查看更多>>摘要：? 2022 Elsevier Inc.Ependymomas are rare primary tumors of the brain and spinal cord that arises from the ependymal cell layer. Cranial ependymomas commonly occur in the posterior fossa; however, approximately 30% of all tumors can be found in the supratentorial region. Supratentorial ependymomas have a shorter progression-free and overall survival than their infratentorial counterparts. We present the case of a 47-year-old man who presented with mild left-sided hemiparesis and confusion secondary to a right-sided 8.5 × 6.0 × 6.0 cm frontotemporal neoplasm encasing the ipsilateral internal and middle cerebral arteries. The patient had undergone a suboccipital craniectomy for resection of a posterior fossa ependymoma at 6 years of age (41 years ago). After multidisciplinary discussion, we performed a right frontotemporal craniotomy for tumor resection (Video) using intraoperative navigation, ultrasound, and intraoperative neurophysiological monitoring. While skeletonizing branches of the middle cerebral artery, an M3 branch was injured inadvertently and repaired immediately. Histopathologic specimens were consistent with ependymoma (World Health Organization grade II). A near-total resection was achieved. The patient developed a transient left-sided hemiparesis but improved to full strength on discharge from the hospital.
Paganelli S.L.Alejandro S.A.Campos Filho J.M.Doria-Netto H.L....
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查看更多>>摘要：? 2022 Elsevier Inc.One of the most popular treatment strategies for complex cerebral aneurysms with wide necks is stent-assisted coiling.1 Although it is a minimally invasive technique, it is associated with higher recurrence rates (approximately 20%) compared with surgical clipping.2 Recanalization is more common principally in ruptured aneurysms as well as in giant aneurysms, aneurysms located in the posterior circulation, aneurysms with a relatively wide neck morphology, and aneurysms followed for >1 year.2-6 Tirakotai et al. classified the indications for surgical treatment after coiling into 3 groups: 1) surgery of incompletely coiled aneurysms; 2) surgery for mass effects on neural structures; 3) surgery for vascular complications.7 Recanalization, if significant, often requires retreatment. Retreating with additional coils fails in perhaps 50% of cases.3 On the other hand, surgical clipping is complicated and difficult to perform. Recanalized aneurysms are categorized into 3 types: type I, coils are compressed; type II, coils are migrated; type III, coils are migrated, and multiple coils fill its neck or the parent artery. Direct clipping can be applied to types I and II, whereas trapping, wrapping, or auxiliary revascularization is required in type III.2 Coil extraction should not be attempted regularly because it is associated with high morbidity.8 In this three-dimensional video, we present the microsurgical treatment of a type I recanalized anterior communicating artery aneurysm, which in serial digital subtraction angiography control scans showed residual patency, progressive growth, and changes in its hemodynamic behavior (Video).
查看更多>>摘要：? 2022 Elsevier Inc.Giant paraclinoid internal carotid artery (ICA) aneurysms are surgically challenging, mainly owing to lack of adequate working space and distortion of the regional anatomy. Anterior clinoidectomy is a vital surgical technique in such cases, allowing optic nerve decompression and exposure of the proximal ICA outside the confines of the arachnoid. While clinoidectomy is generally conducted intradurally, some aneurysms, particularly unruptured and directed medially paraclinoid ICA aneurysms, can allow a completely extradural clinoidectomy. Extradural clinoidectomy avoids bone dust spillage and drill bit–related injury from prolonged intradural drilling times. An 18-year-old man with a giant left superior hypophyseal artery aneurysm presented with progressive headache and visual diminution. He had a very good cross-flow from the contralateral ICA and tolerated balloon test occlusion. The aneurysm was exposed after extradural clinoidectomy and optic nerve mobilization. It was a wide-necked aneurysm and involved the distal dural ring. Owing to intraoperative somatosensory evoked potential findings as well as our concern of inadequate neck occlusion in view of the distal dural ring involvement and a possible future aneurysm regrowth, we trapped the aneurysm. The patient made an uneventful recovery with improvement in vision and normal visual fields. This video demonstrates the feasibility and utility of extradural clinoidectomy in adequate exposure of giant paraclinoid aneurysms and the role of aneurysm trapping for definitive aneurysm obliteration when the distal dural ring is involved. Trapping, in contrast to direct clipping, avoids manipulation of the compressed optic nerves, which is necessary for an optimal environment for postoperative visual recovery.
