Minimally Invasive Neurosurgery最新文献

Introduction: Arteriovenous fistulas (AVF) are rare vascular lesions of the brain that differ from arteriovenous malformations as they present a direct connection between artery and vein, without interposition of the nidus. They are fed by one or more arterial branches, with a single draining vein. Clinically they can be revealed through cerebral hemorrhage, convulsive crisis, neurological deficit, heart failure in neonates and infants, headache, bruit, or intracranial hypertension symptoms.

Patient and methods: A 30-year-old patient was found unconscious on a public street, presenting a generalized tonic-clonic convulsive crisis. At admission, she presented with ocular proptosis, conjunctival hyperemia and bilateral jugular turgescence. The cranial computed tomography showed diffuse subarachnoid hemorrhage, and the cerebral angiography evidenced a giant intracranial pial AVF with high flow supplied by 2 branches of the left anterior cerebral artery.The patient underwent endovascular treatment in 2 sessions, using a mixture of histoacryl and lipiodol for complete occlusion of the lesion. She was discharged after a month, alert, devoid of motor deficit, and the ocular proptosis and the conjunctival hyperemia had decreased.

Conclusion: AVFs are rare vascular lesions that require prompt treatment. The endovascular treatment must be considered, especially when the lesions are deep and the risks of neurological deficit associated with the surgery are high. Endoscopic intervention represents an effective and safe option for the treatment of this type of lesion.

Background: Parenchymal hemorrhage is one of the most feared risks of stereotactic brain biopsies potentially resulting in neurological deficits or even a fatal outcome. Patients with disorders of the coagulation system are at particular risk, so identifying these is one of the main tasks prior to surgery. Some patients may have a bleeding tendency despite normal laboratory values of the hemostatic system.

Case report: We report the case of a patient with coagulopathy of unclear etiology undergoing a stereotactic brainstem biopsy.

Conclusion: A medication scheme with tranexamic acid and desmopressin effectively decreased the patient's bleeding time in vivo and the procedure was carried out without complications.

Background: The retrosigmoid approach is often used for posterior fossa pathology. Many variations of positioning exist. Here, we report a simple, safe, and quick positioning technique which maximizes patient safety, surgeon comfort, and intraoperative view.

Methods: We reviewed the senior author's prospective surgical database for retrosigmoid approaches to the posterior fossa and noted any complications or difficult exposures.

Results: Over 970 retrosigmoid operations were performed over the course of 19 years. There were no positioning-related complications and no aborted surgeries due to inadequate exposure. No normal cerebellum was ever resected to increase exposure and no retractor was ever used in the posterior fossa.

Conclusions: Supine positioning for the retrosigmoid approach is an excellent and safe positioning alternative.

Background: The main purpose of this project is to define the major indications, preferences, techniques, limitations, and complications associated with intraventricular tumor removal using purely endoscopic techniques.

Methods: Published papers on neuroendoscopy were reviewed, and a questionnaire about purely endoscopic surgery for intraventricular brain tumors was designed. The questionnaire included details regarding neuroendoscopic techniques, surgeons' endoscopic experience, and clinical vignettes. 20 experienced neuroendoscopists from the 10 represented countries were surveyed.

Results: 15 physicians (75%) responded to the survey, having an estimated 264 cumulative years of endoscopic experience. There was general agreement regarding: the instrumentation used, endoscope features, irrigation, technique of colloid cyst and solid intraventricular tumor removal, complications, future technologies, and the treatment of sample clinical vignettes. There was appreciable variability in endoscope control preferences.

Conclusions: Endoscopic intraventricular surgery is a feasible minimally invasive alternative to open transcranial surgery for specific ventricular tumors. With the currently available instrumentation, the technique can be applied to small avascular solid intraventriclular tumors and colloid cysts of the third ventricle. The majority of the complications are based on hemostasis potential. The development of compatible instrumentation with an enhanced ability for solid tumor removal and more adequate hemostasis appear to be the principle limitations in furthering the technique of endoscopic removal of intraventricular brain tumors.

