Neurocirugia (English Edition)最新文献

Hydrocephalus, an extremely rare complication of craniocervical junction injuries, is postulated to result from compression of the fourth ventricular cerebrospinal fluid (CSF) outlets by fractured and displaced bone fragments, a swollen upper spinal cord or adhesions formed after a traumatic subarachnoid haemorrhage. We present the case of a 21-year-old woman for whom an injury to the cervical spine complicated by a type I atlanto-occipital dislocation contributed to the development of non-communicating hydrocephalus. The hydrocephalus was probably a consequence of impaired CSF circulation at the fourth ventricular outlets (the foramina of Luschka and Magendie), caused by post-haemorrhagic adhesions formed after severe injury to the craniocervical junction.

Objective

To analyze the primary complications related to semisitting position in patients undergoing cerebelo-pontine angle surgery.

Methods

Retrospective data analysis from patients undergoing elective tumoral cerebelo-pontine angle surgery in a semisitting position. The incidence, severity, occurrence moment, treatment, duration, and outcomes of venous air embolism (VAE), pneumocephalus, postural hypotension, and other complications were recorded. Neurointensive care unit (NICU), length of stay (LOS), hospital LOS, and modified Rankin scale scores were calculated six months after surgery.

Results

Fifty patients were operated on. Eleven (22%) presented VAE (mean duration 8 ± 4.5 min): five (10%) during tumor resection, and four (8%) during dural opening. Ten (20%) were resolved by covering the surgical bed, air bubbles aspiration, jugular compression, and one (2%) tilted to a steep Trendelenburg position. One (2%) had intraoperative hemodynamic instability. The only variable associated with VAE was meningioma at histopathology OR = 4.58, p = 0.001. NICU was higher in patients with VAE (5.5 ± 1.06 vs. 1.9 ± 0.20 days, p = 0.01). There were no differences in the Rankin scale. All patients presented postoperative pneumocephalus with a good level of consciousness, except one (2%) who required evacuation. Seven patients (14%) showed postural hypotension, three (6%) after positioning, and one (2%) after developing a VAE; all were reversed with usual vasoactive drugs. No other position-related complications or mortality were registered in this series.

Conclusions

The semisitting position is a safe option with the knowledge, prevention, detection, and early solution of all the possible complications. The development of VAE rarely implies hemodynamic instability or greater disability after surgery. Postoperative pneumocephalus is very common and rarely requires evacuation. Excellent cooperation between anesthesia, nursing, neurophysiology, and neurosurgery teams is essential to manage complications.

Background and objective

The development of a high level of competence and technical proficiency is one of the main objectives of any neurosurgical training program. Due to many factors, this progressive skill development can be complex during the residency. Despite its high cost and infrastructure requirements, there is renewed interest regarding the role of anatomy labs. The study and dissection of the human cadaver has been the environment where many surgeons have developed the necessary skills for microneurosurgery. We propose a structured endoscopic and microsurgical training dissection program to enable residents to maximize the benefits of their training in the lab.

Material and methods

During the months of September, October and November 2021, a stay was done at the Microneurosurgery and Skull Base Laboratory of the Miguel Hernández University of Alicante. A total of 2 specimens were used. The first specimen underwent a first endoscopic endonasal dissection phase. After completing the endonasal part, a set of incisions were made to perform the transcranial part. In the second specimen, the transcranial part was performed first, leaving the endonasal endoscopic work for the last phase.

Results

The results of the dissection program are presented. During the endonasal endoscopic phase, the transsphenoidal approach to the sella was simulated while focusing on the extended approaches in the sagittal plane. During the transcranial phase, right and left anterolateral approaches, a left anterior transcallosal interhemispheric approach, a left transcondylar posterolateral approach and a combined right lateral approach were performed.

Conclusions

The structured dissection of the specimen allowed both endonasal endoscopic and transcranial microsurgical training in the same specimen. This design facilitated the realization of the core skull base approaches in the same specimen. According to our initial experience, we believe that developing common dissection programs is a powerful tool to maximize the results of our residents’ laboratory training.

