Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach.

BACKGROUND: Clipping continues to be one of the treatment strategies for ophthalmic artery aneurysms not amenable for stenting or coiling, or when long-term treatment durability is a concern. However, crescent development of endovascular techniques demands minimal invasiveness in the transcranial approaches while ensuring satisfactory results. METHODS: We describe an extradural micropterional keyhole approach (eMKA) to the paraclinoid region and highlight the key anatomical elements of this surgical approach. CONCLUSION: The eMKA is a minimally invasive approach that provides access to the paraclinoid region using an extradural corridor. Therefore, it is suitable for clipping of ophthalmic artery aneurysms and other paraclinoid aneurysms.

Technical Description of Minimally Invasive Extradural Anterior Clinoidectomy and Optic Nerve Decompression. Study of Feasibility and Proof of Concept.

BACKGROUND: Several diseases that involve the optic canal or its contained structures may cause visual impairment. Several techniques have been developed to decompress the optic nerve. OBJECTIVE: To describe minimally invasive extradural anterior clinoidectomy (MiniEx) for optic nerve decompression, detail its surgical anatomy, present clinical cases, and established a proof of concept. METHODS: Anatomic dissections were performed in cadaver heads to show the surgical anatomy and to show stepwise the MiniEx approach. In addition, these surgical concepts were applied to decompress the optic nerve in 6 clinical cases. RESULTS: The MiniEx approach allowed the extradural anterior clinoidectomy and a nearly 270° optic nerve decompression using the no-drill technique. In the MiniEx approach, the skin incision, dissection of the temporal muscle, and craniotomy were smaller and provided the same extent of exposure of the optic nerve, anterior clinoid process, and superior orbital fissure as that usually provided by standard techniques. All patients who underwent operation with this technique had improved visual status. CONCLUSIONS: The MiniEx approach is an excellent alternative to traditional approaches for extradural anterior clinoidectomy and optic nerve decompression. It may be used as a part of more complex surgery or as a single surgical procedure.

Abordaje pterional: alcances y revisión de la técnica quirúrgica / Pterional approach: scope and revision of the surgical technique

Objetivo: exponer nuestra experiencia quirúrgica en el abordaje pterional resaltando los alcances y detalles técnicos de dicho procedimiento. Material y método: Se realizó un estudio descriptivo retrospectivo, analizando las historias clínicas de 145 pacientes intervenidos quirúrgicamente a través de un abordaje pterional clásico o alguna de sus variantes, entre octubre de 2009 y octubre de 2012, en nuestro servicio. Se recabaron datos epidemiológicos y los relacionados a las diferentes patologías alcanzadas mediante esta vía. Para una mejor interpretación, las imágenes fueron adquiridas en 3D. Resultados: Durante dicho período se realizaron 149 craneotomías pterionales sobre un total de 145 pacientes, 4 de los cuales debieron ser sometidos a abordaje pterional bilateral. Fueron intervenidos 95 pacientes con aneurismas cerebrales, 9 de ellos con enfermedad aneurismática múltiple...

Objective: to report our surgical experience in the pterional approach, highlighting the extent and technical details of that procedure. Material and Method: we performed a retrospective study analyzing the medical records of 142 patients who went under surgery through a classic pterional approach or one of its variants, between October 2009 and October 2012. Epidemiological data was collected and also that related to the different pathologies achieved by this route. For a better interpretation, the images were taken in 3D. Results: during that period we performed 149 pterional craniotomies over a total of 145 patients, 4 of them underwent bilateral pterional approach. There were 95 patients with cerebral aneurysms, 9 of them with multiple aneurysmal disease...

Abordaje supracerebeloso infratentorial a la región pineal. técnica, indicaciones y anatomía microquirúrgica en 3D / Supra-adventitious approach to the pineal región. technique, indications and 3D microsurgical anatomy