Background: Suprasellar tumors can be removed through a variety of approaches including conventional frontotemporal craniotomies, the transsphenoidal route, or the supraorbital (SO) eyebrow craniotomy. Herein we assess the utility of the SO route for recurrent or residual suprasellar tumors previously treated by an alternative route.

Material and methods: A retrospective analysis of all consecutive patients who underwent an SO approach for removal of a recurrent/residual tumor was undertaken.

Results: Between December 2007 and February 2010, 11 patients underwent an SO craniotomy for a recurrent or growing residual tuberculum sellae meningioma (n=7) or craniopharyngioma (n=4). All 11 patients had prior craniotomies, 5 had transsphenoidal surgery, 6 had radiation treatment, and 1 had chemotherapy. In the last 5 cases, the endoscope was used in addition to the microscope for intraoperative visualization. 3 patients underwent decompression of multicystic craniopharyngiomas and the remaining 8 patients had tumor debulking, all achieving 70% or more tumor removal. Of 9 patients with preoperative visual deterioration, 6 (67%) had improvement and no patient had visual worsening. No new adenohypophysis or neurohypophysis dysfunction was noted. One patient had a postoperative CSF leak requiring reoperation.

Conclusion: The SO approach should be considered as a safe and effective alternative route for recurrent or residual suprasellar tumors previously treated by conventional craniotomy or TS surgery. It typically offers a simplified trajectory that minimizes scar tissue from prior approaches and provides excellent access for optic apparatus decompression. Endoscopy is helpful to visualize hidden tumor remnants and maximize safe tumor removal.

Background: The expanded endonasal approach of the cranio-cervical junction provides comfortable working space while avoiding some of the disadvantages of the transoral route. We report a purely endonasal endoscopic resection of the odontoid process for basilar invagination in a patient with a Chiari type I malformation, without posterior decompression or fusion.

Case report: A 54-year-old female patient presented with cranial nerve and brainstem deficits. CT and MRI showed a Chiari type I malformation and compression of the medulla by basilar invagination of the odontoid process. The tip of the latter was displaced up to the bulbo-pontine sulcus. The odontoid process was resected via the expanded endoscopic endonasal approach, without additional posterior decompression or fusion. The post-operative course was uneventful, including the absence of velopharyngeal insufficiency. Neurological deficits regressed rapidly. The preoperative cervical pain virtually disappeared. At 9 months follow-up, the patient had normal activity with minimal residual neurological deficits. Post-op dynamic radiography and CT showed stability of the cranio-cervical junction.

Conclusion: Decompression of the bulbomedullary junction by purely endoscopic transnasal resection of the odontoid process is well tolerated and efficient. Immediate stabilization is not mandatory in all cases of congenital causes of basilar invagination.

Background: The term "central post-stroke pain" is more appropriate to describe neuropathic pain following a cerebrovascular accident. Most patients complain of burning and other symptoms like lacerating and shooting pain. Treatment options for central pain are limited in number and efficacy.

Case report: This paper reports on a 47-year-old man with central post-stroke pain refractory to treatment. The patient underwent insertion of a deep brain stimulator utilizing the Leksell frame. The target was the left centromedian thalamic nuclei. He had a qualitative symptomatic improvement.

Conclusion: Deep brain stimulation can be a useful tool when all other modalities have failed. It is a minimally invasive neurosurgical procedure that may improve the quality of life in carefully selected (often desperate) patients with central post-stroke pain.

Background: The aim of this study was to identify the anatomic landmarks of sella turcica on the surface of the head, and to investigate the feasibility of studying sella turcica anatomy individually by three-dimensional computed tomography (3D-CT) before an endonasal transsphenoidal operation.

Patients and methods: The three-dimensional anatomic structures of the heads of 49 patients were studied by 3D-CT using image reconstruction with surgical clip image registration. The tip of the nose and the apex of the ear helix were used as surface markers on the head, and the locations of the sphenoid sinus and sellar floor with respect to a line defined by these 2 markers were investigated. Using an endonasal transsphenoidal approach with a surgical trajectory guided by the nose tip-ear apex line and 3D-CT anatomic images of the sella turcica, 12 patients with pituitary adenoma were treated surgically.

