Clinical outcomes and complications of eyelid versus eyebrow approaches to supraorbital craniotomy: systematic review and indirect meta-analysis.

OBJECTIVE: Eyebrow supraorbital craniotomy is a versatile keyhole technique for treating intracranial pathologies. The eyelid supraorbital approach, an alternative approach to an eyebrow supraorbital craniotomy, has not been widely adopted among most neurosurgeons. The purpose of this systematic review and meta-analysis was to perform a pooled analysis of the complications of eyebrow or eyelid approaches for the treatment of aneurysms, meningiomas, and orbital tumors. METHODS: A systematic review of the literature in the PubMed, Embase, and Cochrane Review databases was conducted for identifying relevant literature using keywords such as "supraorbital," "eyelid," "eyebrow," "tumor," and "aneurysm." Eyebrow supraorbital craniotomies with or without orbitotomies and eyelid supraorbital craniotomies with orbitotomies for the treatment of orbital tumors, intracranial meningiomas, and aneurysms were selected. The primary outcomes were overall complications, cosmetic complications, and residual aneurysms and tumors. Secondary outcomes included five complication domains: orbital, wound-related, scalp or facial, neurological, and other complications. RESULTS: One hundred three articles were included in the synthesis. The pooled numbers of patients in the eyebrow and eyelid groups were 4689 and 358, respectively. No differences were found in overall complications or cosmetic complications between the eyebrow and eyelid groups. The proportion of residuals in the eyelid group (11.21%, effect size [ES] 0.26, 95% CI 0.12-0.41) was significantly higher (p < 0.05) than that in the eyebrow group (6.17%, ES 0.10, 95% CI 0.08-0.13). A subgroup analysis demonstrated significantly higher incidences of orbital, wound-related, and scalp or facial complications in the eyelid group (p < 0.05), but higher other complications in the eyebrow group. Performing an orbitotomy substantially increased the complication risk. CONCLUSIONS: This is the first meta-analysis that quantitatively compared complications of eyebrow versus eyelid approaches to supraorbital craniotomy. This study found similar overall complication rates but higher rates of selected complication domains in the eyelid group. The literature is limited by a high degree of variability in the reported outcomes.

Anterolateral keyhole transorbital routes to the skull base: a comparative anatomical study.

OBJECTIVE: Although keyhole transorbital approaches are gaining traction, their indications have not been adequately studied comparatively. In this study the authors have defined them also as transwing approaches-meaning that they use the different facies of the sphenoid wing for cranial entry-and sought to compare the four major ones: 1) lateral orbitocraniotomy through a lateral canthal incision (LatOrb); 2) modified orbitozygomatic approach through a palpebral incision (ModOzPalp); 3) modified orbitozygomatic approach through an eyebrow incision (ModOzEyB); and 4) supraorbital craniotomy through an eyebrow incision (SupraOrb), coupled with its expanded version (SupraTransOrb). METHODS: Cadaveric dissections were performed at the neuroanatomy lab. To delineate the skull base exposure, four formalin-fixed heads were used, with two sides dedicated to each approach. The outer limits were assessed via image guidance and were mapped and illustrated accordingly. A fifth head was dissected purely endoscopically, just to facilitate an overview of the transwing concept. Qualitative features were also rigorously examined. RESULTS: The LatOrb proves to be more versatile in the middle cranial fossa (MCF), whereas the anterior cranial fossa (ACF) exposure is limited to a small area above the sphenoid ridge. An anterior clinoidectomy is possible; however, the exposure of the roof of the optic canal is suboptimal. The ModOzPalp adequately exposes both the ACF and MCF. Its lateral trajectory allows the inferior to superior view, yet there is restricted access to the medial anterior skull base (olfactory groove). The ModOzEyB also provides extensive exposure of the ACF and MCF, but has a more superior to inferior trajectory compared to the ModOzPalp, making it more appropriate for pathology reaching the medial anterior skull base or even the contralateral side. The anterior clinoidectomy is performed with improved visualization of the optic canal. The SupraOrb provides mainly anterior cranial base exposure, with minimal middle fossa. An anterior clinoidectomy can be performed, but without any direct observation of the superior orbital fissure. Some MCF access can be accomplished if the lateral sphenoid wing is drilled inferiorly, leading to its highly versatile variant, the SupraTransOrb. CONCLUSIONS: All the aforementioned approaches use the sphenoid wing as skull base corridor from a specific orientation point; hence these are designated as transwing approaches. Their peculiarities mandate careful case selection for the effective and safe completion of the surgical goals.

