Is nasal airflow disrupted after endoscopic skull base surgery? A short review.

Even the most delicate endonasal surgery for skull base lesion causes changes in the nasal cavity, some of them permanent. Morphological changes in the nasal cavity and their consequences (changes in nasal airflow) are often studied by advanced numerical analysis called computational fluid dynamics. This review summarizes current knowledge of endoscopic transsphenoidal skull base surgery effects on nasal airflow. Several studies have shown that endoscopic skull base surgery changes nasal anatomy to the extent that nasal airflow changes significantly postoperatively. Removing any intranasal structure increases the cross-sectional area of the respective nasal meatus, leading to increased nasal airflow in this area while airflow in the narrower periphery decreases. Middle turbinate resection increases airflow in the middle meatus and reduces airflow in the superior and inferior meatus. Small posterior septectomy does not cause a significant change in nasal airflow. Nasal septum deviation is an important factor in airflow changes. Current studies describe nasal changes after rather extensive procedures (e.g., middle turbinectomy, ethmoidectomy) that are unnecessary in routine pituitary adenoma surgery. No studies have compared changes using pre- and postoperative scans of the same patients after actual surgery.

Radiological analysis of the results of expandable implant insertion in one- to two-level cervical somatectomy.

INTRODUCTION: The aim of the study was to radiologically analyse the results of expandable implant insertion in one- to two-level cervical spine somatectomy. METHODS: A total of 28 patients undergoing one- to two-level somatectomy in cervical spine were postoperatively examined by CT. The following radiological parameters were studied: Cobb angle C2-7, segmental Cobb angle, implant subsidence and bone fusion. RESULTS: The average Cobb angle of C2-7 in preoperative images was 13.7 degrees, 13.4 degrees in the early postoperative period (p=0.88), and 10.3 degrees (p=0.043) 2 years after the surgery. The average segmental Cobb angle in preoperative images was 4.4 degrees, 5.2 degrees in the early postoperative period (p=0.61), and 0.2 degrees (p=0.01) 2 years after the surgery. Significant implant subsidence was observed in 15 cases (53.6%). Grade I fusion was achieved in 6 cases (21.4%), grade II fusion in 12 cases (42.9%), and stable pseudoarthrosis (grade III) in 9 cases (32.1%). No cases of unstable pseudoarthrosis (grade IV) were detected. CONCLUSION: Implantation of an expandable vertebral body implant in one- to two-level cervical spine somatectomy with ventral plate fixation is a fully acceptable way to reconstruct the ventral column of the cervical spine, providing sufficient long-term stability of the cervical spine and instrumentation and an adequate cervical spine curve.

Chronic subdural hematoma - review article.

INTRODUCTION: Chronic subdural hematoma (ChSDH) is, by definition, a subdural collection of blood older than 21 days. It is not exceptional that ChSDH is diagnosed in regional hospitals and thus we believe that basic knowledge on this topic is relevant for every general surgeon. Below, we summarize information on ChSDH and present simple clinical management guidelines. TREATMENT: In asymptomatic patients with ChSDH, monitoring alone may be sufficient. Subdural collections of only a few millimeters are a relatively common incidental finding on graphical examination of the brain, especially in the elderly with brain atrophy. In symptomatic patients, surgical treatment is justified. As a first step, burr hole evacuation of the hematoma in local anesthesia is performed. It is a simple, well-tolerated procedure and advantageous in elderly polymorbid patients. In symptomatic patients with recurrent ChSDH, reoperation using either the same burr hole or a new one is indicated. Patients with multilobulated hematomas that recur after the burr hole are scheduled for a craniotomy. CONCLUSION: ChSDH is a common condition encountered by all general surgeons during their clinical practice. The most common clinical presentations of ChSDH are headache, confusion, hemiparesis and aphasia. Asymptomatic patients may be followed by watchful waiting, whereas symptomatic patients are indicated for surgical treatment. All patients with ChSDH should be referred to a neurosurgical department (preferably a certified level 1 trauma center) with experience in neurotrauma care.

[Surgical approaches to pineal region - review article]. / Chirurgické prístupy do pineální krajiny - prehled.

