Safety margin for the preservation of the nasoseptal artery during trans-nasal endoscopic approach.

BACKGROUND: The introduction of the nasoseptal flap for the reconstruction of extended endoscopic approaches decreased the incidence of postoperative fistula. In order to preserve the septal vascular pedicles, many have started to prepare the flap systematically, prior to the opening of the sphenoid rostrum. The aim of this study is to obtain an average measure of the location of the posterior septal artery using the upper edge of the choana as a landmark. METHODS: Ten cadaveric heads, fixed with formaldehyde and injected with colored silicone, were studied. The course, branching pattern and dominance of the branches of the posterior septal artery were recognized, as well as the distance in of its superior and lower branches respect to the medial upper edge of the choana. RESULTS: In all cases, the posterior septal artery enters as an only vessel through the sphenopalatine foramen. In its sphenoid segment, over the sphenoid rostrum, the posterior septal artery divides into its upper and lower branches, in most cases, laterally to the sphenoid ostium (70%, N.=14). The lower branch was dominant in 60% of the cases (N.=12). Regarding the mean distance in millimeters from the medial upper edge of the choana to the superior branch, it was 14.45±0.4102 (18-11.5) and, to the lower branch, 10.9±0.4682 (14-7). CONCLUSIONS: A rostrum opening to 15 mm over the upper edge of the choana is safe to avoid vascular complications, and to be able to prepare a viable nasoseptal flap only if it is necessary.

Cadaveric Specimen Study of Prostate Microvasculature: Implications for Arterial Embolization.

PURPOSE: To describe the prostatic microvasculature anatomy and to measure the diameter of the intraprostatic vessels from human cadaveric specimens. MATERIAL AND METHODS: The prostates of 18 white males (35-68 years of age; mean prostate volume, 60.11 mL) were fixed in a solution of phosphate-buffered 10% formaldehyde and processed histologically with hematoxylin and eosin stain, Masson trichrome stain, immune peroxidase, and immunofluorescence. Fluorescence-conjugated antibodies (anti-CD34 and anti-actin smooth muscle) were used to mark the endothelium and the fibromuscular stroma, respectively. Each slide was digitally scanned and photographed under microscopy to measure the intraprostatic arterial diameters using image analysis software. RESULTS: In 28 hemipelvises (77.8%) a single dominant prostate artery was found (mean diameter, 1.96 mm). The microvasculature study identified 3 types of intraprostatic arterial distributions: internodal (IT), perinodal (PN), and intranodal (IN). The IT arteries are located at the trabeculae of the hyperplastic stroma between the nodules. The PN arteries were located at the periphery of each hyperplastic nodule before entering into it. The IN vessels were located inside the hyperplastic nodules as terminal arteries to the glands. The mean IT artery diameter was 317 µm (min-max range, 155-555 µm), mean PN artery diameter was 150 µm (min-max range, 59-266 µm), and the mean IN artery was 56 µm (min-max range, 24-104 µm). The diameters of intraprostatic arteries did not correlate with prostate volume (IT arteries, P = .303; PN arteries, P = .686; and IN arteries, P = .413). CONCLUSIONS: The description of the prostate microvasculature anatomy, as described by this cadaveric study, may provide useful information for prostate artery embolization.

Tratamiento endoscópico de 140 tumores de hipófisis, resultados y complicaciones / Endoscopic treatment of 140 pituitary tumors, results and complications

Objetivo: Presentar los resultados y las complicaciones de 140 pacientes con adenomas hipofisarios operados por vía transnasal endoscópica en un período de 4 años. Material y métodos: Se realizó un análisis retrospectivo desde marzo del 2011 hasta diciembre del 2014. Se analizaron las imágenes, los estudios oftalmológicos y hormonales, tanto pre como postoperatorios, así como también la morbimortalidad asociada al procedimiento quirúrgico. Resultados: Se registró un 57,9% de pacientes con tumores funcionantes (n = 81), siendo la patología más frecuente la acromegalia (29,3%). El 78,6% fueron macroadenomas (n = 110), de los cuales el 56,4% (n = 62) presentaban invasión del seno cavernoso; 61 presentaron alteración en el campo visual computarizado (44%). Tras la intervención, el 50,8% de los pacientes obtuvo mejoría. En un 60% de los casos se alcanzó una resección completa. De los pacientes con patología funcionante (81 casos), un 25% persistió con enfermedad activa tras la cirugía. Se registró un 15% de pacientes complicados (n = 21) y un solo fallecimiento (0,7%). Conclusión: Según los resultados obtenidos, esta técnica presenta baja morbimortalidad y elevado éxito terapéutico. La principal limitante para la resección quirúrgica completa es la invasión del seno cavernoso

