Posterior fossa epidermoid tumors: a single-center study and proposed classification system.

BACKGROUND: Epidermoid tumors of the cerebellopontine angle and posterior fossa account for approximately 1% of all intracranial tumors. Classifications that may guide surgical planning in the current neurosurgical practice are lacking. This study aimed to focus on the surgical outcome and suggest a classification system that may aid neurosurgeons in determining the goal of resection to minimize morbidity and mortality rates. METHODS: The study population comprised patients who underwent surgery and follow-up for tissue-proven epidermoid tumors between 2015 and 2020. Patients' data, including demographic features, clinical symptomatology, the extent of surgical resection, and postoperative outcomes, were retrospectively evaluated. A new classification system was designed based on the anatomical-radiological findings and was evaluated in terms of clinical symptomatology, radiological features, surgical approach, and postoperative outcomes. RESULTS: The patient population comprised 22 women (57.9%) and 16 men (42.1%), with a mean age of 34.9 years. A practical classification system based on the radiological-anatomical vertical (1, 2, and 3) and horizontal (a, b, and c) tumor extensions was designed. No significant differences were found in the patients in terms of sex/age. The most commonly observed symptom was gait disturbance (34.2%). The preoperative tumor diameter was significantly larger in the subtotal resection (STR) group than in the gross total resection (GTR) and near-total resection (NTR) groups. Significantly more cistern involvement was observed in the STR group than in the GTR group. The GTR, NTR, and STR rates were higher in grade 1, 3, and 2 cases, respectively. The subgroup 'a' was correlated with higher resection rates (GTR and NTR), whereas the subgroup 'b' was correlated with STR. CONCLUSIONS: Our suggested classification system represents a simple and practical model that may guide neurosurgeons in predicting the goal of resection during surgical planning and in minimizing potential morbidity.

Single-Center Surgical Experience of the Treatment of Craniopharyngiomas With Emphasis on the Operative Approach: Endoscopic Endonasal and Open Microscopic Transcranial Approaches.

This study aimed to report the authors' single-center clinical experience about craniopharyngiomas and discuss surgical outcomes of these patients according to the type of surgical approach (endoscopic endonasal or open microscopic transcranial approach).Twenty-four patients diagnosed with craniopharyngiomas between May 2013 and April 2017 were considered for inclusion. The patients were divided into 2 groups according to the surgical approach (open transcranial microscopic approach [group A] and endoscopic endonasal approach [group B]). These groups were compared in terms of postoperative surgical outcome scores (extent of tumor removal, visual deficit, hydrocephalus, metabolic disorders, and Glasgow coma scale) and hospitalization interval.There was no patient of mortality in both groups. In this study, 4 of the 13 patients in group A and 9 of the 11 patients in group B underwent gross total resection. However, 1 patient in group B underwent repair because of cerebrospinal fluid leakage postoperatively. In addition, 1 patient in group A had a wound healing problem postoperatively. The postoperative outcome scores were 9.5 in group A and 11.5 in group B. The hospitalization interval in group A (range, 7-9 days) was longer than that in group B (range, 5-7 days).The endoscopic endonasal approach should be considered the first-line surgical treatment modality in patients with a preliminary diagnosis of craniopharyngioma in terms of low complication risk, minimal invasiveness, and better outcome scores. Open microscopic transcranial procedures may be combined with this approach in a single session for challenging cases.

The outcome of bifocal surgical resection in non-small cell lung cancer with synchronous brain metastases: results of a single center retrospective study.

BACKGROUND: The reported median survival in patients with non-small cell lung cancer (NSCLC) metastases to the brain varies from 3 to 12 months with combined treatment modalities. Bifocal surgical resection of synchronous brain metastasis and primary NSCLC has not been reported widely, and there have been only a small number of articles published in the literature. The aim of this retrospective study was to evaluate the prognostic factors among patients undergoing bifocal surgical resection. MATERIALS AND METHODS: We retrospectively analyzed 28 patients who had a solitary metastatic brain lesion at the time of diagnosis, and underwent synchronous surgical resection of the brain metastasis and primary lung tumor. Survival time was measured in all the patients from the date of craniotomy until death or the most recent date of follow-up for those still surviving. RESULTS: Mean age was 53 years. The mean length of follow-up was 23.6 (4-69) months. The overall survival rates were 79, 42, and 8% at the 1st, 2nd, and 5th years, respectively. The median length of survival was 24 ± 3.8 months. The median survival was found to be statistically significantly lower for the stage T3 tumors when compared with both stage T1 and T2 tumors (p = 0.037). CONCLUSION: NSCLC patients with resectable solitary cranial metastasis, low locoregional stage (stages IA, IB, IIA) in which T3 status is counted out, with no mediastinal lymph node involvement or any other extrathoracic spread will mostly benefit from consecutive complete resection of both tumors and are supposed to have a better survival.

