Ventriculo-gallbladder shunt: case series and literature review.

BACKGROUND: The ventriculoperitoneal shunt (VPS) is the gold-standard surgical technique to treat hypertensive hydrocephalus; however, it may fail in 20 to 70% of cases. The present study shows an alternative for patients with contraindications to VPS. METHODS: A case series of nine patients. The medical records of all patients under 17 years of age who underwent ventriculo-gallbladder (VGB) shunt at a pediatric hospital from January 2014 to October 2022 were reviewed. RESULTS: There were 6 (66.7%) males and 3 (33.3%) females. The average age of 73.6 months or 6.1 years at the time of surgery. They had undergone, on average, 5.1 VPS reviews before the VGB shunt. Five (55.5%) had complications of VGB shunt: infection (11.1%), atony (11.1%), hypodrainage (11.1%), and ventriculoenteric fistula (22.2%); all these patients got better at surgical reapproach, and in two of them, the VGB shunt was re-implanted. CONCLUSION: This case series shows a lower risk of death and a similar risk of complications compared to other alternative shunts. This article spotlighted VGB as a viable alternative when VPS fails or has contraindications.

The artery of Wollschlaeger and Wollschlaeger.

INTRODUCTION: The artery of Wollschlaeger and Wollschlaeger (AWW), named after the German neuroradiologists who discovered it, is a unique and remarkable anatomical structure. This review will delve deeper into the intricate details of the AWW its origin, significance, and the studies associated with it. METHODS: A comprehensive evaluation of the available literature on the AWW was conducted by doing searches on reputable academic databases such as PubMed, Google Scholar, and Web of Science. The present study incorporated the terminology "The artery of Wollschlaeger and Wollschlaeger," "medial dural-tentorial artery," and "meningeal branch of the superior cerebellar artery." We conducted an investigation on the literature pertaining to its existence, anatomy, pathology, and clinical implications. RESULTS: Upon conducting a comprehensive examination of the existing literature and primary sources pertaining to the AWW, it was observed that a limited number of scholarly investigations have been undertaken to explore this subject matter. We made observations on the anatomical characteristics of the subject and engaged in a discussion regarding their prospective applications and importance in the context of neurosurgical procedures. CONCLUSIONS: Despite its minute size, its role in vascular circulation is considerable. The understanding of this artery's characteristics and its links to certain neurosurgical conditions assists neurosurgeons and researchers in their pursuit to advance medical knowledge and design effective treatment strategies.

Liliequist membrane: A systematic review of history, anatomy, clinical importance, and surgical challenges.

BACKGROUND: The Liliequist membrane (LM) represents a crucial yet challenging anatomical structure in neuroanatomy. First observed in 1875 and later elucidated by Bengt Liliequist in 1956, the LM's precise anatomical description and boundaries remain complex. Its significance extends to neurosurgery, impacting various procedures like endoscopic third ventriculocisternostomies, aneurysm and tumor surgeries, treatment of suprasellar arachnoid cysts, and managing perimesencephalic hemorrhages. However, a comprehensive understanding of the LM is hindered by inconsistent anatomical descriptions and limitations in available literature, warranting a systematic review. METHODS: A systematic review was conducted by searching PubMed, Science Direct, and Google Scholar for articles pertaining to Liliequist's membrane. The search employed Mesh terms like "Liliequist membrane," "Liliequist's diaphragm," and related variations. Inclusion criteria encompassed studies exploring the historical evolution, anatomical structure, radiological characteristics, and clinical implications of the LM in neurosurgery. RESULTS: The search yielded 358 articles, with 276 unique articles screened based on relevance. Following a meticulous screening process, 72 articles underwent full-text assessment, resulting in the inclusion of 5 articles meeting the eligibility criteria. The selected studies varied in methodology, including anatomical dissections, radiological evaluations, and clinical significance in neurosurgical procedures. Insights were derived on LM's anatomical variations, radiological visualization, and its critical role in guiding neurosurgical interventions. CONCLUSIONS: Despite advancements in understanding its clinical significance and radiological visualization, challenges persist in precisely delineating its boundaries. Further research, especially on embryological development and histological characterization, is essential. Enhancing comprehension of LM-related pathologies is crucial for accurate preoperative planning and optimizing patient outcomes in neurosurgery.

