Neurosurg Focus
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The posterior skull base and the nasopharynx have historically represented technically difficult regions to approach surgically given their central anatomical locations. Through continued improvements in endoscopic instrumentation and technology, the expanded endonasal approach (EEA) has introduced a new array of surgical options in the management of pathology involving these anatomically complex areas. Similarly, the transoral robotic surgical (TORS) approach was introduced as a minimally invasive surgical option to approach tongue base, nasopharyngeal, parapharyngeal, and laryngeal lesions. ⋯ Given these limitations, several institutions have published feasibility studies with the combined EEA and TORS approaches for a variety of skull base and nasopharyngeal pathologies. In this article, the authors present their clinical experience with the combined endonasal and transoral approach through a case series presentation, and discuss advantages and limitations of this approach for surgical management of the middle and posterior skull base and nasopharynx. In addition, a presentation is included of a unique, simultaneous endonasal and transoral dissection of the nasopharynx through an innovative intraoperative setup.
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Endovascular therapy has become a widely used method for achieving arterial recanalization in patients who are ineligible for intravenous thrombolysis or those in whom it is unsuccessful. Young stroke patients with large vessel occlusions may particularly benefit from endovascular intervention. This study aims to assess the authors' experience with the use of modern endovascular techniques to treat young patients (≤ 55 years old) with acute ischemic stroke and large vessel occlusions. ⋯ The results of this study demonstrate that endovascular therapy provides remarkably high rates of arterial recanalization and favorable outcomes in young patients with acute ischemic stroke and large vessel occlusions. These findings support aggressive interventional strategies in these patients. Randomized, controlled trials reflecting modern acute ischemic stroke treatment will be needed to confirm the findings of this study.
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Object In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach. Methods Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. ⋯ The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.
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Case Reports
Retrosigmoid approach for resection of cerebellopontine angle meningioma and decompression of the trigeminal nerve.
Cerebellopontine angle (CPA) lesions account for up to 10% of all intracranial tumors. The most common CPA lesions are vestibular schwannomas (70-80%), meningiomas (10-15%) and epidermoid cysts (5%). CPA tumors are estimated to be the secondary cause for up to 9.9% patients with trigeminal neuralgia. ⋯ The patient had immediate and dramatic symptomatic improvement after surgery. Detailed surgical techniques of retrosigmoid craniotomy and tumor dissection are presented in high definition video with narration. The video can be found here: http://youtu.be/55j9QCQEsH8 .
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The authors demonstrate a step-by-step surgical technique of the combined petrosal approach for resection of petroclival meningioma. The basic concept of this approach is the combination of the anterior- and posterior-petrosal approaches uniting the infra- and supratentorial surgical fields, thereby providing wide surgical exposure. Our techniques are featured by 1) mastoidectomy preceding craniotomy for minimal bone loss; 2) removal of the tentorium over the tumor for achieving devascularization and wide exposure; 3) water-tight dural closure by using autologous fascia graft, non-penetrating titanium clips, and multi-layered technique for avoiding postoperative cerebrospinal fluid leakage. The video can be found here: http://youtu.be/zMlNE8kMcHA .