Results: The nose tip-ear apex line passed through the sphenoid sinus in 100% of the cases and through the sellar floor in 41.4% of the cases. The mean distance from the sellar floor clivus point perpendicularly to the nose tip-ear apex line was 3.5±2.0 mm. The 3D-CT imaging clearly showed the configuration of the sphenoid sinus, bone septum, optic protuberance, carotid protuberance and the sellar floor. 12 pituitary adenomas were resected totally.

Conclusion: The nose tip-ear apex line provides a precise, simple, and practical tool for orienting the sphenoid sinus, sellar floor and surgical trajectory of the endonasal transsphenoidal approach. 3D-CT images more clearly and intuitively display the sella turcica anatomy. Preoperative 3D-CT increases the surgeon's confidence in endonasal transsphenoidal operations and should be routinely performed in patients with pituitary adenomas.

Background: Intraventricular tumors account for approximately 3% of adult brain tumors and 16% of childhood and adolescent brain tumors. Half of the intraventricular tumors in adults and one quarter of those in children are found in the lateral ventricles. Ependymoma, astrocytoma, oligodendroglioma, choroid plexus papilloma, meningioma and subependymal giant cell astrocytoma are the common tumors encountered at this particular site. A germinoma at this site is rare. Microsurgery of intraventricular tumors can be challenging and is performed with potential functional and cognitive complications.

Case report: A 25-year-old female harboring an intraventricular tumor at the foramen of Monro with resultant obstructive hydrocephalus underwent a right intraventricular endoscopic resection of the tumor by means of frameless neuronavigation guidance and temporary external ventricular drainage. Histology showed the tumor to be a germinoma. The post-operative imaging showed that there was some residual tumor tissue in the fornix. Concerned with possibility of cerebrospinal fluid seeding, we administered postoperative adjuvant craniospinal irradiation. The patient was discharged with a Glascow outcome scale score of 5 and at last the 6-month follow-up there was no evidence of recurrence.

Conclusion: This report suggests that in selected cases endoscopic resection of an intraventricular tumor under frameless neuronavigation guidance is feasible and safe. The target can be precisely located and procedure-related adverse events can be minimized.

Background: The management of symptomatic thoracic disc herniation (TDH) has evolved tremendously ever since the first laminectomy was performed. The last decade has witnessed the evolution of minimally invasive approaches for TDH most of which have been posterior/posterolateral. Traditional anterior approaches involve a thoracotomy or more recently, thoracoscopic techniques. The authors describe a less invasive anterior retropleural surgical approach to address central thoracic disk herniations which is less extensive than a thoracotomy and allows better anterior access than posterior or posterolateral approaches. The retropleural approach allows the use of the operative microscope with a tubular retractor in the anterior thoracic spine.

Material and methods: 7 patients with central disc herniation who were managed with the minimally invasive lateral retropleural approach from 2007-2010 at our institution were included in the study. Surgical technique consisted of a lateral position followed by retro-pleural exposure through tubular retractor system without the need of intraoperative lung collapse. Clinical details including age, sex, clinical presentation, surgical details, complications and outcome at last follow-up were analyzed.

Results: Patients age ranged in age from 30 to 70 years (mean: 52 years). The duration of symptoms ranged from 4 days to 3 years. All patients presented with thoracic myleopathy on physical examination. The average length of stay in the hospital was 2.6 days (range: 1-4 days). Follow-up was available for all the patients. Myelopathy was assessed by the Nurick scale. On examination, 3 of 7 patients improved by one point on the Nurick scale. No patient deteriorated after surgery. There were no complications related to the approach.

Conclusions: A minimally invasive retropleural approach using tubular retractor system for central thoracic disc herniation is feasible and may be a less invasive anterior alternative to a thoracotomy.