Symptomatic Outcome after Bone-only Suboccipital Decompression in Adult Patients with Chiari Type I Malformations in the Absence of Hydromyelia or Hydrocephalus.

Background Type I Chiari malformation presents without an associated hydromyelia in 30 to 70% of cases, yet there is no agreement regarding the optimal surgical treatment for these patients. We review our experience for treating symptomatic adult type I Chiari malformation without hydromyelia using a suboccipital bone decompression of the hindbrain and no duraplasty in 12 adult patients. Outcome was measured according to the Chicago Chiari Outcome Scale (CCOS). Results Nine of 12 patients were female; average age at surgery was 34.4 years (range: 17-67 years). Average duration of symptoms prior to surgery was 9.6 years (2 months-29 years). The most common symptom was head and/or neck pain (11/12 patients). All patients additionally presented with at least one non-pain symptom. Mean degree of tonsillar herniation on magnetic resonance imaging was 6.8 mm (range: 5-12 mm) below McRae's line. Operative time was on average 68 minutes (range: 47-120 minutes). No surgical complications were noted in any patient. Length of hospital stay was 2 days (1 overnight) for all patients. Mean follow-up was 167 weeks (range: 13-378 weeks). CCOS for all patients on average was 14.50 (range: 12-16). Pain symptoms underwent improvement (7/11 [63.6%]) or complete resolution (4/11 [36.4%]) in all affected patients. A shorter duration of preoperative symptoms significantly correlated with a better CCOS (p = 0.03). Degree of tonsillar herniation had no significant effect on CCOS (p = 0.67). Of non-pain symptoms, paresthesias/dysesthesias and visual symptoms improved or resolved completely in all affected patients. No patient experienced a worsening of either pain or non-pain symptoms. Conclusion In the subset of adult patients with a type I Chiari malformation and no associated hydromyelia, a craniectomy without an additional opening of the dura may achieve good overall results according to the CCOS.

Endoscopic fenestration of intraventricular cerebrospinal fluid cysts: the contralateral approach.

OBJECTIVE: The endoscopic fenestration of intraventricular CSF cysts has evolved into a well-accepted treatment modality. However, definition of the optimal trajectory for endoscopic fenestration may be difficult. Distorted ventricular anatomy and poor visibility within the cyst due to its contents can make endoscopic fenestration challenging if approached from the ipsilateral side. In addition, transcortical approaches can theoretically cause injury to eloquent cortex, particularly in patients with dominant-sided lesions. The aim of this study was to examine the value of the contralateral transcortical transventricular approach in patients with dominant-sided ventricular cysts. METHODS: During a 5-year period between 2007 and 2011, 31 patients with intraventricular CSF cysts underwent surgery by the senior author (R.R.). Fourteen of these patients had cysts located on the dominant side. An image-guided endoscopic cyst fenestration via the contralateral transcortical transventricular approach was performed in 11 patients. A retrospective chart review was performed in all these patients to extract data on clinical presentation, operative technique, and surgical outcome. RESULTS: The most common presenting symptom was headache, followed by memory deficits and cognitive deterioration. In all cases CSF cysts were space occupying, with associated obstructive hydrocephalus in 8 patients. Image-guided endoscopic fenestration was successfully performed in all cases, with septum pellucidotomy necessary in 6 cases, and endoscopic third ventriculostomy in 1 case for additional aqueductal occlusion. Postoperative clinical outcome was excellent, with no associated permanent neurological or neuropsychological morbidity. No recurrent cysts were observed over a mean follow-up period of 2 years and 3 months. CONCLUSIONS: The contralateral approach to ventricular cysts can achieve excellent surgical outcomes while minimizing approach-related trauma to the dominant hemisphere. Careful case selection is essential to ensure that the contralateral endoscopic trajectory is the best possible exposure for sufficient cyst fenestration and restoration of CSF circulation.

Pineal cyst resection in the absence of ventriculomegaly or Parinaud's syndrome: clinical outcomes and implications for patient selection.

