Resection of ruptured spinal pial arteriovenous fistula under ultrasound control: how I do it.

BACKGROUND: Spinal pial arteriovenous fistulae are rare intradural superficial vascular lesion consisting in a direct shunt between spinal pial arteries and veins. The presentation of pial arteriovenous fistula is caused by venous congestion with spinal cord ischemia, mass effect, or hemorrhage. The treatment is surgery or endovascular procedure. METHODS: We illustrate the case of thoracic pial arteriovenous fistula in a 66-year-old female operated with posterior midline approach and B-mode US. CONCLUSION: Posterior midline approach with targeted laminotomy using high-speed drill affords an ideal surgical exposure. B-mode US is helpful to detect the fistula and study their relationship with the surrounding structures.

Endoscopic resection of a low-grade ependymoma of the pineal region.

BACKGROUND: Full endoscopic resection of solid brain tumors represents a challenge for neurosurgeons. This can be achieved with modern technology and advanced surgical tools. CASE DESCRIPTION: A 23-years-old male was referred to our unit with raised intracranial pressure. Head computed tomography and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus and a third ventricle lesion. Endoscopic third ventriculostomy and biopsy were performed, a left frontal external ventricular drain was left in place. A second-look surgery for endoscopic removal was planned. Decision to proceed with an endoscopic removal was supported by the following characteristics found during the first surgery: tumor exophytic, soft texture, scarce vascularity, and low-grade appearance. A rescue strategy for microscopic resection via transcallosal approach was decided. A straight trajectory to the tumor was planned with navigation. A further anterior left frontal burr-hole was performed, and the ventricular system was entered via the left frontal horn. Resection was carried out alternating laser for hemostasis and cutting, endoscopic ultrasonic aspirator, and endoscopic forceps for piecemeal resection. Laser hemostasis and cutting (1 Watt power at tip, continuous wave mode) were useful at the ventricular wall-tumor interface. Relevant landmarks guided the approach and the resection (foramen of Monro, mammillary bodies, aqueduct, pineal and suprapineal recess, and posterior commissure). The surgery was carried uneventfully. Histopathology confirmed a lowgrade ependymoma. Post-operative MRI showed residual tumor within the lower aqueduct. At 3 years follow-up, residual tumor is stable. CONCLUSION: In selected cases, endoscopic resection for third ventricular tumors is feasible and safe, and represents a valid alternative to microsurgical approaches.

Isolated subarachnoid hemorrhage in mild traumatic brain injury: is a repeat CT scan necessary? A single-institution retrospective study.

BACKGROUND: Traumatic brain injury (TBI) with isolated subarachnoid hemorrhage (iSAH) is a common finding in the emergency department. In many centers, a repeat CT scan is routinely performed 24 to72 h following the trauma to rule out further radiological progression. The aim of this study is to assess the clinical utility of the repeat CT scan in clinical practice. METHODS: We reviewed the medical charts of all patients who presented to our institution with mild TBI (mTBI) and isolated SAH between January 2015 and October 2017. CT scan at admission and control after 24 to 72 h were examined for each patient in order to detect any possible change. Neurological deterioration, antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries, and length of stay in hospital were analyzed. RESULTS: Of the 649 TBI patients, 106 patients met the inclusion criteria. Fifty-four patients were females and 52 were males with a mean age of 68.2 years. Radiological iSAH progression was found in 2 of 106 (1.89) patients, and one of them was under antiplatelet therapy. No neurological deterioration was observed. Ten of 106 (9.4%) patients were under anticoagulation therapy, and 28 of 106 (26.4%) were under antiplatelet therapy. CONCLUSION: ISAH in mTBI seems to be a radiological stable entity over 72 h with no neurological deterioration. The clinical utility of a repeat head CT in such patients is questionable, considering its radiation exposure and cost. Regardless of anticoagulation/antiplatelet therapy, neurologic observation and symptomatic treatment solely could be a reasonable alternative.

Transpalpebral Superolateral Orbitotomy for Orbital Cavernous Hemangioma Extirpation: 2-Dimensional Operative Video.

