Ventricular Access Utilizing Cutaneous Reference Points: Statistical Analysis and Proposal of a New Ventricular Entry Point.

OBJECTIVES: Perform radiologic measurements and analysis of normal brain computed tomography (CT) scans; delineate a new ventricular entry point from cutaneous landmarks, highlighting the potential surgical implications of these findings. METHODS: Six radiologic distances (AR; BR; AL; BL, C, and D) were measured in normal brain CT scans using Horos software. Statistical analysis of the measurements was performed with minitab18 software based on age, sex, and side. RESULTS: 132 brain CT scans were analyzed, yielding the following mean results: AR distance: 2.1 cm; BR distance: 7 cm; AL distance: 2.1 cm; BL distance: 7.1 cm; C distance: 12.4 cm; D distance: 7 cm; new ventricular entry point: 12.4 cm posterior to the nasion, and 2.1 cm lateral to the midline. CONCLUSIONS: The freehand technique for accessing the lateral ventricles is a common neurosurgical procedure but is often accompanied by complications. To address this, we suggest a novel entry point for ventricular access, determined by cutaneous reference points. This point is situated 12.4 cm posterior to the nasion along the midline and 2.1 cm lateral to the midline. Although our findings may play a role in presurgical planning for ventricular pathologies, future prospective studies are warranted.

Microsurgical Resection of a Medulla Oblongata Cavernoma: 3-Dimensional Operative Video.

Cavernous malformations occur in approximately 0.5% of the population. When it comes to the medulla oblongata, the incidence rate is around 5%.1,2 Patients with these conditions face potential risks such as hemorrhaging, substantial mortality, and morbidity. The symptoms experienced by the patient vary depending on the extent of hemorrhaging and the location of the lesion. Surgery stands as the primary and essential form of treatment in these cases.1-4 The aim of this operative video was to present the removal of a medulla oblongata cavernoma. The patient consented to the procedure and to the publication of her images and surgical video. We describe the case of a 53-year-old woman presenting with headaches and with swallowing difficulties, being tracheostomized on hospital admission. Magnetic resonance imaging showed a lesion located at the medulla oblongata. Owing to the patient's symptoms and cavernoma bleeding, surgical resection was determined. There were no adverse outcomes after surgery, and the patient evolved favorably. Postoperative imaging displayed complete removal of the cavernoma. Microsurgical resection of cavernomas in this location with neurophysiological monitoring and selection of the safe entry zone is an effective option.1-4.

COVID-19-Associated Portal Vein Thrombosis Post-Cholecystitis.

This case study describes a 45-year-old Caucasian male with a past medical history of obesity, hypertension, and non-insulin-dependent diabetes mellitus, who in the setting of coronavirus disease 2019 (COVID-19) pneumonia, developed portal vein thrombosis (PVT) presenting as an acute abdomen after hospital discharge from a cholecystitis episode. PVT is a very infrequent thromboembolic condition, classically occurring in patients with systemic conditions such as cirrhosis, malignancy, pancreatitis, diverticulitis, autoimmunity, and thrombophilia. PVT can cause serious complications, such as intestinal infarction, or even death, if not promptly treated. Due to the limited number of reports in the literature describing PVT in the COVID-19 setting, its prevalence, natural history, mechanism, and precise clinical features remain unknown. Therefore, clinical suspicion should be high for PVT, in any COVID-19 patient who presents with abdominal pain or associated signs and symptoms. To the best of our knowledge, this is the first report of COVID-19-associated PVT causing extensive thrombosis in the portal vein and its right branch, occurring in the setting of early-stage cirrhosis after a preceding episode of cholecystitis.

Intracranial Hypertension following Acute Mesenteric Ischemia: A Case Study on the Multiple Compartment Syndrome.

