Operative Neurosurgery最新文献

Background and objectives: Upper cervical spine bony tumors pose a challenge to surgeons because of their extensiveness and proximity to vital structures. Reconstruction following resection is necessary to prevent instability. Our objective is to describe a technical note on the C1 anterior arch screw with mesh cage reconstruction for anchoring the upper end of the cervical plate after resection of the upper cervical tumor.

Methods: A retrospective review of patients with primary bony tumors of the upper cervical spine after surgical resection between 2018 and 2022 was included in the study. Imaging workup included computed tomography, MRI, and computed tomography angiogram.

Results: A total of 4 patients with primary bony tumors of the upper cervical spine underwent C1 anterior screw fixation with mesh cage reconstruction. The mean age was 33.8 ± 14.3 years. Tumor extent was C2-C4 in 2 patients (50%) and C2 in 2 patients (50%). Three patients had a spinal instability neoplastic score of >12 and were deemed unstable preoperatively, mandating the stabilization procedure. All patients underwent surgical resection: gross total resection (1, 25%), near-total excision (1, 25%), and tumor decompression (2, 50%). Surgery was staged in 3 patients (75%) because of the extensiveness of the tumor and massive blood loss. There was no perioperative mortality. The mean postoperative Nurick grading score was 1.5 ± 1.3 (range 0-3). All patients were ambulatory and showed neurological improvement postoperatively with a mean follow-up of 37.5 ± 21.9 months and evidence of fusion on the latest imaging.

Conclusion: Radical resection of tumors involving the upper cervical spine requiring C2 corpectomy is challenging. En bloc resection is not always feasible. Neurosurgeons can consider using the anterior arch as an anchor point. The use of neuronavigation facilitates the precise placement of the C1 arch screws.

Background and importance: Intracranial intraluminal mass lesions are rare and challenging to biopsy using noninvasive methods. Obtaining tissue for diagnosis is critical for guiding treatment, yet traditional approaches such as craniotomy pose significant risks. In this case report, we describe the first use of an aspiration catheter and stent retrieval system to safely and successfully perform an endovascular biopsy in a patient with an exclusively intraluminal meningioma.

Clinical presentation: The patient had a history of medulloblastoma, which was resected and treated with craniospinal radiation. During routine surveillance MRI, an incidental filling defect was identified in the superior sagittal sinus, suspected to be either thrombus or intraluminal meningioma. The lesion demonstrated rapid growth despite anticoagulation therapy, prompting the decision to pursue tissue sampling to guide further treatment. A combined approach using a large-bore suction thrombectomy catheter and a 6-mm Solitaire X stentriever was used through a transvenous femoral approach. Although no tissue was obtained from the suction effluent, sufficient tissue fragments were captured on the stentriever to diagnose meningioma. The patient tolerated the procedure well, with no periprocedural complications.

Conclusion: Obtaining intravascular tissue with a stent retrieval system, particularly for firmer sinus wall lesions such as a meningioma may offer a safe alternative technique to craniotomy for intraluminal sinus tissue diagnosis.

Background and objectives: Several surgical techniques have been developed to treat mesial temporal lobe epilepsy, the most common form of drug-resistant epilepsy. Although surgical treatment for mesial temporal lobe epilepsy has proven to be highly effective in controlling seizures and improving patients' quality of life, it carries potential risk to critical neurovascular structures, which can result in significant complications. With the advent of endoscopic techniques, the transorbital route has emerged as a potential alternative for mesial temporal lobe surgery. This study aims to assess the feasibility, potential advantages, and disadvantages of the transorbital transsylvian selective amygdalohippocampectomy (TTSA) and to provide a step-by-step anatomic description of this approach.

Methods: A TTSA was performed on three injected cadaveric specimens (six sides). Computer tomography and MRI scans were performed before and after each dissection to demonstrate the extent of amygdalohippocampectomy. Neuronavigation was used to identify the optimal trajectory and the position of intra-axial structures, including the amygdala and hippocampus. For each side, a TTSA was performed and all the anatomic landmarks verified from the standard transcranial perspective through a frontotemporal craniotomy.

Results: The dissection procedure was organized into four sequential steps: (1) the extradural approach, (2) identification and opening of the sylvian fissure, (3) identification and removal of the amygdala, and (4) identification and removal of the hippocampus and parahippocampal gyrus. The intradural steps were performed in accordance with the technique described by Yasargil. Furthermore, a unique and educational comparison between the transorbital anatomic view and the related standard transcranial perspective was provided.

Conclusion: The described technique represents an innovative and feasible approach for amygdalohippocampectomy, achieving comparable surgical resection with traditional open surgery in cadaveric specimens, with potential advantages for neurological and neuropsychological outcomes. However, clinical series and further studies are imperative to validate these findings.

Background and objectives: Using confocal endomicroscopy (CLE) in neurosurgery holds the potential for intraoperative diagnosis and correct identification of tumor margins. Still, the correct employment of such a promising technique requires either an external dedicated person to interact with the neurosurgeon during the operation to check the quality of the acquired images or the operator to look directly and frequently outside of the operative field while maintaining the confocal microscopy probe in the surgical cave, thus interrupting the surgical flow, potentially disturbing the correct execution of surgical maneuvers and hindering a correct image acquisition.

Methods: To overcome this problem, we integrated the confocal microscopy interface (Zeiss CONVIVO®) into the surgical view through the operative microscope (Heads-up display). We enrolled patients undergoing surgery with the use of CLE for different pathologies, and we randomly allocated them to be operated with the heads-up display integration or without it. The mean CLE employment time and the number of usable and nonusable captures were annotated.

Results: Twenty-two patients were enrolled of which 12 patients underwent the procedure without the heads-up integration (54.5%) and 10 (45.5%) with it. The mean usage time of the CONVIVO® was 137 (±134) seconds, 61.1 (±38) seconds for the heads-up display group, and 201.6 (±154.1) seconds for the non-heads-up display group ( P = .01). The heads-up display group showed a higher proportion of usable images (11 [±4] vs 50 [±37], 21.7%) than the non-heads-up display group (30 [±21] vs 163 [±33], 18.4%), although nonsignificant ( P = .06). A significant influence of the intraoperative visualization on overall employment of CLE and a reduced number of images collected (611 vs 2139; P = .007).

Conclusion: By allowing the operator to check the quality of the images directly while still looking inside the operating field, better-quality images and a reduced number of unemployable captures are obtained, resulting in more efficient and less time-consuming use of intraoperative confocal microscopy, ultimately leading to reduced operative length.