Orbitectomía en monobloque en un paciente con sarcoma neurogénico de la órbita / Single block orbitectomy in a patient with neurogenic orbital sarcoma

El sarcoma neurogénico es un tumor maligno que se origina en las células de Schwann de la vaina del revestimiento de los nervios periféricos y son poco frecuentes en la órbita. Se presenta un paciente de 23 años de edad, masculino, blanco, con antecedentes de neurofibromatosis tipo I, con desplazamiento anteroinferior del globo ocular izquierdo, dolor intenso y pérdida de la visión de 4 meses de evolución. Al examen oftalmológico se constató proptosis severa con descenso del globo ocular izquierdo, oftalmoplejia total, quemosis severa, hiperemia, opacidad corneal y aumento de volumen del párpado superior. En los estudios imagenológicos se evidenció lesión tumoral que ocupaba la totalidad del compartimiento orbitario sin infiltración de sus paredes óseas y con desplazamiento del globo ocular por fuera del reborde orbitario. Se realizó un abordaje quirúrgico combinado, y se logró una orbitectomía en monobloque con resección total del tumor y reconstrucción con colgajo rotado de músculo temporal ipsilateral. El estudio histopatológico informó la presencia de un sarcoma neurogénico de la órbita y se complementó con tratamiento adyuvante con radioterapia. El paciente se mantuvo controlado durante un año y a partir de esta fecha comenzó la aparición secuencial de varias lesiones a distancia(AU)

Neurogenic sarcoma is a malignant tumor that starts in Schwann cells of the peripheral nerves sheath and is rarely found in the orbit. Here is a 23 year old, male, Caucasian patient, with a history of Type-I Neurofibromatosis, and a left eye fore and lower side displacement of the left eyeball, intense pain and loss of vision for 4 months. A severe proptosis and the lowering of the left eyeball was detected during the ophthalmologic examination, as well as total ophthalmoplegia, severe chemosis, hyperemia, corneal opacity and increased upper eyelid volume. Imaging studies revealed a tumor lesion occupying the whole orbital compartment, with no bone wall infiltration, but causing the displacement of the eyeball out of the orbit border. A combined surgical approach was performed consisting in a single block orbitectomy with total tumor resection, as well as the reconstruction with the ipsilateral temporal muscle rotated flap. The histopathology study showed the presence of an neurogenic orbital sarcoma, so an adjuvant radiotherapy treatment was indicated. The patient was followed up for a year, after which the sequential occurrence of several lesions began(AU)

Orbitozygomatic craniotomy in three pieces: tips and tricks / Craniotomia orbitozigomática em três peças: dicas e truques

ABSTRACT Objective Didactically describe the orbitozygomatic craniotomy made in three pieces. Method This approach was performed, from 2002 to 2011, in 49 patients admitted at Beneficência Portuguesa of São Paulo Hospital. Results Twenty-seven patients had vascular lesions and twenty-two suffered for intracranial skull base tumors. The vascular lesions varied from cavernous angiomas inside the mesencephalum, high bifurcation basilar tip aneurysms, superior cerebellar arteries aneurysms and arteriovenous malformations in the interpeduncular cistern. Skull base tumors as meningiomas, interpeduncular hamartomas and third ventricle floor gliomas were among the neoplastic lesions approached. We had no permanent injuries and minimal transient complications had occurred. Conclusion It is a descriptive text, organized in the sequence of the main stages in which such a craniotomy is performed, describing in details the technique in which this group of evolutionarily authors came to accomplish the task.

RESUMO Objetivo Descrever didaticamente a craniotomia orbitozigomática realizada em três peças. Método Esse acesso foi realizado em 49 pacientes, de 2002 a 2011 em pacientes admitidos no Hospital Beneficência Portuguesa de São Paulo. Resultados Vinte e sete pacientes apresentavam lesões vasculares e vinte e dois sofriam de tumores da base do crânio. As lesões vasculares variaram entre angiomas cavernosos do mesencéfalo, aneurismas topo da artéria basilar com bifurcações altas, aneurismas da artéria cerebelas superior a malformações arteriovenosas na cisterna interpeduncular. Tumores da base do crânio como meningeomas, hamartomas interpedunculares e gliomas no assoalho do terceiro ventrículo estão entre as lesões neoplásicas abordadas. Nós não tivemos sequelas definitivas e tivemos mínimas complicações temporárias. Conclusão Trata-se de um texto descritivo, dividido conforme as principais etapas da realização desta craniotomia, o qual descreve com detalhes a técnica com que o presente grupo de autores evolutivamente veio a realizá-la.