查看更多>>摘要：? 2022 Elsevier Inc.The internal carotid artery (ICA) course has been discussed extensively. Several classification systems have attempted to delineate an accurate and helpful trajectory for microsurgical and endoscopic guidance, thus allowing a better neurosurgical performance while avoiding intraoperative complications. Also, the practicality of the classification systems has been emphasized for scholarly communication among disciplines. Nevertheless, the nomenclature of the ICA remains heterogeneous and confusing for health care professionals, trainees, and students. We present an illustrative review of 8 notable ICA classification systems using lateral and anterior views as a rapid tool for neuroanatomic consultation. The appraisal of the vessel anatomy from different perspectives while recognizing their usefulness and limitations might provide a comprehensive understanding of the ICA, optimize the intraoperative performance, and facilitate communication.
查看更多>>摘要：? 2022 Elsevier Inc.Cerebral revascularization surgery has been advanced by the refinement of several adjunctive tools. These tools include perioperative blood thinners, intraoperative spasmolytic agents, electrophysiological monitoring, and methods for assessing bypass patency or marking arteriotomies. Despite the array of options, the proper usage and comparative advantages of different complements in cerebral bypass have not been well-cataloged elsewhere. In this literature review, we describe the appropriate usage, benefits, and limitations of various bypass adjuncts. Understanding these adjuncts can help surgeons ensure that they receive reliable intraoperative information about bypass function and minimize the risk of serious complications. Overall, this review provides a succinct reference for neurosurgeons on various cerebrovascular bypass adjuncts.
查看更多>>摘要：? 2022 Elsevier Inc.Background: Moyamoya disease may present with either hemorrhagic or ischemic strokes. Surgical bypass has previously demonstrated superiority when compared to natural history and medical treatment alone. The best bypass option (direct vs. indirect), however, remains controversial in regard to adult ischemic symptomatic moyamoya disease. Multiple studies have demonstrated clinical as well as angiographic effectiveness of direct bypass in adult hemorrhagic moyamoya disease. In particular, there are limited data regarding strategies in the setting of failed indirect bypass with recurrent hemorrhagic strokes. Here, we describe a salvage procedure. Methods: We describe a case of a 52-year-old man who presented with hemorrhagic moyamoya disease and failed previous bilateral encephaloduroarteriosynangiosis (EDAS) procedures at an outside institution. On a 3-year follow-up diagnostic cerebral angiogram, no synangiosis was noted on the right side and only minimal synangiosis was present on the left. The left hemisphere was significant for a left parietal hypoperfusion state. We performed a salvage left proximal superficial temporal artery to distal parietal M4 middle cerebral artery bypass using the descending branch of the lateral circumflex artery as an interposition graft with preservation of the existing EDAS sites. Results: The patient underwent the procedure successfully and recovered well with resolution of headaches and no further strokes or hemorrhages on the 1-year follow-up magnetic resonance imaging of the brain. Conclusions: This case presents the use of a salvage direct bypass technique for recurrent symptomatic hemorrhagic moyamoya disease after failed EDAS. The strategy, approach, and technical nuances of this unique case have implications for revascularization options.
