Minimally Invasive Neurosurgery最新文献

Introduction: Despite improvements in sanitation, diagnosis and treatment, neurocysticercosis is still a public health problem in many countries. In symptomatic patients, there is a broad spectrum of clinical manifestations. When cysticerci are lodged in the ventricles or the subarachnoid space, the flow of cerebrospinal fluid can be obstructed and lead to hydrocephalus and intracranial hypertension. The endoscopic view may be useful as a diagnostic tool.

Patients: This report clearly shows a common endoscopic pattern in 4 selected patients with ventricular cysticercosis (2 third ventricle/2 lateral ventricle). The endoscopic view of the cysts in the ventricles resembles a "full moon". This analogy helped to identify the features of cysticerci with intact walls and the vesicular stage, malleable due to its cystic content and having an irregular surface, as evidence of the microscopic structure of the cyst wall in a cysticercus.

Conclusions: This finding is not seen in other intraventricular cysts or tumors that can actually be considered as an additional diagnostic criterion among the definitive findings to establish the diagnosis of cysticercosis, since it involves direct endoscopic visualization of a cysticercus under histopathological demonstration. Additionally, the endoscopic approach can be used as primary treatment for these cases, following the minimally invasive approach principle.

Introduction: Since the first reported endoscopic treatment of colloid cysts of the third ventricle by Powel et al. in 1983, several endoscopic techniques have been described. Therefore, the authors describe their technique of neuroendoscopic colloid cyst removal, developed during the last 16 years.

Technique: With the aid of the specially designed, no-through perforator, the colloid cyst is first partially evacuated to facilitate further dissection and mobilization. By intermittent gentle traction to mobilize the cyst out of the foramen of Monro, detachment from the tela choroidea is finally obtained, making total removal possible.

Conclusions: With the described endoscopic technique, complete removal of colloid cysts is possible in almost 90 % of cases.

Background: Patients who undergo stereotactic gamma knife radiosurgery (GKRS) need a rigid frame fixation for the stereotactic procedures. Many patients suffered from postoperative wound pain after frame removal. The present study investigated whether an additional application of a topical anesthetic prior to frame removal could reduce this discomfort.

Patients and methods: 60 patients who underwent GKRS were enrolled in this study. Of these 60 patients, 30 were treated with a topical application of EMLA, a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine; the remaining 30 were treated with a placebo. The nurses explained the definition of the visual analogue scale (VAS, scored from 0 to 10), and the patients evaluated their pain at 7 time points during the GKRS procedure by using the VAS. After each of these evaluations, the patients' vital signs (blood pressure, heart rate, and respiratory rate) were measured.

Results: There was no significant difference in the patients' age, gender, duration of frame fixation, and types of the lesions between the EMLA and placebo groups. The EMLA group reported significantly lower pain scores 20 and 60 min after frame removal than the placebo group (p=0.001 and p<0.001, respectively). Additionally, patients in the placebo group had significantly higher blood pressure readings compared with baseline data, during and after frame removal, thus indicating that postoperative wound pain caused them more discomfort after frame removal.

Conclusion: EMLA when applied 60 min before frame removal has an anesthetic effect of reducing the postoperative wound pain in patients who undergo GKRS.

Background: The surgical management of deep intra-axial lesions still requires microsurgical approaches that utilize retraction of deep white matter to obtain adequate visualization. We report our experience with a new tubular retractor system, designed specifically for intracranial applications, linked with frameless neuronavigation for a cohort of intraventricular and deep intra-axial tumors.

Methods: The ViewSite Brain Access System (Vycor, Inc) was used in a series of 9 adult and pediatric patients with a variety of pathologies. Histological diagnoses either resected or biopsied with the system included: colloid cyst, DNET, papillary pineal tumor, anaplastic astrocytoma, toxoplasmosis and lymphoma. The locations of the lesions approached include: lateral ventricle, basal ganglia, pulvinar/posterior thalamus and insular cortex. Post-operative imaging was assessed to determine extent of resection and extent of white matter damage along the surgical trajectory (based on T (2)/FLAIR and diffusion restriction/ADC signal).

Results: Satisfactory resection or biopsy was obtained in all patients. Radiographic analysis demonstrated evidence of white matter damage along the surgical trajectory in one patient. None of the patients experienced neurological deficits as a result of white matter retraction/manipulation.

Conclusion: Based on a retrospective review of our experience, we feel that this access system, when used in conjunction with frameless neuronavigational systems, provides adequate visualization for tumor resection while permitting the use of standard microsurgical techniques through minimally invasive craniotomies. Our initial data indicate that this system may minimize white matter injury, but further studies are necessary.

The cryoprobe device is commonly used by orbital surgeons for the extraction of intraorbital lesions. Cryoprobes provide a safe mechanism to manipulate fluid-filled tumors. Such lesions can present in locations in which intraoperative neurosurgical assistance is essential. The authors describe a technique whereby removal of an orbital hemangioma was facilitated by the aid of an endoscopic, transnasal cryoprobe while standard microsurgical dissection was performed concurrently via a transconjunctival approach.