Pineal Apoplexy: Highlighting the Causes, Treatment, and Outcome.

BACKGROUND: Pineal apoplexy, alternatively referred to as pineal hemorrhage or pineal gland hemorrhagic stroke, is an infrequent pathologic condition characterized by bleeding within the pineal gland. In this review, we encompass the primary factors contributing to this uncommon ailment. METHODS: The retrieval of pertinent research, including patients with pineal apoplexy, was conducted through PubMed, Google Scholar, and Scopus databases. This study exclusively incorporated comprehensive articles written in the English language. The search encompassed the MeSH terms "pineal apoplexy" and "pineal hemorrhage." RESULTS: A total of 41 articles were identified, encompassing a collective sample size of 57 patients. The median age of the patients in the study was 30 years, with a range spanning from 1 to 73 years. There were 27 males, representing 47.4% of the participants. The study identified the most often reported symptoms as headache (49; 86%), nausea/vomiting (19; 33.3%), and Parinaud's syndrome (16; 28.1%). The treatment options encompass several approaches, including open resection, shunting, ventriculostomy, endoscopic aspiration, and conservative care. In the conducted study, a notable number of patients, amounting to 45 cases (78.9%), indicated an amelioration of their symptoms upon their discharge. CONCLUSION: Data from a cohort of 57 cases provide insights into symptoms, lesions, treatments, and outcomes. Management approaches range from conservative measures to surgical interventions, with prognosis hinged on timely intervention. This investigation serves as a valuable resource for clinicians and researchers, underscoring the need for early diagnosis before permanent neurologic dysfunction happens and tailored treatments for optimal outcomes in pineal apoplexy cases.

Surgical outcomes and follow-up results of 53 pediatric craniopharyngioma cases: a single-center study.

OBJECTIVE: Craniopharyngiomas are locally invasive neoplasms, and they cause potential lifelong morbidity because of their tendency for local recurrence. Despite advancements in endoscopic techniques, gross-total resection (GTR) of tumors with invasion or adhesion to important surrounding anatomical structures is extremely difficult. The authors present a single-center study that evaluated the impact of the endoscopic endonasal approach (EEA) on the surgical outcomes of pediatric craniopharyngiomas, the factors affecting the resection rate, and recurrence. METHODS: A total of 44 pediatric patients (age ≤ 18 years) who were treated via the EEA for craniopharyngioma from August 1997 to June 2022, as well as their 53 operations, were included in this study. The preoperative radiological configuration and surgical data of these cases were assessed. Also, preoperative and postoperative clinical (endocrinologic, neurological, and ophthalmological), hypothalamic, physical and social development, and neurocognitive assessment data were described. RESULTS: In total, 37 cases (69.8%) had no history of operation beforehand. The most common symptoms at presentation were endocrine disturbances (98.1%), headache without vomiting (84.3%), and visual disturbance (51%). Cases were classified as infrasellar (1.9%), sellar (32.1%), sellar-suprasellar (52.8%), and suprasellar (13.2%) localization. GTR was achieved in 34/53 cases (64.1%). The rate of GTR was higher in infrasellar and sellar tumors compared with sellar-suprasellar and suprasellar tumors (p = 0.003), and preoperative hypothalamic involvement was associated with lower likelihood of GTR (p = 0.024). Moreover, with experience, the rate of GTR increased (p = 0.037). Postoperative complications, other than endocrine impairment, occurred in 10/53 cases (18.9%). The mean duration of follow-up was 53.57 months. At follow-up, 21/53 (39.6%) cases presented with tumor recurrence. The 5-year progression-free survival (PFS) rate was 48.5%. There was a statistically significant difference between the GTR and other-than-GTR groups in terms of PFS (p < 0.001). According to univariate analysis, smaller tumor (p = 0.017), infrasellar and sellar localization (p = 0.031), and GTR (p < 0.001) were significantly associated with decreased rate of recurrence. Also, there was a statistically significant association between the recurrence rate and adhesion strength of the tumor (p < 0.001). CONCLUSIONS: This retrospective cohort study revealed surgical indications for EEA, as well as factors affecting the resection rate, recurrence, and quality of life during the follow-up period of the included cases. The authors believe that GTR should be the goal for craniopharyngioma treatment, but the authors' treatment approach was to provide a balance between radical surgery with maximum safety and adjuvant treatment for long-term disease control.