INTRODUCTION: The pineal region is a deep-seated part of the brain surrounded by highly eloquent structures. Differential diagnosis of space-occupying lesions in this region encompasses pineal gland cysts, pineal gland tumours, metastases, germ cell tumours, meningiomas, gliomas, hemangioblastomas and neuroectodermal tumours. A treatment strategy is based mainly on tumour anatomical characteristics and histological type. Except germinatous tumours, a surgical excision is the treatment of choice. METHODS: Microsurgical approaches: The microsurgical supracerebellar-infratentorial approach is an essential approach to the pineal region. Despite certain risks, it allows a straightforward and completely extracerebral approach with a minimal cerebellar retraction. The other basic approach is the microsurgical occipital-transtentorial approach that is advantageous in patients with a supratentorial tumour extension or a steep tentorium. The interhemispheric-transcallosal approach and the transcortical-transventricular approach are possible options in selected cases.Endoscopic approaches: The neuroendoscopy provides a minimally invasive method to perform a tumour biopsy and to treat hydrocephalus in one session. Stereotactic biopsy: The stereotactic needle biopsy represents an alternative to the endoscopic biopsy in patients without hydrocephalus and in patients with dorsally located lesions inaccessible from the third ventricle. CONCLUSION: Modern neurosurgery offers a rich variety of surgical approaches to the pineal region. The complexity of space-occupying lesions in this region requires an individualised treatment, a prudent preoperative planning and a meticulous surgical technique.

[Endoscopic endonasal treatment of cerebrospinal fluid leak caused by clival fracture--a case report]. / Endoskopické endonazální osetrení nasální likvorey pri zlomenine klivu--kazuistika.

INTRODUCTION: Clivus is a central structure of the skull base located in the vicinity of the brainstem and vital brain vessels. Clival fractures are usually caused by a high-energy trauma. Cerebrospinal fluid leak is one of the most common complications. CASE REPORT: A middle-aged male sustained a mild head trauma, followed by a nasal cerebrospinal fluid leak. CT scan revealed the massive pneumocephalus and the fracture of the clivus in the posterior wall of the sphenoidal sinus. We performed an endoscopic endonasal surgery to seal the defect. DISCUSSION: Pneumatization of a sphenoidal sinus shows high variability. In the presented case, extreme pneumatization of the sinuses was combined with the gracile clivus, which was the predisposing factor for fracture. Traumatic cerebrospinal fluid leak carries the risk of intracranial hypotension and meningitis. Microscopic transseptal management is the classical surgical approach, while endoscopy provides the modern miniinvasive option. CONCLUSION: Endoscopic endonasal treatment of traumatic cerebrospinal fluid leak is the treatment of choice for the clival fractures.

Surgery of brainstem cavernous malformations.

BACKGROUND: Cavernomas are vascular hamartomas made up of thin-walled, grossly dilated blood vessels lined with endothelium. Between 4 and 35 % (mean 15 %) of cerebral cavernomas are located in the brainstem making resection of these lesions one of the most challenging tasks in neurosurgery. METHODS: Patients with cavernomas within the brainstem or deep supratentorial structures were chosen from our prospectively collected database of operated patients with brain cavernomas. The timespan of treatment was between January 1998 and June 2012. Primary outcome was defined as percentage of patients with favourable outcome (Glasgow Outcome Scale (GOS) 4 or 5) at 1 year. Secondary outcome was defined as operation-related morbidity and mortality (drop at least 1 point on GOS at 1 year). RESULTS: A total of 37 patients underwent surgery. The mean age was 34.7 ± 11.7 years. The male to female ratio was 19:16. Thirty-two patients had a solitary lesion and 12 patients harboured multiple lesions. The Glasgow outcome score 4 or 5 was achieved after 34 operations (89.5 %). The mean follow-up was 39 months. We experienced two early post-operative deaths (5.3 %) and decrease in the Glasgow outcome scale postoperatively in 4 patients (10.5 %). CONCLUSIONS: • Favourable outcome was achieved in 89.5 % of cases. • Although M&M appears to be relatively high, surgery is method of choice for surgically accessible lesion which has bled for the first time due to reported high rebleed rate and high probability of poor outcome after cavernoma rebleed. • Radiosurgery should be reserved for those lesions which are deemed unresectable and where surgical intervention is considered favourable to observation alone.