Objective

The main objective of this study has been to demonstrate why additive printing allows to make complex surgical pathological processes that affect the spine more visible and understandable, increasing precision, safety and reliability of the surgical procedure.

Methods

A systematic review of the articles published in the last 10 years on 3D printing-assisted spinal surgery was carried out, in accordance with PRISMA 2020 declaration. Keywords “3D printing” and “spine surgery” were searched in Pubmed, Embase, Cochrane Database of Systematic Reviews, Google Scholar and Opengrey databases, which was completed with a manual search through the list of bibliographic references of the articles that were selected following the defined inclusion and exclusion criteria.

Results

From the analysis of the 38 selected studies, it results that 3D printing is useful in surgical planning, medical teaching, doctor–patient relationship, design of navigation templates and spinal implants, and research, optimizing the surgical process by focusing on the patient, offering magnificent support during the surgical procedure.

Conclusions

The use of three-dimensional printing biomodels allows: making complex surgical pathological processes that affect the spine more visible and understandable; increase the accuracy, precision and safety of the surgical procedure, and open up the possibility of implementing personalized treatments, mainly in tumor surgery.

Neurosurgical management of basilar invagination (BI) has traditionally been aimed at direct cervicomedullary decompression through transoral dens resection or suboccipital decompression with supplemental instrumented fixation. Dr. Goel introduced chronic atlantoaxial dislocation (AAD) as the etiology in most cases of BI and described a technique for distracting the C1–C2 joint with interfacet spacers to achieve reduction and anatomic realignment. We present our modification to Goel’s surgical technique, in which we utilize anterior cervical discectomy (ACD) cages as C1–C2 interfacet implants. A young adult male presented to our institution with BI, cervicomedullary compression, occipitalization of C1, and Chiari 1 malformation. There was AAD of C1 over the C2 lateral masses. This reduced some with preoperative traction. He underwent successful C1–C2 interfacet joint reduction and arthrodesis with anterior cervical discectomy (ACD) cages and concomittant occiput to C2 instrumented fusion. BI can be effectively treated through reduction of AAD and by utilizing ACD cages as interfacet spacers.

The irrigation of the thalamus depends mainly on the thalamoperforating arteries. There are many anatomical variations in these arteries, the best known being the artery of Percheron. We report a case of a 13-year-old male presented with headache and decline in his mental status. Imaging features showed obstructive hydrocephalus secondary to a mass at the level of the mesencephalon so an endoscopic third ventriculostomy was performed. During the procedure a thalamoperforating artery was encountered at the level of the tuber cinereum limiting the perforation of the third ventricle floor. The present case emphasizes the importance of knowing the anatomy of these arteries and the identification of their main variants during neurosurgical procedures.

Purpose of the study

A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 20% mannitol and 3% hypertonic saline (HS) during elective supratentorial brain tumour surgery in patients with midline shift.

Material and methods

Sixty patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 5 mL/kg of 20% mannitol (n = 30) or 3% HS (n = 30) administered at skin incision. P_CO2 in arterial blood was maintained within 35–40 mmHg and arterial blood pressure was controlled within baseline values ±20%. The primary outcome was the proportion of satisfactory brain relaxation. The surgeon assessed brain relaxation on a four-point scale (1 = excellent with no swelling, 2 = minimal swelling, 3 = serious swelling not requiring treatment, 4 = severe swelling requiring treatment). Postsurgical intracranial changes determined by imaging techniques, postoperative complications, PACU and hospital stay, and mortality at 30 days were also recorded. Appropriate statistical tests were used for comparison; P < 0.05 was considered as significant. This trial was registered in Eudract.ema.europa.eu (#2021-006290-40).

Results

There was no difference in brain relaxation: 2.00 [1.00–2.00] and 2.00 [1.75–3.00] for patients in mannitol and HS groups, respectively (P = 0.804). Tumour size (OR: 0.99, 95% CI: 0.99–1.01; P = 0.371), peritumoral oedema classification (OR: 0.57, 95% CI: 0.11–2.84; P = 0.493), mass effect (OR: 0.86, 95% CI: 0.16–4.87; P = 0.864), anaesthesia (OR: 4.88, 95% CI: 0.82–28.96; P = 0.081) and midline shift (OR: 5.00, 95% CI: 0.84–29.70; P = 0.077) did not have a significant influence on brain swelling in patients treated with either mannitol or HS. No significant differences in perioperative outcomes, mortality and length of PACU and hospital stay were observed.