OBJECT: Surgical indications for patients with pineal cysts are controversial. While the majority of patients harboring a pineal cyst require no treatment, surgery is a well-accepted option for a subset of those patients with secondary hydrocephalus or Parinaud's syndrome. The majority of pineal cysts are identified incidentally during workup for other potential conditions, which may or may not be related to the presence of the cyst. In the absence of clear obstruction of CSF pathways, the treatment of presumed symptomatic pineal cysts is debatable. To clarify the role of surgery in these borderline cases, the authors reviewed their experience with resection of pineal cysts in the absence of ventriculomegaly or Parinaud's syndrome. METHODS: The authors retrospectively reviewed medical records and imaging of all patients surgically treated between 2001 and 2014 with a pineal cyst in the absence of ventriculomegaly and Parinaud's syndrome. The presenting symptoms, preoperative cyst size, preoperative radiographic aqueductal compression, extent of resection, and radiographic and clinical follow-up were documented. RESULTS: Eighteen patients (14 female and 4 male; mean age 24 years, range 4-47 years) underwent cyst resection in the absence of ventriculomegaly or Parinaud's syndrome. Presenting symptoms included headache (17 patients), visual disturbances (10 patients), gait instability (5 patients), dizziness (5 patients), episodic loss of consciousness (2 patients), and hypersomnolence (1 patient). The mean preoperative cyst diameter was 1.5 cm (range 0.9-2.2 cm). All patients had a complete resection. At a mean clinical follow-up of 19.1 months (range postoperative to 71 months), 17 (94%) patients had resolution or improvement of their presenting symptoms. CONCLUSIONS: The authors' results suggest that ventriculomegaly and Parinaud's syndrome are not absolute requisites for a pineal cyst to be symptomatic. Analogous to colloid cysts of the third ventricle, intermittent occlusion of cerebrospinal fluid pathways may cause small pineal cysts to become intermittently symptomatic. A select cohort of patients with pineal cysts may benefit from surgery despite a lack of hydrocephalus or other obvious compressive pathology.

Patients' cosmetic satisfaction, pain, and functional outcomes after supraorbital craniotomy through an eyebrow incision.

OBJECT: The supraorbital approach through an eyebrow incision offers the opportunity to access a wide variety of lesions of the anterior, middle, and even the posterior fossa. The minimally invasive keyhole craniotomy limits brain exploration and retraction and offers the potential for improved surgical outcomes and reduced approach-related complications. Patient satisfaction, however, has not yet been reported in the literature. METHODS: From January 2002 through December 2011, the lead author (R.R.) used a supraorbital approach through an eyebrow incision for 418 patients with cerebral aneurysms, brain tumors or cystic lesions, and other miscellaneous pathological conditions. For 408 of these patients, a detailed retrospective case note review was conducted to extract data on surgical outcomes and complications, and 375 patients completed a follow-up patient satisfaction questionnaire. RESULTS: During the early perioperative period, 8 patients died (overall mortality rate 2.0%). Among patients surveyed, the overall level of satisfaction was high. Patients rated pain from the scar and headache on a scale from 1 to 5 (1 = no pain, 5 = severe pain) as follows: pain was a score of 1 for 289 patients (77.0%), 2 for 46 (12.3%), 3 for 22 (5.9%), 4 for 12 (3.2%), and 5 for 6 (1.6%). Patients also rated cosmetic outcome on a scale from 1 to 5 (1 = very pleasant, 5 = very unpleasant) as follows: outcome was a score of 1 for 315 patients (84.0%), 2 for 33 (8.8%), 3 for 14 (3.7%), 4 for 10 (2.7%), and 5 for 3 (0.8%). Postoperative chewing difficulty was reported for 8 patients (8 [2.1%] temporary, 0 permanent); palsy of the frontal muscle for 21 patients (5.6%; 13 [3.5%] temporary, 8 [2.1%] permanent); frontal hypesthesia for 31 patients (8.3%; 18 [4.8%] temporary, 13 [3.4%] permanent); and hyposmia for 11 patients (2.9%; 3 [0.8%] temporary, 8 [2.1%] permanent). CONCLUSIONS: The supraorbital approach to the anterior, middle, and posterior fossae through an eyebrow incision offers a favorable rate of approach-associated surgical complications and high patient satisfaction with cosmetic outcome.

Cerebrospinal fluid leaks after planned intradural spine surgery: a single-center analysis of 91 cases.

UNLABELLED: BACKGROUND AND STUDY OBJECT: A leak-proof dura closure after elective surgery for intradural spinal lesions is important to achieve an uncomplicated postoperative course. Because many different closure techniques and dura substitutes exist, we tried to identify the superior material and technique to avoid cerebrospinal fluid leaks (CSFLs). PATIENTS AND METHODS: Between 2004 and 2009, 91 patients underwent surgical treatment of intradural spinal pathologies with primary dura closure with or without the use of dura substitutes at our institution. Pre- and postoperative images and the clinical course were analyzed retrospectively with respect to the occurrence of CSFL. RESULTS: In 34% of the 91 patients, radiological signs of CSFL were observed. A total of 12 patients (13%) were symptomatic for CSFL and required a single puncture, lumbar drain, or surgical revision. No significant relation between CSFL and patient characteristics, underlying diagnosis, localization, or extension was noted. In contrast, the incidence of CSFL was significantly increased if more than one substitute for dura closure was used. The results showed that 41.7% of these patients showed radiological signs of CSFL as compared with 10.4% of patients in which only a single material was used. CONCLUSION: In our study, none of the applied products appeared to be superior to the others. Surgery with the combined use of multiple dura closure substitutes was associated with the enhanced incidence of postoperative CSFL. However, our findings concerning the various dura sealants could not be used to compare those different materials, due to the great variety of combinations of dura sealants and the retrospective analysis of the data.