Pub Date : 2024-09-23DOI: 10.1227/ons.0000000000001377
Ying Huang, Xu Wang, Zhi-Feng Tian, Li Cai, Xu-Ming Wang, Dan Tang, Jian Ren, Xiao-Hai Liu, Ge Chen, Peng Hu, Ming-Chu Li
Background and objectives: The common tendinous ring (CTR), also known as the common annular tendon or annulus of Zinn, is a critical anatomic structure located at the convergence of the orbital apex, superior orbital fissure (SOF), optic canal, and the anterior aspect of the lateral sellar compartment. It plays a vital role in both neurosurgical and neuro-ophthalmological interventions. The aim of this study was to delineate the complex 3-dimensional (3D) topography of the CTR and explore its implications for surgical procedures.
Methods: Ten formalin-fixed skull base specimens from adult Chinese cadavers were meticulously dissected to investigate the morphology of the CTR, focusing particularly on its relationship with the 4 extraocular rectus tendons, the optic strut, the SOF, and the optic canal. Additional skull base specimens were subjected to 3D surface scanning, computed tomography, and histopathological examinations to deepen our understanding of the CTR's structural complexities.
Results: The CTR establishes a spatial, 3D tendinous assembly, encompassing 4 rectus tendons, 2 tendinous connections, and a singular common tendinous root. These components interlink to form a distinctive dual-ring configuration, featuring the optic foramen and the oculomotor foramen. The posterior part of the superior rectus tendon demarcates the common boundary between these 2 foramina. The oculomotor foramen itself serves as the central sector of the SOF. Precise incisions of the medial and lateral tendinous connections and fusions are essential for safely opening the CTR.
Conclusion: The structural composition, interconnections, and dual-ring configuration of the CTR are crucial for precise and safe surgery of orbital apex and adjacent regions.
{"title":"Microsurgical Anatomy of the Common Tendinous Ring and Its Surgical Implications.","authors":"Ying Huang, Xu Wang, Zhi-Feng Tian, Li Cai, Xu-Ming Wang, Dan Tang, Jian Ren, Xiao-Hai Liu, Ge Chen, Peng Hu, Ming-Chu Li","doi":"10.1227/ons.0000000000001377","DOIUrl":"https://doi.org/10.1227/ons.0000000000001377","url":null,"abstract":"<p><strong>Background and objectives: </strong>The common tendinous ring (CTR), also known as the common annular tendon or annulus of Zinn, is a critical anatomic structure located at the convergence of the orbital apex, superior orbital fissure (SOF), optic canal, and the anterior aspect of the lateral sellar compartment. It plays a vital role in both neurosurgical and neuro-ophthalmological interventions. The aim of this study was to delineate the complex 3-dimensional (3D) topography of the CTR and explore its implications for surgical procedures.</p><p><strong>Methods: </strong>Ten formalin-fixed skull base specimens from adult Chinese cadavers were meticulously dissected to investigate the morphology of the CTR, focusing particularly on its relationship with the 4 extraocular rectus tendons, the optic strut, the SOF, and the optic canal. Additional skull base specimens were subjected to 3D surface scanning, computed tomography, and histopathological examinations to deepen our understanding of the CTR's structural complexities.</p><p><strong>Results: </strong>The CTR establishes a spatial, 3D tendinous assembly, encompassing 4 rectus tendons, 2 tendinous connections, and a singular common tendinous root. These components interlink to form a distinctive dual-ring configuration, featuring the optic foramen and the oculomotor foramen. The posterior part of the superior rectus tendon demarcates the common boundary between these 2 foramina. The oculomotor foramen itself serves as the central sector of the SOF. Precise incisions of the medial and lateral tendinous connections and fusions are essential for safely opening the CTR.</p><p><strong>Conclusion: </strong>The structural composition, interconnections, and dual-ring configuration of the CTR are crucial for precise and safe surgery of orbital apex and adjacent regions.</p>","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142300824","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-23DOI: 10.1227/ons.0000000000001369
Ahmed Abdelsalam, Ian A Ramsay, Evan M Luther, Joshua D Burks, Eva M Wu, Michael A Silva, John W Thompson, Miguel Bandes, Hayes B Fountain, Tiffany Eatz, Sai Sanikommu, Adib A Abla, Mohamed M Salem, Jan-Karl Burkhardt, Visish M Srinivasan, Denise Brunozzi, Ali Alaraj, Gursant Atwal, Fawaz Al-Mufti, Christopher P Kellner, Ansaar T Rai, Robert M Starke
Background and objectives: As the aging population increases, the incidence of chronic subdural hematomas (cSDHs) is expected to rise. Surgical evacuation, though effective, sees up to 30% recurrence. Middle meningeal artery (MMA) embolization, particularly with n-butyl cyanoacrylate (n-BCA) glue diluted in D5W for distal penetration, has shown promise in reducing recurrences. Limited reports have investigated the safety and technical feasibility of n-BCA as a primary liquid embolic agent using the D5W push technique in cSDH. This series is the largest in the literature investigating the outcomes of this technique in cSDH.
