Transnasal Transsphenoidal Elevation of Optic Chiasm in Secondary Empty Sella Syndrome Following Prolactinoma Treatment.

BACKGROUND: Prolactinomas are typically treated nonsurgically with a dopamine agonist. Once the tumor shrinks, adjacent eloquent structures, such as the optic apparatus, can become skeletonized and herniate into the dilated parasellar space. CASE DESCRIPTION: A 48-year-old man with a prolactin-secreting macroadenoma treated with cabergoline presented with progressive bitemporal hemianopsia. Magnetic resonance imaging showed no recurrence of disease and a stretched optic chiasm herniating into an empty sella. Elevation of the optic chiasm via a transnasal transsphenoidal approach with ALLODERM graft and septal cartilage strut was performed. The patient was discharged home the next day with significant improvement in vision; magnetic resonance imaging showed interval elevation of the optic chiasm. CONCLUSIONS: We review secondary empty sella syndrome and discuss surgical strategies for optic chiasmapexy.

Carotid Endarterectomy to Remove Retained Solitaire Stent Retriever inside Carotid Stent after Mechanical Thrombectomy.

BACKGROUND: Tandem occlusions of the internal carotid artery (ICA) and middle cerebral artery (MCA) occur in up to a third of patients with acute ischemic strokes undergoing endovascular mechanical thrombectomy. Understanding open neurosurgical management of associated complications with this procedure is important. CASE REPORT: A 67-year-old man with acute onset of left hemiparesis and a tandem right ICA and MCA occlusion. He underwent carotid stent angioplasty of a stenotic ICA, followed by attempted Solitaire stent retrieval of an MCA clot. On withdrawal, the tines of the Solitaire stent lodged inside the Precise carotid stent. The patient was started on aspirin, Plavix, and heparin infusion, and underwent a carotid endarterectomy (CEA) with safe removal of the stents and primary vessel repair. CONCLUSION: This is the first case reported to date of a Solitaire stent becoming lodged inside a Precise carotid stent, salvaged by CEA with safe removal of the stents and primary vessel repair. We discuss the timing, indication, alternatives, and technical nuances of a CEA in this setting.

Symbiotic relationship of IV-tPA and mechanical thrombectomy in a case of acute tandem ICA-MCA occlusion.

INTRO: In light of the recent successful mechanical thrombectomy trials, the need for IV-tPA prior is under investigation. Few cases demonstrate angiographically the role of both mechanical and chemical strategies at achieving reperfusion. CASE REPORT: A 63year-old male presented with an NIHSS 20. CTA demonstrated an acute occlusion of the left cervical and intracranial ICA and MCA. IV-tPA was administered, followed by immediate reperfusion of the cervical ICA with carotid stenting and mechanical thrombectomy. Within the next 10min, the entire intracranial clot burden dissolved under angiographic control. TICI 3 reperfusion was achieved without any further intervention. Post-procedure, the patient recovered fully to an NIHSS of 0. CONCLUSION: This case underscores the importance of IV-tPA administration in conjunction to mechanical thrombectomy. The interventionalist should take advantage of the symbiotic effect of the IV-tPA administration, which remains the standard of care so far.

Optimal pediatric dosing of anti-platelet agents for pipeline stent embolization -a case report and review of the literature.

BACKGROUND: Various strategies are emerging for dosing antiplatelet therapies in preparation for pipeline stent embolization in adults. Hyper-response is associated with hemorrhagic complications. Hypo-response is associated with thromboembolic events. Dosing of antiplatelet agents is highly variable, with little consensus among experts for adults-and even more so for children. To date, pipeline stents have been deployed in 11 pediatric patients, ages 4-15. A variety of clopidogrel and aspirin dosing regimens have been used, with response tested in only three patients, who were all therapeutic. Thrombotic events occurred in two patients, neither of whom were tested. CASE: We describe here the first case of a hemorrhagic complication in a hyper-responsive pediatric patient undergoing placement of a pipeline stent. DISCUSSION: As the use of endovascular therapies requiring dual anti-platelet agents becomes more established, there is an increasing need to develop titration protocols that minimizes the risk of thrombotic and hemorrhagic events.

Rare Lesions of the Internal Auditory Canal.