Abordaje órbito-cigomático asociado a peeling de fosa media en la resolución quirúrgica de un caso de meningioma paraclinoideo / Orbito-zygomatic approach associated with peeling of the middle fossa in the surgical resolution of a case of paraclinoid meningioma

OBJETIVO: demostrar la utilidad del abordaje órbito-cigomático (O-C) asociado a peeling de fosa media para la resolución quirúrgica de un caso de meningioma paraclinoideo (MP). MATERIAL Y MÉTODO: se presenta el caso de un paciente de sexo femenino de 53 años de edad, que consulta por disminución de la agudeza visual del ojo derecho como síntoma principal. Se identificó además, durante el examen neurológico, hipoestesia en el territorio de las ramas V1 y V2 del V par craneal. Se realizó IRM de cerebro sin y con contraste, que muestra una lesión compatible con MP derecho con extensión predominantemente para y supraselar. La angiografía digital objetiva aferencias predominantes desde la arteria meníngea media (AMM). Se decidió intervenir quirúrgicamente mediante un abordaje O-C en 2 piezas asociado a peeling de fosa media. RESULTADOS: se logró la exéresis total (Simpson 2) del tumor. La paciente presentó mejoría de la sintomatología visual, manteniendo los síntomas trigeminales. La tomografía de cerebro de control mostró la exéresis completa del MP. CONCLUSIÓN: el abordaje órbito-cigomático en 2 piezas permitió una mayor exposición del MP, necesaria para lograr la exéresis total del tumor y en especial de la extensión superior de la lesión. La disección, coagulación y sección de la AMM mediante el peeling de fosa media, disminuye drásticamente el sangrado intraoperatorio. Esta técnica brinda además la posibilidad de disecar de forma extradural, el plano que separa el tumor de las ramas del nervio trigémino. La combinación de estas técnicas permitió la resolución quirúrgica del caso con excelente resultado, por lo que recomendamos su utilización en casos similares al que se presenta

OBJECTIVE: to demonstrate the usefulness of the fronto-orbital-zygomatic approach with associated peeling of the middle fossa for the surgical resolution of a case of paraclinoid meningioma. MATERIAL AND METHODS: we report the case of a 53-year-old woman, whose main symptom was a decreased visual acuity of the right eye. During neurological examination we also identified hypoesthesia in the territory of V1 and V2 branches of of the Vth cranial nerve. Brain MRI with and without contrast was performed showing injury compatible with paraclionid meningioma with suprasellar extension. Digital angiography showed predominant afferent vessels from the middle meningeal artery. Therefore we decided to perform a surgical procedure through an orbital-zygomatic approach in 2 pieces associated to a middle fossa peeling and subsequently a transsylvian approach. RESULTS: the patient experienced visual improvement after the procedure, but no changes in trigeminal symptoms were found. Control brain scan showed complete excision without evidence of any remnant. CONCLUSION: the orbital-zygomatic approach in 2 pieces allows the surgeon to achieve greater exposure, required to achieve a better view of the superior extension of this brain injury. Dissection, coagulation and section of the middle meningeal artery through a middle fossa peeling, drastically decreased intraoperative bleeding. For reduced shrinkage during the extradural step, it is necessary to install a continuous lumbar drainage

Application of three-dimensional measurement and computer-aided navigation system in management of orbitozygomatic complex fracture / 中华创伤杂志