Purpose: 5 self-expanding intracranial stents Neuroform (N), Wingspan (W), Solitaire (S), Leo(+) (L), and Enterprise (E) were subjected to an in vitro examination and comparison of their physical features and functional properties in order to better understand the clinical advantages and potential limitations of each device.

Material and methods: The following features were examined for each stent: visual appearance, radial strength, wall apposition, bending stiffness, gator backing, kink resistance, ovalization, vessel wall coverage, cell size, ease of delivery.

Results: Given are rankings for the 5 stents: radial force at 50% oversizing: L

Conclusion: The 5 stents have fundamentally different features and there is no stent that is superior in all tested aspects. The selection in an individual treatment should be based on clinical and technical requirements.

In deep brain stimulation (DBS) surgery, after intracranial lead implantation, lead caps are tunneled into the subgaleal space for later connection to internal pulse generator (IPG) extension wires. In the subsequent IPG implantation procedure, the lead cap must be localized by palpation in order to plan an incision in the scalp to complete this connection. However, if the IPG implantation is done the same day as the intracranial lead implantation, palpation of the lead cap may be challenging in a thick or postoperatively edematous scalp. Manufacturers suggest using fluoroscopy in these instances, but fluoroscopy provides poor soft tissue visualization, requires further unnecessary radiation exposure to both the patient and the surgical team, and can be cumbersome. Portable ultrasound (US) machines are readily available in many operating rooms, and can be used to easily and accurately localize the lead cap prior to IPG implantation.

Background: This study employs 3D stereoscopic virtual reality technology to demonstrate the surgical results of microvascular decompression (MVD) for trigeminal neuralgia.

Patients/material and methods: 3D models were rendered by fusing CTA and MRI fast imaging employing steady state acquisition (FIESTA) modalities of both pre- and post-operative scans. The brainstem, trigeminal nerve root and relevant vasculature were extracted, superimposed, and co-registered to bony and ventricular anatomy.

Results: 3 clinically successful MVD cases were evaluated for superior cerebellar artery (SCA) vessel displacement. Qualitative parameters included translational and rotational shift of the SCA, and distance decompressed from the trigeminal nerve root entry zone. Parameters were met in each case, with demonstration of vessel displacement and decompression of the nerve root.

Conclusion: The 3D virtual-reality environment with stereoscopic visualization offers a method through which to visualize the results of MVD, and a potential reference point to evaluate cases of treatment failure or relapse.

Background: The laparoscopically assisted ventriculoperitoneal (VP) shunt has been widely used in the clinical treatment of hydrocephalus for its simplicity and reliability. Despite significant improvements in shunt procedures, shunt complications remain common. Our clinical experiences suggest that the fixation of the distal (peritoneal) shunt catheter using threads and hemoclips may partially contribute to complications of the distal shunt including obstruction of the shunt and infection. In this study, we explored a novel fixation method in the laparoscopically assisted VP shunt with use of the liver falciform ligament as a natural support for fixation of the distal shunt catheter.

Methods: 10 patients with hydrocephalus underwent laparoscopically assisted VP shunt and the distal shunt catheter was placed into the hepatodiaphragmatic space and the catheter was traversed through 2-3 drilled holes in the liver falciform ligament without using any artificial material for fixation.

Results: In all the patients who received surgery with the adopted new procedure the clinical symptoms were alleviated. The size of cerebral ventricles returned to normal after 1 week. The distal catheters were in the hepatodiaphragmatic space in 9 of 10 patients, while in 1 patient it migrated to the peritoneal cavity underneath the liver. All the 9 patients were followed up for 1 year and no surgery-related catheter obstructions and infections were observed.

Conclusions: The modified laparoscopically assisted VP shunt in the treatment of hydrocephalus with fixation of the distal shunt catheter to a natural anatomic structure could potentially reduce the necessity of repeat surgery for addressing the complications caused by catheter obstruction and infections, reduce the chance of adhesions, and would be of benefit to those patients who need future revisions.

Introduction: Hyperhidrosis can be a very annoying and troublesome problem. It can interfere with the daily activities of the patient, cause psychosocial troubles, even a simple handshake can be quite a challenge. The objective of this study is to assess the safety and efficacy of a new method for chemical ablation of D2 and D3 dorsal sympathetic ganglia to control medically refractory palmar hyperhidrosis.

Patients and methods: This study was conducted on 30 patients with refractory palmar hyperhidrosis in the period from January 2006 till January 2008 to detect the efficacy of dorsal chemical sympathectomy using absolute (97%) alcohol to make chemical lesions in the D2 and D3 sympathetic ganglia as a treatment for excessive palmar hyperhidrosis. All patients were followed up in the outpatient clinic at 1 week, 1 month, 3 months, and 1 year intervals after the procedure.

Results: The procedure was found to cause complete cessation of palmar hyperhidrosis in 27 of our 30 patients (90%) at 1 year of follow-up. No serious complications were encountered with the procedure in the perioperative or postoperative follow-up.

Conclusion: Percutaneous chemical dorsal sympathectomy is an easy, effective, and safe procedure for control of palmar hyperhidrosis.