BACKGROUND: Approximately 95% of tumors occurring within the internal auditory canal (IAC) are vestibular schwannomas. Many undergo stereotactic radiation without definitive tissue diagnosis. Rare IAC tumors are not all radiosensitive and are poorly described. METHODS: Between 1992 and 2015, 289 consecutive patients with IAC lesions operated on were reviewed retrospectively. RESULTS: Fifteen patients (5.2%) (16 operations) had unusual histologic findings, including nonvestibular schwannomas (2 facial schwannomas, 2 cochlear schwannomas, 2 intermedius schwannomas), 3 meningiomas, 3 cavernous hemangiomas, a mucosa-associated lymphoid tissue lymphoma, an arachnoid cyst, and a lipochoristoma. None of these rare tumors could be identified before surgery. Three operative approaches were used: the retrosigmoid approach, middle fossa subtemporal approach, or translabyrinthine approach. Few complications occurred, including facial nerve palsy, loss of hearing, and vestibular function. Five-year average follow-up revealed one patient with recurrence. CONCLUSIONS: Clinical examination and imaging alone were insufficient to correctly identify these tumors. Definitive pathologicdiagnosis should be strongly considered to help tailor treatment.

Inferior Vena Cava Filter Thrombosis in the Postoperative Neurosurgical Setting: Case Report and Review of the Literature.

There are no definitive treatment guidelines for caval-filter thrombosis in the postoperative setting. Clinical management for partial or complete postoperative inferior vena cava (IVC) occlusion relies solely on expert opinion, anecdotal evidence, and small clinical trials. As such, the primary objective of the present report is to offer a complex case of extensive IVC filter occlusion in a neurosurgical patient with past medical history significant for protein C deficiency. The presentation, unique radiological findings, management, and outcome will be discussed. No similar cases of massive IVC-occlusive disease in a thrombophilic patient early in the postoperative course following neurosurgical intervention are documented in the medical literature.

Superficial temporal artery: the "C" shape half-buttonhole configuration as it courses over the zygomatic arch.

PURPOSE: To describe the course and configuration of the superficial temporal artery (STA) around the zygomatic arch. METHODS: Volume rendered 3D reconstructions of computed tomography angiography of 25 healthy patients were performed and analyzed at Duke University Hospitals. RESULTS: The STA coursed over the zygomatic arch or over the condylar process of the mandible in all cases (25/25 pts, 100 %). The STA courses over the posterior zygomatic arch in 23/25 pts (92 %), creating a characteristic "C" shape half-buttonhole configuration as it embraces the arch. When the STA travels posterior to the zygomatic arch, there is no C shape configuration (2/25 pts, 8 %). The STA bifurcates distal to the zygomatic arch in 24/25 pts (96 %). CONCLUSIONS: The "C" shape half-buttonhole configuration is a useful identifying characteristic of the most common course of the STA-over the posterior zygomatic arch before it bifurcates.

Simulation in Neurosurgery-A Brief Review and Commentary.

Neurosurgery is one of the most technically demanding and liable of all medical professionals. More than 75% of neurosurgical errors are deemed as preventable and technical in nature. Yet in a specialty that requires such high level of technical expertise, with large consequences for error, there are even fewer opportunities for residents in training to practice on the most complicated cases. Although there is no replacement for actual experiences in the operating room, interpersonal mentorship, coaching, and training, there is room to supplement residency education through simulation. Here we review the evidence to support surgical simulation, describe the strengths and weaknesses of existing technologies in direct neurosurgery specific and indirect simulation applications, and advocate for the development of more neurosurgery-specific applications using emerging kinetic technologies.

Direct Repair of Iatrogenic Internal Carotid Artery Injury During Endoscopic Endonasal Approach Surgery With Temporary Endovascular Balloon-Assisted Occlusion: Technical Case Report.

BACKGROUND AND IMPORTANCE: Iatrogenic internal carotid artery (ICA) injuries during endoscopic endonasal approach (EEA) surgeries are associated with a high morbidity and mortality, with few acceptable methods described for repair. CLINICAL PRESENTATION: A 13-year-old girl with a large anterior and central skull base osteoblastoma incurred an iatrogenic cavernous ICA injury during a staged EEA approach. Intraoperative angiogram was performed with balloon-assisted EEA primary microsurgical repair of the lacerated ICA. CONCLUSION: By integrating current techniques commonly used in open aneurysm surgeries and in endovascular procedures, we developed a rapid, safe technique to repair an EEA-associated iatrogenic ICA injury.