INTRODUCCIÓN: el abordaje supracerebeloso infratentorial fue descripto originalmente por Sir Victor Horsley, siendo posteriormente adaptado por Stein quien aplica la técnica microquirúrgica mejorando los resultados de las cirugías de la región pineal. OBJETIVOS: resaltar y sistematizar las indicaciones, detalles técnicos-anatómicos en el abordaje supracerebeloso infratentorial en base a nuestra experiencia quirúrgica y la revisión de la anatomía microquirúrgica de la región Pineal. MATERIAL Y MÉTODOS: se realizó un estudio descriptivo retrospectivo analizando las historias clínicas de 7 pacientes intervenidos quirúrgicamente a través de un abordaje supracerebeloso infratentorial, entre septiembre 2010 hasta septiembre 2013 en nuestro servicio. Las imágenes intraquirúrgicas y de preparados anatómicos fueron adquiridas en 3D. La revisión bibliográfica se realizó en Pub Med utilizando las palabras claves: Abordaje Supracerebeloso Infratentorial; Región Pineal; Craniectomía Suboccipital. RESULTADOS: durante el período 2010-2013 fueron intervenidos 7 pacientes. A todos se le practicó un abordaje supracerebeloso infratentorial. Fueron tratados 5 tumores de la región pineal, 1 glioma del culmen cerebeloso y 1 MAV de la fisura cerebelo mesencefálica. Se estandarizaron los siguientes pasos para la realización del abordaje supracerebeloso infratentorial de Stein: preparación prequirúrgica, posición sentado, posición de la cabeza, marcación y antisepsia cutánea, colocación de campos estériles, incisión de piel y tejido celular subcutáneo, disección de plano muscular, craneotomía, apertura dural, preparación del corredor supracerebeloso, disección intradural y anatomía microquirúrgica de la región pineal y consideraciones sobre elcierre. CONCLUSIONES: se sistematizó el abordaje supracerebeloso infratentorial con el que pudimos acceder a tumores pineales y también a lesiones vasculares en la región. En todos los casos la exposición anatómica fue suficiente para tratar en forma adecuada las patologías mencionadas, con mínima retracción de las estructuras del SNC

INTRODUCTION: even though Horsley was the first one to describe the supracerebellar infratentorial approach, it was Stein who adapted it to microsurgical techniques in an attempt to improve the results of surgical procedures on the pineal gland. OBJECTIVES: to enhance the indications and technical details of the supracerebellar infratentorial approach, based upon our experiences, we review the microsurgical anatomy of the pineal region that is exposed via this approach. MATERIALS AND METHODS: a retrospective descriptive study was conducted by analyzing the records of seven patients who had been operated on using this approach at our institution between September 2010 and September 2013. The images shown were obtained in 3D. RESULTS: the indications for surgery in these seven patients were a pineal gland tumor in five patients, and a culmen glioma and mesencephalic-fissure AVM in one patient each. The following steps were standardized according to Stein's description of the supracerebellar infratentorial approach: pre-surgical preparation, sitting position, head position, incision drawing and anti-sepsis, surgical field, collocation, skin and hypodermis incision, muscular dissection, hemostatic control, craniotomy, dural opening, supracerebellar corridor preparation, intradural dissection, microsurgical anatomy study, and considerations regarding closure. CONCLUSIONS: via this approach, we not only have been able to access pineal gland tumors but also vascular lesions in this region. The anatomical exposure achieved was enough to treat these lesions successfully, with minimal manipulation of the CNS

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

Microsurgical clipping of previously coiled aneurysms.

OBJECTIVE: This study sought to show and analyze the main authors' experience (P.R. and J.M.C.) in previously coiled aneurysm surgery as an emerging challenge in today's neurosurgical practice. METHODS: Twelve female and 8 male patients, whose ages ranged from 32 to 56 years (average 43.5), underwent surgery between April 2009 and September 2012 in 2 centers. Reasons for surgery were 13 partially occluded aneurysms and 7 recanalized aneurysms. RESULTS: There was no mortality in this series. Aneurysmal sites were 5 anterior communicating artery aneurysms, 5 posterior communicating artery aneurysms, 3 middle cerebral artery aneurysms, 6 paraclinoid carotid artery aneurysms, and 1 aneurysm in the pericallosal artery. A patient sustained a postsurgical frontal infarction with mild neurological deficit. One of the aneurysms presented with an arterial branch at the level of the aneurysmal neck; therefore, partial clipping and packing was required. Microsurgical clipping in the remaining patients was performed successfully. Eight cases required partial coil removal before clipping. CONCLUSIONS: Surgical management of previously coiled aneurysms is an emerging challenge in neurosurgery. Incomplete or ineffective embolizations pose an increased risk for the patient, thus requiring surgical treatment. Although not advisable, coil removal might be necessary when in the vicinity of the aneurismal neck in order to place the clip correctly. The authors believe that adequate patient selection and careful preoperative planning are essential to reduce the incidence of patients with unsuccessful coils who will later need surgical treatment.

Three-dimensional imaging as a teaching method in anterior circulation aneurysm surgery.