Objective To evaluate the application of three-dimensional measurement and computer-aided navigation system in treatment of orbitozygomatic complex fiacture.Methods Pre-and post-operative three-dimensional measurements were taken by Mimics software to locate the zygomatic bones of 15 patients with orbitozygomatic complex ftacture to determine distance of optical foramen to zygomaticotemporal suture (On-Zm)/ zygomaticofrontal suture (On-Or)/zygomaticomaxillary suture (OnTz),horizontal angle of zygomatic arch,horizontal angle of the zygomatic process,and inferior angel of the frontal process of zygomatic bone.Preoperative design and simulation,intraoperative real time navigation and postoperative evaluation were applied using computer assisted navigation system.Results OnTz,On-Or,and On-Zm was (48.6-±4.5)mm,(42.5±2.2)mm,and (47.5±3.2)mmin the unaffected side,but was (50.4 ± 2.2) mm,(37.2 ± 1.0) mm,and (53.4 ± 3.6) mm in the affected side before operation (P ＜ 0.05).Whereas On-Tz,On-Or,and On-Zm improved to (46.4 ± 3.7) mm,(41.2 ± 1.8) mm,and (46.4 ± 2.5) mm in the affected side after operation,similar with the values in the unaffected side (P ＜ 0.05).Horizontal angle of zygomatic arch,horizontal angle of the zygomatic process,and inferior angel of the frontal process of zygomatic bone was (144.7 ±4.1)°,(132.5 ± 2.3)°,and (112.0 ± 3.4)° in the affected side,with significant differences from (150.3 ± 8.0)°,(141.1 ±4.2)°,and (114.9 ±5.1)° in the affected side before operation (P ＜0.05),but they were improved to almost the normal values (144.6 ± 4.1) o,(132.8 ± 2.0) °,and (111.9 ± 3.6) ° after operation.Satisfactory surgical outcomes,such as three dimensional symmetry and recovery of normal mouth-openingand occlusion,had been achieved.Conclusions Three-dimensional measurement is a quantitative study on the spatial displacement of orbitozygomatic complex.Combined with computer-assisted navigation system with preoperative design and simulation,intraoperative real time navigation and postoperative evaluation,three-dimensional measurement attains the overall management of orbitozygomatic complex fracture.

Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

OBJECTIVE: Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications. METHODS: Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography. RESULTS: Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely. CONCLUSION: The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.

Medpor combined with autogenous outer table of calvarial in management of deformities secondary to orbitozygomatic fracture / 中华医学美学美容杂志

Objective To study Medpor combined with autogenous outer table of calvarial in management of deformities secondary to orbitozygomatic fracture.Methods In the reconstruction of the orbitozygomatic fracture,we firstly did the operation of osteotomies to reset reliable internal fixation,then Medpor combined with autogenous outer table of calvarial was used to repair wall and in correction of depressed orbitozygomatic region.Results From January 2007 to December 2010,13 cases of deformities secondary to orbitozygomatic fracture were repaired.The enlarged orbital volume was reduced,enophthalmos and facial asymmetry were corrected or improved.Facial deformity was significantly improved and no complications occurred.Conclusions Medpor combined with autogenous outer table of calvarial is benefit to most of secondary deformities to orbitozygomatic fracture.It is an effective solution to the orbital content shift and double vision problem,and it also can reduce the autologous damage and foreign body rejection.

Usefulness of the Blink Reflex Study as a Preoperative Evaluation in the Orbitozygomatic Complex Fracture

PURPOSE: As the evaluation of the preoperative sensibility in the orbitozygomatic complex fracture, used by most surgeons, depends on the patient's subjective judgements, it is difficult to make generalization and to use it as an objective evaluation method. We used the blink reflex study to objectively evaluate injury to the infraorbital nerve. METHODS: From December 2008 to November 2009, a total of 16 patients underwent the patient's subjective report on sensory symptoms and the blink reflex study preoperatively. Among patients having orbitozygomatic complex fracture of type III or more according to Henderson's classification and simultaneously suspected as being injured along the infraorbital nerve pathway, patients who had difficulty in checking preoperative sensibility and said 'normal sensibility' were selected as candidates. RESULTS: Fifteen patients showed abnormal R1 on the fracture side. These results suggested that most of patients had injury to the infraorbital nerve. CONCLUSION: Contrary to the existing tests, the blink reflex study is a useful diagnostic tool in reflecting injury to the infraorbital nerve objectively.

