Neurocirugia (English Edition)最新文献

Introduction and objectives: The sellar region is an area in the base of the skull that is among the most common sites for tumors of the central nervous system. Surgical interventions are currently performed via different routes. While the optic chiasm occupies its expected position in 70% of the population, it can deviate from this position. In such cases, surgery involving this region becomes more difficult as the known surgical routes are narrowed. Advance awareness of these variations can help surgeons to identify the optimal route for safe surgical intervention in the sellar region. By performing simple measurements of both the lengths of the optic nerves and the angle between them, a surgeon can predict the location of the chiasm.

Materials and methods: Twenty specimens collected from autopsies performed at Bursa Forensic Medicine İnstitute were examined to determine the optic chiasm types and the relationships between the surrounding subchiasmal structures.

Results: Among the 20 specimens, we found two prefixed (10%), 10 normo-fixed (50%), and eight postfixed chiasms (40%). The mean interoptic angle was 81.03 (±17.41)⁰. Prefixed chiasms had angles in the range 115.36°-124.76 ° (mean 120.06 [±6.65]⁰), normo-fixed chiasm angles were between 83.11° and 97.53 ° (mean 86.07 [±6.73]⁰), and postfixed chiasms ranged between 53.01 ° and 78.71 ° (mean 69.20 [±9.13]⁰). The length of the right optic nerve ranged between 6.95 and 13.83 mm (mean 10.25 [±1.81] mm), and the length of the left between 7.25 and 12.51 mm (mean 10.40 [±1.47] mm). Obtuse angles indicated that the chiasm was prefixed, and acute angles were indicative of a postfixed chiasm. There was a strong negative correlation between optic nerve lengths and the interoptic angle; thus, as the length of the nerves increases, the interoptic angle becomes more acute.

Conclusions: We have proposed a simple measurement of the optic nerve lengths and the angle between them to predict the relative location of the OC, which can be done easily on MRI.

Petroclival lesions represent a surgical challenge during the endonasal endoscopic approach, as they may involve maneuvers with severe comorbidity. To avoid the morbidity caused by these maneuvers, a contralateral transmaxillary approach (CTA) has been proposed to complement the endoscopic endonasal approach. The aim of our study is to review the safety and efficacy of this approach. We included three patients with lesions affecting the petroclival region, one cholesterol granuloma and two macroadenomas, who were surgically treated with a combined ipsilateral transpterygoid approach and a CTA. The latter was performed by wide osteotomy on the anterior wall of the maxillary sinus through a gingivolabial incision. Complete resection was achieved in the patient with a cholesterol granuloma and subtotal resection in the two patients diagnosed with macroadenoma. One patient presented ecchymosis of the malar area as the only complication. The contralateral transmaxillary approach may improve exposure and dissection of the petroclival area compared to the homolateral endoscopic endonasal approach allowing reaching the most lateral and posterior region of this territory without the need to manipulate the internal carotid artery.

Introduction: Chronic subdural hematoma (cSDH) is a prevalent neurosurgical condition with an increasing incidence due to the rising life expectancy and the widespread use of anticoagulant and antiplatelet therapies. Insights into the inflammatory origins of cSDH led to the exploration of Middle Meningeal Artery (MMA) embolization as a therapeutic strategy. In recent years the endovascular treatment of MMA has gained momentum. Herein we present the initial experience of a dual trained neurovascular unit implementing this therapeutic technique.

Methods: This single-center, prospective pilot study aimed to evaluate the feasibility, safety, and efficacy of MMA embolization in the treatment of cSDH. Following ethical approval and informed consent, demographic, clinical, and radiological data were collected. Patients requiring emergent surgical treatment were excluded. The study focused on assessing clinical outcomes, including the Modified Rankin Score (mRS) and volumetric analysis of cSDH, before and after embolization.

Results: Fifteen patients underwent MMA embolization, with a predominance of males (80%) and a mean age of 72.4 years. The most common presenting symptom was headache (53.3%). The average hospital stay was 3.9 days. Various embolization techniques were employed, with DMSO-EVOH being the most frequent. All procedures were successfully conducted without complications. Although not statistically significant, trends suggested better outcomes in patients with homogeneous cSDH on the CT scan, displaying the cotton wool sign on angiography and treated with EVOH-DMSO.

Conclusion: MMA embolization for cSDH demonstrates promise as a safe and effective treatment, potentially reducing the need for surgical intervention and recurrence rates. This study lays the groundwork for a larger, randomized controlled trial which protocol is herein presented.

