World Neurosurg
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Fluorescein (FS) was first used to visualize malignant brain tumors in 1948. FS accumulates in malignant gliomas where the blood-brain barrier is disrupted and provides intraoperative visualization that is similar to preoperative contrast-enhanced T1 images in which gadolinium accumulation is seen.1 FS can be viewed under white light, but the use of an operating microscope fitted with a dedicated filter (YELLOW 560 nm Filter, Carl Zeiss Meditec, Oberkochen, Germany) allows us to significantly reduce the dose needed to highlight tumoral tissue.1,2 FS is excited at 460-500 nm and emits a green, fluorescent emission wavelength at 540-690 nm.2 It is virtually free of side effects and has low costs3 (approximately 6.9 USD each vial: Brazil). Video 1 presents a case of a 63-year-old man who underwent a left temporal craniotomy to remove a temporal polar tumor. ⋯ The tumor was then removed with standard microneurosurgical technique by the alternating use of white light and YELLOW 560 nm filter illumination. The use of FS was found "helpful" to discriminate the brain tissue and tumor tissue (bright yellow). Fluorescein-guided technique with a dedicated filter on the surgical microscope is safe and allows complete resection of high-grade gliomas.
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Choroidal fissure arteriovenous malformations (ChFis-AVMs) are uncommon and challenging to treat due to their deep location and pattern of supply.1 The choroidal fissure lies between the thalamus and fornix, from the foramen of Monroe to the inferior choroidal point.2 AVMs in this location receive their supply from the anterior, lateral posterior choroidal artery and medial posterior choroidal arteries and drain to the deep venous system.3 The anterior-transcallosal corridor to the ChFis is favored due to the ease in opening the taenia fornicis from the foramen Monroe, and it increases in length for lesions located more posteriorly.4-7 We present a case of a posterior ChFis-AVM. The patient, a previously healthy woman in her 20s, presented with a sudden severe headache. She was diagnosed with intraventricular hemorrhage. ⋯ It received its supply from the left lateral posterior choroidal artery and medial posterior choroidal artery and drained directly into the internal cerebral vein, classified as Spetzler-Martin grade II.8 A posterior-transcallosal approach to the ChFis was chosen to reduce the working distance and afford a wider corridor by avoiding cortical bridging veins (Video 1). Complete resection of the AVM was achieved with no additional morbidity. Microsurgery in experienced hands offers the best chance of cure for AVMs.9 In this case we demonstrate how to adapt the transcallosal corridor to the choroidal fissures for safe AVM surgery in this complex location.
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Simple clip trapping may not adequately decompress giant paraclinoidal or ophthalmic artery aneurysms for safe permanent clipping.1-10 Full temporary interruption of the local circulation via clipping of the intracranial carotid artery with concomitant suction decompression via an angiocatheter placed in the cervical internal carotid artery as originally described by Batjer et al3 allows the primary surgeon to use both hands to clip the target aneurysm. Detailed understanding of skull base and distal dural ring anatomy is critical for microsurgical clipping of giant paraclinoid and ophthalmic artery aneurysms.2-4 Microsurgical approaches allow for direct decompression of the optic apparatus as opposed to endovascular coiling or flow diversion that may contribute to increased mass effect.11 We describe the case of a 60-year-old woman who presented with left-sided visual loss, a family history of aneurysmal subarachnoid hemorrhage, and a giant unruptured clinoidal-ophthalmic segment aneurysm with both extradural and intradural components.2 The patient underwent an orbitopterional craniotomy, Hakuba "peeling" of the temporal dura propria from the lateral wall of the cavernous sinus, and anterior clinoidectomy (Video 1). ⋯ The aneurysm was trapped, and retrograde suction decompression via the "Dallas Technique" was employed for safe clip reconstruction of the aneurysm.3,4 Postoperative imaging showed complete obliteration of the aneurysm, and the patient remained at her neurologic baseline. The technical considerations and literature regarding the suction decompression technique to treat giant paraclinoid aneurysms are reviewed.2-4 The patient and family provided informed consent for the procedure and consented to the publication of her images.
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Revascularization of the anterior circulation using a high-capacitance graft is sometimes necessary for treatment of cervical tumors encasing the internal carotid artery (ICA). In this surgical video, we aim to demonstrate the technical nuances of high-flow extra-to-intracranial bypass using a saphenous vein graft. The patient is a 23-year-old female who presented with a 4-month history of an enlarging left-sided neck mass, dysphagia, and 25-lb weight loss. ⋯ Postoperative imaging demonstrated complete tumor removal and filling of the left anterior circulation via the saphenous vein graft. Video 1 discusses important preoperative and postoperative considerations, as well as highlights the technical nuances of this complex procedure. High-flow ICA to middle cerebral artery bypass using a saphenous vein graft can be employed to facilitate gross total resection of malignant tumors encasing the cervical internal carotid artery.