Extended Endoscopic Endonasal Transplanum and Transdorsum Sellar Approach for the Resection of Retroinfundibular Craniopharyngioma With Two-Piece Dural Opening: A Technical Case Report.

The surgical treatment of retroinfundibular craniopharyngiomas is challenging due to their location and the surrounding neurovascular structures. In this report, the transdorsum sellar approach with posterior clinoidectomy, the efficacy of direct cyst puncture, and the suitability of a two-piece dural opening are presented. A 56-year-old male with visual and cognitive disturbances was referred to our hospital. Preoperative CT and MRI demonstrated a mostly cystic lesion with calcifications in the suprasellar and retroinfundibular areas. The imaging findings were suspected craniopharyngioma, and an extended endoscopic endonasal transdorsum sellar approach with posterior clinoidectomy was performed for direct access to the lesion. Two pieces of the dura were opened to prevent postoperative CSF leakage. The patient's postoperative course was uneventful. The endoscopic transdorsum sellar approach gives direct access to the posterior cranial fossa. A direct puncture of the cyst without CSF drainage is helpful for large cystic lesions. A two-piece dural opening is easy to suture and can reduce the chance of postoperative CSF leakage.

Simplifying the Technique of Awake Brain Surgery in a Condition of Less Equipped Neurosurgical Institution in Uzbekistan.

Currently, awake craniotomy (AC) is one of the most often employed procedures to map and resect tumors in eloquent brain areas, avoiding the use of general anesthesia (GA) and thereby reducing anesthesia-related complications and cost of surgery. Resource limitations are one of the basic reasons for avoiding AC in low- and middle-income countries (LMICs). The aim of this study is to describe the simplified protocol of awake brain surgery that can be implemented in a limited financial setting in LMICs and to share our first experience. Twenty-five patients diagnosed with tumor of the left frontotemporal lobes, all involving Broca's and Wernicke's areas, were operated on using AC. Brain mapping was executed using mono- and bipolar direct electrical stimulation including cortical and subcortical (axonal) mapping profiles, investigating basically cortical language centers. Neither neuronavigation nor intraoperative magnetic resonance imaging (MRI) was utilized due to financial constraints. AC was performed successfully in 23 of 25 patients, achieving a near-total resection in 16 (69.5%) patients, subtotal resection in 4 patients (17.39%) patients, and partial resection in 3 (13.04%) patients. In two patients, due to psychological instability-agitation and fear during the awake phase-speech test was not technically possible, so they were reintubated by giving them GA. There was no mortality in the early or postoperative period. In spite of the absence of advanced pre- and intraoperative technologies such as intraoperative MRI and navigation systems, AC can be safely performed in LMICs. These tools along with intraoperative cortical mapping and language testing can guarantee better surgical outcomes and quality of life. However, our study confirms that omitting these tools does not make a huge difference in getting good results with AC and that AC is not absolutely impossible. AC can be performed successfully, preserving eloquent brain areas, with minimum and basic set of the armamentarium like system for cortical and subcortical intraoperative neurostimulation which provides cortical/subcortical brain mapping.

Comparing Two Improved Techniques With the Traditional Surgical Techniques for Intra and Extramedullary Spinal Tumor Resection: A Report of 280 Cases.

Objectives: Spinal tumors remain a challenging problem in modern neurosurgery. The high rate of postoperative morbidity associated with intramedullary tumors makes the need for safer surgical techniques invaluable. This study analyses our experience with the treatment of spinal cord tumors and compares traditional management and a new different surgical approach to intramedullary tumors with an associated hydrosyringomyelia. Materials and Methods: This retrospective study compared standard surgical techniques and 2 newer modified techniques for intra and extramedullary spinal tumors at the Neurosurgery center for spinal cord tumors of the Republic of Uzbekistan. Preoperative neurological status was recorded with the ASIA/ISNCSCI scale. Postoperative outcome was graded using the Nurrick score. Results: Of the 280 cases, there were 220 (78.5%) extramedullary and 60 (21.5%) with intramedullary spinal tumors. The control and main group had 159 (56.8%) and 121 (43.2%) patients, respectively. Severe compression myelopathy (ASIA- A, B, C) was 217 (77.5%) patients i.e., ASIA A-39 (13.9%); B-74 (26.4%), and C-104 (37.1%). In 74 extramedullary tumors (33.6%) treated with the new method, good postoperative outcomes in 44 cases (59.5%) with OR = 1.9; 95% CI 1.1-3.3 (p < 0.05). Thirty-seven (61.7%) intramedullary tumors were treated with the newer modified technique. There was no difference with the standard method (p = 0.15). However, when comparing postoperative Nurick grade 1-2 with grade 3-4, the newer strategy was superior with improvement in 24 (65%) patients, OR = 3.46; 95% CI 1.2-10.3 (p < 0.05). Conclusion: When compared with standard methods, the proposed newer modified strategy of surgical treatment of spinal cord tumors with the insertion of a syringosubarachnoid shunt in the presence of an associated hydrosyringomyelia is associated with better postoperative outcome (Nurick 1 and 2) in 64.8%.

The Importance of Measuring Mamillopontine Distance as a Diagnostic Criterion of Hydrocephalus Degrees.

OBJECTIVES: The occurrence of obstructive hydrocephalus (ObH) as sequelae of deep midline brain tumors (third and lateral ventricles, thalamic, pineal region, brainstem, and fourth ventricle) can be estimated up to 90% of cases. We believe that the mamillopontine distance (MPD) - the distance between the lower surface of the mammillary body and the upper surface of the pons in the sagittal images - can be a sufficiently reliable alternative to the Evans' index (EI) for the diagnosis of ObH. PATIENTS AND METHODS: The results of mamillopontine distance (MPD), Evans' index (EI), and angle of corpus callosum (ACC) measurement of 43 patients with non-communicative hydrocephalus were analyzed compared with results of 30 people without brain pathology. RESULTS: Findings revealed that MPD is a strong and reliable alternative to the EI. MPD showed high specificity and sensitivity in the diagnosis of occlusive hydrocephalus. Moreover, from those findings, we have proposed classification of the degree of hydrocephalus severity, depending on the MPD. CONCLUSION: MPD one of the more accurate and powerful method for defining presence of hydrocephalus in-patient even in early stage of occlusion. It has high specificity and sensitivity and capable classify hydrocephalus into grades according to severity.

Unspecific clinical manifestation of cauda equina myxopapillary ependymoma.

A 9-year-old boy admitted to the neurosurgical hospital complaining of headache, vomiting, abdominal pain, and weakness in the arms and legs, urinary retention. Previously, the patient had a treatment of pediatricians. He was examined, magnetic resonance imaging revealed the tumor of the conus medullaris and cauda equina. The surgery was performed with removal myxopapillary ependymoma (ME). Postoperative neurological symptoms regressed; he has received radiotherapy postoperatively. This case illustrates a rare clinical presentation of ME, which simulated intracranial, thoracic, and caudal pathology. We presented features of the clinical presentation, diagnostics, and treatment options of this ependymoma.