360° around the orbit: key surgical anatomy of the microsurgical and endoscopic cranio-orbital and orbitocranial approaches.

OBJECTIVE: Several pathologies either invade or arise within the orbit. These include meningiomas, schwannomas, and cavernous hemangiomas among others. Although several studies describing various approaches to the orbit are available, no study describes all cranio-orbital and orbitocranial approaches with clear, surgically oriented anatomical descriptions. As such, this study aimed to provide a comprehensive guide to the microsurgical and endoscopic approaches to and through the orbit. METHODS: Six formalin-fixed, latex-injected cadaveric head specimens were dissected in the surgical anatomy laboratory at the authors' institution. In each specimen, the following approaches were modularly performed: endoscopic transorbital approaches (ETOAs), including a lateral transorbital approach and a superior eyelid crease approach; endoscopic endonasal approaches (EEAs), including those to the medial orbit and optic canal; and transcranial approaches, including a supraorbital approach, a fronto-orbital approach, and a 3-piece orbito-zygomatic approach. Each pertinent step was 3D photograph-documented with macroscopic and endoscopic techniques as previously described. RESULTS: Endoscopic endonasal approaches to the orbit afforded excellent access to the medial orbit and medial optic canal. Regarding ETOAs, the lateral transorbital approach afforded excellent access to the floor of the middle fossa and, once the lateral orbital rim was removed, the cavernous sinus could be dissected and the petrous apex drilled. The superior eyelid approach provides excellent access to the anterior cranial fossa just superior to the orbit, as well as the dura of the lesser wing of the sphenoid. Craniotomy-based approaches provided excellent access to the anterior and middle cranial fossa and the cavernous sinus, except the supraorbital approach had limited access to the middle fossa. CONCLUSIONS: This study outlines the essential surgical steps for major cranio-orbital and orbitocranial approaches. Endoscopic endonasal approaches offer direct medial access, potentially providing bilateral exposure to optic canals. ETOAs serve as both orbital access and as a corridor to surrounding regions. Cranio-orbital approaches follow a lateral-to-medial, superior-to-inferior trajectory, progressively allowing removal of protective bony structures for proportional orbit access.

Association of persistent postoperative hyperglycemia with mortality after elective craniotomy.

OBJECTIVE: The influence of persistent postoperative hyperglycemia after craniotomy has not yet been explored. This study aimed to investigate the hypothesis that persistent postoperative hyperglycemia is associated with mortality in patients undergoing an elective craniotomy. METHODS: This study included adult patients (age ≥ 18 years) undergoing an elective craniotomy between January 2011 and March 2021 at the West China Hospital, Sichuan University. Peak daily blood glucose values measured within the first 7 days after craniotomy were collected. Persistent hyperglycemia was defined by two or more consecutive serum glucose levels of mild, moderate, or severe hyperglycemia. Normoglycemia, mild hyperglycemia, moderate hyperglycemia, and severe hyperglycemia were defined as glucose values of ≤ 6.1 mmol/L, > 6.1 and ≤ 7.8 mmol/L, > 7.8 and ≤ 10.0 mmol/L, and > 10.0 mmol/L, respectively. RESULTS: This study included 14,907 patients undergoing an elective craniotomy. In the multivariable analysis, both moderate (adjusted OR 3.76, 95% CI 2.68-5.27) and severe (adjusted OR 3.82, 95% CI 2.54-5.76) persistent hyperglycemia in patients were associated with higher 30-day mortality compared with normoglycemia. However, this association was not observed in patients with mild hyperglycemia (adjusted OR 1.32, 95% CI 0.93-1.88). Interestingly, this association was observed regardless of whether patients had preoperative hyperglycemia. There was no interaction between moderate or severe hyperglycemia and preexisting diabetes (p for interaction = 0.65). When postoperative peak blood glucose values within the first 7 days after craniotomy were evaluated as a continuous variable, for each 1-mmol/L increase in blood glucose, the adjusted OR of 30-day mortality was 1.17 (95% CI 1.14-1.21). Postoperative blood glucose (area under the curve [AUC] = 0.78) was superior to preoperative blood glucose (AUC = 0.65; p < 0.001) for predicting mortality. Moderate and severe persistent hyperglycemia in patients were associated with an increased risk of deep venous thrombosis (adjusted OR 3.20, 95% CI 2.31-4.42), pneumonia (adjusted OR 2.77, 95% CI 2.40-3.21), myocardial infarction (adjusted OR 4.38, 95% CI 3.41-5.61), and prolonged hospital stays (adjusted OR 1.43, 95% CI 1.29-1.59). CONCLUSIONS: In patients undergoing an elective craniotomy, moderate and severe persistent postoperative hyperglycemia were associated with an increased risk of mortality compared with normoglycemia, regardless of preoperative hyperglycemia.