A Retrospective Study on the Injury of Infraorbital Nerve According to Types of Orbitozygomatic Complex Fracture

In the orbitozygomatic complex fracture, sensory impairment due to the damage of the infraorbital nerve is one of the most common symptom and complication. In this report, we have the assumption that surgical approach for rigid fixation method may have correlations to the damage and regeneration of the nerve. Among patients who had open reduction and internal fixation for unilateral orbitozygomatic complex fracture in our hospital from March 1997 to August 2000, we selected 40 cases. The pin-prick test and the 2-point discrimination test on the infraorbital nerve regions were done for testing the sensory impairments. Two different fracture classification methods were used in this research. First, Henderson's method was used. The results of preoperative test results showed that 17 patients out of 40 patients were abnormalities. More specifically, type IV patients had the highest sensory impairments. In a comparison of the approach methods, the patients who adopted both method showed higher tendency of recovery of sensory impairments. From these results, the degree of deviation in the fracture and the type of approach may be an important prognostic factor for the sensory impairments due to the orbitozygomatic complex fracture.

Surgical Results of Anterior Circulation Aneurysm by Inexperienced Neurosurgeon

OBJECTIVE: The authors report the surgical results of anterior circulation aneurysm surgery by inexperienced neurosurgeon and the results are compared to those of experienced one. METHODS: The pterional approach for the anterior circulation aneurysm was performed on 20 cases from July 2000 to July 2001 by experienced neurosurgeon. The pterional approach and orbitozygomatic with orbital rim osteotomy were performed on 10 cases respectively from Oct 2001 to May 2002 by inexperienced neurosurgeon. RESULTS: All of aneurysms were treated by direct clipping. Good outcomes(Glasgow Outcome Scale score 4 or 5) were achieved in 60%, fair(GOS score 3) 10%, poor(GOS score 1 or 2) 30% through pterional approach by inexperienced neurosurgeon. Good outcomes were achieved in 70%, fair 20%, poor 10% through orbital rim or orbitozygomatic approach by inexperienced neurosurgeon. Good outcomes were achieved in 65%, fair 20%, poor 15% by experienced neurosurgeon. CONCLUSION: The clinical outcomes of anterior circulation aneurysmal surgery through the orbital rim or orbitozygomatic osteotomy by inexperienced neurosurgeon showed no statistical differences compared with routine pterional approach. However, the authors could obtain lesser brain retraction and easy access of the target through the orbital rim or orbitozygomatic osteotomy.

Dual Pedicle Artery Giant Aneurysm: Case Report

The term of "pedicle aneurysm" has been only cited in combination with the arteriovenous malformation (AVM). However, authors report a case with a pure pedicle aneurysm, which is not associated with AVM. A 29-year-old female patient presented with postpartum seizure and vomiting. Four days before, she delivered her second baby through Cesarean section. On admission, neuroimaging studies demonstrated the Fisher Grade II subarachnoid hemorrhage with a large round partially thrombosed supra- and retrosellar vascular mass. The subsequent magnetic resonance and cerebral angiography revealed a giant saccular aneurysmal sac which was fed by two pedicle arteries. Despite the intraoperative rupture, the aneurysm was completely obliterated via orbitozygomatic approach and the dural pedicle arteries were verified. On postoperative third day, hypothalamic ischemic infarction with moderate hemispheric brain swelling developed. She died on the 4th postoperative days . We report a special case of dual pedicle artery giant aneurysm supplied from the anterior and posterior cerebral circulation simultaneously.

Observation on Microsurgery of the Willis Circle by Combined Frontotemporal-Orbitozygomatic Approach / 中国医师杂志

Objective To get more detailed information about the microsurgery of the Willis circle,in order to provide evidence of clinical operation.Methods The microsurgical anatomy of the Willis circle via combined frontotemporal-orbitozygomatic approach was studied in 5 adult cadaver brains under microsurgical scope. Results The Willis circle was composed of anterior communicating artery (ACOA), A 1 segments of the right and left anterior cerebral arteries (ACA), right and left internal carotid arteries(ICA) right and left, posterior communicating artery (PCOA), Pi segments of the right and left posterior cerebral arteries (PCA).The variation are present obviously in A 1 segment of the ACA. The outer diameter of left A 1 segment are larger than that of right ones. There are many perforating arteries of each part of Willis circle. Most of them arise from their original arteries, then course medial-superiorly to the optic tract, the pituitary stalk, the optic chiasm, the thalamus, hypothalamus, the floor of third ventricle, basal nuclei and internal capsule etc blood supplied areas. Conclusion To understand the microsurgical anotamy of the Willis circle and protections against its penetrating branches perfectly are the key to gain a good curative effect during the concerned operation .