Anatomical relationship and positions of the lumbar and sacral segments of the spinal cord according to the vertebral bodies and the spinal roots.

Segments of the spinal cord generally do not correspond to the respective vertebral level and there are many anatomical variations in terms of the segment and the level of vertebra. The aim of this study is to investigate the variations and levels of lumbar and sacral spinal cord segments with reference to the axilla of the T11, T12, and L1 spinal nerve roots and adjacent vertebrae. Morphometric measurements were made on 16 formalin fixed adult cadaveric spinal cords. We observed termination of the spinal cord between the axilla of the L1 and L2 spinal nerve roots in 15 specimens (93.8%). In all cadavers the emergence of the T11, T12, and the L1 spinal nerve roots was at the level of the lower one-third of the same vertebral body. In 15 specimens (93.8%), the beginning of the lumbar spinal cord segment was found to be above the T11 spinal nerve root axilla and corresponded to the upper one-third of the T11 vertebral body. The beginning of the sacral spinal cord segment occurred above the L1 spinal nerve root axilla and corresponded to the upper one-third of the L1 vertebral body. The results of this study showed that when the conus medullaris is located at the L1-L2 level, the beginning of the lumbar spinal cord segment always corresponds to the body of T11 vertebra. This study provides detailed information about the correspondence of the spinal cord segments with reference to the axilla of the spinal nerve roots.

Microsurgical anatomy of the denticulate ligaments and their relationship with the axilla of the spinal nerve roots.

The denticulate ligaments (DL), 20 or 21 pairs of meningeal extensions, spread from the lateral aspect of the spinal cord to the internal aspect of the spinal dura mater. The aim of this study is to define the specific relationship of the DL with adjacent axilla of the spinal nerve roots and to investigate the anatomical features of the DLs and their variations. The topographical anatomy of the DLs and their relationships with the adjacent axilla of the spinal nerve roots was examined on 16 formalin-fixed adult cadaveric spinal cords. The distances from the dural attachment of the DL to the axilla of the superior and inferior spinal nerve roots were measured bilaterally at every spinal level. Also the distances from the dural attachment of the DL to the lateral aspect of the spinal cord were measured bilaterally. Cervical DLs showed a triangular shape, while in the thoracic segment the ligament changes the shape to "Y." Also the most caudal DL was identified to be at the L1-2 level. Our study revealed that the distances from the dural attachment of the DL to the superior and inferior spinal nerve root axilla were different at the cervical, upper thoracic and the lower thoracic segments. Both distances to the superior and inferior spinal nerve root axilla were shown to increase from cervical to lower thoracic segments. This study provides a detailed anatomy of the DLs and their relationship with the adjacent spinal nerve root axilla.

Defining the Temporal and Occipital Lobes: Cadaveric Study with Application to Neurosurgery of the Inferior Brain.

BACKGROUND: For surgical interventions, a precise understanding of the anatomical variations of the brain and defined anatomical landmarks to demarcate the regions of the temporal lobe is essential. Many anatomical studies have facilitated important surgical approaches to the temporobasal region. Because there is considerable sulcal variability, morphological analysis of the brain is imperative. The aim of this study was to define the boundaries of the temporal and occipital lobes and to define the variations in sulci and gyri in the inferior aspect. METHODS: In 110 cerebral hemispheres variations were identified and the major landmarks of the gyral-sulcal pattern at the inferior aspect of the brain were defined. RESULTS: The anatomy of the inferior aspect of the brain is defined in detail by morphological analysis of formalin-fixed hemispheres with a view to informing important surgical approaches. CONCLUSIONS: Since the literature defines no clear separation between the temporal and occipital lobes, certain landmarks such as the preoccipital notch and a basal temporo-occipital line were suggested as ways of making the distinction. The parahippocampal ramus is a constant structure that can be used as a reliable landmark for the posterior end of the hippocampus.