Resection of the quadrangular lobule of the cerebellum to increase exposure of the cerebellomesencephalic fissure: an anatomical study with clinical correlation.

OBJECTIVE: The lateral aspect of the cerebellomesencephalic fissure frequently harbors vascular pathology and is a common surgical corridor used to access the pons tegmentum, as well as the cerebellum and its superior and middle peduncles. The quadrangular lobule of the cerebellum (QLC) represents an obstacle to reach these structures. The authors sought to analyze and compare exposure of the cerebellar interpeduncular region (CIPR) before and after QLC resection and provide a case series to evaluate its clinical applicability. METHODS: Forty-two sides of human brainstems were prepared with Klingler's method and dissected. The exposure area before and after resection of the QLC was measured and statistically studied. A case series of 59 patients who underwent QLC resection for the treatment of CIPR lesions was presented and clinical outcomes were evaluated at 1-year follow-up. RESULTS: The anteroposterior surgical corridor of the CIPR increased by 10.3 mm after resection of the QLC. The mean exposure areas were 42 mm2 before resection of the QLC and 159.6 mm2 after resection. In this series, ataxia, extrapyramidal syndrome, and akinetic mutism were found after surgery. However, all these cases resolved within 1 year of follow-up. Modified Rankin Scale score improved by 1 grade, on average. CONCLUSIONS: QLC resection significantly increased the exposure area, mainly in the anteroposterior axis. This surgical strategy appears to be safe and may help the neurosurgeon when operating on the lateral aspect of the cerebellomesencephalic fissure.

Minimally invasive keyhole approach for supramaximal frontal glioma resections: technical note.

OBJECTIVE: The authors aimed to review the frontal lobe's surgical anatomy, describe their keyhole frontal lobectomy technique, and analyze the surgical results. METHODS: Patients with newly diagnosed frontal gliomas treated using a keyhole approach with supramaximal resection (SMR) from 2016 to 2022 were retrospectively reviewed. Surgeries were performed on patients asleep and awake. A human donor head was dissected to demonstrate the surgical anatomy. Kaplan-Meier curves were used for survival analysis. RESULTS: Of the 790 craniotomies performed during the study period, those in 47 patients met our inclusion criteria. The minimally invasive approach involved four steps: 1) debulking the frontal pole; 2) subpial dissection identifying the sphenoid ridge, olfactory nerve, and optic nerve; 3) medial dissection to expose the falx cerebri and interhemispheric structures; and 4) posterior dissection guided by motor mapping, avoiding crossing the inferior plane defined by the corpus callosum. A fifth step could be added for nondominant lesions by resecting the inferior frontal gyrus. Perioperative complications were recorded in 5 cases (10.6%). The average hospital length of stay was 3.3 days. High-grade gliomas had a median progression-free survival of 14.8 months and overall survival of 23.9 months. CONCLUSIONS: Keyhole approaches enabled successful SMR of frontal gliomas without added risks. Robust anatomical knowledge and meticulous surgical technique are paramount for obtaining successful resections.

Effect of different positive end expiratory pressure levels on optic nerve sheath diameter in patients with or without midline shift who are undergoing supratentorial craniotomy.

