Microsurgical and endoscopic-assisted supraorbital keyhole approach for intra-suprasellar cysticercosis.

Background: Treatment for intra/suprasellar cysticercosis can be challenging and may result in visual disturbances if not managed properly. Despite its limited knowledge, an effective surgical option exists to treat this condition. This article presents three cases of sellar cysticercosis, comprising one female and two male patients, managed with microsurgical supraorbital keyhole approach (mSKA) and endoscopic-assisted supraorbital keyhole approach (eaSKA). Case Description: The first patient is a 35-year-old man with no prior medical history who suffered from memory deficits and visual disturbances due to a sellar cyst pushing the orbitofrontal gyrus treated with mSKA. The second case involved a 52-year-old man who experienced visual deficits caused by a rostral sellar cyst with posterior displacement of the pituitary gland treated with eaSKA. The third case was a 46-year-old woman who experienced decreased visual acuity and memory loss due to multifocal neurocysticercosis (NCC) with sellarsuprasellar cyst extension treated with mSKA. All case diagnoses were confirmed by neuropathology department. Conclusion: The authors confidently suggest that the SKA is an effective surgical option and could be considered for removing sellar cystic lesions with suprasellar extension. With endoscopic assistance, it improves adequate neurovascular structure visualization.

The "ePTFE Sleeve" for Microvascular Decompression of the Facial Nerve.

Hemifacial spasm is a cranial nerve compression syndrome caused by the anteroinferior cerebellar artery (AICA) and posteroinferior cerebellar artery (PICA), characterized by involuntary tonic/clonic contractions of the muscles. The refractory hemifacial spasm can be treated with microvascular decompression, and multivessel compression could require more than conventional microvascular decompression. Multivessel compression may be challenging, and placement of conventional materials may not be sufficient and risks migration. Some transposition techniques for the vertebral artery may even increase the risk of injuring some perforators. Our circumferential expanded polytetrafluoroethylene (ePTFE) (IMPRA, Tempe, Arizona, USA) sleeve technique is unique and accessible, and it could solve this issue. The 2-dimensional Video 1 demonstrates the case of a 38-year-old woman who presented with debilitating left hemifacial spasm for 11 years. On physical examination, she exhibited involuntary, recurrent twitches of left facial muscles and loss of sensory taste. Magnetic resonance imaging revealed touching of the left dominance dolicoectasic vertebral artery, with compression of the PICA and AICA over cranial nerve VII. Conservative measures were recommended. Nevertheless, progressive worsening symptoms presented despite botulinum toxin injections. Left retrosigmoid craniotomy was performed, first placing a 3/4 ePTFE sleeve for decompression of the cisternal portion and the second ePTFE sleeve at the root entry zone of cranial nerve VII to optimize decompression of the offending vessel. In this case, we decided to use ePTFE prosthetic material. The semirigidity and semielastic property force brings an adequate decompression of the nerve and isolates it from the offending artery (AICA-PICA and vertebral artery). Without an uneventful postoperative course, the patient remained neurologically intact with immediate recovery after surgery without facial spasms or facial paresis. At 14 months' follow-up, the patient was without any alteration. The circumferential ePTFE Sleeve is an effective option for microvascular decompression. This technique offers semielastic continuous isolation of the nerve keeping it away from the offending artery. In addition, the circumferential ePTFE fit between neurovascular structures could avoid migration out of position. No cases using this technique have been reported; beyond that, we would like to illustrate this procedure, which is not widely available as a video article.

Wound Dehiscence After Occipital Encephalocele Surgical Repair in a Neonate: Management Alternative.

Encephaloceles are congenital malformations of the neural tube, mostly located in the occipital region in the Western world. Its presence is related to many complications, among which cognitive impairment and death are the most important. The diagnosis is usually made in the prenatal period, but sometimes due to poor control, this is not feasible. Surgery is required as early as possible to prevent further damage. Sometimes we can face complications related to the procedure, such as wound dehiscence, which has been the aim of this work. Many different types of treatments have been proposed for this complication: nevertheless, they result in invasive management. We present the case of a neonate's wound dehiscence, managed with potable water washes and a correct sterile technique, shown to be safe, reduce the in-patient costs, as well as improve the patient's and their family's quality of life (QoL).

Anterior Fontanelle Dermoid Cyst: Surgical Technique.

Dermoid cysts are benign congenital lesions that usually appear on the surface of the skull, mainly on the anterior fontanelle. Diagnosis is usually made in the first months of life by physical examination and imaging studies such as CT, MRI, or ultra sound (US) Doppler. It is important to distinguish it from other similar lesions that represent greater surgical complexity, morbidity, and mortality. In this work, we show the principle differential diagnoses, the diagnostic approach, and the surgical technique used in the resection of the dermoid cyst located over the anterior fontanelle.