Methods: A multicenter retrospective database analysis was conducted on consecutive patients who underwent MMA embolization using n-BCA embolisate. Data collected included patient demographics, procedural information, angiographic data, and periprocedural complications.
Results: The study included 269 patients with a median age of 76 years. Nearly half of the patients had previous surgeries, and 93 underwent contralateral embolization for bilateral cSDH. Successful MMA embolization with effective distal penetration was achieved in all cases. The complication rate was 2.2%. Significant improvements were noted at a 60-day follow-up, with a median reduction in cSDH diameter of 40.6% (P < .001) and 53% of patients showing neurological improvement. No recurrent cSDH or need for retreatment was observed in patients who underwent follow-up.
Conclusion: MMA embolization using n-BCA with the D5W push technique is safe and technically feasible. It can be used adjunctively or as an alternative to surgery in patients with cSDH, resulting in decreased recurrence, high technical success, improved distal penetration, and low complication rates.
{"title":"Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Using N-Butyl Cyanoacrylate With a D5W Push Technique: A Multicentric North American Study of 269 Patients.","authors":"Ahmed Abdelsalam, Ian A Ramsay, Evan M Luther, Joshua D Burks, Eva M Wu, Michael A Silva, John W Thompson, Miguel Bandes, Hayes B Fountain, Tiffany Eatz, Sai Sanikommu, Adib A Abla, Mohamed M Salem, Jan-Karl Burkhardt, Visish M Srinivasan, Denise Brunozzi, Ali Alaraj, Gursant Atwal, Fawaz Al-Mufti, Christopher P Kellner, Ansaar T Rai, Robert M Starke","doi":"10.1227/ons.0000000000001369","DOIUrl":"https://doi.org/10.1227/ons.0000000000001369","url":null,"abstract":"<p><strong>Background and objectives: </strong>As the aging population increases, the incidence of chronic subdural hematomas (cSDHs) is expected to rise. Surgical evacuation, though effective, sees up to 30% recurrence. Middle meningeal artery (MMA) embolization, particularly with n-butyl cyanoacrylate (n-BCA) glue diluted in D5W for distal penetration, has shown promise in reducing recurrences. Limited reports have investigated the safety and technical feasibility of n-BCA as a primary liquid embolic agent using the D5W push technique in cSDH. This series is the largest in the literature investigating the outcomes of this technique in cSDH.</p><p><strong>Methods: </strong>A multicenter retrospective database analysis was conducted on consecutive patients who underwent MMA embolization using n-BCA embolisate. Data collected included patient demographics, procedural information, angiographic data, and periprocedural complications.</p><p><strong>Results: </strong>The study included 269 patients with a median age of 76 years. Nearly half of the patients had previous surgeries, and 93 underwent contralateral embolization for bilateral cSDH. Successful MMA embolization with effective distal penetration was achieved in all cases. The complication rate was 2.2%. Significant improvements were noted at a 60-day follow-up, with a median reduction in cSDH diameter of 40.6% (P < .001) and 53% of patients showing neurological improvement. No recurrent cSDH or need for retreatment was observed in patients who underwent follow-up.</p><p><strong>Conclusion: </strong>MMA embolization using n-BCA with the D5W push technique is safe and technically feasible. It can be used adjunctively or as an alternative to surgery in patients with cSDH, resulting in decreased recurrence, high technical success, improved distal penetration, and low complication rates.</p>","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142300827","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1227/ons.0000000000001344
Nebojsa Lasica,Kara A Parikh,Kenan I Arnautović
BACKGROUND AND OBJECTIVESDespite advances in cranial base techniques, surgery of the sellar and parasellar regions remains challenging because of complex neurovascular relationships. Lesions within this region frequently present with progressive visual deterioration caused by distortion and compression of the optic chiasm and nerves. In addition to the direct mass effect from mechanical forces acting on the optic apparatus, these lesions alter blood supply and reduce vascular perfusion, prompting surgical treatment to remove the lesion, alleviate compression, and improve blood flow to the optic nerve. We sought to describe a 2-stage, 4-by-4-step approach, broken down and described as a "four-by-four" technique for optic apparatus decompression and a wide approach to different sellar and parasellar lesions.METHODSWe describe the operative nuances and key anatomic points in the microsurgical removal of sellar and parasellar lesions. The technique is illustrated with examples of different cases with pre- and follow-up MRI imaging and a brief overview of visual outcomes.RESULTSThe described technique has been demonstrated in various lesions in 5 patients. Patients presented with bilateral visual loss in 4 (80.0%) cases and with unilateral visual loss in 1 (20.0%) case. Improvement in visual function was noted in all cases, confirmed with visual acuity and visual field testing.DISCUSSIONThe transcranial approach ("from above") remains an important surgical option for patients with excellent exposure and visualization of the sellar and parasellar regions. It permits early access to the optic canal for careful microsurgical decompression and relaxation of the optic nerve to preserve and improve its microvascularization and ultimately vision.CONCLUSIONThe authors augmented the 2-stage, 4-by-4-step technique of decompression with elaborate illustrations of diverse sellar and parasellar lesions to demonstrate the versatility of this approach.