In this case study, we describe a 25-year-old male who was admitted due to a severe traumatic brain injury, requiring invasive intracranial pressure monitoring. At 48 hours posttrauma, he developed intracranial hypertension refractory to medical treatment without tomographic changes in the brain. Subsequently, intra-abdominal hypertension and tomographic signs of abdominal surgical pathology were observed. An exploratory laparotomy was performed with an intraoperative diagnosis of acute mesenteric ischemia. After surgical intervention for the abdominal pathology, intracranial pressure was restored to physiological values with a favorable recovery of the patient. In this report, the relationship between intracranial pressure and intra-abdominal pressure is discussed, highlighting the delicate association between the brain, abdomen, and thorax. Measures should be taken to avoid increases in intra-abdominal pressure in neurocritical patients. When treating intracranial hypertension refractory to conventional measures, abdominal causes and multiple compartment syndrome must be considered. The cranial compartment has physiological interdependence with other body compartments, where one can be modified by variations from another, giving rise to the concept of multiple compartment syndrome. Understanding this relationship is fundamental for a comprehensive approach of the neurocritical patient. To the best of our knowledge, this is the first report of a comatose patient post-traumatic brain injury, who developed medically unresponsive intracranial hypertension secondary to acute mesenteric ischemia, in which surgical resolution of intra-abdominal pathology resulted in intracranial pressure normalization and restitutio ad integrum of neurological status.

"Ping-pong" fracture: An exclusive entity of neonates and infants? A case analysis and literature review.

Background: "Ping-pong" fractures are a type of depressed fracture in which there is no rupture of the inner or outer table of the skull. It is produced by incomplete bone mineralization. Its appearance is frequent during neonatal and infant ages and is extremely rare outside of these age periods. The objective of this article is to present the case of a 16-year-old patient who presented a "ping-pong" fracture after a traumatic brain injury (TBI) and discuss the underlying physiopathogenesis of these types of fractures. Case Description: A 16-year-old patient presented to the emergency department with a TBI, referring headaches and nausea. Non-contrast brain computed tomography displayed a left parietal "ping-pong" fracture. Laboratory tests showed hypocalcemia, subsequently diagnosing hypoparathyroidism. The patient remained under observation for 48 h. He was managed conservatively and started on calcium carbonate and vitamin D supplements with a favorable evolution. Hospital discharge was granted with TBI discharge instructions and warning signs. Conclusion: The age of presentation of our case was atypical, according to the reported literature. When faced with a "ping-pong" fracture outside of an early age, underlying bone pathologies must be ruled out, which could potentially generate incomplete bone mineralization of the skull.

Virtual preoperative planning and 3D tumoral reconstruction with Horos open-source software.

Background: Presurgical three-dimensional (3D) reconstructions allow spatial localization of cerebral lesions and their relationship with adjacent anatomical structures for optimal surgical resolution. The purpose of the present article is to present a method of virtual preoperative planning aiming to enhance 3D comprehension of neurosurgical pathologies using free DICOM image viewers. Case Description: We describe the virtual presurgical planning of a 61-year-old female presenting a cerebral tumor. 3D reconstructions were created with the "Horos®" Digital Imaging and Communications in Medicine viewer, utilizing images obtained from contrast-enhanced brain magnetic resonance imaging and computed tomography. The tumor and adjacent relevant structures were identified and delimited. A sequential virtual simulation of the surgical stages for the approach was performed with the identification of local gyral and vascular patterns of the cerebral surface for posterior intraoperative recognition. Through virtual simulation, an optimal approach was gained. Accurate localization and complete removal of the lesion were achieved during the surgical procedure. Virtual presurgical planning with open-source software can be utilized for supratentorial pathologies in both urgent and elective cases. Virtual recognition of vascular and cerebral gyral patterns is helpful reference points for intraoperative localization of lesions lacking cortical expression, allowing less invasive corticotomies. Conclusion: Digital manipulation of cerebral structures can increase anatomical comprehension of neurosurgical lesions to be treated. 3D interpretation of neurosurgical pathologies and adjacent anatomical structures is essential for developing an effective and safe surgical approach. The described technique is a feasible and accessible option for presurgical planning.