Malformaciones cavernosas cerebrales, presentación de 14 casos y revisión de literatura / Brain cavernous malformations, presentation of 14 cases and literature review

Objetivo: Presentar los resultados de tratamiento quirúrgico obtenidos en una serie de 14 casos de malformación cavernosa, situadas en diferentes localizaciones encefálicas, además de realizar una revisión bibliográfica sobre el tema. Material y métodos: En el periodo de los años 2014-2019, se diagnosticaron y protocolizaron 14 pacientes por medio de la consulta externa de neurocirugía del Hospital Juárez de México. Todos menos 2, fueron intervenidos quirúrgicamente. Resultados: En 12 de los 14 casos que recibieron tratamiento quirúrgico, se documentó mejoría neurológica posterior a la resección total en 10 pacientes, 1 paciente de cavernoma gigante temporal se hizo resección subtotal, en 1 paciente con lesión de localización protuberancial se le realizó únicamente drenaje de hematoma. El déficit preoperatorio tendió a mejorar progresivamente en las lesiones de mayor tamaño y en ningún caso se documentaron complicaciones, las crisis convulsivas se controlaron disminuyendo progresivamente la dosis de fármacos anticonvulsivantes en el periodo postquirúrgico de este grupo de pacientes. Y dos pacientes, uno con lesión mesencefálica y el otro con cavernomatosis solo se sometieron a observación. Conclusiones: La cirugía es el método de elección hoy en día para el tratamiento de las malformaciones cavernosas, siendo los mejores resultados a menor tamaño de la lesión y con localizaciones más superficiales. Los resultados quirúrgicos de nuestros pacientes son similares a lo reportado en la literatura mundial.

Objectives: To present the surgical outcomes obtained in a series of 14 cases of cavernous malformation, located in different brain locations, in addition to conducting a literature review on the subject. Method: Between the years, 2014 and 2019, 14 cases were diagnosed and protocolized in neurosurgery department of Hospital Juárez of México. All patients except two, were surgically treated. Results: In 12 of the 14 cases received surgical treatment, neurological improvement was documented after the total resection in ten patients, one patient with giant temporal cavernoma performed a subtotal resection, other case with a lesion in the pontine location a hematoma drainage was performed. All surgical patients the preoperative clinical deficit tended to improve progressively in larger lesions and no complications were documented. Seizures were controlled by gradually decreasing the dose of anticonvulsant drugs in the post-surgical period of this group of patients. And two patients, one with mesencephalic lesion and another with cavernomatosis, were only observe. Conclusion: Surgery is the method of choice today for the treatment of cavernous malformations, with the best outcome being the smallest size of the lesion and with more superficial locations. The surgical outcomes in our patients are similar to those reported in the world literature

[Melanocytoma and meningeal melanocytosis, similar but different lesions]. / Melanocitoma y melanomatosis meníngea, lesiones similares pero diferentes.

BACKGROUND: Meningeal melanomatosis is an extra-axial well-encapsulated malignant tumour with diffuse meningeal growth and dark coloration (due to high melanin contents), while meningeal melanocytoma is the focalized benign variant. Melanocytic lesions may be secondary to melanoma or be histologically benign, however, their diffuse nature makes them impossible to cure. Melanocytosis is a diffuse tumour that can form solitary extra-axial tumours, which invades the parenchyma and presents signs of malignancy with increased mitosis and Ki67, observed in 1 to 6% of immunopathological exams. Melanoma of the leptomeninges, presents signs of malignancy with anaplastic cells, which cluster in fascicles of melanin in the cytoplasm, with more than 3 atypical mitoses per field and Ki67 presenting in more than 6% of the immunopathological fields analysed. CLINICAL CASE: We present the case of a patient with long-term meningeal melanomatosis, with progressive neurologic deficit and characteristic radiologic features, and another case of meningeal melanocytoma. CONCLUSIONS: Benign melanocytic neoplasms of the central nervous system must be treated aggressively in the early phases with strict follow-up to avoid progression to advanced phases that do not respond to any treatment method. Unfortunately, the prognosis for malignant melanocytic lesions is very poor irrespective of the method of treatment given.

[Preoperative embolization with microspheres of giant supratentorial meningiomas: 5-year experience]. / Embolización preoperatoria con microesferas en meningiomas gigantes supratentoriales: experiencia de 5 años.

BACKGROUND: Preoperative embolization of hypervascular tumours such as meningiomas has proven to be a favorable factor for resection of the latter because it diminishes intraoperative bleeding and the need for blood transfusions. OBJECTIVES: Evaluation of surgical outcomes of preoperative embolization with microspheres of giant supratentorial meningiomas. METHODS: We retrospectively analyzed patient records from 2007 to 2012 with the diagnosis of giant supratentorial meningiomas (> 5 cm) (n= 27) and obtained two samples: those with preoperative embolization (n= 14) and patients without any properative embolization (n= 13). We evaluated and compared statistically significant surgical bleeding, surgical time and resection grade (via Simpson scale). Additionally, we evaluated internal/external vascularization rate and the histopathologic diagnosis. RESULTS: According to the Simpson scale, the mean resection grade was 1.21 for embolized meningiomas, whereas for non-embolized meningiomas it was 1.92 . No differences were found in surgical bleeding and operative time. We used microspheres whose diameters were 40-120 µm, and these were easily observed with common microscopy techniques. In all cases we observed predominance in extracranial vascularization. No morbidity and mortality were recorded with the endovascular procedure. CONCLUSIONS: Embolization with microspheres improves resection rate evaluated by the Simpson scale in patients with giant supratentorial meningiomas.