Objective: To present the clinical and radiographic outcomes of 140 patients with pituitary adenomas treated by an endoscopic endonasal approach (EEA) over a period of 4 years. Material and methods: A retrospective analysis was performed between 2011 and 2014. Pre and post operative MRI, ophtalmological assessment, endocrinological laboratory evaluation and surgical morbidity and mortality were assessed. Results: 57,9% of the patients had functional tumors (n = 81), acromegaly being the most frequent sub-type (29.3%). 78.6% of the lesions were macroadenomas (n = 110) of which 56.4% (n = 62) involved the cavernous sinus, 61 patients presented with visual field defects (44%) of which 50.8% of patients showed improvement after surgery. Gross total removal was achieved in 60% of the cases. Hormonal remission was achieved in the 75% of the patients with functional tumors. The morbidity rate was 15% and one patient died after surgery (mortality 0.7%). Conclusion: EEA is a safe and effective tool to treat pituitary adenomas. The main limitation for complete surgical resection is the cavernous sinus invasion

[Endoscopic treatment of 140 pituitary tumors, results and complications]. / Tratamiento endoscópico de 140 tumores de hipófisis, resultados y complicaciones.

OBJECTIVE: To present the clinical and radiographic outcomes of 140 patients with pituitary adenomas treated by an endoscopic endonasal approach (EEA) over a period of 4 years. MATERIAL AND METHODS: A retrospective analysis was performed between 2011 and 2014. Pre and post operative MRI, ophtalmological assessment, endocrinological laboratory evaluation and surgical morbidity and mortality were assessed. RESULTS: 57,9% of the patients had functional tumors (n=81), acromegaly being the most frequent sub-type (29.3%). 78.6% of the lesions were macroadenomas (n=110) of which 56.4% (n=62) involved the cavernous sinus, 61 patients presented with visual field defects (44%) of which 50.8% of patients showed improvement after surgery. Gross total removal was achieved in 60% of the cases. Hormonal remission was achieved in the 75% of the patients with functional tumors. The morbidity rate was 15% and one patient died after surgery (mortality 0.7%). CONCLUSION: EEA is a safe and effective tool to treat pituitary adenomas. The main limitation for complete surgical resection is the cavernous sinus invasion.

[Microsurgical approach to the ambient cistern]. / Abordaje a la Cisterna Ambiens.

OBJECTIVE: To describe a step-by-step approach to the ambient cistern by the suboccipital retrosigmoid supracerebellar infratentorial (RSI) approach. DESCRIPTION: The RSI approach is performed in the same manner as the suboccipital retrosigmoid approach, usually used to access the pathology of the cerebellopontine angle, with the following modifications: (1) we always use the semi-sitting position, (2) the craniotomy-craniectomy must expose the transverse sinus and extend 5 cm medially to the inion, (3) when performing the dural opening it is necessary to mobilize the dura with the transverse sinus upwards, (4) under magnification with surgical microscope the cerebellomedullary cistern should be opened in order to drain cerebrospinal fluid for relaxing the cerebellum, and (5) arachnoidal adherences and bridging veins must be coagulated and cut if necessary. These maneuvers create a wide corridor to the ambient cistern. CONCLUSION: This approach allows a safe access to the ambient cistern, especially to the infratentorial portion.

Meningioma cordoide: reporte de dos casos y revisión de la literatura / Cordoid meningioma: report of two cases and review of the literature

El meningioma cordoide es un subtipo infrecuente de meningioma. La mayoría es de gran tamaño y de localización supratentorial. Suelen presentarse clínicamente con síntomas inespecíficos. La Resonancia Magnética de Cerebro muestra una lesión extraaxial compatible con meningioma, siendo la histología y las pruebas de inmunohistoquímica necesarias para realizar el diagnóstico definitivo. La anatomía patológica remeda a la del cordoma ya que se encuentran constituidos por células vacuoladas, epiteloides o fusiformes, dispuestas en cordones o islas dentro de una matriz mixoide. La importancia de conocer esta variante de meningioma radica en su alta tasa de recurrencia, principalmente si la exéresis es incompleta, por lo que son considerados como tumores de mayor agresividad y peor pronóstico. Se presentan dos casos de meningioma cordoide operados en nuestro centro.

