Lateral cervical approach for ventrally located upper cervical meningioma: experience of 14 cases with a narrative comparison with other surgical techniques.

BACKGROUND: Upper cervical meningioma represents a large portion of intradural extramedullary tumors that occur in the cervical spinal canal. Most of them are located ventrally or ventrolateral to the spinal cord. Reaching lesions at this location surgically is technically challenging. OBJECTIVES: The ideal approach to ventrally located upper cervical lesions continues to be controversial. The aim of this study was to discuss the advantage of the lateral cervical approach and compare it with other surgical routes. METHODS: This retrospective study was conducted on all cases of ventrally located upper cervical meningiomas (C1-C3) who have been operated on using the lateral cervical approach in a tertiary neurosurgery unit between 2006 and 2020. Demographic, clinical, surgical, and follow-up data were collected from hospital records. RESULTS: During the study period, fourteen patients (Nine females and five males, aged 42-73 years) were recruited. The follow-up period was 2-16 years. The most frequent presenting symptoms were neck pain, occipital headache, motor deficits, and sensory disturbances. Total excision was achieved in all patients. All patients who had preoperative motor deficits improved significantly postoperatively, and those who presented with sensory disturbance had partial recovery. There was neither mortality nor permanent neurological morbidity. CONCLUSION: A lateral cervical approach is a safe approach for ventrally located upper cervical lesions. In our series, it offered enough exposure for a safe dissection and total or extensive subtotal removal of the tumors. Retraction or rotation of the neuroaxis was avoided, and the incidence of complications (injury of neural or vascular structures, instability, infection) was very low.

Endoscopic-assisted paramedian supracerebellar infratentorial approach to the posterior portion of the third ventricle. Anatomical study and surgical cases.

BACKGROUND: To date, morphometrical data providing a systematic quantification of accessibility and operability parameters to the boundaries of the posterior portion of the third ventricle (PTV) when applying an endoscopic-assisted paramedian supracerebellar infratentorial approach (EPSIA) are lacking. We performed an anatomical study and complemented our findings with surgical cases. METHODS: Eight EPSIAs towards the PTV were performed in cadaveric specimens. Optimal approach angles (OA), surgical freedom (SF) and operability indexes (Oi) to the PTV boundaries were assessed. Additionally, a 54-year-old man and 33-year-old woman were operated on PTV tumors applying the EPSIA. RESULTS: Sagittal OA to ventricle's roof and floor was 36±1.4° and 25.5±3.5° respectively, axial OA to the ipsilateral and contralateral ventricle's wall were 9.5±1.3° and 28.5±1.6°. SF was maximal on the contralateral wall (121.2±19.3mm2), followed by the roof (112.7±18.8mm2), floor (106.6±19.2mm2) and ipsilateral wall (94.1±15.7mm2). SF was significantly lower along the ipsilateral compared the contralateral wall (p<0.01) and roof (p<0.05). Facilitated surgical maneuvers with multiangled exposure were possible up to 8.5±1.07mm anterior to ventricle's entrance, whereas surgical maneuvers were possible but difficult up to 15.25±3.7mm. Visualization of more anterior was possible up to a distance of 27±2.9mm, but surgical maneuvers were barely feasible. EPSIA enabled successful resection of both PTV tumors and postoperative course was uneventful. CONCLUSIONS: EPSIA can be effective for approaching the PTV, enabling surgery along all boundaries, but especially on its roof and contralateral wall. In the not-enlarged ventricle, surgical maneuvers are feasible up to the level of the Monro foramen, becoming more limited anteriorly.

Two-stage endoscopic assisted approach for large pineal region and falcotentorial meningioma: first stage paramedian supracerebellar infratentorial approach, second stage interhemispheric occipital transtentorial approach: surgical cases and anatomical study.