Giant intrasacral meningocele: a case report.

A peculiar case of intrasacral meningocele and spinal cord tethering is reported. Contents of the intrasacral meningocele and importance of CSF flow analyses with MRI are discussed. Demonstration of CSF flow from the thecal sac to meningocele in the CSF flow MR imaging may be helpful for determining the possibility of meningocele growth. In this report, we have presented the determination of CSF flow as a new surgical indication in this type of cases.

A comparison between stereotactic targeting methods of the subthalamic nucleus in cases with Parkinson's disease.

BACKGROUND: Several methods are used for targeting of the subthalamic nucleus (STN) for the surgical treatment of Parkinson's disease (PD). The goal of this study is to determine the most suitable morphological method for localizing the STN in order to perform deep brain stimulation (DBS) in the treatment of PD. METHODS: Twelve cases with PD underwent bilateral STN-DBS and followed up for 5 years. Indirect calculation of the STN using AC-PC coordinates, and direct targeting of the STN using stereotactic CT/MRI fusion, were used for targeting. A microelectrode recording method was used to localize the STN. RESULTS: Direct targeting of the STN using CT/MRI fusion was very precise in every case, based upon evaluation of the intraoperative microelectrode recordings, postoperative MRI scans, and clinical follow-up of the cases. The coordinate differences obtained from these two methods were statistically significant. CONCLUSION: Direct targeting method of the STN using CT/MRI fusion provided higher precision than the indirect calculation method. This method may be used as a standard targeting technique, and may obviate the need for using complicated technologies such as microelectrode recording, which may sometimes be risky and counterproductive.

The subparietal and parietooccipital sulci: an anatomical study.

The subparietal and parietooccipital sulci are both located on the medial surface of the brain. Both of these sulci reveal significant variability in pattern and complexity. Both subparietal and parietooccipital sulci play an important role as surgical landmarks using posterior interhemispheric parietooccipital approach to lesions located adjacent to the ventricular trigon deep to the cingulate gyrus. The aim of this study is to analyze variations in the patterns of the subparietal and parietooccipital sulci and to emphasize their surgical importance. Fifty-six formalin-fixed cadaveric cerebral hemispheres from 28 adult humans are examined. Subparietal and parietal sulci patterns, variations and their relationship with the cingulate sulcus are studied according to the terminology introduced by Ono et al. The H-pattern was observed in 50% (n = 28) of all hemispheres, being the most common pattern of the subparietal sulcus. The Straight pattern was observed in the 30.4% (n = 17) of all hemispheres, being the most common pattern of the parietooccipital sulcus. Furthermore, more detailed results among the patterns, connections, side branches and the relationship with the adjacent sulci are given. Our study further confirms the complexities in the patterns of the subparietal and parietooccipital sulci and demonstrates that these sulci fall within an expected range of variations. Better knowledge of these variations will further help neurosurgeons to navigate easily during approaches involving the medial surface of the parietal lobe. Clin. Anat. 26:667-674, 2013. © 2013 Wiley Periodicals, Inc.

Surgery in Intracerebral Arteriovenous Malformations: The Role of Preoperative Embolization.

AIM: To examine the outcomes of microsurgery only versus combined microsurgery and embolization in treating cerebral arteriovenous malformations (AVM). MATERIAL AND METHODS: A total of 62 patients (34 male and 28 female) with Spetzler-Martin grade 3 (n=44) and grade 4 (n=18) AVMs were examined. Thirty-seven patients were treated with a combination of microsurgery + embolization, whereas 25 patients were treated with microsurgery alone. The clinical characteristics of the treatment groups were compared (ruptured/unruptured, eloquent/non-eloquent, modified Rankin scores, duration of surgery, preoperative and postoperative hemoglobin levels, and use of blood products). RESULTS: The number of patients with ruptured or eloquently localized AVMs was more in combination of microsurgery + embolization. On the other hand, the duration, preoperative versus postoperative hemoglobin levels, and usage of blood products did not differ between treatment groups. CONCLUSION: The results of the study showed no superiority of the combined treatment in managing AVMs in parallel to recent meta-analyses. However, a patient-tailored approach is recommended while making the treatment decision for such challenging intracerebral AVM cases.

