Operative Neurosurgery最新文献

Far-lateral craniotomy is a versatile skull base approach that combines a suboccipital craniotomy with a C1 hemilaminectomy. The approach was initially described to manage vascular pathologies of the vertebrobasilar junction; however, the corridor provided by this approach can be applied to various pathologies in the ventral and ventrolateral craniovertebral region. Safe and successful execution of the approach requires an extensive understanding of the anatomy and technique. In this article, we discuss the advantages and disadvantages of the approach, as well as important technical nuances and common pitfalls. The goal of this article is to provide an up-to-date technical report of this approach supplemented by original high-quality dissections and a 4K 2-dimensional video as an educational resource for trainees and junior neurosurgeons.

Background and objectives: MRI-based neuronavigation may suffer from inaccuracies that can be compensated by navigated 3D intraoperative ultrasound (iUS) and applying MRI-iUS rigid image fusion (RIF). In this work, such an automated application is evaluated.

Methods: Twenty-five adult patients with gliomas were enrolled and underwent resection using navigated iUS. Intraoperative evaluation and postoperative quantification [ie, measurement of the target registration error (TRE)] were conducted to assess the accuracy of registration-based fusion and automated RIF at various stages of surgery [before dura opening (BDO), after dura opening (ADO), after partial resection (APR), after completion of resection (ACR)]. Linear mixed models were used to assess and analyze TRE and the effect of patient- and tumor-related factors on the performance of the RIF. Furthermore, the TRE was measured after applying different prealignments.

Results: In total, 79 MRI-iUS data sets derived from 24 patients and enriched with 600 anatomic landmark pairs were evaluated. Overall, RIF resulted in a significantly reduced mean TRE compared with registration-based fusion (from 4.7 mm to 3.5 mm, P < .002). This difference in TRE was dependent on the stage of surgery, being significant for BDO, ADO, and APR stages, but not ACR. It was independent of any tumor-related factors. Simulation tests showed that RIF can significantly improve TRE for a range of ±15 mm prealignment accuracy with highest effect for BDO and ADO.

Conclusions: RIF using intraoperative navigated ultrasound improves registration accuracy for intra-axial tumor surgeries. It shows reliable results not only for preresection stages but also partially for later surgical stages.

Background and objectives: In endoscopic endonasal surgery, the Doppler probe has proven useful for localizing the paraclival and cavernous internal carotid arteries (ICA) and avoiding ICA injury. Similarly, during transcranial brain tumor removal, the Doppler probe may help avoid major vascular injury, particularly for tumors encasing or adherent to Circle of Willis branches. In this study, we describe the technique, outcomes, and potential neurovascular benefits of real-time navigation using the Doppler probe during craniotomy for brain tumor removal.

Methods: Patients from 2015 to 2022 who underwent craniotomy for brain tumor resection and the Doppler probe was used were retrospectively analyzed. Data collection included demographics, tumor pathology, incidence of major/minor vascular injury, MRI-confirmed stroke/infarction, and extent of tumor resection.

Results: In total, 695 patients underwent 840 craniotomies for brain tumor resection; in 501 craniotomies (59.6%), the Doppler was used. One major vascular injury (0.2%) of a supraclinoid ICA was directly attributed to non-Doppler probe use immediately before vessel injury, leading to stroke and severe neurological decline. There were 7 strokes (1.4%) leading to permanent neurological deficit attributable to vasospasm or small vessel injury and 26 asymptomatic infarctions/strokes (5.2%) attributable to unrecognized vascular injury or spasm at the time of surgery.

Conclusion: In this series of 501 craniotomies for brain tumor removal where the Doppler probe was used, the rate of direct large vessel injury was under 1%. Although our data show that smaller vessel injuries can still occur and may lead to permanent neurological deficits, routine Doppler probe use may help guide tumor dissection and aggressiveness of removal, avoiding inadvertent major arterial injury. Our experience suggests that it is most useful as tumor dissection progresses as the resulting brain shift makes stereotactic neuronavigation less reliable. We recommend routine Doppler probe use during transcranial brain tumor removal, particularly for tumors encasing or adherent to major arteries.

Background and importance: Pyogenic ventriculitis is a rare, but fatal complication associated with community-acquired meningitis and invasive procedures. The blood-brain barrier poses a major challenge for systemic antibiotics to adequately treat infections confined to the ependyma of the ventricles.

Clinical presentation: In this case report, we demonstrate 2 cases of pyogenic ventriculitis that responded to active cerebrospinal fluid (CSF) exchange where continuous irrigation with antibiotics allowed for adequate CSF distribution. The first case is an 83-year-old man who acquired ventriculitis secondary to epidural injections for pain. The second case is that of a 60-year-old woman who developed ventriculitis as a complication of external ventricular drainage placement for left thalamic intracerebral hemorrhage with intraventricular extension.

Conclusion: Although both patients had a complex medical history, inpatient complications, and initially failed to respond to systemic antibiotic therapy, their infections were cleared rapidly on initiation of active CSF exchange. Larger scale studies will be needed to demonstrate efficacy of this novel technique.

Background and importance: Surgery for jugular paragangliomas (JPs) is known to be a formidable challenge because of the tumor's intimate involvement of neurovascular structures. Although radiosurgery is commonly the first-line treatment, recent advances in neuroimaging, surgical techniques, and intraoperative monitoring have positioned surgery as a feasible alternative for aggressive tumors with substantial intradural extension not amenable to upfront radiosurgery, provided the surgeon has an in-depth knowledge of lateral skull-base anatomy and access to safe and effective preoperative embolization.

Clinical presentation: A patient with a Fisch Type D JP with extensive intradural tumor and brainstem compression underwent a combined petrosal approach with transcochlear extension at our institution. The transcochlear extension allowed additional anteromedial access to the petrous apex and internal carotid artery, whereas the combined craniotomy granted access to the supratentorial space for the tumor with transtentorial extension. The surgery's critical steps, along with key neurovascular structures, were documented and reviewed in a surgical video.

Conclusion: The combined petrosal approach with transcochlear extension is a complex but effective surgical approach for large JPs invading the petrous apex and involving the internal carotid artery not amenable to upfront radiosurgical treatment. This procedure relies on a thorough understanding of temporal bone anatomy and should be reserved for experienced multidisciplinary teams in specialized centers.