{"title":"Cranio-Orbital Approach and Decompression of the Optic Nerves: A 2-Stage, 4-by-4-Step Approach to Improve Vision in Sellar and Parasellar Lesions.","authors":"Nebojsa Lasica,Kara A Parikh,Kenan I Arnautović","doi":"10.1227/ons.0000000000001344","DOIUrl":"https://doi.org/10.1227/ons.0000000000001344","url":null,"abstract":"BACKGROUND AND OBJECTIVESDespite advances in cranial base techniques, surgery of the sellar and parasellar regions remains challenging because of complex neurovascular relationships. Lesions within this region frequently present with progressive visual deterioration caused by distortion and compression of the optic chiasm and nerves. In addition to the direct mass effect from mechanical forces acting on the optic apparatus, these lesions alter blood supply and reduce vascular perfusion, prompting surgical treatment to remove the lesion, alleviate compression, and improve blood flow to the optic nerve. We sought to describe a 2-stage, 4-by-4-step approach, broken down and described as a \"four-by-four\" technique for optic apparatus decompression and a wide approach to different sellar and parasellar lesions.METHODSWe describe the operative nuances and key anatomic points in the microsurgical removal of sellar and parasellar lesions. The technique is illustrated with examples of different cases with pre- and follow-up MRI imaging and a brief overview of visual outcomes.RESULTSThe described technique has been demonstrated in various lesions in 5 patients. Patients presented with bilateral visual loss in 4 (80.0%) cases and with unilateral visual loss in 1 (20.0%) case. Improvement in visual function was noted in all cases, confirmed with visual acuity and visual field testing.DISCUSSIONThe transcranial approach (\"from above\") remains an important surgical option for patients with excellent exposure and visualization of the sellar and parasellar regions. It permits early access to the optic canal for careful microsurgical decompression and relaxation of the optic nerve to preserve and improve its microvascularization and ultimately vision.CONCLUSIONThe authors augmented the 2-stage, 4-by-4-step technique of decompression with elaborate illustrations of diverse sellar and parasellar lesions to demonstrate the versatility of this approach.","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142267233","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1227/ons.0000000000001384
Simona Serioli, Riccardo Maria Brancaleone, Maria Grazia De Antoniis, Mario Rigante, Michele di Domenico, Valentina Masini, Alessandro Izzo, Pier Paolo Mattogno, Liverana Lauretti, Vincenzo Arena, Simona Gaudino, Jacopo Galli, Alessandro Olivi, Marco Maria Fontanella, Francesco Doglietto
{"title":"Endoscopic Combined Transnasal and Contralateral Transmaxillary Approach for Chondrosarcoma: 2-Dimensional Operative Video.","authors":"Simona Serioli, Riccardo Maria Brancaleone, Maria Grazia De Antoniis, Mario Rigante, Michele di Domenico, Valentina Masini, Alessandro Izzo, Pier Paolo Mattogno, Liverana Lauretti, Vincenzo Arena, Simona Gaudino, Jacopo Galli, Alessandro Olivi, Marco Maria Fontanella, Francesco Doglietto","doi":"10.1227/ons.0000000000001384","DOIUrl":"https://doi.org/10.1227/ons.0000000000001384","url":null,"abstract":"","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142300813","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1227/ons.0000000000001341
Gianna Fote, Hania Shahin, Nolan J Brown, Joseph Falcone, Alexander Lopez, Edward C Kuan, Frank P K Hsu, Michael Y Oh, Ahmed Mohyeldin
Background and objectives: We present an illustrative case of spontaneous intracranial hypotension (SIH) in the setting of a suspected C1-2 cerebrospinal fluid (CSF) leak that was successfully treated with muscle, collagen, and epidural blood patch. We examined the literature to identify similar cases reporting Cl-2 retrospinal fluid collections identified on imaging in the setting of SIH and quantified the success of targeted treatment to this area despite previous reports that caution about a "C1-2 false localizing sign."
Methods: A systematic search was performed identifying cases of SIH resulting from CSF leak with C1-2 fluid collection observed on imaging. PubMed, Google Scholar, and Web of Science were queried, and articles were screened for possible inclusion by 2 authors and supervised by the senior author.