Cavernous hemangiomas of the orbit are low-pressure vascular tumors. Usually benign, they become symptomatic by the local mass effect, pushing the eyeball forward, causing exophthalmia, by oculomotor muscle and nerve compression causing diplopia or by optic nerve compression, leading to visual impairment. Radiotherapy is of limited value in their treatment because of the fragility of the optic nerve and subsequent blindness risk. Surgery remains the gold standard and definitive treatment. We illustrate in this video a transpalpebral superolateral orbitotomy and extirpation of an orbital cavernous hemangioma. A 52-yr-old healthy woman was sent for neurosurgical consultation by her ophthalmologist. She described a history of progressive unilateral right exophthalmia in the last months. A cerebral magnetic resonance imaging (MRI) revealed a 2.5-cm-large orbital lesion located superiorly and laterally to the eyeball. Surgery was proposed and accepted by the patient. The frontozygomatic component of the orbital rim needed to be removed to safely extirpate the cavernous hemangioma without exerting unnecessary and risky pressure on the eyeball.1,2 We decided to go for a superolateral orbitotomy via a transpalpebral incision.3 Total removal of the lesion was achieved with no complication. Exophthalmia normalized. Written patient consent was obtained for use and publication of their image after complete information. The patient consented to the surgery.

Transconjunctival Extirpation of a Voluminous Orbital Cavernoma: 2-Dimensional Operative Video.

Purely intraorbital cavernomas remain rare, but still are the most common benign orbital tumors.1 These expansive lesions are now rapidly detected and adequately treated. Surgical resection is the gold standard and a definitive solution. The choice of approach varies between different possibilities, including orbitotomies, trans-sinusal routes, and transconjunctival accesses.2-4 Because the last technique is less known to the neurosurgeon, we describe here a step-by-step guide to perform it. The technique is illustrated with the case of a 62-yr-old male with a voluminous right retroocular cavernoma. He presented a progressive right exophthalmia without visual acuity or campimetric deterioration. Because the cavernoma was purely medial from the optic nerve in the intraconal space, no osteotomy was deemed necessary to extirpate the lesion. The video shows the conjunctival dissection, followed by the medial rectus muscle being dissected, allowing us to attain the retrobulbar space in the orbit. The cavernoma is then dissected from the surroundings and reduced in volume by coagulation so its removal does not apply hyperpressure on the adjacent fragile structures. We then pursue with the closure by stitching the medial rectus muscle to the eyeball. Finally, the conjunctiva is sutured. Postoperatively, there was no complication. A transient mydriasis due to ciliary nerve manipulation spontaneously resolved. Extirpation of the lesion was total. The patient's exophthalmia normalized over the next months. No visual or campimetric deterioration was noted at follow-up. A slight horizontal diplopia was noted after surgery, which normalized at 1 yr. The patient's consent was obtained for the procedure.

Supraorbital Keyhole Approach for Resection of Prechiasmatic Craniopharyngioma: 2-Dimensional Operative Video.

Craniopharyngioma are benign extra-axial tumors occurring classically in the vicinity of the sella. Because of the complex anatomy surrounding the sella turcica comprising, among others, the vessels of the circle of Willis, the optic nerves, chiasma and optic pathway, the hypothalamus, the third ventricle, and the pituitary gland, a large variety of technical approaches have been described. We illustrate, in this video, a unilateral supraorbital keyhole approach to access and entirely extirpate a prechiasmatic craniopharyngioma. A 40-yr-old healthy male presented to the emergency department with a history of rapid visual deterioration in the left eye in the last 10 d. A brain computed tomography scan showed a circumscribed prechiasmatic cystic lesion partially calcified that was radiologically compatible with a craniopharyngioma on the magnetic resonance imaging. We decided to access the lesion by a right-sided subfrontal corridor using a frontal wrinkle for the skin incision. This technique allows rapid and safe access to the central prechiasmatic region. By choosing a contralateral approach, we aim at optimizing the control on the opposite optic nerve with a perpendicular view. Total removal of the craniopharyngioma was accomplished without causing neurological deterioration. In fact, left eye visual disturbances were immediately retrieved after the surgery. No endocrinological issue or postoperative complication was reported. Minimal cosmetic disturbances are achieved with a meticulous skin incision and bone flap reconstruction.