Retinal vascular and structural recovery analysis by optical coherence tomography angiography after endoscopic decompression in sellar/parasellar tumors.

We assessed the potential retinal microcirculation alterations for postoperative visual recovery in sellar/paraseller tumor patients with Optical Coherence Tomography Angiography (OCT-A). Two hundred ten eyes with sellar/parasellar tumor for which preoperative and postoperative (3 months) MRI Scans, Visual Acuity Test, Optical Coherence Tomography (OCT), OCT-A and, Visual Field Test data were available, besides 92 healthy eyes were evaluated. In the preoperative phase, significant reductions were observed in retinal vascular densities in various regions, including the Superficial Retinal Capillary Plexus (SRCP) (whole: p < 0.001, fovea: p = 0.025, parafovea: p < 0.001), Deep Retinal Capillary Plexus (DRCP) (whole: p < 0.001, fovea: p = 0.003, parafovea: p < 0.001), Peripapillary Vascular Density (PVD) (whole: p = 0.045, peripapillary: p < 0.001, nasal: p < 0.001, inferior: p < 0.001, temporal: p < 0.001), and Retinal Nerve Fiber Layer (RNFL) (nasal: p = 0.024, inferior: p < 0.001, temporal: p < 0.001, superior: p < 0.001) compared to the healthy control group. After surgery, the postoperative data of patients without chiasmal distortion were compared to their preoperative data. In the postoperative evaluation, significant increases were observed in vascular densities in patients without chiasmal distortion in the SRCP (whole: p < 0.001, parafovea: p = 0.045), DRCP (whole: p = 0.007, fovea: p = 0.006, parafovea: p = 0.040), PVD (peripapillary: p = 0.010, inferior: p < 0.001, temporal: p < 0.001, superior: p < 0.001), and RNFL (nasal: p = 0.011, inferior: p = 0.034, temporal: p = 0.046, superior: p = 0.011). Furthermore, significant associations were observed in the ROC analysis between the postoperative Visual Field Mean Deviation (VFMD) and SRCP (whole AUC = 0.793, p < 0.001, cut-off = 51.45, parafovea AUC = 0.820, p < 0.001, cut-off = 53.95), DRCP (whole AUC = 0.818, p < 0.001, cut-off = 55.95, parafovea AUC = 0.820, p < 0.001, cut-off = 59.05), PVD (temporal AUC = 0.692, p < 0.001, cut-off = 55.10), and RNFL (whole AUC = 0.690, p = 0.001, cut-off = 119.5, inferior AUC = 0.712, p < 0.001, cut-off = 144.75). These findings indicate a potential role of pre and post-operative OCT-A measurements in the assessment of surgical timing and postoperative visual recovery in patients with or without optic chiasm distortion.

Cystic dilatation of the ventriculus terminalis: A narrative review.