A simple technique for generating 3D endoscopic images.

Background: Most neurosurgical photographs are limited to two-dimensional (2D), in this sense, most teaching and learning of neuroanatomical structures occur without an appreciation of depth. The objective of this article is to describe a simple technique for obtaining right and left 2D endoscopic images with manual angulation of the optic. Methods: The implementation of a three-dimensional (3D) endoscopic image technique is reported. We first describe the background and core principles related to the methods employed. Photographs are taken demonstrating the principles and also during an endoscopic endonasal approach, illustrating the technique. Later, we divide our process into two sections containing explanations, illustrations, and descriptions. Results: The results of taking a photograph with an endoscope and its assembly to a 3D image has been divided into two parts: Photo acquisition and image processing. Conclusion: We conclude that the proposed method is successful in producing 3D endoscopic images.

Clinical Applicability of the Sellar Barrier Concept in Patients with Pituitary Apoplexy: Is It Possible?

There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.

Predictors of hospital readmissions in adult patients with sickle cell disease.

BACKGROUND: Sickle cell disease (SCD) is the most common inherited blood disorder, affecting primarily Black and Hispanic individuals. In 2016, 30-day readmissions incurred 95,445 extra days of hospitalization, $152 million in total hospitalization costs, and $609 million in total hospitalization charges. OBJECTIVES: 1) To estimate hospital readmissions within 30 days among patients with SCD in the State of California. 2) Identify the factors associated with readmission within 30 days for SCD patients in California. METHODS: We conducted a retrospective observational study of adult SCD patients hospitalized in California between 2005 and 2014. Descriptive statistics and logistic regression models were used to examine significant differences in patient characteristics and their association with hospital readmissions. RESULTS: From 2,728 individual index admissions, 70% presented with single admission, 10% experienced one readmission, and 20% experienced ≥ two readmissions within 30 days. Significant predictors associated with zero vs. one readmission were male gender (OR=1.37, CI: 1.06-1.77), Black ethnicity (OR=3.27, CI: 1.71-6.27) and having Medicare coverage (OR=1.89, CI: 1.30-2.75). Lower likelihood of readmission was found in those with a Charlson Comorbidity index of three or more (OR=0.53, CI: 0.29-0.97). For zero vs. ≥ two readmissions, significant predictors were male gender (OR=1.43, CI: 1.17-1.74), Black ethnicity (OR=6.90, CI: 3.41-13.97), Hispanic ethnicity (OR=2.33, CI: 1.05-5.17), Medicare coverage (OR=3.58, CI: 2.68-4.81) and Medi-Cal coverage (OR=1.70, CI: 1.31-2.20). Lower likelihood for having two or more readmissions were associated with individuals aged 65+ (OR=0.97, CI: 0.96-0.98) and those with self-payment status (OR=0.32, CI: 0.12-0.54). CONCLUSIONS: In California, male, Black, and Hispanic patients, as well as those covered by Medicare or Medi-Cal, were found to have an increased risk of hospital readmissions. Redirecting outpatient goals to address these patient populations and risk factors is crucial for reducing readmission rates.

Single-Stage Complete Removal of Dumbbell-Shaped Trigeminal Schwannoma: 3-Dimensional Operative Video.

Intracranial trigeminal schwannomas are rare tumors that may extend into multiple cranial compartments and may emerge from the root, ganglion, or intracranial portion of any of its branches.1-6 The aim of this 3-dimensional operative video is to present a single-stage complete removal of a dumbbell-shaped trigeminal schwannoma through a pretemporal approach (Video 1). Informed consent was given by the patient for use of images and the surgical video. We describe the case of a 43-year-old female presenting with chronic headaches and left facial pain in the trigeminal territory of V2 and V3. Magnetic resonance imaging showed a tumoral lesion located within the cerebellopontine angle, petroclival region, and middle fossa. Due to the patient's symptoms, tumor size, and growth on sequential imaging, single-stage surgical removal was determined through a frontotemporal approach. There were no adverse outcomes posterior to the surgery, and the patient evolved favorably without neurologic deficits. Postoperative imaging showed complete resection of the tumoral lesion. Presurgical planning is essential for an effective and safe surgical strategy. For cases of trigeminal schwannomas with extension to the middle and posterior fossa, single-stage surgery is feasible for complete and safe removal.