Chordoid meningiomas are a rare form of meningioma that, as with most meningiomas, typically present as a bulky, supratentorial tumor. Otherwise, their clinical presentation is non-specific. Brain MRI shows an extra-axial lesion compatible with a meningioma; however, the diagnosis must be confirmed by histopathology and immunohistochemistry. Microscopically, these tumors are composed of spindle or epithelioid, partly-vacuolated cells arranged in nests or cords in a myxoid matrix, resembling a chordoma. Recurrence rates are high following subtotal resection. As such, these tumors are considered a more aggressive variant associated with poorer outcomes. Two patients with a chordoid meningioma treated surgically at our centre, using microsurgical techniques, are presented.

Pterional transsylvian-transinsular approach in three cavernomas of the left anterior mesiotemporal region.

OBJECTIVE: To describe the pterional transsylvian-transinsular approach for cavernomas of the left anterior mesiotemporal region in three patients. METHODS: A retrospective analysis of patients who underwent surgery for cavernous angiomas in the temporal lobe was performed via the left mesiotemporal lobe (MTL). The technique was as follows: using the pterional approach, the Sylvian fissure was widely opened, distally to proximally. The temporal branch of the middle cerebral artery was displaced medially, and once the limiting sulcus of the insula was located, an 8mm long corticotomy was performed, just behind the limen insulae. The dissection was extended through the white matter until the anterior portion of the temporal horn was reached. Finally, lesion resection was performed. RESULTS: Three patients presented with cavernomas in the anterior sector of the MTL and underwent the transsylvian-transinsular approach. There were no deaths in this series. One patient sustained a permanent postoperative deficit, a right homonymous quadrantanopia. CONCLUSION: The pterional transsylvian-transinsular approach allows for selective resection of lesions located in the anterior mesiotemporal region (MTR) of the dominant hemisphere, while avoiding damage to the lateral or basal cortex of the temporal lobe or to structures in the dominant hemisphere.

Human cadaveric specimen study of the prostatic arterial anatomy: implications for arterial embolization.

PURPOSE: To describe and illustrate the prostatic arterial anatomy from human cadaveric specimens, highlighting implications for prostatic arterial embolization. MATERIALS AND METHODS: Dissection of 18 male pelves from white adults 35-68 years old was performed in the anatomy laboratory. Arterial branches were identified according to standard dissection technique using a 20-diopter magnifying lens for the prostatic sector. The branches were colored with red acrylic paint to enhance contrast and improve visualization. RESULTS: Two main arterial pedicles to the prostate from each hemipelvis were identified in all cadaveric specimens: the superior and inferior prostatic pedicles. The superior prostatic pedicle provides the main arterial supply of the gland and provides branches to both the inferior bladder and the ejaculatory system. The inferior prostatic pedicle distributes as a plexus in the prostatic apex and anastomoses with the superior pedicle. This pattern of prostatic arterial distribution was constant in all cadaveric specimens. In contrast, the origin of the superior prostatic pedicle was variable from different sources of the internal iliac artery. CONCLUSIONS: The description and illustration of the prostatic arterial anatomy, as demonstrated by this cadaveric study, may provide useful information and guidance for prostatic arterial embolization.

Supratentorial and infratentorial brain abscesses: surgical treatment, complications and outcomes--a 10-year single-center study.