ANTECEDENTES: la embolización preoperatoria de tumores hipervascularizados, como los meningiomas, ha demostrado ser un factor favorable para su resección quirúrgica en términos de menor sangrado transquirúrgico y transfusiones sanguíneas. OBJETIVOS: evaluar el beneficio quirúrgico de la embolización preoperatoria con microesferas en meningiomas gigantes supratentoriales. MATERIAL Y MÉTODOS: estudio retrospectivo de los expedientes de pacientes postoperados entre 2007 y 2012 con diagnóstico de meningiomas gigantes supratentoriales (>5 cm) (n= 27). La muestra se dividió en dos grupos: pacientes embolizados antes de la intervención (n= 14), y pacientes a quienes no se realizó embolización (n= 13). Se comparó la cantidad de sangrado transoperatorio, el tiempo quirúrgico, y el grado de resección evaluado por la escala de Simpson. Además, se evaluó el tamaño tumoral, la tasa de vascularización de la carótida interna y externa y el diagnóstico histopatológico. RESULTADOS: el promedio de resección de acuerdo con la escala de Simpson para meningiomas embolizados fue de 1.21, mientras que para meningiomas no embolizados fue de 1.92 (t de Student, p= < 0.014). No encontramos diferencias significativas en tiempo quirúrgico o en el sangrado transoperatorio. En más de la mitad de los casos utilizamos microesferas de 40-120 µm de diámetro. Las microesferas se observaron fácilmente con los métodos usuales de microscopia y tinción, su existencia se correlacionó con áreas focales de necrosis. En todos los casos se encontró predominio de vascularización extracraneal, sin que el procedimiento endovascular se asociara con mortalidad. CONCLUSIONES: la embolización de meningiomas gigantes supratentoriales con microesferas mejora el grado de resección quirúrgica evaluada por la escala de Simpson.

Importancia neuroquirúrgica del complejo venoso petroso superior / No disponible

Objetivo Conocer la anatomía microquirúrgica del complejo venoso petroso superior (CVPS).Material y métodos Se realizó estudio descriptivo y prospectivo. Se utilizaron 6 especímenes (12 lados) inyectados. Se estudió la anatomía microquirúrgica del CVPS en los encéfalos, mediante un abordaje retrosigmoideo y transpetroso anterior. Se utilizó instrumental neuroquirúrgico, endoscopio rígido de 0 grados, microscopio quirúrgico OPMI-1 con magnificación 6× a 20×. Se analizó el patrón de drenaje hacia el seno petroso superior, la formación de las venas tributarias, la relación con el nervio trigémino y las variantes del CVPS.Resultados El CVPS se encontró en todos los lados, la vena tributaria que se encontró en el 100% de los lados fue la vena de la fisura cerebelopontina. El patrón de drenaje del CVPS fue dividido en relación a la cresta suprameatal en: lateral, medial y en un punto intermedio. Se encontró el CVPS simple, formado por un tronco con sus tributarias, en 8 lados y duplicado en 4 lados. En el estudio se observó un triángulo formado por el tentorio, el CVPS y parte de la cara petrosa y tentorial del cerebelo con bordes y contenidos bien definidos, el cual se llamó triángulo petroso-tentorial. Conclusión Es necesario entender la anatomía microquirúrgica del CVPS. Así, proponemos el triángulo petroso-tentorial como corredor neuroquirúrgico para el manejo de lesiones del ángulo pontocerebeloso a la región petroclival superior (AU)

[Neurosurgical importance of the superior petrosal venous complex]. / Importancia neuroquirúrgica del complejo venoso petroso superior.

OBJECTIVE: To study the microsurgical anatomy of the superior petrosal venous complex (SPVC). MATERIAL AND METHODS: We conducted a descriptive and prospective study. Six injected specimens were used (12 sides). The microsurgical anatomy of the SPVC was studied by means of an anterior, retrosigmoid and transpetrosal approach. Neurosurgical equipment, 0-degree rigid endoscopy and OPMI-1 surgical microscope with 6× to 20× magnification were all used in this study. The venous drainage pattern toward the superior petrosal sinus was analysed, as were the formation of tributary veins, the relationship with the trigeminal nerve and the anatomical variants of SPVC. RESULTS: The SPVC was present in all cases. A tributary, cerebellopontine fissure vein was identified in 100% of cases. The venous drainage pattern of the SPVC was divided into medial, intermediate and lateral with respect to the suprameatal crest. The SPVC was simple in 8 sides and duplicate in 4 sides. A triangle formed by the tentorium, the SPVC and part of the tentorial and petrosal surface of the cerebellum was also observed in the study. This triangle was called the petrosal-tentorial triangle. CONCLUSIONS: It is important to understand the microsurgical anatomy of the SPVC. Therefore, we propose the petrosal-tentorial triangle as a neurosurgical route for the management of pathologies from the cerebellopontine angle to the superior petroclival region.