Introduction: The terminal ventricle, also known as the fifth ventricle, is a tiny relic cavity in the conus medullaris of the human spinal cord. Our purpose in bringing attention to this condition is to get the word out about the signs and symptoms, diagnostic hurdles, and therapeutic options available for it. Methods: All relevant studies involving patients diagnosed with ventriculus terminalis (VT) were retrieved from PubMed, Google Scholar, and Scopus. Studies published in complete English language reports were included. The terms VT, terminal ventricle, and 5th ventricle. Age, gender, presenting symptoms, magnetic resonance imaging findings, treatment, and outcome of patients with ventriculus terminalis were all included and recorded. Results: The average age of the patients was 39 years, and there were 13 men among them (14.4%). Motor deficits and sciatica were the most commonly reported symptoms in 38 and 34 patients (42.2%, 37.7%), respectively. In 48 patients (53.3%), cyst fenestration was performed, and in 25 patients (27.7%), myelotomy was performed. Fifty-eight patients (64.4%) saw a reduction in cyst size after surgery. The majority of patients reported an improvement in their symptoms in 64 cases (51.1%), with only three cases (3.3%) reporting a worsening. Conclusions: In cases where the VT is the source of symptoms such as motor, sensory, or bladder dysfunction, surgical intervention is recommended. This review compiles information from the available literature to shed light on the anatomy, clinical presentation, imaging, and treatment options for this variant. It also aims to pinpoint any potential drawbacks or restrictions connected to the surgical techniques.

Effects of Modified Osteoplastic Pterional Craniotomy on Temporal Muscle Volume and Frontal Muscle Nerve Function.

Introduction Pterional craniotomy is a surgical approach frequently used in aneurysm and skull base surgery. Pterional craniotomy may lead to cosmetic and functional problems, such as eyebrow drop due to facial nerve frontal branch damage, temporal muscle atrophy, and temporomandibular joint pain. The aim was to compare the postoperative effects of our modified osteoplastic craniotomy with classical pterional craniotomy in terms of any change in volume of temporal muscle and in the degree of frontal muscle nerve damage. Materials and Methods Aneurysm cases were operated with either modified osteoplastic pterional craniotomy or free bone flap pterional craniotomy according to the surgeon's preference. Outcomes were compared in terms of temporal muscle volume and frontal muscle nerve function 6 months postoperatively. Results Preoperative temporal muscle volume in the modified osteoplastic pterional and free bone flap pterional craniotomy groups were not different ( p > 0.05). However, significantly less atrophy was observed in the postoperative temporal muscle volume of the osteoplastic group compared with the classical craniotomy group ( p < 0.001). In addition, when comparing frontal muscle nerve function there was less nerve damage in the modified osteoplastic pterional craniotomy group compared with the classical craniotomy group, although this did not reach significance ( p > 0.05). Conclusion Modified osteoplastic pterional craniotomy significantly reduced atrophy of temporal muscle and caused proportionally less frontal muscle nerve damage compared with pterional craniotomy, although this latter outcome was not significant. These findings suggest that osteoplastic craniotomy may be a more advantageous intervention in cosmetic and functional terms compared with classical pterional craniotomy.

Endoscopic approach for giant pituitary adenoma: clinical outcomes of 205 patients and comparison of two proposed classification systems for preoperative prediction of extent of resection.