Modified Transsylvian Approach with Orbitozygomatic Resection for Distal Basilar Artery Aneurysms / 대한뇌혈관학회지

Aneurysms arising from the distal basilar artery(BA) and relating to the origin of the superior cerebellar artery (SCA), posterior cerebral artery (PCA) account for more than 15% of all intracranial aneurysms and more than one-half of all aneurysms occurring in the vertebrobasilar circulation. The anatomic complexity of the interpeduncular cistern is directly related to the dangers of surgical manipulation in this region and it is undoubtedly difficult to operate on a distal basilar aneurysm which located deep in a very narrow operative field restricted by unremovable neural and vascular architectures. Although we can not choose no single operative approach suitable to this area because the indivisual patient's vascular, neural and bony anatomy is widly variable, using the modified transsylvian approach with orbitozygomatic resection the distal basilar artery aneurysms could be seen and clipped easily by upward and oblique viewing from below through the wide operative space consisting of the less retracted intracarotid artery, middle cerebral artery and oculomotor nerve. We have operated 64 distal basilar artery aneuysms. Among them, 27 patients were approached using the modified transsylvian approach with orbitozygomatic resection. The operative procedure is presented in detail and compared with other surgical approaches.

Frontosupraorbital Approach and Orbitozygomatic Temporopolar Approach for High Basilar Aneurysms

Surgery of aneurysms around the basilar bifurcation artery is still one of the most difficult and challenging operations in the field of neurosurgery, because of their rare occurrences, unfamiliar anatomy and deeply located lesions. Two major surgical approaches, pterional approach and subtemporal approach, are conventionally used for upper basilar artery aneurysm. Neither approach, however, ensures easy treatment of high basilar bifurcation aneurysm, because there is always the chance of excessive retraction of the brain, nerves and vessels. In order to gain sufficient exposure of highly placed basilar bifurcation aneurysms, the surgical approach needs to be in the direction in which the surgeon can see the interpeduncular fossa from below. In an attempt to gain better exposure of these lesions, neurosurgeons have used a variety of surgical approaches. We have used forntosupraorbital(FSO) approach and orbitozygomatic temporopolar(OZTP) approach for seven cases of high basilar aneurysm including basilar bifurcation artery-SCA aneurysm. The advantage of these approaches are multidirectional view, wide operative field, less brain retraction and easy application of temporary clip. Therefore, authors would like to recommended these approaches in case of for high basilar aneurysm as a effective method of aneurysmal neck clipping.

Trigeminal Neurinomas: Report of 8 Cases with Special Reference to Operative Approach

The authors have treated eight cases of trigeminal neurinomas for the past thirteen years. We have been treating these tumors in accordance with the principle of radical resection through one-staged operation. Three were male and five were female. The age ranged from 25 to 56 years with the mean age of 41.5 years. One was a case of von Recklinghausen's disease. Topographically, the tumors were mainly located within the middle fossa in two cases, within the posterior fossa in two, and extended both supra- and infratentorially in four cases. Facial pain and hearing disturbance were the main symptoms and various other symptoms such as focal seizure, hemiparesis, gait disturbance, symptoms of increased intracranial pressure and visual disturbance were also noted. Surgical operations were performed in all cases. As a surgical approach, either transpetrosal-transtentorial or orbitozygomatic-infratemporal route was employed. The choice of the better approach depends on the topography of the tumor. Total removal was performed in all cases. Only one case, which was an early one in this series required second operation to remove the tumor completely. In one case, the tumor recurred five years after the operation. There has been no operative mortality, but the injury or permanent damage to the trigeminal branches was inevitable in many cases. Surgical results were excellent in three, good in four, and fair in one case.

Thrombosed Giant Posterior Communicating Aneurysm Simulating Brain Neoplasm: A Case Report

A giant intracranial aneurysm(GIA) is an aneurysm greater than 2.5cm in size. GIA may simulate brain tumor on computed tomography scans. We report a case of giant thrombosed posterior communicating artery aneurysm simulating brain tumor. To minimize brain retraction and achieve excellent exposure in the shortest possible distance during the operation, we used a new surgical technique, an orbitozygomatic infratemporal approach, with good results.