Evaluation of the Utility of Indocyanine Green Video Angiography in Cerebral Arteriovenous Malformation Surgery.

OBJECTIVE: To assess the utility of intraoperative indocyanine green video angiography (ICG-VA) during microsurgical resection of arteriovenous malformations (AVMs). METHODS: Data of the 24 patients, who were surgically treated for AVM using intraoperative ICG-VA, were reviewed retrospectively. Postoperative digital subtraction angiography (DSA) was performed in all patients before they regained consciousness and became fully awake, and the results were compared with those obtained with intraoperative ICG-VA. A scheduled DSA was performed in all patients in the third, sixth, and 12th postoperative months as well. RESULTS: Authors retrospectively analyzed the records of intraoperative ICG-VA application of all 24 patients. Though the exposures were limited and the image qualities were poor at higher magnification on the surgical microscope within deep surgical fields, the AVM niduses, feeding arteries, draining veins, and their relations to normal vasculature were observed precisely with ICG-VA in all the procedures. Furthermore, the visualization was not qualified enough to identify these pathological vascular structures accurately before evacuating and irrigating the layer of blood clots that obscure the view in patients who presented with hemorrhage. In a patient in our series, a residual nidus in the tail of the caudate nucleus was detected with immediate postoperative DSA which was not revealed by terminal assessment with final intraoperative ICG-VA. CONCLUSIONS: Intraoperative ICG-VA is particularly effective in the identification of the feeder, nidus, and drainer and in the assessment of the flow dynamics of the nidus in cerebral AVM surgery. It may be a quick and safe technique for intraoperative imaging of the angioarchitecture of superficial AVMs, but it may be less helpful for deep-seated lesions. Furthermore, this method alone may not be useful in the identification of residual disease or improvement of the clinical outcomes. DSA has remained the gold standard for confirming AVM obliteration. Despite the technical limitations associated with ICG-VA, a combination of intraoperative ICG-VA and immediate postoperative DSA may advance the safety and efficacy of AVM surgery.

Could Fluorescein Staining in Low-Grade Glial Tumors Guide for Peroperative Differentiation of Pathological Types?

AIM: To define whether characteristics of fluorescein staining help to distinguish low grade gliomas intraoperatively. MATERIAL AND METHODS: We studied 46 patients with supratentorial newly diagnosed noncontrast-enhancing LGGs removed by fluorescence guidance under the YELLOW 560 nm filter. Patients who were treated between July 2019 and 2022 were retrospectively analyzed. Clinical data were collected from patient records. Patients? intraoperative video recordings, pathological examination, and preoperative magnetic resonance imaging (MRI) were analyzed and compared for each patient after the operation. Histopathologically, patients were divided into WHO Grade 2 oligodendrogliomas, diffuse astrocytomas (IDH mutant, 1p19q negative tumors), and pre-glioblastomas (IDH wild type, 1p19q negative tumors). Resection margins were checked using controls contrastenhanced cranial MRI at the postoperative 24 and72 hours. RESULTS: Our observations indicate that fluorescein primarily stains diffuse astrocytomas (IDH mutant, 1p19q negative tumors) and pre-glioblastomas (IDH wild type, 1p19q negative tumors) rather than WHO Grade 2 oligodendrogliomas. CONCLUSION: Fluorescein staining might be an option to determine tumor borders in WHO Grade 2 glial tumors, particularly for those with a higher malignancy potential.

The Efficacy of Indocyanine Green Video Angiography During Carotid Endarterectomy: An Institutional Experience.

AIM: To present our experience of 44 consecutive carotid endarterectomy procedures in 42 patients and assess the efficacy and success of ICG-VA in the localization of the plaque sites, extent of the arteriotomy, evaluation of the flow, and presence of thrombus after closure. MATERIAL AND METHODS: This study was retrospectively designed, which included all the patients who underwent carotid stenosis operation between 2015 and 2019. ICG-VA was used in all procedures, and patients with available follow-up and full medical data were analyzed. RESULTS: Forty-two consecutive patients who underwent a total of 44 CEAs were included. The population consisted of 5 (11.9%) female and 37 (88.1%) male patients, all of whom had at least 60% carotid stenosis, as assessed using North American Symptomatic Carotid Endarterectomy Trial stenosis ratios. The mean stenosis rate was 80.55% (range, 60%-90%), the mean patient age was 69.8 years (range, 44-88 years), and the mean follow-up duration was 40 months (range, 2-106 months). In 31 (70.5%) of 44 procedures, ICG-VA revealed the exact location of the obstructive plaque's distal end, and it successfully showed the arteriotomy length, identifying the location of the plaque. ICG-VA correctly evaluated the flow in 38 (86.4%) of 44 procedures. CONCLUSION: Our reported study is cross-sectional, reflecting our experiment using ICG during CEA. ICG-VA can be used as a simple, practical, real-time microscope-integrated technique that can enhance the safety and effectiveness of CEA.