PURPOSE: In general, high levels of PEEP application is avoided in patients undergoing craniotomy to prevent a rise in ICP. But that approach would increase the risk of secondary brain injury especially in hypoxemic patients. Because the optic nerve sheath is distensible, a rise in ICP is associated with an increase in the optic nerve sheath diameter (ONSD). The cutoff value for elevated ICP assessed by ONSD is between 5.6 and 6.3 mm. We aimed to evaluate the effect of different PEEP levels on ONSD and compare the effect of different PEEP levels in patients with and without intracranial midline shift. METHODS: This prospective observational study was performed in aged 18-70 years, ASA I-III, 80 patients who were undergoing supratentorial craniotomy. After the induction of general anesthesia, the ONSD's were measured by the linear transducer from 3 mm below the globe at PEEP values of 0-5-10 cmH2O. The ONSD were compered between patients with (n = 7) and without midline shift (n = 73) at different PEEP values. RESULTS: The increases in ONSD due to increase in PEEP level were determined (p < 0.001). No difference was found in the comparison of ONSD between patients with and without midline shift in different PEEP values (p = 0.329, 0.535, 0.410 respectively). But application of 10 cmH2O PEEP in patients with a midline shift increased the mean ONSD value to 5.73 mm. This value is roughly 0.1 mm higher than the lower limit of the ONSD cutoff value. CONCLUSIONS: The ONSD in adults undergoing supratentorial tumor craniotomy, PEEP values up to 5 cmH2O, appears not to be associated with an ICP increase; however, the ONSD exceeded the cutoff for increased ICP when a PEEP of 10 cmH2O was applied in patients with midline shift.

Long-term results of minimally invasive strip craniectomy without helmet therapy for scaphocephaly - a single-centre experience.

Scaphocephaly is the most common type of craniosynostosis and various surgical techniques are used for treatment. Due to late postoperative changes of the head shape, long-term outcome data is important for evaluating any new surgical technique. At our institution, minimally invasive strip craniectomy without regular helmet therapy is the standard treatment in scaphocephalic patients. Between October 2021 and February 2023, we retrospectively examined the skull shape of patients who underwent minimally invasive strip craniectomy for scaphocephaly using a 3D surface scan technique. The cephalic index (CI), the need for helmet therapy and additional cosmetic outcome parameters were investigated. We included 70 patients (72.5% male). The mean follow-up time was 46 (10-125) months and the mean CI was 75.7 (66.7-85.2). In 58 patients, the final cosmetic result was rated as "excellent/good" (mean CI: 76.3; 70.4-85.0), in 11 as "intermediate" (mean CI: 73.3; 66.7-77.6), and in one case as "unsatisfactory" (CI 69.3). The presence of a suboccipital protrusion was associated with a "less than good" outcome. The CI correlated significantly with the overall outcome, the presence of frontal bossing, and the interval between scan and surgery (age at scan). Minimally invasive strip craniectomy is an elegant and safe method to correct scaphocephaly. Our data show good cosmetic results in the long term even without regular postoperative helmet therapy.

[Microanatomical Investigation of the Subtemporal Transtentorial Approach]. / é¢žä¸‹ç»å°è„‘å¹•å ¥è·¯çš„æ˜¾å¾®è§£å‰–å­¦ç ”ç©¶.

