查看更多>>摘要：? 2022 Elsevier Inc.Surgical resection of a pineal tumor growing into the third ventricle is difficult owing to the complex neurovascular structures, and nongerminomatous germ cell tumor is the most common malignant tumor in pediatric patients. Removing the tumor efficiently with minimal blood loss while protecting the surrounding neurovascular structure is challenging. We present a surgical case of a 9-year-old patient with a third ventricle nongerminomatous germ cell tumor (Video). Mass effect of the tumor or acute hydrocephalus is the possible reason for the coma. In this case, the reason of coma may be mass effect of the tumor, not the acute hydrocephalus. Informed consent was obtained from the patient's guardian. Intraoperatively we used a modified right head-up park bench position and a linear incision. The right occipital bone flap was designed to cross the superior sagittal sinus and transverse sinus. The primary surgical approach was the occipital transtentorial approach; an alternative was the supracerebellar infratentorial approach. After cutting the tentorium, a spatula was applied to retract the cerebellum and incised tentorium, with no extra brain retraction on the occipital lobe to minimize visual disturbance. The quadrigeminal cistern was opened, and the tumor was yellowish with heterogeneous consistency. Instead of rushing into the tumor debulking, we paid more attention to devascularization of the tumor from bilateral posterior medial choroidal arteries as much as possible. After debulking using an ultrasound aspirator, the tumor was removed in a piecemeal fashion, and the surgical field was inspected using an endoscope for any residue.
查看更多>>摘要：? 2022 Elsevier Inc.The authors regret that an error occurred in the Methods Section Subsection “Anesthesia Management” on page e32-e34: Original statement with incorrect values: “Shortly after pre-anesthesia assessment and peripheral intravenous (IV) line placement, dexmedetomidine was started at 0.5 mg/kg/min …” The corrected statement should read as follows: “Shortly after pre-anesthesia assessment and peripheral IV placement, dexmedetomidine was started at 0.5 mcg/kg/hr …” Original statement with incorrect values: “Once in the operating room, the dexmedetomidine infusion of 0.2-0.5 mg/kg/min was supplemented with propofol at 20-50 mg/kg/min, if needed for patient comfort.” The corrected statement should read as follows: “Once in the operating room, the dexmedetomidine infusion of 0.2-0.5 mcg/kg/hr was supplemented with propofol at 20-50 mcg/kg/min, if needed for patient comfort.” Original statement with incorrect values: “Maintenance anesthetic was standardized to propofol 100-200 mg/kg/min, dexmedetomidine 0.5 mg/kg/min, and fentanyl was titrated based on the discretion of the anesthesia provider.” The corrected statement should read as follows: “Maintenance anesthetic was standardized to propofol 100-200 mcg/kg/min, dexmedetomidine 0.5 mcg/kg/hr, and fentanyl was titrated based on the discretion of the anesthesia provider.” The authors apologise for any inconvenience caused. Elird Bojaxhi MD, on behalf of all co-authors.
查看更多>>摘要：? 2022 Elsevier Inc.Although rare, intramedullary spinal cavernous malformations have a 1.4%–6.8% annual hemorrhage risk and can cause significant morbidity.1 Prior hemorrhage and size >1 cm are risk factors for future hemorrhage that, in addition to notable or progressive symptoms, may justify early surgical intervention.1,2 In this video, we present key steps in surgical management of a large, symptomatic thoracic cavernous malformation. A 56-year-old woman presented with worsening lower extremity weakness, imbalance, and difficulty ambulating. Strength was 3/5 in her right lower extremity and 4/5 in her left lower extremity. She had an incomplete T4 sensory level and hyperreflexia. Magnetic resonance imaging demonstrated a heterogeneous “popcorn”-appearing expansile intradural intramedullary 2.2- × 1.2-cm lesion at T4-5, consistent with a cavernous malformation. Angiography was deferred given the characteristic magnetic resonance imaging appearance. Given her progressive symptoms (including weakness), lesion size, and good health, resection was recommended. Using neurological monitoring, a T4-5 laminectomy, midline myelotomy, and piecemeal microsurgical resection of the lesion was performed, clearly identifying the cavernoma–spinal cord interface and avoiding spinal cord retraction. Histopathology confirmed a cavernoma. Postoperatively, the patient had improved left lower extremity strength and stable right lower extremity strength but worsened dorsiflexion (1/5), which improved with rehabilitation. At 1-year follow-up, she had full strength in her left lower extremity and 4/5 in her right lower extremity, with mild paresthesias below T10. Consistent with prior series demonstrating low complication rates and good long-term neurological outcomes,2 microsurgical resection of selected symptomatic intramedullary spinal cavernous malformations can halt neurological decline and potentially improve neurological function.