查看更多>>摘要：? 2022 Elsevier Inc.A 51-year-old woman presented with 2 years of progressive left facial pain and numbness in maxillary nerve and mandibular nerve distributions. Symptoms were refractory to increasing doses of carbamazepine and gabapentin. Magnetic resonance imaging showed a left cerebellopontine angle nonenhancing mass, with diffusion restriction causing trigeminal nerve compression. Fast imaging employing steady-state acquisition sequences revealed a superior cerebellar artery loop in the angle between cranial nerve V and pons. The patient agreed to resection of the mass and microvascular decompression. Retrosigmoid craniotomy was performed with sensory/motor, and facial-auditory nerves' monitoring. The mass was densely adherent to cranial nerves VII–X and the anterior inferior cerebellar artery, causing compression at the root entry zone of the trigeminal nerve. It was carefully dissected off these structures; pathology confirmed an epidermoid. A large bony tubercle obscured visualization; therefore, a 30° endoscope was used. The tubercle was drilled, and remnant portions of the mass were removed. During mobilization of the superior cerebellar artery loop, it was found to be duplicated, and polytef (Teflon) pledgets were placed for microvascular decompression. The trigeminal nerve was thus discovered intraoperatively to be trapped simultaneously between the duplicated superior cerebellar artery loop from above and the epidermoid from below. Pain relief was immediate; at 12-month follow-up, the patient was pain-free, she had minimal numbness around the angle of the lip, and medications were discontinued. Facial nerve function and hearing were intact. A pure endoscopic approach is minimally invasive with a smaller incision and has been described for microvascular decompression for trigeminal neuralgia. Cerebrospinal fluid leak rates are expected to be lower. This technique has a steep learning curve and could pose a significant challenge for resection of lesions densely adherent to neurovascular structures. A pure microscopic approach generally involves a larger incision and can be better suited for resection of cerebellopontine angle lesions where bimanual dissection would be necessary. Visualization around corners in the presence of large bony protuberances (e.g., large suprameatal tubercle) around vessels and nerves in the depths is a drawback. Combining microscopic surgery with endoscopic assistance (especially angled endoscope) negates the disadvantages of either method alone, allowing for visualization around structures in the depths of the cerebellopontine angle where microscope lighting may be reduced, and provides a means to achieve gross total resection of tumor hidden from view.
查看更多>>摘要：? 2022 Elsevier Inc.Background: Ventricular catheter placement can be a challenging procedure when treating patients with slit ventricles, despite the use of a neuronavigation system. Methods: We report the case of 3 patients with idiopathic intracranial hypertension who had required revision of their ventricular catheter due to malpositioning, despite initial placement using neuronavigation. Owing to the absence of intraoperative computed tomography in our center, we used the O-arm imaging system to confirm placement of the optimal ventricular tip position intraoperatively. Results: Optimal ventricular drain position was achieved in all 3 patients. Conclusions: This short technical note describes an easy technique for using the O-arm to confirm the optimal ventricular drain position.
查看更多>>摘要：? 2022 Elsevier Inc.Background: In the present study, we aimed to identify the obliteration outcomes, complications, and predictors in gamma knife radiosurgery (GKRS) treatment of brain arteriovenous malformations (AVMs) at a tertiary center in a developing country in a 15-year experience. Methods: We retrospectively reviewed the clinical data and GKRS procedures of patients who had undergone GKRS from 2006 to 2011 (cohort 1) and from 2011 to 2020 (cohort 2) at Cho Ray Hospital, Vietnam. The exclusion criteria included patients with <24 months of follow-up without obliteration or AVM-related hemorrhage during the study period. Results: A total of 870 patients were included in the final analysis. The patients in cohort 1 had had significantly smaller AVMs (8.4 ± 11.6 cm3 vs. 11.2 ± 12.8 cm3; P < 0.001), and the AVMs were less frequently located in eloquent locations (46.6% vs. 65.5%; P < 0.001) than in cohort 2. The mean follow-up time was 49.6 ± 22.6 months (range, 5.9–102.6). The overall AVM obliteration rate was 66.6%. Cohort 1 had a significantly higher rate of complete obliteration compared with cohort 2 (81.0% vs. 55.1%; P < 0.001). The post-GKRS annual hemorrhage risk was 1.0%. Significant radiosurgery-induced brain edema and radiosurgery-induced cyst formation was reported in 24 (2.6%) and 4 (0.5%) patients in cohorts 1 and 2, respectively. Using multivariate analysis, we identified prior AVM hemorrhage (hazard ratio [HR], 1.430; 95% confidence interval [CI], 1.182–1.729), a higher margin dose (HR, 1.136; 95% CI, 1.086–1.188), a noneloquent location (HR, 0.765; 95% CI, 0.647–0.905), and smaller AVM volume (HR, 0.982; 95% CI, 0.968–0.997) as predictive factors for obliteration. Conclusions: GKRS is a safe and effective treatment of brain AVMs. The lack of prior AVM hemorrhage, an eloquent location, and higher AVM were unfavorable predictors for post-GKRS obliteration.
查看更多>>摘要：? 2022 Elsevier Inc.A 75-year-old man presented with bilateral frontal hematomas owing to a dural arteriovenous fistula involving an isolated segment of the superior sagittal sinus. After an unsuccessful attempt of transarterial endovascular embolization of the dural arteriovenous fistula, the fistula was occluded using a transvenous approach through recanalization of the occluded superior sagittal sinus.
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