Background and objective: Neuronavigation in ventriculoscopy has been described in several papers. However, there are different ventriculoscopes and navigation systems. Because of these different combinations, it is difficult to find detailed navigation protocols for each ventriculoscope. We describe, step by step, a simple method to navigate both the trajectory to reach the ventricular system and the intraventricular work for the LOTTA ventriculoscope.

Methods: We used a rigid ventriculoscope (LOTTA, KarlStorz) with an electromagnetic stylet (S8-StealthSystem, Medtronic) as the main navigation tool. The protocol is based on a 3D printed trocar or alternatively, on a modification of the original trocar for extraventricular phase navigation and a modified pediatric nasogastric tube for intraventricular phase navigation.

Results: The protocol can be set up in less than 10min. The extraventricular part is navigated by inserting the electromagnetic stylet inside the 3D printed trocar or inside the original modified trocar. Intraventricular navigation is performed by combining a modified pediatric nasogastric tube with the electromagnetic stylet inside the working channel of the endoscope. The most critical point is to obtain a blunt, bloodless approach to the ventricle and to achieve perfect alignment of all target structures by means of previously planned pure straight trajectories.

Conclusions: This protocol is easy to set up, avoids rigid head fixation, bulky optical navigation accessories, while allows continuous navigation of both parts of the surgery. Since we have implemented this protocol, we have seen a significant improvement in both simple and complex neuroendoscopy procedures as the surgery is dramatically simplified.

Introduction: Microvascular decompression (MVD) is a non-ablative technique aimed at relieving pain in trigeminal neuralgia (TN) by resolving a neurovascular conflict. Despite reported high success rates, a significant percentage of patients experience therapeutic failure.

Methods: Retrospective observational study of patients with suspected TN undergoing MVD was performed with the goal of identifying factors contributing to the persistence and recurrence of pain.

Results: In the present study, 31 patients undergoing 38 MVD procedures for TN were included (7 patients underwent reoperation after the failure of the initial operation). The mean age was 58.5 years with a male predominance (58.1%). The mean duration of pain was 6.4 years, mainly affecting branches V2 and V3 (46.7%). The most frequently described neurovascular conflict was with the superior cerebellar artery (54.8%), predominantly resolved with Teflon (75.9%). In our case series, MVD achieved pain control in 80.6% of patients at one-year post-intervention and 61.3% at the end of the follow-up period. Twelve patients experienced MVD failure: 5 cases of persistent pain and 7 cases of pain recurrence. A detailed analysis of these failures identified misdiagnosis as the reason of persistent pain in 4 patients, while inadequate surgical technique could be the cause of pain recurrence in 6 patients.

Conclusion: In our study, therapeutic failures could mainly be attributed to two factors: misdiagnosis or the use of inappropriate materials. These factors should be considered when optimizing the management of DMV in patients with NT.

The coincidence in a patient of Hemifacial Spasm and Trigeminal Neuralgia is not frequent. A case is presented with the objective of showing this association due to the abnormal activation of the Trigemino-Facial Reflex. A 55-year-old woman with an 8-year history of left-sided hemifacial spasm and typical trigeminal pain in the ipsilateral V1 and V2 territory. The physical examination shows spasms in the left hemiface, with reproduction of intense pain upon sensory stimulation of the skin on the forehead and upper dental arch. The MRI showed a vessel in intimate contact with the entrance area of ​​the left trigeminal nerve. A left retrosigmoid approach was performed. First, the entrance area of ​​the trigeminal nerve was accessed, finding a clear vascular conflict, which was isolated with Teflon. Then, the trajectory was changed and the exit zone of the facial nerve was accessed, and no type of vascular conflict was identified. The patient presented complete resolution of the Hemifacial Spasm and the associated trigeminal pain. The analysis of this case allows us to conclude that during microvascular decompression of the Facial Nerve, if frank proximal compression is not evident, the Trigeminofacial structural relationship must be taken into account, making it necessary to explore the Trigeminal Nerve.

Introduction: Once the World Health Oraganization (WHO) generic surgical checklist has been standardized and following the itinerary proposed, it is up to the different specialties to continue advancing in the improvement and adjustment of the checklists to their specific procedures.

Methods: Through a Failure Mode and Effects Analysis (FMEA) in which professionals from the surgical area of ​​the Torrecárdenas University Hospital, Jaén Hospital Complex and Gregorio Marañón General University Hospital participated, aspects that threaten patient safety in spine surgery and that are not included in the WHO generic surgical checklist were proposed. The authors scored each of the proposed items incrementally based on the degree of suitability. Based on the score obtained, they selected those who would be incorporated into the specific safety checklist.

