The Mini-Spheno-Supraorbital Craniotomy for Treatment of Ruptured Anterior Circulation Aneurysms.

Objective:Yasargil introduced the pterional approach mainly for clipping of anterior circulation (AC) aneurysms. We implemented the mini-spheno-supraorbital (MSS) craniotomy, changing the shape and reducing the size of the classical pterional craniotomy. The literature on clipping ruptured AC aneurysms through reduced-in-size craniotomies is sparse. This study aims to describe the technique and present our experience in clipping ruptured AC aneurysms through the MSS approach. Materials and methods: The MSS craniotomy was used in 114 cases of clipping ruptured AC aneurysms. A single burr hole was placed at the "keyhole" and an ellipsoid bone flap in the spheno-supraorbital region was raised. The tabula interna was thinned circumferentially, the roof of the orbit was flattened. Among aneurysm clipping, the lamina terminalis and the subarachnoid basal cisterns were opened. The imaging modality, the severity of the subarachnoid hemorrhage (SAH) according to Hunt & Hess (H&H), the size of the bone flap, the surgery duration and the aneurysm obliteration rate seen at the postoperative DSA were examined. Results:Out of all patients in the study, 71% had exclusively CT-angiogram as initial imaging and suffered low-grade (H&H I°) SAH (71%). The mean size of the bone flap was 1.6 x 4.5 cm (1.3 x 4.3 - 2 x 8.5 cm). The approach allowed adequate 360°-dissection, sufficient proximal and distal control, brain relaxation though laminoterminotomy and opening of the basal cisterns. The mean duration from skin incision to clip application was 130 minutes (64-236 mins). Total obliteration rate was 97.3%. Conclusion:The MSS craniotomy is feasible in terms of safety and speed for clipping of ruptured AC aneurysms especially in lower-grade SAH.

Tissue Healing in Hemicraniectomy.

Introduction Decompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse "question mark" ("Dandy flap") incision. The goal of this study was to analyze the details of tissue healing problems in DHC.  Materials and methods A total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the "Dandy flap" incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05. Results The most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins). Conclusion A noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic "Dandy flap" incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.

The evaluation of the usefulness of CO2 laser in microsurgical resection of brain tumors.

Background: Since its introduction to surgery, the CO2 laser has been used in the treatment of various neurosurgical pathologies as it combines cutting, vaporizing, and coagulating properties in one tool and has a safe penetration depth. In this case series of 29 patients, we present the evaluation of the usefulness of the closed system type - sealed tube surgical CO2 laser in the surgical removal of brain tumors. Methods: The Sharplan 40C model SurgiTouch, sealed tube type CO2 laser, was used in the resection of 29 brain tumors; 13 meningiomas, six metastases, nine gliomas, and one acoustic neuroma. The same senior surgeon (BT) assessed and classified the benefit provided by the CO2 laser in the resection of the neoplasms to considerable (Group 1), moderate (Group 2), and poor (Group 3). Results: Group 1 included 14 patients with 13 meningiomas and one acoustic neuroma, Group 2 included six patients, all of whom had metastases, and Group 3 included nine patients of which six had glioblastoma and three astrocytoma. No complications or technical problems occurred due to the use of the CO2 laser. Conclusion: The CO2 laser is a valuable complementary tool in brain tumor surgery displaying high efficacy and practicality in the resection of neoplasms which are fibrous and have hard consistency. It has high acquisition and maintenance cost and cannot replace the bipolar diathermy. The newest generation of flexible CO2 laser fiber provides more ergonomy and promises new perspectives of its neurosurgical use in the modern era.

The Use of Real-Time 3D Intraoperative Ultrasound "Angiography" in Localization and Occlusion Control of a Ruptured Mycotic Aneurysm: A Case Report.

BACKGROUND: Infectious (mycotic) aneurysms are rare with high mortality and are most commonly found at the distal branches of the middle cerebral artery (MCA). Because aneurysms of the distal MCA are located deep in the Sylvian fissure and are small in size, intraoperative identification and safe clip occlusion of these aneurysms are challenging. Thus, the use of intraoperative imaging and navigation can be beneficial. We describe the use of intraoperative real-time 3D ultrasound "angiography" (3D-iUS) in localizing and occlusion control of a ruptured MCA M3 segment mycotic aneurysm. To our knowledge, its application in the surgery of a ruptured mycotic distal MCA aneurysm is not yet reported. CLINICAL PRESENTATION: A 54-year-old woman with a history of septic thrombophlebitis treated with long-term antibiotic therapy presented with sudden onset of headaches, dysphasia, and seizures. Computed tomography (CT) revealed subarachnoid hemorrhage in the distal portion of the left Sylvian fissure. Digital subtraction angiography (DSA) showed an aneurysm at the peripheral branch of the M3 segment of the MCA with characteristics of an infectious aneurysm. A microsurgical treatment was decided. 3D-iUS scan showed an aneurysm within the Sylvian fissure at a depth of 5 cm. The aneurysm was clipped and a repeated 3D-iUS scan showed total occlusion of the aneurysm and patency of the parent artery. The intraoperative findings were confirmed with a postoperative DSA. CONCLUSION: Our case report shows that real-time 3D-iUS, despite its limitations, is an important tool to locate and ascertain the successful clip occlusion of an aneurysm, especially when intraoperative angiography (IA) and indocyanine green (ICG) videoangiography are not available due to low-income settings.

Clipping of a basilar tip aneurysm using hypothermia and circulatory arrest: a case report.

Treatment of complex and giant aneurysms remains challenging despite modern endovascular and microsurgical techniques. We report the first case of microsurgical clipping of a complex basilar tip aneurysm under circulatory arrest and hypothermia performed in Greece. A 52-year-old patient presented with a Hunt and Hess Grade 4 subarachnoid hemorrhage. The digital subtraction angiography revealed a complex basilar tip aneurysm. Due to aneurysm complexity, we decided for microsurgical clipping under hypothermia and circulatory arrest. We performed a right pterional craniotomy with orbitozygomatic osteotomy. The patient was then put on heart-lung-machine. Following hypothermia and circulatory arrest, the aneurysm was clipped with its complete occlusion. The patient was discharged with no neurological deficits. Clipping of complex aneurysms under hypothermia and cardiac arrest performed by experienced team is a safe alternative when endovascular therapy or bypass technique is not feasible.