World Neurosurg
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With the introduction of the 5-aminolevulinic acid (5-ALA) technique, surgical neuro-oncology has made a major advance. 5-ALA fluorescence-guided resection of malignant glioma results in more complete surgical resections and subsequently prolonged survival. However, it remains uncertain how light intensities of the blue light source and 5-ALA-derived fluorescence intensities of the illuminated tissue are connected. The aim of the present study was to compare light intensities of different blue light sources and protoporphyrin (PpIX) fluorescence intensities of PpIX solutions with defined concentrations after illumination with different light sources. ⋯ Intensity of the 5-ALA-derived fluorescence is related to the light source used.
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Parasellar meningiomas involving the cavernous sinus and Meckel's cave pose a management challenge because of invasion around neurovascular structures and the pituitary gland. The management options range from aggressive resection to focused radiotherapy alone. We present a strategy for these tumors that includes endonasal bony decompression, partial tumor removal, and stereotactic radiotherapy (SRT) in select cases. ⋯ Endonasal bony decompression and selective tumor removal, followed by SRT, appears to be a reasonable treatment option for most previously untreated parasellar meningiomas. For patients who have undergone previous debulking and RT, new targeted treatment strategies are needed.
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Comparative Study
Beyond the learning curve: Comparison of microscopic and endoscopic incidences of internal carotid injury in series of highly experienced operators.
As the endoscopic endonasal approach (EEA) has gained popularity as an alternative to microsurgery (MS) for transsphenoidal resection (TSR), numerous studies have attempted to assess the differential risk of internal carotid artery (ICA) injury between the techniques, yet results have been equivocal and contradictory. The aim of this study was to evaluate ICA injury in MS versus EEA among highly experienced neurosurgeons. ⋯ ICA injury is the most serious complication of TSR of pituitary neoplasms. Operator inexperience may be a more important risk factor than choice of surgical technique, given the comparably low rates of injury obtained by highly experienced surgeons independent of technique. This emphasizes the need for consolidated care in pituitary centers of excellence, improvement of high-fidelity simulators, and skull base mentorship between senior and junior staff.
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In recent years, advances in cortical-subcortical mapping, intraoperative neurophysiology, and neuropsychology have increased the ability to remove intrinsic brain tumors, expanding indications and maximizing the extent of resection. This has provided a significant improvement in progression-free survival, time of malignant transformation (in low-grade gliomas), and overall survival. ⋯ In this regard, an extensive preoperative and postoperative neuropsychological evaluation is strongly suggested to assess cognitive impairment due to tumor growth, to assess surgical result, and to plan cognitive rehabilitation. This article discusses the main recent innovations introduced for cognitive mapping with the aim to preserve cognitive functions, which are essential to maintain a high quality of life.
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Spinal arteriovenous malformations (AVM) are an abnormal interconnection of vasculature in the spine than can lead to significant neurologic deficit if left untreated. ⋯ Costs of spinal AVM management continue to rise, even when treatment modalities have reduced length of stay significantly. Open surgery may lead to more postoperative complications and a greater length of stay than endovascular approaches. Further studies should look to identify the efficacy of endovascular approaches for spinal cord AVMs, particularly in complex spinal AVM traditionally treated with open surgery and to isolate factors leading to the elevated hospitalization costs.