Localization of Maxillary Artery for Cerebral Revascularization: L-Shaped Perpendicular Two-Step Drilling Technique Stretching from the Foramen Ovale to Rotundum.

BACKGROUND: The use of the maxillary artery (MA) as a donor has increasingly become an alternative method for cerebral revascularization. Localization difficulties emerge due to rich infratemporal anatomical variations and the complicated relationships of the MA with neuromuscular structures. We propose an alternative localization method via the interforaminal route along the middle fossa floor. METHODS: Five silicone-injected adult cadaver heads (10 sides) were dissected. Safe and effective localization of the MA was evaluated. RESULTS: The MA displayed anatomical variations in relation to the lateral pterygoid muscle (LPM) and the mandibular nerve branches. The proposed L-shaped perpendicular 2-step drilling technique revealed a long MA segment that allowed generous rotation to the intracranial area for an end-to-end anastomosis. The first step of drilling involved medial-to-lateral expansion of foramen ovale up to the lateral border of the superior head of the LPM. The second step of drilling extended at an angle approximately 90° to the initial path and reached anteriorly to the foramen rotundum. The MA was localized by gently retracting the upper head of the LPM medially in a posterior-to-anterior direction. CONCLUSIONS: Considering all anatomical variations, the L-shaped perpendicular 2-step drilling technique through the interforaminal space is an attainable method to release an adequate length of MA. The advantages of this technique include the early identification of precise landmarks for the areas to be drilled, preserving all mandibular nerve branches, the deep temporal arteries, and maintaining the continuity of the LPM.

Management of Persistent Syringomyelia in Patients Operated for Chiari Malformation Type 1.

BACKGROUND: The treatment of persistent syringomyelia associated with Chiari malformation type 1 (CM1) is unclear. This study aims to evaluate the clinical and radiologic outcomes of syringo-subarachnoid shunt (SSS) as a treatment for persistent syringomyelia following posterior fossa decompression (PFD) for CM1. METHODS: Forty-nine cases treated for CM1 associated syringomyelia at a single center were analyzed, 17 of them undergoing reoperation due to persistent syrinx formation. The patients' demographic data, neurologic presentations, and radiologic results were analyzed, including cerebellar herniation, posterior fossa volume, the level at which the syrinx started and finished, the size and diameter of the syrinx. RESULTS: Seventeen patients underwent SSS placement, with 1 minor surgical complication (a cerebrospinal fluid leak) occurring and requiring revision. No morbidity or mortality was observed. Among these 17 reoperated patients, partial or complete resorption of the syrinx was observed in all cases. The results suggest that if the syrinx diameter is >10 mm at its thickest point, extends for more than 10 vertebrae, and starts from the upper cervical region and extends to the upper thoracic region, the syrinx may not regress after the first surgery and potentially predicting the need for a second operation before PFD. CONCLUSIONS: SSS placement for persistent syrinx following PFD for CM1 is a safe and effective surgical treatment method. These criteria may also help predict the need for a second surgery and the overall disease outcome for both the surgeon and patient.

Posterior-only approach in patients with poor general condition and spinal metastatic vertebral fracture / Corpectomía con abordaje solo posterior en pacientes con mal estado general y fractura vertebral metastásica espinal

Purpose The surgical treatment of spinal metastases is mostly palliative in nature and focuses on improving the quality of life of patients. The posterior transpedicular surgical approach provides circumferential 360° decompression, allows reconstruction and stabilisation to be achieved in a single session and can be performed using an open, mini-open or minimally invasive approach. We present and discuss the surgical techniques and outcomes for patients with single-level metastatic spinal disease and in poor general condition who underwent surgery via the posterior-only transpedicular corpectomy approach and reconstruction with expandable corpectomy cages. Methods Patients with a single level thoracolumbar metastatic disease (T3-L5) and a Karnofsky score of ≤70, who underwent a complete posterior transpedicular corpectomy with expandable cage reconstruction of the anterior spinal column were retrospectively reviewed. Patients’ demographics, SINS, modified Tokuhashi scores as well as preoperative and postoperative ASIA scale, Karnofsky scores, VAS scores and vertebral height/Cobb angle values were analysed. Results A total of 44 patients (24 M/20 F) (mean age 53.25±21.26 years) met the inclusion criteria. The modified Tokuhashi scores were as follows: score 0–8, 5 (11.4%) patients; score 9–11, 14 (31.8%) patients; and score 12–15, 25 (56.8%) patients. There were significant improvements in the postoperative VAS scores (mean 7.7–2.9), Karnofsky scores (mean 63.3–79.6) as well as the Cobb angles (18.6–12.8°) and vertebral height (AU)