查看更多>>摘要：? 2022 Elsevier Inc.Endoscopic visualization during microvascular decompression for hemifacial spasm enables better identification of compression areas along the facial nerve, which is especially important in cases with complex compression and enlarged vessels obscuring the compression site. A 40-year-old man presented with a 10-year history of left hemifacial spasm. Magnetic resonance imaging showed a deep compression site with multiple vessels. Within the narrow space, the compression area was clearly visualized using an angled endoscope. Arterial transposition was performed using a polytetrafluoroethylene (Teflon) sling, which was fixed to the nearby dura using an aneurysm clip. Decompression was visually confirmed using the angled endoscope. The patient was free of spasms directly after surgery with no further complications and no recurrence of spasm during 6-month follow-up (Video 1).
De Jesus Encarnacion Ramirez M.Peralta I.Ramirez I.Dauly V....
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查看更多>>摘要：? 2022 Elsevier Inc.Background: Less than a quarter of the world population has access to microneurosurgical care within a range of 2 hours. We introduce a simplified exoscope system to achieve magnification, illumination, and video recording in low-resource settings. Methods: We combined an industrial microscope tube, a heavy-duty support arm, a wide-field c-mount digital microscope camera, and a light-emitting diode ring light. All parts were sterilized with ethylene oxide. We performed 13 spinal and 3 cranial surgeries with the help of the low-budget exoscope. Results: The average preoperative setup time was 12.8 minutes. The exoscope provided similar magnification and illumination like a conventional binocular microscope. It allowed operating in a comfortable posture. The field of vision ranged from 30 mm–60 mm. The surgical field was captured by a 16-megapixel two-dimensional camera and projected to a 55-inch high-definition television screen in real time. Image quality was similar to that of a conventional microscope although our exoscope lacked stereoscopic view. Adjusting camera position and angle was time-consuming. Thus, the benefit of the exoscope was most notable in spine surgeries where the camera remained static for most of the time. The total cost of the exoscope was approximately U.S. $ 750. Conclusions: Our low-budget exoscope offers similar image quality, magnification, and illumination like a conventional binocular microscope. It may thus help expand access to neurosurgical care worldwide. Users may face difficulty adapting to the lack of depth perception in the beginning. Prospective studies are needed to assess its usability and effectiveness compared to the microscope.
查看更多>>摘要：? 2022 Elsevier Inc.Background: Multimodal analgesia is a strategy that can be used to improve pain management in the perioperative period for patients undergoing surgery of the spine. However, no review evidence is available on the quantitative models of multimodal analgesia within this clinical setting. We conducted a systematic review and meta-analysis to examine the effects of maximal (≥3 analgesic agents) multimodal analgesic medication for patients undergoing surgery of the spine. Methods: We included randomized controlled trials that had evaluated the use of ≥3 multimodal analgesia components (maximal multimodal analgesia) in patients undergoing spinal surgery. We excluded patients who had received neuraxial or regional analgesia. The control group consisted of placebo, standard care (any therapeutic modality including ≤2 analgesic components). The primary outcomes were the postoperative pain scores at rest evaluated at 24 and 48 hours. We searched MEDLINE via OvidSP, EMBASE via OvidSP, and the Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). We used the Cochrane standard methods. Results: We identified consistently improved analgesic endpoints across all predetermined primary and secondary outcomes. A total of 11 eligible studies had evaluated the primary outcome of pain at rest at 24 hours. The patients who had received maximal multimodal analgesia were identified to have had lower pain scores with an average mean difference of ?1.03 (P < 0.00001). The length of hospital stay was shorter for the patients who had received multimodal analgesia (mean difference, ?0.55; P < 0.00001). Conclusions: Perioperative maximal multimodal analgesia consistently improved the visual analog scale scores for an adult population in the immediate postoperative period, with a moderate quality of evidence. We found a significant decrease in the hospital length of stay for patients who had received maximal multimodal analgesia with a high level of evidence and no statistical heterogeneity.
查看更多>>摘要：? 2022 Elsevier Inc.Syringomyelia is often resistant to various treatment modalities.1 Chiari I malformations are associated with syringomyelia in approximately 69% of operative cases.2 Failure to resolve syringomyelia after Chiari decompression is common.3 The pathophysiology of Chiari-associated syringomyelia has been well studied, with Oldfield emphasizing the water-hammer mechanism, with treatment limited to bony decompression and duraplasty.4 On the other hand, capacious fourth ventricular drainage is thought to be essential for syrinx resolution. Persistence or progression of the syrinx after decompression is an indication for reoperation. Direct shunting of the syrinx is associated with high failure rates.1,5-7 The technique of shunting the fourth ventricle has been applied successfully in the pediatric population.3,8-10 We emphasize the need to ensure outflow from the fourth ventricle in Chiari decompressions associated with syringomyelia. In revisions to treat progressive syringomyelia after failed decompression, we undertake the following steps: 1) adequate lateral bony decompression,11-13 2) lysis of scar/adhesions around the cisterna magna, 3) opening the fourth ventricle outlet by releasing any web/adhesions, 4) insertion of a shunt from the fourth ventricle to the cervical subarachnoid space, and 5) bipolar coagulation of the lateral tonsillar pia to maintain patency of cerebrospinal fluid pathways.8 We favor autologous fascia or pericranium for expansile duraplasty, as the use of nonautologous materials may cause excessive scarring.14-16 In this video, we demonstrate these tenets in 3 cases of Chiari-associated syringomyelia, 2 revisions and 1 primary case, with excellent resolution of the syrinx (Video 1). The patients consented to surgery and publication of images.
