Acta neurochirurgica
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Acta neurochirurgica · Jun 2013
Review Case ReportsProgressive nerve territory overgrowth after subtotal resection of lipomatosis of the median nerve in the palm and wrist: a case, a review and a paradigm.
Lipomatosis of the nerve (LN) is a rare disorder characterized by the massive enlargement of peripheral nerves, frequently accompanied by generalized fibroadipose proliferation and skeletal overgrowth. The treatment of this disorder remains controversial, in part because of the rarity and the variability of presentation. Some authors have advocated total resection of this benign lesion including the functioning nerve, while others recommend symptomatic decompression alone. ⋯ We present the first medium-term follow-up of a patient who underwent nerve sacrifice to attempt to cure the LN alongside a historical review of treatment. We believe that macroscopic gross total resection (i.e., microscopic subtotal resection) is insufficient in stopping the potential progression of this hamartomatous lesion because of the persistent effect of trophic factors.
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The transcallosal approach provides a direct corridor to the lesions lying in the third ventricle with distinct advantages over alternative routes, such as the possibility to use multiple corridors for tumor resection. ⋯ This approach requires the ability to move around many neurovascular, cortical, and white matter structures. Knowledge of regional anatomy and adherence to principles of microsurgery are basic requirements to obtain a favorable outcome.
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Acta neurochirurgica · Jun 2013
Estimated low risk of rupture of small-sized unruptured intracranial aneurysms (UIAs) in relation to intracranial aneurysms in patients with subarachnoid haemorrhage.
International guidelines for the management of unruptured intracranial aneurysms (UIAs) recommend observation in aneurysms <10 mm due to the estimated low risk of rupture. The aim of our study was analyse the data of recently treated patients with ruptured cerebral aneurysms with the special focus on size and configuration in view of the frequency scale in a daily routine setting. ⋯ Since the results of our study showed that the majority of the aneurysms are <10 mm (mean, 6.2 mm), it is justified to challenge the recommendations of the international guidelines in a daily routine setting. We believe that the published data are not convincing enough to play a guidance role in daily routine. Due to improving surgical and endovascular techniques with satisfying results and the high number of ruptured small aneurysms, we believe a change in attitude in management of small-sized aneurysms is needed. Further diagnostic models are needed to determine the risk of rupture of intracranial aneurysms properly to obtain adequate treatment for UIAs.
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Acta neurochirurgica · Jun 2013
Image-guided resection of spheno-orbital skull-base meningiomas with predominant intraosseous component.
Although meningiomas of the spheno-orbital region commonly result in hyperostosis, intraosseous meningiomas, which feature extensive full thickness infiltration of the anterolateral skull base, are rare. In this study, we assess the value of image guidance during surgery for intraosseous spheno-orbital skull-base meningiomas in achieving safe and maximal abnormal bone resection. ⋯ Intra-operative image guidance allowed total or near-total resection of the hyperostotic skull base around the cranial nerve foramina with minimal morbidity in a group of patients with extensive spheno-orbital meningiomas.
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Acta neurochirurgica · Jun 2013
How I do it : anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment aneurysms.
Power drilling commonly used for anterior clinoidectomy and optic canal unroofing can result in thermal injury to the optic nerve. ⋯ • Anterior clinoidectomy and optic canal unroofing is an important skull base technique required for safe clipping of the majority of ophthalmic segment aneurysms • Power drilling commonly used for optic canal unroofing can cause thermal injury to optic nerve • More than 2 mm free space is available around the optic nerve in the optic canal • Foot plate of 1 mm Kerrison punch can be safely introduced within a normal optic canal without causing mechanical injury to the optic nerve • Reflection of posteriorly based dural flap acts as a dural barrier, preventing direct contact of drill bit to optic nerve, internal carotid artery and aneurysm during drilling • Entanglement of cottonoids to rotating drill bit is a major problem in intradural anterior clinoidectomy • Wet gelfoam pieces do not get entangled to the rotating drill bit • Structures surrounding the area of drilling can be covered with wet gel foam pieces to prevent direct contact of the drill to neurovascular structures • Opened cisterns can be covered with wet gelfoam pieces during drilling to prevent deposition of bone dust in the subarachnoid space • "Limited drill technique" of anterior clinoidectomy and optic canal unroofing is a safe and effective technique for the exposure of ophthalmic segment aneurysms.