World Neurosurg
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Case Reports
Racemose fourth ventricle neurocysticercosis excision through telovelar approach and hydrodissection.
Intraventricular neurocysticercosis is associated with more severe complications and a worse overall outcome.1,2 Fourth ventricle neurocysticercosis (FVNCC) often presents with cerebrospinal fluid obstruction and hydrocephalus by means of direct mechanical occlusion of ventricular outlets by the cysts or due to an ependymal inflammatory response. Unfortunately, there is little consensus on the optimal management for FVNCC. If possible, surgical removal of cysticerci rather than medical therapy and/or shunt surgery is recommended.3 Endoscopic removal of cysts is described to be an effective treatment modality.4 However, endoscopic removal of inflamed or adherent ventricular cysticerci is associated with increased risk of complications.5 Although microdissection through a posterior fossa telovelar approach is a valid method for FVNCC,6,7 scarce reports describe the therapeutic decision making and provide a surgical video of adherent FVNCC cyst resection. ⋯ Magnetic resonance imaging demonstrated obstructive hydrocephalus secondary to a multiloculated cystic mass within the fourth ventricle. According to the diagnostic criteria, probable racemose FVNCC was suspected.8 Magnetic resonance imaging raised suspicion that the cysts could be densely adherent to surrounding structures,9 precluding endoscopic removal. We performed a combined microscopic and endoscopic approach, which permitted removal of the cysts through a telovelar approach and hydrodissection technique without damaging nearby structures and treatment of the associated hydrocephalus through an endoscopic third ventriculostomy, allowing complete resolution of symptoms and avoidance of cerebrospinal fluid shunting.
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There are currently no standard criteria for evaluating the risk of recurrent disk herniation after surgical repair. This study investigated the predictive values of 5 presurgical imaging parameters: paraspinal muscle quality, annular tear size, Modic changes, modified Phirrmann disk degeneration grade, and presence of sacralization or fusion. ⋯ Patients with poor clinical scores and recurrence exhibited additional radiologic abnormalities before surgery, such as poor paraspinal muscle quality, longer annular tears, higher Modic change type, higher modified Phirrmann disk degeneration grade, and sacralization or fusion. This risk evaluation protocol may prove valuable for patient selection, surgical planning, and choice of postoperative recovery regimen.
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Case Reports
Simultaneous clipping and STA-MCA bypass for unruptured MCA aneurysm concomitant with proximal stenosis.
Management of unruptured intracranial aneurysms concomitant with proximal stenosis remains challenging. Video 1 demonstrates simultaneous clipping and superficial temporal artery (STA)-middle cerebral artery (MCA) bypass for unruptured MCA aneurysm concomitant with proximal stenosis. A 56-year-old man presented with paroxysmal left limb weakness for 2 years. ⋯ Six-month follow-up angiography confirmed complete obliteration of the aneurysm and patent STA-MCA anastomosis. For unruptured MCA aneurysms concomitant with proximal stenosis, 1-stage surgical treatment with simultaneous clipping and STA-MCA bypass is a feasible alternative. Further studies are needed to compare the safety and efficacy of 1-stage surgical treatment and endovascular embolization of intracranial aneurysms concomitant with proximal stenosis.