OBJECTIVE: To analyze the variables determining morbidity, mortality and outcome in subjects with brain abscesses treated at a single center over a 10-year period. METHODS: A retrospective study was conducted on a series of 59 patients with brain abscesses surgically treated with stereotactically guided aspiration or open craniotomy excision. Such variables as age, gender, clinical presentation, number of days to diagnosis, location, number of lesions, predisposing factors, mechanism of infection, etiological agent, and therapy were analyzed independently. Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery, and classified according to a four-point gradual severity scale. Postoperative outcome was appraised through the Glasgow Outcome Scale (GOS) 6 months after surgery, 0-4 points were considered poor outcome and 5 points good outcome. RESULTS: Eighty abscesses were diagnosed and surgically managed in 59 patients. The mean age was 44.69 years (range: 0.16-77); 59.3% were female. The median number of days to diagnosis was 7. Most frequent clinical presentations included fever (52.5%), headache (42.4%), and focal neurologic deficits (39%). Mechanism of infection was mainly hematogenous spread (32.2%). Stereotactically guided aspiration was the treatment of choice for 74.6% of the patients, whereas 25.4% of the cases were managed through open craniotomy excision. Outcome was favorable in 81.35% (n = 48) of the subjects. General morbidity was 27.1%, and mortality stood at 10.16%. Out of a total 38.98% (n = 23) of complications, two-thirds were due to medical causes. The analysis of variables revealed that only age (p = 0.02), immunosuppression (OR 5.83; p = 0.012) and hematogenous spread (p < 0.01) were associated with poor outcomes. CONCLUSIONS: Immunosuppression, hematogenous spread and advanced age were predictors of poor prognosis. Most of the complications following brain abscess management were not directly related to surgery or surgical technique.

Exposure of the sciatic nerve in the gluteal region without sectioning the gluteus maximus: an anatomical and microsurgical study.

BACKGROUND: Complete sectioning of the gluteus maximus muscle is an extensive procedure when approaching the sciatic nerve in the buttock, resulting in significant morbidity and a prolonged postoperative recovery period. By contrast, dissecting through the muscle by splitting its fibers is faster, involves less damage to tissues and diminishes recovery time. The objective of the present work was to perform a cadaveric study to obtain measurements of the maximum, minimum and mean exposure that this minimally invasive approach can offer. METHODS: Both gluteal regions from each of ten fresh cadavers were dissected via a transgluteal approach, using a transverse curvilinear incision. After exposure of the sciatic nerve, the maximum length of exposed nerve was measured. As a final step, a 6 cm long sural graft reconstruction was performed, aided by a surgical microscope and microscopic techniques. FINDINGS: The mean sciatic nerve exposure obtained was 115.4 ± 17.9 mm, ranging from a maximum of 152 mm to a minimum of 90 mm. In all 20 cases, it was possible to perform microsurgical reconstruction under the microscope. We further illustrate these findings with three live patients in whom the transgluteal approach was employed to successfully expose and repair the sciatic nerve. CONCLUSIONS: The transgluteal approach is useful in the operative repair of lesions of the proximal sciatic nerve. It is a less invasive technique than classical complete sectioning of the gluteus maximus muscle, and yields better aesthetic results and a faster return to normal daily activities. Complex lesions, like nerve trauma requiring grafts and nerve tumours, can be treated with minimal risk. Nevertheless, it is less comfortable for the surgeon, and the entire extent of the exposed nerve might not be visualized simultaneously during surgery.

Surgical anatomy of the platysma motor branch as a donor for transfer in brachial plexus repair.

OBJECT: Nerve transfers have become a major weapon in the battle against brachial plexus lesions. Recently, a case involving the successful use of the platysma motor branch to re-innervate the pectoralis major muscle was reported. The present anatomical study was conducted to clarify the surgical anatomy of the platysma motor nerve, in view of its potential use as a donor for transfer. METHODS: Microsurgical dissections of the facial nerve and its terminal branches were performed bilaterally in five formaldehyde-fixed cadavers, thereby yielding ten samples for study. The relationships between the platysma motor branch and adjacent structures were studied and measurements performed. Specimens were removed and histologically studied. RESULTS: The platysma branch of the facial nerve was found to arise from the cervicofacial trunk. In five instances, one main nerve innervated the platysma muscle, and there was a smaller accessory nerve; in four cases, there was just a single branch to the muscle; and in one case, there was a main branch and two accessory branches. The distance between the gonion and the platysma motor branch averaged 0.8 cm (range 0.4-1.1 cm). The platysma branch received thin anastomotic rami from the transverse superficial cervical plexus. The neural surface of the platysma motor branch, on average, was 76% the surface area of the medial pectoral nerve. CONCLUSION: The anatomy of the platysma motor branch is predictable. Contraction of the platysma muscle is under voluntary control, which is an important quality for a donor nerve selected for transfer. The clinical usefulness of platysma motor branch transfer still must be elucidated.