World Neurosurg
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The true rate of intraoperative cerebrospinal fluid (iCSF) leak during pituitary surgery is not well known because small iCSF leaks are easily missed. Our objective is to determine the rate and significance of iCSF leak in endoscopic pituitary surgery with intrathecal (IT) fluorescein administration and determine factors predictive of iCSF leak. ⋯ The rate of iCSF leak during endoscopic pituitary surgery using IT fluorescein is higher than previously reported. Tumor diameter and volume are best predictors of the risk of iCSF leak. Based on this knowledge and a closure algorithm that includes a lumbar drain and nasoseptal flap for larger tumors (>2.5 cm), we can conclude that the postoperative CSF leak rate remains exceptionally low, particularly once the learning curve is overcome.
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The introduction of extended endoscopic endonasal approaches for the management of midline skull base lesions has brought again the focus on the problem of postoperative cerebrospinal fluid (CSF) leak management. Notwithstanding the improvements in reconstruction techniques that have reduced the rate of postoperative CSF leakage, no technique has proven to be thoroughly effective. ⋯ An endoscope-guided sealant technique with fibrin glue used while the patient is awake has proven, in our experience, to be effective in reducing the rate of reoperations in the management of postoperative CSF leaking after endoscopic endonasal approaches for the treatment of intradural skull base lesions. This technique, which needs larger case series to be validated, could be considered in the spectrum of possibilities to manage selected postoperative CSF leakages.
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The concept of human brain reorganization due to slow-growing lesions, including low-grade glioma, has been gradually and generally accepted. However, few cases have been reported in which the reorganization, especially in the topographic pure primary motor cortex, was observed during brain surgery. We report a case of slow-growing oligodendroglioma located in the pure primary motor cortex, as detected by magnetic resonance imaging that could be resected in part thanks to the brain plasticity. In addition, we describe a pitfall of topographic guidance using somatosensory-evoked potential (SEP) monitoring. ⋯ Pure primary motor cortex could be reorganized by its own lesion. In reorganized brain, topographic central sulcus defined based on SEP findings may be an inappropriate guidance to estimate true functional area. In such a condition, intraoperative direct electrical stimulation under awake craniotomy makes it feasible to resect pure primary motor cortex invaded by tumors.
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The occipital artery (OA) is an important donor artery for posterior fossa revascularization. Harvesting the OA is believed to be difficult and time consuming due to its 3-dimensional course through different suboccipital tissue layers. We propose a safe and effective means of dissecting the OA. ⋯ This segmentation provided a safe and effective procedure for harvesting the OA, in which dissection of the transitional segment is a critical step. Although the course of the OA is complex, precise anatomical knowledge of the suboccipital muscles and a stepwise dissection make harvesting the OA relatively simple.
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Acrodysostosis is a rare syndrome characterized by peripheral dysostosis, nasal hypoplasia, and frequently mental retardation. Only two adult cases of acrodysostosis have been reported to have neurological symptoms. ⋯ Special attention should be given to these patients to detect signs of spinal stenosis, as early decompression can lead to neurological recovery.