查看更多>>摘要：? 2022 Elsevier Inc.Objective: Primary spinal leiomyosarcoma (PSL) is extremely rare. A case is presented, followed by a systematic review establishing the consensus on presentation, diagnosis, management, and outcomes. Comparison is made with metastatic spinal leiomyosarcoma (MSL). Methods: A systematic review was conducted in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligibility criteria were decided before the literature search was conducted. Data were extracted and analyzed. Results: A total of 397 articles were identified, 25 of which conformed to the eligibility criteria. Thirty-four cases were included in the analysis. PSL had a female preponderance (69.2%), with back pain being the most common presenting symptom (60.9%). Neurologic signs were present in most (69.6%), with tumors typically in the thoracic spine (46.9%). Diagnosis was primarily made using magnetic resonance imaging (64.7%) and computed tomography (55.9%), with a histologic sample being obtained in all cases. Most patients underwent operative management (91.2%), with variable use of neoadjuvant and adjuvant therapies. Operative approach differed greatly and outcome after surgical management was stated in 48.4% of patients, all noting an improvement from presentation. Patient follow-up was limited (median, 7 months), with most patients being free of disease (43.8%). Conclusions: PSL diagnosis is challenging, with positron emission tomography–computed tomography and histopathologic sampling playing an important role. There is a limited evidence base for the treatment strategies used but surgical management is key, with generally good outcomes. Prognosis for PSL seems to be better than for MSL. There is scope for more dedicated research in PSL and MSL.
查看更多>>摘要：? 2022 Elsevier Inc.Previously ruptured aneurysms treated with coil occlusion are at risk of recurrence and require thoughtful strategic planning for adequate aneurysm occlusion.1-3 Alternative strategies, such as coil extraction or trapping and bypass, are options when simple clipping is not feasible.2 A 15-year-old boy presented with a Hunt and Hess grade 4, Fisher grade 4 subarachnoid hemorrhage from a ruptured distal anterior cerebral artery aneurysm. The patient initially underwent coil embolization and craniotomy to evacuate an extensive corpus callosum hemorrhage. Follow-up angiography demonstrated early recurrence of the aneurysm. Subsequently, the patient underwent microsurgical clipping through an anterior interhemispheric approach, while carefully preserving a large venous complex to avoid potentially devastating venous infarction (Video 1).4-9 In this surgical video, we review the case presentation, surgical anatomy, operative technique, and postoperative course and outcome. We also describe various operative strategies with anatomical illustrations. The patient gave verbal consent for participating in the procedure and surgical video.
查看更多>>摘要：? 2022 Elsevier Inc.Arteriovenous malformations (AVMs) are complex, heterogeneous, and uncommon neurovascular disorders that frequently manifest in young adults. Parenchymal AVMs are thought to be congenital, but this has been recently questioned in the literature.1,2 AVMs can change over time and cause focal neurological signs or neurocognitive deficits.3 The clinical presentation of an AVM is variable and depends mainly on the occurrence of bleeding as well as its location, size, and ability to take flow from adjacent areas.4 AVMs can be treated by a single modality or a combination of different modalities. According to the Expert Consensus on the Management of Brain Arteriovenous Malformations, neurosurgery may be the best option for Spetzler-Martin grade 2 AVMs.5 However, the treatment of these lesions when located in eloquent areas, especially in the central lobe, is controversial. Awake craniotomy allows identification of eloquent gyrus and can potentially facilitate resection with functional preservation. An alternative is stereotactic radiosurgery, but a qualitative comparative analysis revealed higher obliteration rate with awake AVM excision compared with stereotactic radiosurgery.6 Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. It was used in the past for surgical management of intractable epilepsy, but its indications are increasing, and it is a widely recognized technique for resection of mass lesions involving the eloquent cortex and for deep brain stimulation.7 Its application for resection of vascular lesions, including AVMs, is still limited. In the Video, we present a case of a cerebral AVM of the precentral gyrus in which we achieved complete resection with awake microsurgical treatment without any neurological sequelae for the patient.
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