Management of bilateral trigeminal neuralgia with trigeminal radiofrequency rhizotomy: a treatment strategy for the life-long disease.

BACKGROUND: The objective of this study was to evaluate the effectiveness of percutaneous controlled radiofrequency trigeminal rhizotomy (RF-TR) in patients with bilateral trigeminal neuralgia (BTN). Patients were analyzed after RF-TR in terms of outcome, safety and complications. METHODS: Eighty-nine BTN patients underwent 186 RF-TR procedures. Eighty-seven patients had idiopathic trigeminal neuralgia (ITN) and two patients had multiple sclerosis (2.2%). Fifty-six (62.9%) were women and 33 (37.1%) were men. Ages ranged from 29 to 85 years. Anesthesia was administered at a determined optimal level, allowing patient cooperation for controlled and selective lesioning. RESULTS: The mean follow-up period was 101.71 ± 77.7 months. Familial occurrence was seen in two (2.2%) patients. Synchronized pain was observed in 25 (28.2%) patients. Pain occurrence on the contralateral side was observed with an average duration of 124.7 ± 87.13 months. Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. During follow-up, 36 patients required the second procedure and 7 required the third procedure. Acute pain relief was reported in 86 (96.6%) patients. Early (<6 months) pain recurrence was observed in 11 (12.3%) and late (>6 months) recurrence in 25 (28.0%) patients. Complications included diminished corneal reflex in four (2.1%) patients, keratitis in two (1.1%), masseter dysfunction in four (2.1%), dysesthesia in two (1.1%), and anesthesia dolorosa in one (0.5%). CONCLUSIONS: RF-TR is an effective, selective, well-controlled, and effortlessly repeatable procedure for treating BTN, especially in the elderly, in terms of low morbidity and mortality rates and high rate of satisfactory pain relief.

Microsurgical anatomy of the dorsal thoracic rootlets and dorsal root entry zones.

BACKGROUND: For successful DREZ (dorsal root entry zone) surgery, optimal neuroanatomical orientation and precise microsurgical dissection are required. Although cervical, lumbar, and sacral spinal segments have been studied in detail, such information is not available for thoracic segments. The objective of this anatomical study is to comprehensively illustrate the microanatomical features of the thoracic DREZs and their variations. METHODS: Fifteen formalin-fixed adult cadaveric spinal cords from T1 to T12 were used. The dorsal rootlet numbers, distance between the posteromedial and posterolateral sulcus, length of each DREZ, length of each segment, and mean length of the dorsal rootlets were measured under a surgical microscope. RESULTS: The longest DREZs were observed at the T6, T7, and T8 segments with mean values of 15.3 mm, 15.6 mm, and 15.4 mm, respectively. The longest segment was observed at the T10 segment with a mean value of 21.0 mm, and the shortest segment was observed at the T1 segment with a mean value of 13.5 mm. CONCLUSIONS: The highest dorsal rootlet density is at the T1 segment of the spinal cord, can be easily distinguished visually, and may be a useful surgical landmark. The DREZs in T6-7 segments are longest, while these two segments have the least number of rootlets. Because the dorsolateral tract is remarkably narrow and the dorsal horn is exceedingly deep, DREZ surgery at the thoracic level may be difficult and risky for the dorsal column and corticospinal tract. Acquaintance with the microanatomy of the DREZ in the thoracic spinal cord is crucial to DREZ surgery.

Isolated Lumbar Atypical Choroid Plexus Papilloma: A Case Report.