Objective: To study the microanatomic structure of the subtemporal transtentorial approach to the lateral side of the brainstem, and to provide anatomical information that will assist clinicians to perform surgeries on the lateral, circumferential, and petroclival regions of the brainstem. Methods: Anatomical investigations were conducted on 8 cadaveric head specimens (16 sides) using the infratemporal transtentorial approach. The heads were tilted to one side, with the zygomatic arch at its highest point. Then, a horseshoe incision was made above the auricle. The incision extended from the midpoint of the zygomatic arch to one third of the mesolateral length of the transverse sinus, with the flap turned towards the temporal part. After removing the bone, the arachnoid and the soft meninges were carefully stripped under the microscope. The exposure range of the surgical approach was observed and the positional relationships of relevant nerves and blood vessels in the approach were clarified. Important structures were photographed and the relevant parameters were measured. Results: The upper edge of the zygomatic arch root could be used to accurately locate the base of the middle cranial fossa. The average distances of the star point to the apex of mastoid, the star point to the superior ridge of external auditory canal, the anterior angle of parietomastoid suture to the superior ridge of external auditory canal, and the anterior angle of parietomastoid suture to the star point of the 10 adult skull specimens were 47.23 mm, 45.27 mm, 26.16 mm, and 23.08 mm, respectively. The subtemporal approach could fully expose the area from as high as the posterior clinoid process to as low as the petrous ridge and the arcuate protuberance after cutting through the cerebellar tentorium. The approach makes it possible to handle lesions on the ventral or lateral sides of the middle clivus, the cistern ambiens, the midbrain, midbrain, and pons. In addition, the approach can significantly expand the exposure area of the upper part of the tentorium cerebelli through cheekbone excision and expand the exposure range of the lower part of the tentorium cerebelli through rock bone grinding technology. The total length of the trochlear nerve, distance of the trochlear nerve to the tentorial edge of cerebellum, length of its shape in the tentorial mezzanine, and its lower part of entering into the tentorium cerebelli to the petrosal ridge were (16.95±4.74) mm, (1.27±0.73) mm, (5.72±1.37) mm, and (4.51±0.39) mm, respectively. The cerebellar tentorium could be safely opened through the posterior clinoid process or arcuate protrusion for localization. The oculomotor nerve could serve as an anatomical landmark to locate the posterior cerebral artery and superior cerebellar artery. Conclusion: Through microanatomic investigation, the exposure range and intraoperative difficulties of the infratemporal transtentorial approach can be clarified, which facilitates clinicians to accurately and safely plan surgical methods and reduce surgical complications.

A Review of the Current Management of Intracranial Infections of Neurosurgical Importance.

Surgically treated intracranial infections are among the common disease entities seen in neurosurgical practice. Several microbiological agents such as bacteria and fungi have been identified as responsible for intracranial infection. It affects all age groups, though microbial agents and risk factors vary with age. Presentation is non-specific and it requires a high index of suspicion, especially with a background febrile illness such as in the setting of poorly-treated meningitis and immunosuppressive conditions such as retroviral illness. Contrast-enhanced magnetic resonance imaging (MRI) scan is the diagnostic tool of choice; it helps to confirm the diagnosis and exclude other ring-enhancing lesions such as glioblastoma and metastatic brain tumours. Treatment involves medical and/or surgical treatment with clear indications. Surgical treatment includes the drainage of abscess via a twist drill or burrhole craniostomy, and craniotomy for recurrent cases. The advances recorded in the evolution of antibiotics and neuroimaging have helped to improve the outcomes of these patients with intracranial infection.

Les infections intracrâniennes traitées chirurgicalement font partie des entités pathologiques courantes rencontrées en pratique neurochirurgicale. Plusieurs agents microbiologiques tels que les bactéries et les champignons ont été identifiés comme responsables des infections intracrâniennes. Cela affecte tous les groupes d'âge, bien que les agents microbiens et les facteurs de risque varient avec l'âge. La présentation est non spécifique et nécessite un haut degré de suspicion, surtout en présence d'une maladie fébrile sous-jacente, comme dans le cas d'une méningite mal traitée et de conditions immunosuppressives telles que l'infection rétrovirale. L'imagerie par résonance magnétique (IRM) avec contraste est l'outil diagnostique de choix ; elle aide à confirmer le diagnostic et à exclure d'autres lésions à rehaussement annulaire telles que le glioblastome et les tumeurs cérébrales métastatiques. Le traitement implique un traitement médical et/ou chirurgical avec des indications claires. Le traitement chirurgical comprend le drainage de l'abcès par une trépanation ou une craniostomie à trou de trepan, et la craniotomie pour les cas récurrents. Les progrès enregistrés dans l'évolution des antibiotiques et de la neuro-imagerie ont contribué à améliorer les résultats de ces patients atteints d'infections intracrâniennes. MOTS-CLÉS: intracrânien, infection, abcès, antibiotiques, chirurgie.

Comparison of Radiofrequency Ablation and Craniotomy Microvascular Decompression for Treatment of Hemifacial Spasm.