Navigated Intraoperative 2-Dimensional Ultrasound in High-Grade Glioma Surgery: Impact on Extent of Resection and Patient Outcome.

BACKGROUND: Maximizing extent of resection (EOR) and reducing residual tumor volume (RTV) while preserving neurological functions is the main goal in the surgical treatment of gliomas. Navigated intraoperative ultrasound (N-ioUS) combining the advantages of ultrasound and conventional neuronavigation (NN) allows for overcoming the limitations of the latter. OBJECTIVE: To evaluate the impact of real-time NN combining ioUS and preoperative magnetic resonance imaging (MRI) on maximizing EOR in glioma surgery compared to standard NN. METHODS: We retrospectively reviewed a series of 60 cases operated on for supratentorial gliomas: 31 operated under the guidance of N-ioUS and 29 resected with standard NN. Age, location of the tumor, pre- and postoperative Karnofsky Performance Status (KPS), EOR, RTV, and, if any, postoperative complications were evaluated. RESULTS: The rate of gross total resection (GTR) in NN group was 44.8% vs 61.2% in N-ioUS group. The rate of RTV > 1 cm3 for glioblastomas was significantly lower for the N-ioUS group (P < .01). In 13/31 (42%), RTV was detected at the end of surgery with N-ioUS. In 8 of 13 cases, (25.8% of the cohort) surgeons continued with the operation until complete resection. Specificity was greater in N-ioUS (42% vs 31%) and negative predictive value (73% vs 54%). At discharge, the difference between pre- and postoperative KPS was significantly higher for the N-ioUS (P < .01). CONCLUSION: The use of an N-ioUS-based real-time has been beneficial for resection in noneloquent high-grade glioma in terms of both EOR and neurological outcome, compared to standard NN. N-ioUS has proven usefulness in detecting RTV > 1 cm3.

Bone Recontouring by Guided Surgical Navigation Integrating "Mirroring" Computational Planning in the Management of Severe Fronto-orbital Asymmetry in Fibrous Dysplasia.

We report the successful treatment of severe fronto-orbital asymmetry in a 20-year-old man with fibrous dysplasia by bone recontouring using a specific approach combining "mirroring" virtual computational planning with intraoperative guided surgical navigation.

Bilateral anterior sternothoracotomy (clamshell incision): a suitable alternative for bilateral lung sarcoma metastasis in children.

BACKGROUND: The aim of our study was to assess the postoperative course of bilateral anterior sternothoracotomy (BAT) in children with sarcoma metastases, in a curative care perspective. METHODS: We reviewed the records of seven patients younger than 18 years old, who underwent surgical procedures for sarcoma metastasis to the lung between 2000 and 2012. We compared the postoperative course of the BAT group with that of patients who underwent unilateral posterolateral thoracotomies (PLTs) for the same etiology. RESULTS: Of 17 surgical procedures, there were seven BAT and 10 unilateral PLT. Mean ages at the time of the procedures were 12.9 ± 5.4 years old for BAT, and 17.4 ± 1.9 years old for PLT. Mean operative time was 173 ± 37 minutes in the BAT group, and 145 ± 39 minutes in the PLT group (P = 0.19). Patients received epidural analgesia in all cases; this was for a mean time of 3.8 ± 1.3 days in the BAT group, and 3.21 ± 4 days in the PLT group (P = 0.36). Chest tubes were removed after 3.6 ± 1.3 days in the BAT group, and 3 ± 1.2 days in the PLT group (P = 0.69). Total hospital stay was 7.7 ± 6.6 days in the BAT group, and 7 ± 1.2 days in the PLT group (P = 0.72). CONCLUSION: In our experience, BAT seems suitable and shows outcomes similar to those of PLT for sarcoma metastasis resection. The BAT procedure allows the manual exploration of both lungs during a single surgical intervention, and so reduces the delay of further therapies.