OBJECTIVE: Our objective is to present and asses the utility of three-dimensional (3D) intraoperative imaging as a teaching method for anterior circulation aneurysm surgery. METHODS: The senior author's experience in anterior circulation aneurysm surgery during a 28-month period was documented and processed as 3D images and compared with two-dimensional (2D) images. Both 2D and 3D sets of images were created, and, along with a specially designed questionnaire, 30 physicians (15 experienced cerebrovascular surgeons and 15 neurosurgical trainees) were asked to answer the query and state the advantages and disadvantages of both methods. RESULTS: All physicians interviewed agreed that 3D imaging was better than 2D imaging, and that depth perception improved understanding of surgical tactics and anatomical landmarks. The resident/young trainee group seemed to receive more benefit from this than the experienced group. A total of 40% of residents and 20% of the experienced surgeons acknowledged a change in clipping strategy when comparing both sets. 3D imaging improved understanding of the ophthalmic segment in 66.6% of residents and 33.3% of the experienced group. CONCLUSION: Real 3D imaging in anterior circulation aneurysm surgery is an excellent tool to enhance vascular training. Inexperienced trainees seem to benefit greatly from it. This technique might be of use in the future development of new technologies.

Monitoreo de la presión intracraneana en paciente pediátricos con traumatismo de cráneo grave / Monitoring of intracranial pressure in pediatric patients with severe head trauma

El aumento y necesidad de control de la presión intracraneana (PIC) está asociado a diversas entidades clínico-quirúrgicas (edema cerebral, hemorragias, control postoperatorio de tumores, etc.) entre las cuales el traumatismo encefalocraneano (TEC) ocupa el lugar más importante. El TEC representa un grave problema sanitario a nivel mundial ya que constituye una de las causas más frecuentes de muerte en la edad pediátrica, siendo además la principal causa de retraso mental, epilepsia e incapacidad física. Hemos podido observar múltiples causas del TEC: obstétricas, caídas del niño, caída de la madre, accidentes pedestres y vehiculares, accidentes deportivos (fútbol, rugby, etc.), misceláneas (elementos arrojados, juguetes voladores, etc.), mordeduras de animales.

Abordaje fronto-orbito-cigomático en dos piezas: indicaciones y técnica quirúrgica / Fronto-orbito-zygomatic two-piece approach: indications and surgical technique

Objetivo: Resaltar las indicaciones y detalles técnicos en el abordaje fronto-órbito-cigomático en dos piezas en base a nuestra experiencia quirúrgica. Material y método: se realizó un estudio descriptivo retrospectivo analizando las historias clínicas de 18 pacientes intervenidos quirúrgicamente a través de un abordaje fronto-orbito-cigomático en dos piezas, entre junio de 2010 y junio de 2013, en nuestro servicio. Se obtuvieron datos epidemiológicos y los relacionados a las diferentes patologías alcanzadas mediante esta vía. Resultados: durante dicho período se realizaron 18 craneotomías fronto-orbito-cigomática en dos piezas. Fueron intervenidos 11 pacientes con aneurismas cerebrales, de los cuales 4 fueron aneurismas del segmento oftálmico de la arteria carótida interna, 3 de bifurcación alta de arteria carótida interna, 2 de la arteria comunicante anterior con orientación cefálica y 2 de la bifurcación de la arteria basilar. Así mismo, se logró la exéresis de 7 lesiones tumorales, de los cuales 4 fueron adenomas de hipófisis, 2 craneofaringioma y 1 glioma hipotalámico. Se estandarizaron los siguientes pasos para la realización del abordaje fronto-órbito-cigomático en dos piezas, compuesto por una craneotomía fronto-temporo-esfenoidal y una segunda pieza compuesta por techo orbitario y arcada cigomática. Conclusiones: dicho abordaje representa una importante vía de acceso para lesiones que comprometen región selar, paraselar y patología vascular del polígono de Willis con menor retracción cerebral y mayor exposición.

Purpose: To highlight the indications and surgical details in the two pieces fronto-orbito-zigomatic approach based on our surgical experience.Material and Methods: a descriptive retrospective study was done by the analysis of 18 medical histories of patients operated by a two pieces fronto-orbito-zigomatic approach, between June 2010-2013 in our sevice. Epidemiological facts and those related to the different pathology approaches were obtainedResults: 18 two pieces fronto-orbito-zigomatic craniotomies were performed during the analized period. 11 patients had cerebral aneurisms, 4 of them arised from the oftalmic segment of the internal carotid artery, 3 from a high bifurcation of the internal carotid artery, 2 from the basilar artery´s bifurcation. We also performed the resection of 7 tumors: 4 pituitary adenomas, 2 craniopharyngiomas and 1 hipotalamic glioma. The following steps were standarized to perform the two pieces fronto-orbito-zigomatic approach: first a fronto-temporo-esphenoidal craniotomy and then a second piece composed by the orbital roof and the zigomatic arc.Conclusions: this approach represents an important route of access to lesions that involve both sellar and parasellar regions and vascular pathology from the Circle of Willis with less brain retraction and more exposure.