BACKGROUND: Hemifacial spasm (HFS) is distinguished by sudden and involuntary spasms of the facial muscles, predominantly on one side of the face. Microvascular decompression (MVD) is an efficacious surgical technique for treating HFS; however, MVD may occasionally lead to noteworthy postoperative complications. Previously, we reported the successful utilization of an innovative awake computed tomography-guided percutaneous puncture of the stylomastoid foramen for administering radiofrequency ablation (RFA) therapy in the treatment of HFS. STUDY DESIGN: Prospective clinical research study. SETTING: Department of Anesthesiology and Pain Medical Center, Ningbo, China. OBJECTIVES: The aim of this study was to compare and contrast the clinical outcomes and adverse reactions associated with attempts to use RFA and MVD to manage primary HFS. METHODS: Three hundred patients received either RFA or MVD treatment (Group R and Group M). We tracked and recorded each patient's cure rate, remission rate, intraoperative and postoperative complications, short-term and long-term therapeutic outcomes, hospitalization duration, hospitalization expenses, and operation time. RESULTS: One hundred and fifty-eight patients were placed in the R group, and 142 patients were sorted into the M group. In the R group, 87.34% of patients showed improvement, 9.49% experienced relief, and 3.16% experienced treatment failure. Similarly, in the M group, 85.92% of patients showed improvement, 10.56% experienced relief, and 3.52% experienced treatment failure. The difference in therapeutic efficacy between the 2 groups was not significant. However, the M group had significantly lower recurrence rates at 3 months, 6 months, and one year post-operation than the R group did. Notably, the M group also experienced a higher rate of postoperative complications. Among the complications reported in the M group were 25 cases of dizziness or headache (17.6%) following the operation, 22 cases of hearing damage, including one case of complete hearing loss on the side involved, and 28 cases of peripheral nerve injury with abnormal skin sensation. Postoperative facial paralysis occurred in 15 patients, including 10 cases of moderate to severe facial paralysis that were relieved to grade II after one year. In comparison, the R group had 40 cases of grade II and 53 cases of grade III, and no cases of more severe facial paralysis were found. There were also 13 cases of peripheral nerve injury, such as local skin numbness and tenderness. Importantly, there were no cases of facial hematoma, intracranial hemorrhage, infection, or any other complications in either group, and no fatalities occurred during the study period. LIMITATIONS: The limitations of this study are the exclusion of transient postoperative complications, the lack of in-person follow-up with patients, and the potential underestimation of certain complications. CONCLUSION: The short-term outcome was found to be comparable between the 2 treatment modalities. Notably, RFA demonstrates both safety and efficacy as a method for managing primary HFS; however, the procedure may lead to mild facial paralysis. In situations during which surgery is contraindicated, especially among elderly or high-risk surgical patients, percutaneous facial nerve RFA at the stylomastoid foramen may be considered as an alternative therapeutic approach.

Irrigation versus no irrigation in the treatment of chronic subdural hematoma: An updated systematic review and meta-analysis of 1581 patients.

Burr hole craniotomy is a common technique employed in the treatment of chronic subdural hematoma. However, its effectiveness and the occurrence of additional complications with various irrigation techniques utilized during the surgery remain unclear. The paper aims to compare the effectiveness and safety of burr hole craniotomy with and without irrigation in the treatment of chronic subdural hematoma. We conducted a systematic review by searching PubMed, Cochrane Library, Scopus, Ovid, and Web of Science for comparative studies that fit the eligibility criteria. All studies up to January 2023 were included, and the two groups were compared based on five primary outcomes using Review Manager Software. Data reported as odds ratio (OR) or risk ratio (RR) and 95% confidence interval (CI). A p-value of less than 0.05 was considered statistically significant. Our analysis included 12 studies with a total of 1581 patients. There was no significant difference between the two techniques in terms of recurrence rate (OR = 0.94; 95% CI [0.55, 1.06], p-value = 0.81) and mortality rate (RR = 1.05, 95% CI [0.46, 2.40], p-value = 0.91). Similarly, there was no significant difference in postoperative infection (RR = 1.15, 95% CI [0.16, 8.05], p-value = 0.89) or postoperative pneumocephalus (RR = 2.56, 95% CI [0.95, 6.89], p-value = 0.06). The burr hole drainage with irrigation technique was insignificantly associated with a higher risk of postoperative hemorrhagic complication (RR = 2.23, 95% CI [0.94, 5.29], p-value = 0.07); however, sensitivity analysis showed significant association based on the results of two studies (RR = 4.6, 95% CI [1.23, 17.25], p-value = 0.024). The two techniques showed comparable recurrence, mortality rate, postoperative infection, and postoperative pneumocephalus results. However, irrigation in burr hole craniotomy could possibly have a higher risk of postoperative hemorrhage compared with no irrigation, as observed during sensitivity analysis, which requires to be confirmed by other studies. Further research and randomized controlled trials are required to understand these observations better and their applicability in clinical practice.

