Operative Neurosurgery最新文献

Background and objectives: The lateral transorbital approach (LTOA) has gained increased recognition, but there is still a paucity of data on its effectiveness and advantages compared with the LTOA with lateral orbitotomy, herein denoted as the lateral orbital wall approach (LOWA). The aim of this study was to provide an anatomical reappraisal and the authors' clinical experience to compare the 2 approaches to the orbit and middle cranial fossa (MCF).

Methods: Eight latex-injected cadaveric specimens were used to perform LTOA and LOWA. The operative depth of each approach to key anatomical landmarks was measured. Fifty high-resolution computed tomography studies were reviewed to calculate the operative angles. We reviewed 40 consecutive cases treated with LTOA and LOWA at our institution.

Results: Compared with the LTOA, the LOWA provided shorter operative depths to the optic foramen (P < .05), foramen ovale (P < .05), and to the junction eyeball-cranial nerve II (P = .13). It also offered better access to the anterior aspect of the orbit with less orbital content retraction. The LTOA and LOWA provided different operative angles to key anatomical landmarks in the orbit and MCF (P < .05). In our chart review, 31 patients underwent the LTOA, whereas 9 underwent the LOWA to treat orbital and MCF lesions. Patients undergoing LOWA experienced postoperative complications related to periorbital nerves, such as frontalis palsy (n = 1) and supraorbital neuralgia (n = 1). Patients undergoing LTOA were more prone to complications associated with intraorbital manipulation (n = 4), including diplopia and ptosis.

Conclusion: Our data suggest that the LTOA can be an effective surgical strategy for addressing orbital apex and MCF lesions. Although the LOWA provides access to the aforementioned areas, it may be more suitable for anterior orbital lesions that require direct access with wider entry exposure and extensive orbital content manipulation.

Background and objectives: Neuromodulation for the treatment of epilepsy is a growing field, and several thalamic nuclei (including the anterior nucleus, centromedian nucleus [CM], and pulvinar) have been implicated and targeted. Although an anterior trajectory approach to the CM is conventionally used, we report on a novel posterior trajectory which can be useful when the conventional anterior approach is surgically challenging, or where dual CM and pulvinar coverage is desired.

Methods: Clinical and imaging data were retrospectively collected from 7 patients with at least 1 posterior trajectory CM lead and 4 patients with at least 1 anterior trajectory CM lead.

Results: Patients in the anterior and posterior trajectory groups had a mean of 48.1% and 65.2% seizure reduction, respectively, and were not significantly different (P = .53). Patients in the posterior trajectory group had contacts within the CM and/or pulvinar. There were no pulvinar contacts in the anterior trajectory group. Analysis of structural connectivity in 1 patient from each group revealed temporal- and occipital-projecting tracts for electrodes within the anterior and medial pulvinar nuclei. Stimulated thalamic nuclei from the anterior trajectory lead did not show any temporal- or occipital-projecting tracts.

Conclusion: We demonstrate that a posterior trajectory approach to the CM is feasible, safe, and effective in drug-resistant epilepsy. This provides an alternative option when the conventional anterior approach is surgically infeasible or when dual CM/pulvinar coverage is desired.

Background and objectives: The ventralis intermedius nucleus of the thalamus (Vim) is the preferred target in magnetic resonance-guided focused ultrasound (MRgFUS) for tremor-dominant Parkinson's disease (TdPD), but some patients with TdPD have persistent tremor after Vim thalamotomy. Basal ganglia outflow through the ventralis oralis anterior and posterior (Voa/p) may be responsible. We present 6 cases with dual Vim and Voa/p MRgFUS thalamotomies for TdPD resistant to Vim treatment.

Methods: Six patients with TdPD underwent Vim MRgFUS thalamotomy with persistent intraprocedural tremors (resting 5 patients and/or action tremors 1 patient), who then underwent Voa/p thalamotomy during the same procedure. Demographic and treatment information was collected. Tremor was evaluated using the Clinical Rating Scale for Tremor (CRST)-A and CRST-B.

Results: Six patients were included in the study. The mean age was 71.5 years (SD = 2.7), 5 were male (83.3%), 4 had right-sided treatments (66.7%), and 1 had a repeat treatment (16.7%). The mean follow-up was 11 months (range 6-18 months). Mean Vim lesion coordinates from the posterior commissure were X = 13.9 mm, Y = 7.5 mm, and Z = 2 mm. Voa/p were targeted by moving approximately 3 to 5 mm anterior and 3 mm medial to the initial Vim lesion. Mean Voa/p lesion coordinates were X = 11.7 mm, Y = 11.3 mm, and Z = 2.3 mm. Five patients with resting tremor had improved postural/action tremor after Vim thalamotomy (mean CRST-B 8.8 improved to 0.4) but unsatisfactory control of resting tremor. After Voa/p thalamotomy, resting tremor improved in all 5 patients (mean CRST-A hand score 3.6 improved to 0.0). For the patient without resting tremor, postural/action tremor improved after Voa/p thalamotomy (CRST 3 improved to 1). All improvements were sustained at last follow-up except for 1 patient, who regressed to preoperative postural/action and resting tremor by 6 months. At last follow-up, 2 patients reported speech (33.3%) and 3 patients reported balance/gait (50%) changes.

Conclusion: Patients with TdPD with tremor refractory to Vim MRgFUS thalamotomy may benefit from a secondary lesion in Voa/p although incidence of adverse effects may be increased.

Background and objectives: With advancements in endovascular techniques, an increasing number of tentorial dural arteriovenous fistulas (TDAVFs) can now be successfully treated with endovascular intervention alone. In this study, we present a summary of one single-center experience in the treatment of TDAVFs, along with a subgroup analysis based on the Lawton classification.

Methods: We conducted a retrospective review of patients with TDAVF treated at a single center over a 21-year period. Patients with TDAVFs were included and categorized into 6 types. Patient demographics and angiographic data were recorded. Postprocedural and follow-up angiographic and clinical outcomes were assessed.

Results: A total of 275 cases of TDAVFs involving the Galenic, straight sinus, torcular, tentorial sinus, petrosal, or incisural regions were recorded in the database. Of the total cases, 236 of DAVFs (85.8%) occurred in male patients, with a mean age of 51.1 ± 11.6 years. In 245 cases (92.8%), fistulas were complete occluded immediately using various modalities, with a treatment-related complication rate of 12.5%. Galenic, straight sinus, and torcular DAVFs had higher incidence of internal cerebral vein drainage (P < .001). Superior petrosal sinus DAVF shows a higher incidence of perimedullary venous drainage (P < .001) and a relatively higher proportion of microsurgical treatments compared with other types (P < .001). Galenic DAVFs had a lower immediate complete occlusion rate compared with other types of TDAVFs (P = .013). Both Galenic and superior petrosal sinus DAVFs exhibited a higher complication rate compared with other types of TDAVFs (P = .008). Torcular DAVFs had a tendency to develop new fistulas after treatment (P = .008).

Conclusion: We present the characteristics of 275 patients with TDAVFs, predominantly middle-aged men. Most TDAVFs can be effectively treated with an endovascular approach, superior petrosal sinus DAVFs more often require microsurgical intervention.