Results: A total of twenty-one candidate items were proposed to be part of the specific check list. These obtained scores between 15 and 11 points. After scoring them, it was decided to include the thirteen best rated in the definitive surgical checklist, seven of them in the initial phase, two in the phase prior to the incision and another four in the final part of the checklist prior to the completion of the procedure.

Conclusions: Professionals in the surgical area of ​​Neurosurgery can identify aspects not included in the generic checklist whose non-compliance can affect patient safety in spine surgery to at least the same extent as those included in WHO checklist. It is possible to propose a specific complementary checklist for spinal surgery, responsible for collecting aspects related to safety and success in these procedures.

Background and objective: Once the WHO generic surgical checklist has been standardized and following the itinerary proposed, it is up to the different specialties to continue advancing in the improvement and adjustment of the checklists to the procedures and interventions in their field.

Methods: Through a Failure Mode and Effects Analysis (FMEA) in which professionals from the surgical area of ​​the Torrecárdenas University Hospital, Jaén Hospital Complex and Gregorio Marañón General University Hospital participated, aspects that could condition patient safety in the surgery of the brain tumors and that are not included in the WHO generic surgical checklist were recognized. The three authors gave a score between 1 and 5 to each of the proposed items incrementally depending on the degree of suitability. Based on the score obtained, they selected those who would be incorporated into the specific surgical checklist.

Results: A total of 24 candidate items were identified to be included in the specific check list. These obtained scores between 14 and 10 points. After this weighting, it was decided to include the 12 best-rated items in the final surgical checklist, six of them in the initial phase, three in the phase prior to the incision and another three in the final part of the checklist prior to the completion of the procedure.

Conclusions: Professionals in the surgical area of ​​Neurosurgery can identify aspects not included in the generic checklist whose non-compliance can condition the patient's safety at least to the same extent as those included in the generic list. It is possible to propose a specific complementary checklist for brain tumor surgery, in charge of collecting aspects related to the safety and success of these procedures.

Background: The scientific debate concerning clinical, translational and surgical aspects of iNPH could still be limited in respect to the incidence of this condition. The aim of this paper is to systematically assess the extent of the debate on INPH in the context of the congresses of the relevant medical and scientific societies in our Country.

Methods: We thoroughly examined the websites and scientific programs of 12 leading scientific societies linked to medical specialities involved in diagnosis and management of INPH, among which the neurological, neurosurgical, neurophysiological, rehabilitation medicine and urologic societies. The amount of time (in hours) was examined in a time span of events which took place between 2019 and 2023.

Results: Notably, across 4 years (2019-2023), a total of 7 out of 12 (58.3%) of the aforementioned leading scientific societies dedicated a total of zero minutes to the topic "iNPH", two further societies hosted talks for a total of less than one hours concerning such condition. The amount of time dedicated to giant intracranial aneurysms and vestibular schwannomas was in respect to the incidence of the conditions, significantly longer than the time spent debating on iNPH.

Conclusions: The results demonstrates that in our country, despite the high and increasing incidence of INPH, the awareness raised on the topic could still be limited, especially compared to other, significantly rarer intracranial conditions such as giant intracranial aneurysms and vestibular schwannomas.

Background and objective: Chronic subdural hematoma is one of the most common diseases in neurosurgical practice. The content of electrolytes and gases in the collection could participate in the growth and expansion mechanism, however, there is no evidence that they have been studied before. The objective has been to identify electrolyte, gas and internal metabolomic markers of the content of chronic subdural hematomas, with the possibility of participating in their growth and expansion and to substantiate a pathophysiological hypothesis that interacts with existing ones.

Material and method: A descriptive study was carried out with 53 patients operated on for chronic subdural hematoma, at the "Roberto Rodríguez Fernández" General Teaching Hospital of Morón in Ciego de Ávila, Cuba, in the period between January 2019 and December 2023. The diagnoses were obtained with computed axial tomography. The electrolyte and blood gas components of hematomas are correlated with clinical and neuroimaging variables.

Results: Patients over 70 years of age predominated, 37 (69.81%) and males 38 (71.70%). The Markwalder scale upon admission showed a predominance of Grade III in 24 cases (45.28%). The Glasgow outcome scale showed a predominance of Grade V, 31 (58.49%).

Conclusions: Electrolyte and gasometric metabolomic markers of subdural blood can promote the phenomenon of progressive growth and expansion and have a synergistic effect with the rest of the pathophysiological mechanisms.