Thickness and design features of clinical cranial implants-what should automated methods strive to replicate?

PURPOSE: New deep learning and statistical shape modelling approaches aim to automate the design process for patient-specific cranial implants, as highlighted by the MICCAI AutoImplant Challenges. To ensure applicability, it is important to determine if the training data used in developing these algorithms represent the geometry of implants designed for clinical use. METHODS: Calavera Surgical Design provided a dataset of 206 post-craniectomy skull geometries and their clinically used implants. The MUG500+ dataset includes 29 post-craniectomy skull geometries and implants designed for automating design. For both implant and skull shapes, the inner and outer cortical surfaces were segmented, and the thickness between them was measured. For the implants, a 'rim' was defined that transitions from the repaired defect to the surrounding skull. For unilateral defect cases, skull implants were mirrored to the contra-lateral side and thickness differences were quantified. RESULTS: The average thickness of the clinically used implants was 6.0 ± 0.5 mm, which approximates the thickness on the contra-lateral side of the skull (relative difference of -0.3 ± 1.4 mm). The average thickness of the MUG500+ implants was 2.9 ± 1.0 mm, significantly thinner than the intact skull thickness (relative difference of 2.9 ± 1.2 mm). Rim transitions in the clinical implants (average width of 8.3 ± 3.4 mm) were used to cap and create a smooth boundary with the skull. CONCLUSIONS: For implant modelers or manufacturers, this shape analysis quantified differences of cranial implants (thickness, rim width, surface area, and volume) to help guide future automated design algorithms. After skull completion, a thicker implant can be more versatile for cases involving muscle hollowing or thin skulls, and wider rims can smooth over the defect margins to provide more stability. For clinicians, the differing measurements and implant designs can help inform the options available for their patient specific treatment.

Surgical evacuation of spontaneous cerebellar hemorrhage: Comparison of safety and efficacy of suboccipital craniotomy and robotic-assisted stereotactic hematoma drainage.

OBJECTIVE: This study compared the efficacies of robotic-assisted stereotactic hematoma drainage and suboccipital craniotomy (SC) in patients with spontaneous cerebellar hemorrhage (SCH). METHODS: This retrospective study included 138 non-comatose patients with SCH (Glasgow Coma Scale score [GCS] >8), divided into the SC and Robotic Stereotactic Assistance (ROSA) groups. The study recorded and analyzed complications and prognoses 90 days after ictus. RESULTS: The inclusion criteria were met by 138 patients: 61 in the SC and 77 in the ROSA group, with no significant differences in sex, age, GCS score, hematoma volume, and the time from ictus to operation. The time of operation was greater in the SC group (287.53±87.57) than in the ROSA group (60.54±20.03). The evacuation rate (ER) was greater in the SC group (93.20±1.58) than in the ROSA group (89.13±2.75). The incidence of pneumonia and stress ulcers, as well as the length or costs of medical services, were lower in the ROSA group than in the SC group. Ninety days after ictus, the modified Rankin Scale (mRS), Glasgow Prognostic Scale (GOS), and Karnofsky Performance Scale (KPS) scores significantly differed between the groups. The rate of good prognosis in the ROSA group was significantly higher compared with that in the SC group. The incidence of balance disorders was lower in the ROSA group than in the SC group; no statistically significant difference was found in the incidence of dysarthria and swallowing disorders. CONCLUSION: Robotic-assisted stereotactic hematoma drainage may be suitable for non-comatose and stable condition patients with SCH. This procedure improves prognosis 90 days after ictus, lowers the incidence of pneumonia and stress ulcers, and reduces the length and costs of medical services.

Comparative analysis of supra-orbital keyhole approach and pterional approach for surgical clipping of intracranial anterior circulation aneurysms in patients with favorable Hunt and Hess grades.

