World Neurosurg
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Head trauma and neurosurgical-related osteomyelitis are common causes of cranial bone defect. Even though cranioplasty is considered a safe and well-consolidated procedure, there are still some issues about the flap's vascularization assessment. In this paper we describe a 2-staged cranioplasty procedure, focusing on the perioperative evaluation of the skin flap vascularization. Our goal is to assess if the skin flap's perfusion measurement with indocyanine green fluorescence can be considered a reliable method to predict good outcome in cranioplasties. ⋯ Surgical procedures were well tolerated; at 1 year of follow-up the cosmetic defect was unremarkable. Indocyanine green fluorescence can be a good aid to predict the probability of the skin flap survival by measuring its perfusion.
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Contrast-induced encephalopathy (CIE) is a rare and misdiagnosed complication of intravascular injection of contrast, responsible for arterial vasospasm and neurologic effects. Conventional radiologic findings are not in themselves specific for cerebral vasospasm diagnosis. We present a case in which arterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) was useful in early diagnosis of CIE. ⋯ CIE should always be considered in patients with focal neurologic deficits after iodinate contrast exposure. ASL perfusion MRI with CBF maps could be a promising tool for prompt, early confirmation of underlying vasospasm, as cortical edema and distal vasospasm could not be detected on conventional radiologic imaging.
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This report discusses the risks and complications of using the extended endoscopic endonasal transsphenoidal approach (EEETA) in a special craniopharyngioma case to caution neurosurgeons. ⋯ The coexistence of severe calcified craniopharyngiomas, especially with sharp calcified spurs, a narrow distance between the anterior communicating artery and the planum sphenoidale, and a narrow distance between the bilateral internal carotid arteries is a significant warning signal during EEETA for craniopharyngiomas. In this circumstance, it may be preferable to use open microsurgical approaches. If the anterior communicating artery or anterior cerebral artery is punctured during EEETA, another method is available to fix the problem using an aneurysm clip through the nose, and not only endovascular embolization.
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Dissection of C2 guiding to the C1 lateral mass and facilitation of screw placement: Technical note.
Surgical intervention at the craniovertebral junction requires preoperative and intraoperative planning to get optimum postoperative results. Careful positioning minimizes the risk of iatrogenic injury and can also facilitate adequate surgical exposure. Tortuous venous channels that are usually encountered as the dissection proceeds may cause excessive bleeding before reaching the lateral mass (LM). However, both localization and placement may be made easier by altering the dissection technique and modifying the patient's position. Traditionally, the military tuck position is described for the dorsal approach to the craniovertebral junction. The objective of this study is to emphasize the role of arc or bow like position, a modification of prone position for adequate placement of C1 LM screw in these cases. ⋯ Visual axis to the lateral mass of C1 in an arc/bow position with head elevation puts C1 LM more in the visual axis of the operator, which makes the trajectory straight without causing much angulation while inserting the screw. At the same time, the axis vertebra guides the surgeon to the C1 lateral mass with no handling of dura.
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Peripheral aneurysms are known to be a source of intracranial hemorrhage in patients with moyamoya disease. However, the natural history of ruptured peripheral aneurysms remains unclear. Some regress spontaneously, whereas others may rebleed. Direct treatments, such as surgical or intravascular treatment of the peripheral aneurysm, can have a risk of severe neurologic complications owing to the depth of the operative field and the fragility of the parent artery. A careful treatment policy is required. ⋯ Given that spontaneous resolution of an aneurysm may occur in a short period of time, we suggest that conservative treatment be considered as an option for ruptured peripheral aneurysms associated with moyamoya disease when direct treatment is risky.