Resection of complex falcotentorial meningiomas, growing along the pineal region (PR), and posterior incisural space (PIS) represents a neurosurgical challenge. Here, we present our strategy for effective resection of large falcotentorial meningiomas applying a paramedian supracerebellar infratentorial and interhemispheric occipital transtentorial approach in staged surgeries. We further systematically compared the effectiveness of midline (MSIA) and paramedian (PSIA) supracerebellar infratentorial, as well as interhemispheric occipital transtentorial approaches (IOTA) to operate along the PR and PIS in 8 cadaveric specimens. The staged PSIA and IOTA enabled successful resection of both falcotentorial meningiomas with an uneventful postoperative course. In our anatomo-morphometrical study, superficial vermian veins at an average depth of 11.38 ± 1.5 mm and the superior vermian vein (SVV) at 54.13 ± 4.12 mm limited the access to the PIS during MSIA. MSIA required sacrifice of these veins and retraction of the vermian culmen of 20.88 ± 2.03 mm to obtain comparable operability indexes to PSIA and IOTA. Cerebellar and occipital lobe retraction averaged 14.31 ± 1.014 mm and 14.81 ± 1.17 mm during PSIA and IOTA respectively, which was significantly lower than during MSIA (p < 0.001). Only few minuscule veins were encountered along the access through PSIA and IOTA. The application of PSIA provided high operability scores around the pineal gland, ipsilateral colliculus and splenium, and acceptable scores on contralateral structures. The main advantage of IOTA was improving surgical maneuvers along the ipsilateral splenium. In summary, IOTA and PSIA may be advantageous in terms of brain retraction, vein sacrifice, and operability along the PR and PIS and can be effective for resection of complex falcotentorial meningiomas.

Translamina Terminalis Approach to the Hypothalamus Using Supraorbital Craniotomy: Technical Note and Comparison with Other Surgical Corridors.

OBJECTIVES: Approaches to the hypothalamus and anterior third ventricle are variable. We present a technical note on access of the hypothalamus using the trans-lamina terminalis approach by supraorbital craniotomy in a patient who had a hypothalamic cavernoma and presented to us with recurrent hemorrhage. PATIENTS AND METHODS: The trans-lamina terminalis approach, including anatomical landmarks and surgical steps through a supra-orbital craniotomy, is described and a comparison with other surgical corridors is discussed. RESULTS: The supraorbital trans lamina terminalis approach allowed an effective access to the hypothalamic lesions. This approach provided a safe and minimally invasive corridor for gross total resection of the lesion since trespass of viable brain tissue is avoided. One clinical case illustrates the feasibility of the approach allowing complete removal of a cavernoma without surgery related neurological of endocrinological deficits. CONCLUSIONS: The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for hypothalamic lesions. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long and narrow surgical corridor requires some technical familiarization. The clinical outcomes are comparable to other surgical corridors.

Ten Years' Experiences in the Treatment of Nonaneurysmal Subarachnoid Hemorrhage: A Retrospective Analysis of Outcome Parameters in a Single-Center Study.

OBJECTIVES: Subarachnoid hemorrhage (SAH) with negative angiographic findings has a heterogeneous nature with variations in clinical course and outcome as compared to the aneurysmal SAH. It makes up to 15% of the spontaneous SAH and is characterized by milder clinical presentation. The purpose of this study was the analyses of risk factors, clinical observations, radiologic characteristics, and outcome in patients with nonaneurysmal SAH (NA-SAH). PATIENTS AND METHODS: In a retrospective design, 77 consecutive patients with NA-SAH were recruited from May 2008, to October 2018. All patients underwent conventional cerebral angiography. We stratified patients into two groups based on the distribution of blood on their CT scan into perimesencephalic (PM) and non-PM (NPM) SAH. We performed the Outcome using Glasgow Coma Scale (GCS) and modified Rankin scale (favorable mRS 0-2 vs. unfavorable mRS 3-6). Data were analyzed using IBM® SPSS® Statistics V22.0. RESULTS: The mean age at presentation was 48.5 ± 8.4 years with male predominance (71.4%). About 76.7% of the patients had headache and vomiting, most of the patients (75.3%) presented with GCS 15 at initial clinical presentation (61.03%) had NPM versus (38.96%) with PM characters in computed tomography scans. Fourteen (17.9%) patients developed hydrocephalus and 12 (15.3%) needed external ventricular drain placement, while none of the patients needed permanent shunt placement. However, all patients had a favorable clinical and functional outcome at discharge and at late follow-up (up to 3 months). CONCLUSIONS: NA-SAH does not affect the short- and long-term prognosis. In our results, the pattern of bleeding affects the initial presentation, clinical course, and complications. The clinical and functional outcomes in the majority of our patients were comparable in both groups with good prognosis. Hypertension, smoking, and elevated venous pressure, such as a history of deep venous thrombosis and asthma might be considered as a risk factor.