OsiriX software as a preoperative planning tool in cranial neurosurgery: A step-by-step guide for neurosurgical residents.

BACKGROUND: OsiriX (Pixmeo, Switzerland) is an open-source Digital Imaging and Communications in Medicine (DICOM) viewer that is gaining more and more attention in the neurosurgical community because of its user-friendly interface, powerful three-dimensional (3D) volumetric rendering capabilities, and various options for data integration. This paper presents in detail the use of OsiriX software as a preoperative planning tool in cranial neurosurgery. METHODS: In January 2013, OsiriX software was introduced into our clinical practice as a preoperative planning tool. Its capabilities are being evaluated on an ongoing basis in routine elective cranial cases. RESULTS: The program has proven to be highly effective at volumetrically representing data from radiological examinations in 3D. Among its benefits in preoperative planning are simulating the position and exact location of the lesion in 3D, tailoring the skin incision and craniotomy bone flap, enhancing the representation of normal and pathological anatomy, and aiding in planning the reconstruction of the affected area. CONCLUSION: OsiriX is a useful tool for preoperative planning and visualization in neurosurgery. The software greatly facilitates the surgeon's understanding of the relationship between normal and pathological anatomy and can be used as a teaching tool.

A case of early extraneural medulloblastoma metastases in a young adult.

Extraneural metastases are a relatively rare manifestation of the primary brain tumors, and a major part of the cases has been associated with initial medulloblastoma. Herein, we present the case of a young female adult diagnosed and operated for medulloblastoma. The patient developed extraneural metastases in the first postoperative year. The condition exhibited an aggressive course of development, and the applied treatment approaches were unable to halt its progression. A short literature review identifies the predictive factors determining both prognosis and treatability of the condition; the current limitations and future perspectives of the treatment options are discussed.

Central trigeminocardiac reflex in pediatric neurosurgery: a case report and review of the literature.

INTRODUCTION: Trigeminocardiac reflex is a well-known phenomenon in neurosurgery, craniofacial surgery, ophthalmology and interventional neuroradiology. Even though the trigeminocardiac reflex has become an important factor in skull base surgery and neurosurgery, the central form of trigeminocardiac reflex has only been described in adult subpopulations until now. CASE PRESENTATION: We present a clear form of repetitive trigeminocardiac reflex expressed during revision surgery of a giant (110×61mm) right temporoparietal meningioma in an 18-month-old male Caucasian patient. After cessation of the surgical stimulus, his heart rate and mean arterial blood pressure returned to normal physiological levels. The further follow-up was uneventful. CONCLUSION: Our case demonstrates that the central trigeminocardiac reflex also exists in pediatric patients, especially if manipulating trigeminal innervated structures or around the nerve itself. Whether the incidence and the behavior of the trigeminocardiac reflex is similar in pediatric neurosurgery compared with adult patients has to be shown in further studies.

Use of hydrogen peroxide in neurosurgery: case series of cardiovascular complications.

OBJECTIVES: Postoperative complications induced by hydrogen peroxide (H(2)O(2)) are described in the neurosurgical literature and mainly involve oxygen venous emboli, postoperative pneumocephalus; some of them even fatal. However, recently there are more and more published case reports for significant cardiac dysrhythmia related to the use of this chemical agent during routine neurosurgical interventions. DESIGN: Retrospective, two-centre study. SETTING: Retrospective review of clinical/radiological documentation (including preoperative medical history, operation report and intraoperative anesthesiology data charts). PARTICIPANTS: Patients scheduled for cranial neurosurgical interventions. MAIN OUTCOME MEASURES: Intraoperative occurrence of trigeminocardiac reflex (TCR), according the earlier defined by our group criteria, or other severe cardiovascular complications related to the intraoperative use of H(2)O(2). RESULTS: Five cases were included in the study fulfilling the strict inclusion/exclusion criteria. Two of the cases were recognized as intraoperative TCR, in the other three cases the cardiovascular effects were possibly due to TCR in one, mechanical stimulation of vital centre in anterior hypothalamus, brainstem, or either mechanical or thermal action of H(2)O(2). CONCLUSIONS: According to this two-centre study, we can give, for the first time, evidence that cardiovascular complications according to the intraoperative use of H(2)O(2) in neurosurgery are not rare with an incidence of 3%. Special reference is given to the occurrence of the TCR in this context.

Neuronavigation in cranioorbital neurosurgery - do we really need it?

AIM: The value of neuronavigation in cranioorbital neurosurgery is controversial and relatively unstudied. The aim of this study was to evaluate the application, the usefulness and the reliability of neuronavigation in the neurosurgical treatment of orbital tumours. MATERIAL AND METHODS: A frameless armless infrared-based neuronavigation system was applied in the microsurgical removal of 7 orbital tumors. Image guidance was CT-based in 3 cases, MRI-based in another 3 cases and based on image fusion between CT and MRI image sets in one patient. The extradural fronto-orbital approach was performed in 3 cases, lateral orbitotomy in 2 cases, trans-supraciliar approach in 1 case and inferomedial orbitotomy in 1 case. RESULTS: The surgical procedures were successful in all cases. The procedure-related morbidity and mortality rate in the series was zero. The registration accuracy of the neuronavigation ranged between 1.0 and 1.7 mm, with an average of 1.3 mm. Neuronavigated image guidance was evaluated as useful in all patients. Total tumour removal was achieved in 5 patients and partial tumour excision in 1 case. One patient was only biopsied. CONCLUSION: Neuronavigation is not a substitute for surgical knowledge and experience, but it is a valuable complement with significant intraoperative potential in cranioorbital surgery.

A new predisposing factor for trigemino-cardiac reflex during subdural empyema drainage: a case report.

INTRODUCTION: The trigemino-cardiac reflex is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hypermotility during stimulation of any of the sensory branches of the trigeminal nerve. Clinically, trigemino-cardiac reflex has been reported to occur during neurosurgical skull-base surgery. Apart from the few clinical reports, the physiological function of this brainstem reflex has not yet been fully explored. Little is known regarding any predisposing factors related to the intraoperative occurrence of this reflex. CASE PRESENTATION: We report the case of a 70-year-old Caucasian man who demonstrated a clearly expressed form of trigemino-cardiac reflex with severe bradycardia requiring intervention that was recorded during surgical removal of a large subdural empyema. CONCLUSION: To the best of our knowledge, this is the first report of an intracranial infection leading to perioperative trigemino-cardiac reflex. We therefore add a new predisposing factor for trigemino-cardiac reflex to the existing literature. Possible mechanisms are discussed in the light of the relevant literature.

Ependymoma of the cauda equina starting with communicating hydrocephalus: a case report.

The presence of concomitant hydrocephalus in cases with spinal cord tumors is relatively rare. Here, we describe a case of myxopapillary ependymoma of the cauda equina starting with communicating hydrocephalus in a 14-year-old boy. The patient presented to the clinic without underlying causes of hydrocephalus on the neuroimaging data. After ventriculoperitoneal shunt placement, despite the numerous malfunction incidents, the patient was doing well. Eight years later, he developed progressive weakness and coldness of the lower limbs. Multiple cystic lesions in the cervicothoracic area were found on magnetic resonance imaging. Decompressive hemilaminectomy of the cervicothoracic region was performed with temporary improvement of the patient's condition. Because of persisting complaints, the sacral area of the spine was also observed and neuroimaging data for a tumoral lesion in the cauda equina region were found. The lesion was surgically removed and the histological result was myxopapillary ependymoma. Therefore, cases presenting with internal hydrocephalus without clear-cut intracranial etiology should have detailed neuroimaging of the whole central nervous system.