Propósito El tratamiento quirúrgico de las metástasis espinales es principalmente de naturaleza paliativa y se enfoca en mejorar la calidad de vida de los pacientes. El abordaje quirúrgico transpedicular posterior proporciona una descompresión circunferencial de 360°, permite lograr la reconstrucción y estabilización en una sola sesión y se puede realizar mediante un abordaje abierto, miniabierto o mínimamente invasivo. Presentamos y discutimos las técnicas quirúrgicas y los resultados para pacientes con enfermedad espinal metastásica de un solo nivel, y en mal estado general, que se sometieron a cirugía mediante el abordaje de corpectomía transpedicular solo posterior y reconstrucción con jaulas de corpectomía expandibles. Métodos Se revisaron retrospectivamente pacientes con una enfermedad metastásica toracolumbar de un solo nivel (T3-L5) y una puntuación de Karnofsky≤70, que se sometieron a una corpectomía transpedicular posterior completa con reconstrucción de la columna anterior con jaula expandible. Se analizaron los datos demográficos de los pacientes, SINS, las puntuaciones de Tokuhashi modificadas, así como la escala ASIA preoperatoria y posoperatoria, las puntuaciones de Karnofsky, las puntuaciones VAS y los valores de altura vertebral/ángulo de Cobb. Resultados Un total de 44 pacientes (24 M/20 F) (edad media 53,25±21,26 años) cumplieron los criterios de inclusión. Las puntuaciones de Tokuhashi modificadas fueron las siguientes: puntuación de 0 a 8, 5 (11,4%) pacientes; puntuación 9-11, 14 (31,8%) pacientes; y puntuación 12-15, 25 (56,8%) pacientes. Hubo mejoras significativas en las puntuaciones VAS postoperatorias (media de 7,7 a 2,9), las puntuaciones de Karnofsky (media de 63,3 a 79,6), así como los ángulos de Cobb (18,6° a 12,8°) y la altura vertebral. Treinta y cinco pacientes mostraron una función neurológica mejorada en al menos un grado ASIA, mientras que 9 no mostraron mejoría durante el período postoperatorio (AU)

Endoscopic Endonasal Optic Nerve Decompression in Idiopathic Intracranial Hypertension: When to Implement Optic Nerve Sheath Fenestration.

BACKGROUND AND OBJECTIVE: Idiopathic intracranial hypertension (IIH) is a syndrome characterized with increased intracranial pressure and normal cerebrospinal fluid (CSF) composition. Treatment is mainly conservative, whereas CSF diversion surgery is the most frequently used surgical intervention. Endoscopic endonasal optic nerve decompression (EOND) is a newer surgical treatment of this patient group. This study presents a single clinic's case series with comparative results of unilateral an bilateral EOND with or without optic nerve fenestration. METHODS: Sixteen patients with IIH syndrome who underwent 18 EOND procedures by a single neurosurgeon were evaluated with MRI and digitally subtracted angiography preoperatively. Both preoperative and postoperative visual acuity and perimetry and fundoscopy examinations were routinely performed. All patients underwent sphenoidotomy using the endoscopic binostril approach; however, unilateral or bilateral optic nerve decompression and accompanying optic sheath fenestration was determined on a case-by-case basis, after which all patients were also evaluated for the outcome of headaches. RESULTS: Most of the patients were female, and the mean age was 30.28 ± 9.78 years. CSF pressure was increased in all patients (406.43 ± 112.91 mm of H 2 O), and the follow-up period was 61.72 ± 21.67 months. In patients with unilateral EOND, visual fields improved in 83%, visual acuity in 70%, headache in 75%, and papilledema in 27% of cases. In patients with bilateral EOND, perimetry improved in 86%, visual acuity in 43%, headache in 50%, and papilledema in 57% of cases. CONCLUSION: EOND is an effective surgical option in the treatment of IIH. Bilateral decompression is preferable in patients with bilateral visual involvement, and optic nerve fenestration may prove to be helpful in patients with IIH whose primary complaint is headache.

Posterior-only approach in patients with poor general condition and spinal metastatic vertebral fracture.