AIM: To report the first case of an isolated lumbar grade II atypical choroid plexus papilloma (CPP). CASE REPORT: A 42-year-old man was admitted to the hospital because of back and leg pain. No urinary or rectal dysfunction was detected. Lumbar magnetic resonance imaging (MRI) showed a well-circumscribed, contrast-enhancing, intradural extramedullary mass at L2-3. He underwent L2 and L3 partial laminectomies for tumor resection and complete resection was achieved without causing neurological deficit. Histopathologic examination of the tumor resulted in a diagnosis of grade II atypical CPP. The Ki-67 staining index was 7%. No lesion was detected on postoperative craniospinal MRI. CONCLUSION: Isolated lumbar atypical CPP in the lumbar region has not been previously reported. In the presence of a single spinal lesion, the diagnosis of CPP should be considered. Unlike metastatic and synchronous tumors, the pathogenesis of isolated choroid plexus tumors within the spinal canal has not been explained.

Intraventricular Hematoma Removal with Combined Drainage Techniques in Patients with High-Grade Subarachnoid Hemorrhage: A Surgical Technique.

AIM: To describe a surgical technique for removal of hematomas in the third ventricle in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH) and report our intraoperative observations and surgical and clinical outcomes. MATERIAL AND METHODS: Ninety-four patients with high-grade aneurysmal subarachnoid hemorrhagic were included in the study. Prior to Sylvian dissection, a ventricular catheter was inserted as soon as possible. After surgical corridor opening and aneurysm clipping, the lamina terminalis (LT) was fenestrated. The free flow of isotonic solution from the back-side open syringe to the distal end of the catheter inside the third ventricle was allowed under gravitational force. The blood clot trapped in the third ventricle was removed through the aperture of the LT by propulsion of blood through the anterior movement of the solution. The procedure was continued until the clearance of solution was observed. RESULTS: The study population consisted of two groups, the combined surgical technique group and the control group, which included patients who underwent operation before the planned study, with 47 patients in each group. The Glasgow Coma, Hunt and Hess, and Fisher scales were used to determine the clinical and radiological severities of the cases. The Modified Rankin Scale was used to evaluate the surgical outcomes at presentation and the 6 < sup > th < /sup > and 12 < sup > th < /sup > postoperative months. CONCLUSION: Our reported surgical technique, which combines ventricular drainage and opening of the LT, will be useful for removing blood clots and blood breakdown products, and recirculating cerebrospinal fluid as much and as soon as possible in high-grade SAH patients with ventricular hemorrhage. Although combining these two well-known procedures as a novel technique does not have any reducing effect on mortality, it may have a significant reducing effect on hydrocephalus and shunt dependency.

An attempt to treat patients who have injured spinal cords with intralesional implantation of concentrated autologous bone marrow cells.

BACKGROUND AIMS: Spinal cord injury is common among young subjects involved in motor vehicle accidents. Mechanisms and attempts to reverse post-traumatic pathophysiologic consequences are still being investigated. Unfortunately no effective and well-established treatment modality has been developed so far. The regeneration capability of the human nervous system following an injury is highly limited. METHODS: The study involved four patients (two male, two female) who had suffered spinal cord injury as a result of various types of trauma. On neurologic examination, all the patients were determined to be in American Spinal Injury Association (ASIA) grade A. All patients were treated with decompression, stabilization and fusion for vertebral trauma anteriorly, as well as intralesional implantation of cellular bone marrow concentrates using a posterior approach 1 month after the first operation. The patients were then treated and followed-up in the physical rehabilitation clinic. RESULTS: At the end of the post-operative 1-year follow-up, two of the patients were classified as ASIA C while one was classified as ASIA B. One patient showed no neurologic change; none of the patients suffered from any complications or adverse effects as a result of intralesional application of bone marrow cells. CONCLUSIONS: The results of this experimental study show the potential contribution of intralesional implantation of bone marrow to neuronal regeneration in the injured spinal cord, with neuronal changes. In light of the results of this experimental study, the potential for regenerative treatment in injuries of the human spinal cord is no longer a speculation but an observation.

Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase.

Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis. A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA-CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA-CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.

Is Placing Prophylactic Dural Tenting Sutures a Dogma?

OBJECTIVE: In this study, we investigated if and when dural tenting sutures are necessary during craniotomy. METHODS: Results from 437 patients 18-91 years of age (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups: patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1); patients who had at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2); or patients who had no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients. RESULTS: Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when dural tenting sutures were placed during postsurgical closure. CONCLUSIONS: Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important.