Mechanical Thrombectomy and Thrombolysis for Dural Venous Sinus Thrombosis.

Dural venous sinus thrombosis is a rare yet major cause of stroke and mortality, especially affecting young women and children. Anticoagulation is the mainstay of therapy; however, nearly 13% of the patients experience poor outcome with anticoagulation alone.1 In addition, nearly one third of the patients with severe presentation have a risk of incomplete recovery with systemic anticoagulation.2 The subgroup of patients who have incomplete recovery or who develop rapid deterioration in spite of anticoagulation can benefit from mechanical thrombectomy with or without intrasinus thrombolysis. Our patient is a 33-year-old lady on oral contraceptive pills who developed extensive dural venous sinus thrombosis after undergoing lumboperitoneal shunt for pseudotumor cerebri (Video 1). In view of clinical deterioration despite systemic heparin therapy, we performed mechanical thrombectomy and intrasinus thrombolysis using an Angiojet device (Boston Scientific Corporation or its affiliates Inc., Marlborough, Massachusetts, USA). The Angiojet system has the unique capability of a Power Plus technique in which thrombolytic agents can simultaneously be used to facilitate clot removal. However, its utility for intracranial use is limited by the stiffness, large (6-French) catheter diameter, and short length (120 cm). After the procedure, the patient achieved rapid clinical improvement and was maintained on systemic oral anticoagulation. In addition to the case presentation, the video article also demonstrates the technical aspects of mechanical venous thrombectomy.

Posterior Interhemispheric Precuneal Approach: Fundamental Principles and Case Illustration: 3-Dimensional Operative Video.

Peritrigonal lesions are deeply seated and are surrounded by critical neurovascular structures. Traditional transcortical approaches carry the risk of damage to important surrounding white matter tracts. In this regard, a posterior interhemispheric approach gives a more direct and less invasive route and therefore is a reasonable alternative to transcortical approaches. The 3-dimensional video includes illustrations and animations showing the anatomy of the white matter tracts around the trigone and explains the physiological basis of posterior interhemispheric precuneal approach to this complex region. This also includes a 3-dimensional operative video of the same approach in a 50-yr-old male patient with left periatrial lesion describing surgical techniques and nuances. An informed written consent has been obtained from the patient.

Repeat Gamma Knife radiosurgery versus microvascular decompression following failure of GKRS in trigeminal neuralgia: a systematic review and meta-analysis.

OBJECTIVE: Gamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution. METHODS: The authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after post-GKRS failure or relapse is presented. RESULTS: A total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors' final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors' institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors' institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment. CONCLUSIONS: The current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.

Meningioma: The Tumor That Taught Us Neurosurgery.

The history of neurosurgery is ever fascinating. The journey has been tedious; nevertheless, in the landscape of success and failures we have become more efficient and polished. Skills were learned, innovations were made, and in the process we evolved. The immense contribution of meningioma surgery in this maturation process is attested by history itself. Countless stories that testify the momentous role of meningioma in the process of evolution and reformation of neurosurgical techniques exist in the literature. With every step and every attempt at conquering this tumor, we reformed to be better surgeons, more skilled and more precise. In this paper we have walked down the lane of neurosurgery and paid a due tribute to this "necessary evil."

Surgery of Tuberculum Sellae Meningioma: A Technical Purview on Pterional Approach.

Objective Amidst the raging debate between transnasal and transcranial approaches, the critical factor that dictates success lies in the meticulous dissection of the tumor from the optic apparatus, anterior communicating artery complex, and the pituitary stalk. In this surgical video, we describe the resection of a tuberculum sellae meningioma through the pterional approach highlighting dissection through the appropriate arachnoidal plane. Case Description The patient is a 75-year-old female who presented with optic nerve compression with bitemporal hemianopia and endocrine function abnormalities. A transcranial approach was done to effectively decompress the optic nerve. The video includes a detailed discussion on the surgical techniques including working between the different surgical corridors, working in the arachnoid plane to dissect the neurovascular structures away from the tumor, identification, and preservation of pituitary stalk. Postoperatively, the patient's visual field deficit improved with a remaining isolated right temporal field defect at 2 months follow-up. Her endocrine function improved after the surgery. Conclusion In the era of endoscopic surgery, transcranial approaches for suprasellar tumors like tuberculum sellae meningiomas still have a distinct surgical role. Our discussion extends to reiterate the strengths and weaknesses of the transcranial approach to this region as compared with the endoscopic approach. We believe decompression of optic nerves, separation of Acom complex from the tumor, and preservation of pituitary stalk are better achieved through a transcranial approach. The link to the video can be found at : https://youtu.be/kw5eP3oUd6Q .

Cervical Vestibular Evoked Myogenic Potential in Hypoglossal Nerve Schwannoma: A Case Report.

BACKGROUND: Schwannoma of the hypoglossal nerve is rare. This case report documents an atypical abnormality of the cervical vestibular evoked myogenic potential (cVEMP) in a patient with schwannoma of the hypoglossal nerve. The observed abnormality was attributed to the proximity of the hypoglossal nerve to the spinal accessory nerve in the medullary cistern and base of the skull. PURPOSE: To report cVEMP abnormality in a patient with hypoglossal nerve schwannoma and provide an anatomical correlation for this abnormality. RESEARCH DESIGN: Case report. STUDY SAMPLE: A 44-yr-old woman. DATA COLLECTION: Pure-tone and speech audiometry, tympanometry, acoustic stapedial reflex, auditory brainstem response, and cVEMP testing were performed. RESULTS: The audiological test results were normal except for the absence of cVEMP on the lesion side (right). CONCLUSIONS: A cVEMP abnormality indicating a compromised spinal accessory nerve was observed in a patient with hypoglossal nerve schwannoma. This case report highlights the importance of recording cVEMP in relevant neurological conditions and provides clinical proof for the involvement of the spinal accessory nerve in the vestibulocollic reflex pathway.