Results: In total, 28 studies were included with a total of 32 patients. The number of patients in each study with C1-2 fluid collections, number of patients with fluid collections at multiple levels, specific intervention used, and outcomes of each intervention were recorded, with a focus on whether treatment occurred at the levels exhibiting fluid signal.
Conclusion: Although the C1-2 fluid signal in SIH has previously been described as a "false localizing sign," our study indicates that treating this level as the source of CSF leak results in successful and durable outcomes. Most SIH cases with signal at C1-2 did not have a fluid signal at any other level and were treated successfully and most commonly through epidural blood patch at the C1-2 level. Symptom resolution was also reported after direct repair of C1-2 CSF leaks through primary closure, Gelfoam patch, and muscle fragment with fibrin. In patients with SIH, C1-2 fluid signal, and no other source of CSF leak identified on imaging, surgical intervention at the C1-2 level seemed to have a high success rate.
{"title":"Reappraisal of the Previously Described False Localizing Sign at C1-2 in Cases of Spontaneous Intracranial Hypotension.","authors":"Gianna Fote, Hania Shahin, Nolan J Brown, Joseph Falcone, Alexander Lopez, Edward C Kuan, Frank P K Hsu, Michael Y Oh, Ahmed Mohyeldin","doi":"10.1227/ons.0000000000001341","DOIUrl":"https://doi.org/10.1227/ons.0000000000001341","url":null,"abstract":"<p><strong>Background and objectives: </strong>We present an illustrative case of spontaneous intracranial hypotension (SIH) in the setting of a suspected C1-2 cerebrospinal fluid (CSF) leak that was successfully treated with muscle, collagen, and epidural blood patch. We examined the literature to identify similar cases reporting Cl-2 retrospinal fluid collections identified on imaging in the setting of SIH and quantified the success of targeted treatment to this area despite previous reports that caution about a \"C1-2 false localizing sign.\"</p><p><strong>Methods: </strong>A systematic search was performed identifying cases of SIH resulting from CSF leak with C1-2 fluid collection observed on imaging. PubMed, Google Scholar, and Web of Science were queried, and articles were screened for possible inclusion by 2 authors and supervised by the senior author.</p><p><strong>Results: </strong>In total, 28 studies were included with a total of 32 patients. The number of patients in each study with C1-2 fluid collections, number of patients with fluid collections at multiple levels, specific intervention used, and outcomes of each intervention were recorded, with a focus on whether treatment occurred at the levels exhibiting fluid signal.</p><p><strong>Conclusion: </strong>Although the C1-2 fluid signal in SIH has previously been described as a \"false localizing sign,\" our study indicates that treating this level as the source of CSF leak results in successful and durable outcomes. Most SIH cases with signal at C1-2 did not have a fluid signal at any other level and were treated successfully and most commonly through epidural blood patch at the C1-2 level. Symptom resolution was also reported after direct repair of C1-2 CSF leaks through primary closure, Gelfoam patch, and muscle fragment with fibrin. In patients with SIH, C1-2 fluid signal, and no other source of CSF leak identified on imaging, surgical intervention at the C1-2 level seemed to have a high success rate.</p>","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142300828","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1227/ons.0000000000001354
Eva M Wu, Meredith C Costello, Ahmed Abdelsalam, Jacques J Morcos
{"title":"Transcavernous Approach Through Eyebrow Incision for Radiation-Induced Medial Temporal Lobe Cavernoma: 2-Dimensional Operative Video.","authors":"Eva M Wu, Meredith C Costello, Ahmed Abdelsalam, Jacques J Morcos","doi":"10.1227/ons.0000000000001354","DOIUrl":"https://doi.org/10.1227/ons.0000000000001354","url":null,"abstract":"","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142300831","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1227/ons.0000000000001365
Atul Goel
{"title":"Commentary: Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlantoaxial Dislocation and Basilar Invagination: 2-Dimensional Operative Video.","authors":"Atul Goel","doi":"10.1227/ons.0000000000001365","DOIUrl":"https://doi.org/10.1227/ons.0000000000001365","url":null,"abstract":"","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142300809","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1227/ons.0000000000001363
Harsh Jain, Ranbir Ahluwalia, Scott L Zuckerman
{"title":"Commentary: Bilateral High-Riding Persistent First Cervical Intersegmental Arteries in a Case of Klippel-Feil Syndrome: The Technique of Vertebral Artery Mobilization for C1-C2 Reduction and Fusion for Atlantoaxial Dislocation and Basilar Invagination: 2-Dimensional Operative Video.","authors":"Harsh Jain, Ranbir Ahluwalia, Scott L Zuckerman","doi":"10.1227/ons.0000000000001363","DOIUrl":"https://doi.org/10.1227/ons.0000000000001363","url":null,"abstract":"","PeriodicalId":54254,"journal":{"name":"Operative Neurosurgery","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142300808","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}