Piggyback Stacking and Booster Clipping Technique: A Technical Note.

In certain cases, the closing force of a single vascular clip is not sufficient for complete aneurysmal occlusion, and the use of multiple clips, or clip stacking, is required. Many stacking techniques have been described in the literature, such as in tandem stacking and overstacking. However, these may not be feasible during procedures with limited exposure or narrow corridors. Clip reinforcement with a second high-pressure booster clip, also known as the piggyback technique, is an alternative for these cases along with anatomically complex aneurysms or aneurysms demonstrating atypical morphological features. Although this technique has been cited as a potential resource for certain aneurysms, descriptions of its characteristics and advantages are scarce. The purpose of this technical note was to discuss our experience with the piggyback clipping technique and use of a booster clip for a partially embolized and recanalized saccular posterior communicating artery aneurysm in a 50 year-old patient.

Contralateral Interhemispheric Transfalcine Approach for Supratentorial Extraventricular Ependymoma Resection.

BACKGROUND/AIM: Extraventricular supratentorial ependymomas are rare entities. Most ependymomas are located at the infratentorial and intraventricular level, and only in a small group of cases they do not present continuity with the ventricular system. This is a case report of a patient with an atypical location of a cerebral ependymoma, which required the implementation of a complex and infrequent approach for its complete microsurgical removal. CASE REPORT: A 16-year-old male patient was referred at our department with a diagnosis of a 40 mm × 50 mm × 60 mm solid-cystic space-occupying lesion, sited between the left superior frontal-cingulate gyri. A contralateral transfalcine interhemispheric approach was selected, which achieved total resection of the tumor. The histopathological diagnosis of Grade II ependymoma was obtained according to WHO classification. CONCLUSION: The contralateral transfalcine interhemispheric approach represents a favorable surgical corridor to achieve a total resection of the tumor lesion and is favored by an adequate working angle and reduced brain manipulation.

Classification and Management of Pontecerebellar-Petrosal Bridging Veins.

OBJECTIVES: The risks and benefits of coagulating intradural venous elements during a retrosigmoid approach for trigeminal neurovascular decompression has not been accurately established. The objectives of this study were to identify the veins that drain into the superior petrosal sinus, classify them in relation to the suprameatal tubercle, and determine the implication of their coagulation. METHODS: A retrospective study of 3-dimensional surgical videos of retrosigmoid approaches for trigeminal neurovascular decompression from the Laboratory of Neurosurgical Innovations of Tucumán (LINT) digital archive was carried out. The veins encountered were classified into 3 groups: retromeatal, meatal and premeatal. The neurosurgical postoperative complication scale proposed by Landriel et al. was utilized to assess complications from venous coagulation. A grade 0 was added for patients without complications. The STATA 14 program was utilized for statistical analysis. RESULTS: The pontocerebellar-petrosal veins of 28 patients who underwent trigeminal decompressive surgery were analyzed. In 7 cases these were found in the retromeatal region; 100% were sacrificed. Eleven cases revealed veins within the meatal region; 90.91% were coagulated. Veins in the premeatal region were found in 14 cases; 57.14% were sacrificed. In the postoperative follow-up, 27 patients were grade 0 and 1 patient developed postoperative meningitis (grade Ib complication). No patient suffered vascular complications. CONCLUSIONS: The venous elements identified in trigeminal neurovascular decompressive surgery are variable. We propose classifying them into retromeatal, meatal, and premeatal groups. Retromeatal and meatal veins can be safely sacrificed for appropriate visualization of the neurovascular conflict. The premeatal venous elements should be coagulated only in justified cases.

