysts were reduced in size in 20 patients and completely disappeared in 4 patients. For the 27 patients with symptoms before operation, the symptoms disappeared in 8 cases and improved in 17 cases after operation. There were asymptomatic subdural hydroma in 4 patients, intracranial infection and incision cerebro-spinal fluid leakage in 1 patient respectively. The complication incidence rate was 18.8%. CONCLUSIONS: Endoscopic fenestration is an effective treatment for symptomatic arachnoid cysts of middle cranial fossa and could be performed as the first surgical choice for these patients.

[Microsurgical treatment of giant cell tumor of skull].

OBJECTIVE: To explore the diagnosis and microsurgical treatment of giant cell tumor (GCT) of skull. METHODS: The investigators reviewed the clinical features, operative approach and prognosis of 23 consecutive cases of GCT of skull operated at our department between July 2000 and November 2008. RESULTS: Headache was the most common presenting symptom (86.96%) found among the patients with GCT of skull. Besides, the symptoms induced by the consequent lesions of II-XII intracranial nerves were also commonly observed. The mean duration of symptoms was 29.3 months and the mean preoperative KPS (Karnofsky performance scale) was 76 +/- 6. Among these cases, 10 tumors occurred in sphenoid bone, 9 in temporal bone, 3 in posterior fossa and 1 in frontal bone. Gross total resections were achieved in 6 cases, subtotal resections in 10 cases and partial resections in 7 cases. There was no operative death case. The follow-up data of 18 patients (78.26%) were collected with a mean follow-up duration of 35.5 months. All patients lived in normal postoperative life. CONCLUSION: GCT of skull is a generally low-degree malignancy showing a local bone invasion mostly in sphenoid and temporal bones.

[Using MR PC cine to evaluate CSF dynamics in neuroendoscopic third ventriculostomy:an analysis of 146 cases].

OBJECTIVE: To evaluate the change of CSF dynamics using MR PC Cine for neuroendoscopic third ventriculostomy. METHODS: 146 cases of hydrocephalus were treated by neuroendoscopic third ventriculostomy including 36 cases checked with MR PC Cine study randomly. The successful result was assessed by clinical symptom and imaging study. All the patients were given 3 months to 1 year follow-up. RESULTS: The symptoms of 121 (83%) patients were recovered soon. CT, MRI and MR PC Cine demonstrated the CSF velocity, flow rate and dynamics change to the normal level compared with preoperative check. The effective rate of this group was 75.3% with one year follow-up. CONCLUSION: The method of MR PC Cine to evaluate the CSF dynamics result for neuroendoscopic third ventriculostomy is simple, fast and safe. It is worth the clinical application.

Correlation of alternative splicing of the D2 dopamine receptor mRNA and estrogen receptor mRNA in the prolactinomas and gonadotrope tumors.

OBJECTIVE: Estradiol (E2) acts to modulate the ratio of two dopamine D2 receptor isoforms (D2L/D2S) by the nuclear estrogen receptor (ER) and to reduce dopamine's inhibitory action on PRL secretion. Here we demonstrate the correlation between the expression of ER mRNA and D2R mRNA isoforms in pituitary neoplasms cells. METHODS: Twenty-four human pituitary adenomas (14 prolactinomas and 10 gonadotrope tumors) were examined for the expression of both ER mRNA and D2R mRNA by means of semi-quantitative RT-PCR analysis. RESULTS: No significant difference was found in ERbeta mRNA expression levels between prolactinomas and gonadotrope tumors (P = 0.871), but there was a significant difference in the expression of ERalpha mRNA (P = 0.003). The significant difference was found between the two pituitary adenomas types in both levels of D2S and D2L mRNA expression (P = 0.036 and 0.007 respectively). Furthermore, both levels of expression in prolactinomas were significantly higher than that in gonadotrope tumors. Additionally, a negative correlation between D2S and ERalpha mRNA expression and a positive correlation between D2L and ERalpha mRNA expression were found in these tumors. CONCLUSION: This study for the first time shows a good correlation between expression of ER and D2R isoforms in prolactinomas and gonadotrope tumors. Reducing the amount of the ERalpha in neoplasm cells can alter the ratio of D2L/D2S, which may increase the drug sensitivity of pituitary adenomas.

[Endoscopic treatment of suprasellar arachnoid cysts].

OBJECTIVE: To analyze the clinical manifestation and neuroendoscopic techniques in treatment of suprasellar arachnoid cysts. METHODS: Between October 2000 and June 2006, 42 patients (22 male and 20 female with a mean age of 10.4 years) with suprasellar arachnoid cysts were treated by endoscopy. All patients presented with hydrocephalus in CT and MRI scanning before operation. Endoscopic ventriculocystostomy was performed in 39 patients and cystocisternostomy was also performed in the other 3 patients. The mean duration of follow-up was 20.8 months. RESULTS: There was no surgery-related death and only two patients (4.8%) had postoperative complications. 25 cases (59.5%) recovered completely and 14 cases (33.3%) improved clinically. Ventriculoperitoneal shunting was performed in 3 patients because of recurrent hydrocephalus. Postoperative CT or/and MRI showed cyst volume decreased in all cases. Cine-MR imaging was performed in 21 patients that confirmed CSF could flow through all fenestration sites and aqueduct fluently. CONCLUSIONS: Endoscopic ventriculocystostomy (ventriculocystocisternostomy) is an effective and safe method in the treatment of suprasellar arachnoid cysts.

[Endoscopic third ventriculostomy in treatment of obstructive hydrocephalus].

OBJECTIVE: To explore the effects, influencing factors, and complications of endoscopic third ventriculostomy for obstructive hydrocephalus. METHODS: The clinical data of 55 patients with obstructive hydrocephalus, 29 males and 26 females, aged 18.4 (6 months - 59 years), who underwent endoscopic third ventriculostomy were analyzed retrospectively. RESULTS: Endoscopic third ventriculostomy was performed successfully in 54 patients, and one patient failed to undergo endoscopic third ventriculostomy because of densely distributed blood vessels at the bottom of the third ventricle. Satisfying post-operative results were obtained in 50 cases and no effect was seen in 4 cases that underwent V-P shunt 3 months later. Subdural hygroma occurred in 4 of the 55 cases, subscale hydrops in 8 cases, post-operative fever in 4 cases, epilepsy in 1 case, and epidural hemorrhage in 1 case. CONCLUSION: Endoscopic third ventriculostomy is safe and effective in the treatment of obstructive hydrocephalus.