INTRODUCTION: Traditional large craniotomies have been the standard for aneurysm surgery. However, minimally invasive "keyhole" approaches have gained popularity for aneurysm clipping in recent years. This study focuses on Supra-Orbital Keyhole Approach (SOKHA),its use in clipping of aneurysms of the anterior Circle of Willis. Here we share the experiences of a tertiary care center regarding aneurysm clipping using SOKHA. MATERIALS AND METHODS: We retrospectively reviewed 166 cases involving aneurysm clipping, with 62 patients undergoing SOKHA and 104 patients undergoing the pterional approach. Factors evaluated included patient demographics, aneurysm characteristics, incidence of intraoperative complications, temporary-clipping usage, and postoperative clinical outcomes. Glasgow Outcome Scale scores were utilized to assess clinical outcomes. RESULTS: The study found that both the SOKHA and pterional approaches were similar in terms of age distribution, Hunt and Hess grades, and the incidence of hydrocephalus. The majority of aneurysms in both groups were anterior communicating artery aneurysms.Hydrocephalus was observed in 14.5 % of SOKHA cases and 13.5 % of pterional cases. Intraoperative aneurysm rupture occurred in 8.1 % of SOKHA cases and 7.7 % of pterional cases. There were no mortalities in the SOKHA group, while the pterional group had 1.92 % mortality rate. At the last follow-up, 77.4 % of SOKHA cases and 75.9 % of pterional cases had a favorable outcome (Glasgow Outcome Scale IV and V), with no significant difference. CONCLUSION: SOKHA offers the advantage of potential cosmetic benefit with neurological outcomes comparable to those of the traditional pterional approach, in properly selected patients.

[Comparison of polymethyl methacrylate skull implant fixation by three types of titanium fasteners]. / Sravnenie sposobov fiksatsii implantov cherepa iz polimetilmetakrilata tremya vidami titanovykh krepezhei.

OBJECTIVE: To evaluate mechanical strength of three methods of polymethyl methacrylate skull implant fixation in two experimental models. MATERIAL AND METHODS: The first experiment was performed on a plastic model that was as close as possible to bone in structural characteristics. The second experiment was performed on a biological specimen (a ram's head). We assessed the quality of implant fixation to bone window edges by craniofixes, ties and microscrews and lateral intercortical screws. RESULTS: Craniofixes are feasible for small flat flaps, but not advisable for wide highly curved implants. They are also the most expensive method of fixation. Implant fixation by ties and microscrews is a universal method comparable in price to craniofix. Lateral intercortical fixation is effective both for small flat implants and wide implants with large curvature. However, this method is not always applicable. CONCLUSION: Combined fixation by lateral intercortical screws and ties allows for the most effective fixation while reducing the overall price of consumables.

The efficacy and safety of using a combination of rocuronium and sugammadex for awake craniotomy anesthesia: A randomized clinical trial.

BACKGROUND: Awake craniotomy (AC) is a neurosurgical method for the resection of brain lesions located in eloquent areas to achieve maximal and safe resection. A patient's arousal quality is essential for the success of the operation. This study compared the arousal time and quality after AC achieved by 2 different drug combinations: rocuronium with sugammadex and propofol with remifentanil. METHODS: This prospective, randomized, controlled trial included 42 adult patients undergoing AC with a laryngeal mask, who were randomly assigned to either a rocuronium-sugammadex group (RS; n = 21) or a propofol-remifentanil without muscle relaxant group (nRS; n = 21). The primary outcomes were the arousal time and arousal quality. The secondary outcomes included the number of laryngeal mask airway (LMA) adjustments and diaphragmatic excursion length. RESULTS: This study included 42 participants. The median (IQR) arousal time was 13.5 minutes (7-20) in the RS group and 21 minutes (16.5-26.5) in the nRS group (P = .005). There was no significant difference in arousal quality between the 2 groups (P = .229). LMA adjustments were significantly less frequent in the nRS group than in the RS group [0.25 times (±0.62) vs 1.26 times (±1.17), P = .001]. Adverse events, such as spontaneous movements and brain swelling, were more frequent in the nRS group than in the RS group. CONCLUSIONS: Using a combination of rocuronium and sugammadex with propofol and remifentanil may shorten the awakening time, reduce the duration of laryngeal mask adjustment, and do not affect the arousal quality and postoperative outcomes for patients undergoing awake craniotomy, compared to propofol and remifentanil alone.