Supracerebellar Transtentorial Approach for Posterior Temporomesial Cavernoma: 3-Dimensional Operative Video.

The temporomesial region is a frequent site of neurosurgical lesions such as tumors, cavernomas, or arteriovenous malformations. This region has been divided into 3 regions: anterior, middle, and posterior.1-4 The objective of Video 1 is to present the case of a posterior temporomesial cavernoma resection through a supracerebellar transtentorial approach, highlighting the surgical technique. The case is a 50-year-old female with history of temporomesial bleeding, headaches, and seizures refractory to medical treatment. In the neuroimaging studies a posterior temporomesial image was diagnosed. We selected a paramedian supracerebellar transtentorial approach in semisitting position for the surgery. With the use of neuronavigation guidance, the cavernoma was located and removed in 1 piece. The patient evolved favorably, without neurologic deficit, improving the symptoms after surgery. The approach is an excellent alternative for exposing the temporomesial region, and the semisitting position facilitates the retraction by gravity of the cerebellum, maintaining a clean surgical field during the microsurgical procedure.3-5.

Fresado de hueso temporal: modelo de bajo costo y aplicación sencilla / Temporal bone drilling: low-cost and easy-to-use model

Introducción: Desarrollar y potenciar las habilidades neuroquirúrgicas que se requieren en la disección del hueso temporal aplicado a la realización de abordajes quirúrgicos transtemporales, a través de modelos de bajo costo y aplicación sencilla. Materiales y métodos: Trabajamos sobre huesos temporales secos, con insumos hospitalarios descartables y con materiales básicos obtenidos en ferreterías. Se identificaron con silicona y teflón coloreados con acrílico, estructuras vasculares y nerviosas que forman los principales reparos anatómicos y se utiliza material sintético de látex adherido a la superficie endocraneal para recrear duramadre. Realizamos un estudio exhaustivo del hueso temporal con las diferentes estructuras anatómicas íntimamente relacionadas con él, abordándolo desde diferentes vistas. Una vez familiarizados con la anatomía, se ensayan abordajes neuroquirúrgicos y disecciones anatómicas profundizando el conocimiento sobre las estructuras relevantes no visibles previa a la disección. Discusión: En la formación neuroquirúrgica no solo importa el conocimiento teórico, sino que se requiere praxis eficaz aplicada al mismo y se logra sólo a través de auténticas experiencias, la cual da al practicante, la oportunidad de ensayar aspectos de un abordaje para lograr competencia previa a su aplicación en el paciente. Conclusión: El residente puede utilizar esta técnica de fácil acceso y bajo costo para realzar su experiencia de aprendizaje anatómico y fresado de huesos temporales y así poder discutir aspectos y ensayar un abordaje previo a una cirugía.

Introduction: Develop and enhance the neurosurgical skills required for temporal bone drilling applied to transtemporal surgical approaches through low cost and simple application models. Materials and methods: We worked on dry temporal bones with disposable hospital supplies and basic materials obtained in hardware stores. Vascular and nervous structures that form the main anatomical structures are identified with silicone and Teflon colored with acrylic and synthetic latex material is attached to the endocranial surface to recreate the dura mater. We carried out an exhaustive study of the temporal bone with the different anatomical structures intimately related to it, approaching it from different views. Once familiarized with the anatomy, neurosurgical approaches and anatomical dissections are practiced, increasing the understanding of the relevant structures not visible prior to dissection. Discussion: During neurosurgical training theoretical knowledge is not the only domain that matters, rather effective praxis applied to i t is needed and achieved only through authentic experiences, which gives the practitioner the opportunity to examine aspects of an approach in order to achieve expertise prior to its application to the patient. Conclusion: The resident can use this accessible and low cost technique to enhance their experience in anatomical learning and temporal b ones drilling and therefore, be able to discuss certain aspects and practice an approach prior to surgery.