PURPOSE: The surgical treatment of spinal metastases is mostly palliative in nature and focuses on improving the quality of life of patients. The posterior transpedicular surgical approach provides circumferential 360° decompression, allows reconstruction and stabilisation to be achieved in a single session and can be performed using an open, mini-open or minimally invasive approach. We present and discuss the surgical techniques and outcomes for patients with single-level metastatic spinal disease and in poor general condition who underwent surgery via the posterior-only transpedicular corpectomy approach and reconstruction with expandable corpectomy cages. METHODS: Patients with a single level thoracolumbar metastatic disease (T3-L5) and a Karnofsky score of ≤70, who underwent a complete posterior transpedicular corpectomy with expandable cage reconstruction of the anterior spinal column were retrospectively reviewed. Patients' demographics, SINS, modified Tokuhashi scores as well as preoperative and postoperative ASIA scale, Karnofsky scores, VAS scores and vertebral height/Cobb angle values were analysed. RESULTS: A total of 44 patients (24 M/20 F) (mean age 53.25±21.26 years) met the inclusion criteria. The modified Tokuhashi scores were as follows: score 0-8, 5 (11.4%) patients; score 9-11, 14 (31.8%) patients; and score 12-15, 25 (56.8%) patients. There were significant improvements in the postoperative VAS scores (mean 7.7-2.9), Karnofsky scores (mean 63.3-79.6) as well as the Cobb angles (18.6-12.8°) and vertebral height. Thirtyfive patients showed improved neurological function by at least one ASIA grade, whereas 9 showed no improvement during the postoperative period. CONCLUSIONS: This technique, which has a low complication rate and a short recovery time, can help achieve satisfactory results even in patients with poor metabolic profiles and Karnofsky scores in the preoperative period. Further clinical studies with large patient groups are warranted to confirm the results of this study.

Surgical Outcome of Young and Adult Patients with Temporal Lobe Epilepsy Related to Hippocampal Sclerosis in Modern Era.

AIM: To evaluate the preoperative, operative, and postoperative outcomes of young and adult patients who underwent surgery for temporal lobe epilepsy related to hippocampal sclerosis (TLE-HS). MATERIAL AND METHODS: This retrospective study assessed prospectively registered data collected from 2010 to 2020. Clinical, electrophysiological, pathological, and postoperative outcomes were evaluated and compared. Post-surgical seizure outcome was classified into continuous seizure freeness without aura and relapse. RESULTS: In total, 16 young and 48 adult patients with TLE-HS were included in the analysis. The clinical, electrophysiological, pathological, and postoperative outcomes were similar between the young and adult groups. However, the seizure outcome did not significantly differ between the two groups (p=0.38). A significant proportion of patients in both groups were satisfied with the surgical outcomes. CONCLUSION: Surgery is extremely effective against TLE-HS in young patients, as in adults. Furthermore, the clinical, radiological, and pathological outcomes are similar between young and adult patients with TLE-HS.

Do we need postoperative antibiotics in supratentorial clean neurosurgery? A prospective, randomized, single-blind, and placebo-controlled study.

BACKGROUND: To assess the efficacy of postoperative antibiotics on postoperative infection in clean supratentorial craniotomies. METHODS: This study is a prospective, randomized, single-blind, and placebo-controlled clinical trial that included consecutive patients who underwent clean supratentorial craniotomy between November 2017 and September 2020 and evaluated the effectiveness of postoperative antibiotic prophylaxis on postoperative infection. RESULTS: A total of 80 patients were included and the whole group was divided into two groups. Group A included patients who received antibiotic prophylaxis and group B who did not receive antibiotic prophylaxis after surgery. Each group included the same number of patients (40 patients in each). Two patients showed postoperative infection, and both were in group B. No significant difference was found regarding postoperative infection between the two groups (p = 0.15). The rate of postoperative infection was found to be 2.5% in the whole group (2 cases out of 80) and it was 5% in group B (2 cases out of 40). DISCUSSION: Our results showed that antibiotic prophylaxis after a clean supratentorial craniotomy has no effect on the prevention of postoperative infection and we do not suggest using antibiotic prophylaxis after clean supratentorial neurosurgery.

Trigeminal neuralgia as a complication after anterior temporal lobectomy: A case report.

Temporal lobe epilepsy (TLE) is one of the most common forms of focal epilepsy. Anterior temporal lobectomy (ATL) leading to high rate of seizure freedom is a safe and well-established procedure in TLEs. Cranial nerve deficits, especially for oculomotor, trochlear and facial nerve were reported as a complication after ATL. Nonetheless, trigeminal neuralgia due to ATL is a very rare complication documented in the literature. The surgeons performing ATL procedures must be aware of the risk of trigeminal nerve injury, avoid excessive electrocautery use in the medial part of middle fossa and provide clean surgery in there to prevent this rare complication.