OBJECTIVE: Giant pituitary adenoma is considered a challenging pathology for surgery owing to its complications and low resection rate. In this study, the authors present their experience of using the endoscopic endonasal approach to treat patients with giant pituitary adenoma, and they aimed to develop a classification system for prediction of extent of resection. METHODS: The institutional medical records of patients diagnosed with giant pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery between August 1997 and December 2019 were retrospectively reviewed. Surgical and clinical outcomes were evaluated in detail. The effects of tumor characteristics on extent of resection were analyzed. The findings were used to develop two classification systems that could preoperatively predict extent of resection. Morphological score was based on tumor characteristics, and landmark-based classification was defined according to surgical zones based on neurovascular landmarks. The effects of change in surgical strategy, which aimed to maximize tumor resection and capsule dissection, on rates of resection and complications were evaluated before and after 2017. RESULTS: This study included 205 patients, with a mean patient age of 46.95 years and mean preoperative tumor diameter of 46.56 mm. Gross-total resection (GTR) was achieved in 35.12% of patients, near-total resection (NTR) in 39.51%, and subtotal resection (STR) in 25.36%. Extent of resection differed significantly between the grades and zones of the classification systems (p < 0.001 for both). Among patients with grade 3 tumor, 75.75% of patients achieved STR, 21.21% achieved NTR, and 3.03% achieved GTR. Among patients with zone 3 tumor, 65.75% achieved STR, 32.87% achieved NTR, and 1.36% achieved GTR. Both grade 3 and zone 3 indicated limited extent of resection. The mean (range) follow-up duration was 50.16 (9-247) months. Postoperative recovery of at least one hormone axis was seen in 15.24% of patients with pituitary deficiency, and development of new hormonal deficiency was observed in 22.43% of patients. Complications included permanent diabetes insipidus (7.80%), cerebrospinal fluid leakage (3.90%), postoperative apoplexy (3.90%), meningitis (3.41%), and epistaxis (3.41%). The surgical mortality rate was 1.46%. Among 85 patients treated before 2017, 27.05% of patients achieved GTR, 37.64% achieved NTR, and 35.29% achieved STR; among 120 patients treated after 2017, 40.83% achieved GTR, 40.83% achieved NTR, and 18.33% achieved STR. Seven patients in the pre-2017 cohort had postoperative apoplexy versus only 1 patient in the post-2017 cohort. There were no statistically significant differences between the two periods in terms of the incidence rates of other complications. CONCLUSIONS: Capsule dissection and GTR are valuable for preventing serious complications and reducing recurrence of giant adenoma. Treatment of giant pituitary adenoma may be better managed with the help of a classification system that provides information about extent of resection that can be achieved with an endoscopic approach.

Operative nuances and surgical limits of the endoscopic approach to clival chordomas and chondrosarcomas: A single-center experience of 72 patients.

OBJECTIVE: Gross total resection (GTR) is the mainstay therapy for chordomas and chondrosarcomas to have the best prognosis. The aims of this study were to specify the limits of EEA, emphasize the need for additional combined approaches for tumors beyond these limitations for high resection rates, discuss the prognostic factors and operative nuances that affect GTR, and present the causes and characteristics of early and late recurrences. METHODS: We retrospectively analyzed the endoscopic endonasal surgeries in the Pituitary Research Center and Neurosurgery Department of the Kocaeli University Faculty of Medicine, Turkey between January 2004 and December 2019. We retrospectively reviewed the medical data, radiological images, and surgical videos of patients, and 72 patients with chordoma and chondrosarcoma were included in the study. RESULTS: Based on pathology reports, 72 patients (seven pediatric) were identified, to whom 91 endoscopic operations were performed. We determined the surgical limitations for each clival segment as superior, middle, and inferior. Then, we divided these into three subgroups according to whether the tumor shows dural invasion (extradural chordoma, large extradural - minimal intradural component, and minimal extradural - large intradural component). The tumors of 19 (26.4%), 25 (26.4%), and nine (12.5%) patients originated from the superior, middle, and inferior clivus, respectively. Nineteen (26.4%) patients had panclival involvement. GTR was performed in 47 (65.3%) the patients. The GTR rate in patients with panclival tumors was 47.3% (9/19). The experience, lateralization, dural involvement, and origin of the clivus affecting GTR were analyzed. Extradural - intradural extensions were verified as negative predictor factors for GTR, whereas tumors located in the superior (OR: 16.710, p=0.030) and middle (OR: 11.154, p=0.023) segments were positive predictive factors for GTR. CONCLUSION: An increasing experience in endoscopic surgery significantly increases the GTR rates by widening the surgical limitations. Due to dense bone infiltration and adhesion to critical neurovascular structures, recurrence rates are high despite performing GTR. Although surgery and adjuvant treatments improve the 5-year survival of patients, the mortality rates remain high. Therefore, surgery of these tumors should be performed by experienced centers. In addition to surgical and adjuvant therapies, targeted molecular and translational biological therapies are also needed for chordomas and chondrosarcomas in the future.