Conclusions

5 mL/kg of 20% mannitol or 3% HS result in similar brain relaxation scores in patients undergoing craniotomy for supratentorial brain tumour with midline shift.

Brain metastases are tumors that arise from a tumor cell originated in another organ reaching the brain through the blood. In the brain this tumor cell is capable of growing and invading neighboring tissues, such as the meninges and bone.

In most patients a known tumor is present when the brain lesion is diagnosed, although it is possible that the first diagnose is the brain tumor before there is evidence of cancer elsewhere in the body.

For this reason, the neurosurgeon must know the management that has shown the greatest benefit for brain metastasis patients, so treatments can be streamlined and optimized.

Specifically, in this document, the following topics will be developed: selection of the cancer patient candidate for surgical resection and the role of the neurosurgeon in the multidisciplinary team, the importance of immunohistological and molecular diagnosis, surgical techniques, radiotherapy techniques, treatment updates of chemotherapy and immunotherapy and management algorithms in brain metastases.

With this consensus manuscript, the tumor group of the Spanish Society of Neurosurgery (GT-SENEC) exposes the most relevant neurosurgical issues and the fundamental aspects to harmonize multidisciplinary treatment, especially with the medical specialties that are treating or will treat these patients.

Cerebrospinal fluid (CSF) shunt placement is a commonly performed procedure for patients with hydrocephalus of various etiologies.

We present the case of a 68-year-old male patient treated with a ventriculoperitoneal shunt for obstructive hydrocephalus management. Eight years later, a computed tomography (CT) scan detected migration of distal catheter into the pulmonary artery. We conducted a systematic review in Medline database using PubMed search engine to identify previous cases and their management. Our literature review identified eighteen single case reports describing this complication and different strategies to attempt catheter retrieval. To the best authors’ knowledge, this is the first case where conservative management was chosen.

Objectives

To evaluate the efficacy of treatment with linear accelerator-based stereotactic radiosurgery (LINAC) in cerebellopontine angle meningiomas.

Methods

We analyzed 80 patients diagnosed with cerebellopontine angle meningiomas between 2001 and 2014, treated with stereotactic radiosurgery (SRS), of whom 81.9% (n = 68) were women, with an average age of 59.1 years (32–79). SRS was applied as primary treatment in 83.7% (n = 67) and in 16.3% (n = 13) as an adjuvant treatment to surgery. SRS treatment was provided using LINAC (Varian 600, 6 MeV) with M3 micromultilamines (brainLab) and stereotactic frame. The average tumor volume was 3.12 cm³ (0.34–10.36 cm³) and the coverage dose was 14 Gy (12–16 Gy). We performed a retrospective descriptive analysis and survival analysis was performed with the Kaplan–Meier method and multivariate analysis to determine those factors predictive of tumor progression or clinical improvement.

Results

After an average follow-up period of 86.9 months (12–184), the tumor control rate was 92.8% (n = 77). At the end of the study, there was an overall reduction in tumor volume of 32.8%, with an average final volume of 2.11 cm³ (0–10.35 cm³). The progression-free survival rate at 5, 10 and 12 years was 98%, 95% and 83.3% respectively. The higher tumor volume (p = 0.047) was associated with progression. There was clinical improvement in 26.5% (n = 21) of cases and clinical worsening in 16.2% (n = 13). Worsening is related to the radiation dose received by the brainstem (p = 0.02). Complications were 8.7% (7 cases) of hearing loss, 5% (4 cases) of brain radionecrosis, and 3.7% (3 cases) of cranial nerve V neuropathy. Hearing loss was related to initial tumor size (p = 0.033) and maximum dose (p = 0.037). The occurrence of radionecrosis with the maximum dose (p = 0.037).

Conclusions

Treatment of cerebellopontine angle meningiomas with single-dose SRS using LINAC is effective in the long term. Better tumor control rates were obtained in patients with small lesions.