World Neurosurg
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Endoscopic ventricular surgery (EVS) shows overall reduced morbidity compared to open craniotomy, but carries, however, the risk for neurocognitive impairment caused by fornix-, hypothalamus-, and injuries other structures adjacent to the ventricular system. Objective or subjective neurocognitive impairment after EVS is rarely reported. The aim of this study was to assess the subjective neurocognitive outcome in patients undergoing EVS for various pathologies. ⋯ Subjective neurocognitive outcome and quality of life improvement are often achieved after EVS and permanent neurocognitive impairment is rare. Further well-designed trials on subjective and objective neurocognitive outcome after EVS are warranted.
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Currently, there is a unanimous opinion that the first line of the treatment of insular gliomas is microsurgical removal.1-3 At the same time, surgery of insular glial tumors remains a challenge because of the complex anatomy of the insular region. Among the most crucial anatomical structures are branches of the middle cerebral artery (MCA), lenticulostriate arteries (LSAs), and corticospinal tract.4 Surgery of the insular glioma becomes much more complicated in cases when the tumor extends to the anterior perforated substance, which, according to our data, occurs in 29,1% of cases.5 We present a 33-year-old woman with a history of generalized seizures (Video1). ⋯ The video demonstrates the technique of a Sylvian fissure dissection, manipulations with MCA branches and LSA, removal of the tumor from the region of the anterior perforated substance, and a discussion of surgical nuances and safety aspects. The most challenging part of the operation was to identify and protect the LSAs.6 Advanced microsurgical techniques, and the correct patient selection for surgical treatment, are cornerstones for a successful outcome and provide an acceptable frequency of postoperative neurologic deficits in patients who undergo surgery of insular gliomas through the transsylvian approach.
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Tectal plate tumors are a rare subset of midbrain tumors in pediatric populations. They are slow growing and low grade, with indolent and subtle manifestation unless they cause hydrocephalus.1-5 We present a tectal tumor in an 8-year-old girl (Video 1). Her clinical onset occurred with headache, vomiting, and seizure secondary to intracranial hypertension. ⋯ When this approach is selected, the venous anatomy must be navigated with caution. Angiography's venous phase may provide additional planning information.6 Coagulation of vascular structures such as occipital veins is carefully avoided since it creates risk of venous infarction, leading to visual loss. Histologic examination revealed a rosette-forming glioneuronal tumor (grade I WHO 20217).
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Intracranial kissing aneurysms, arising either from the same artery or from 2 adjacent arteries at similar locations, are rare.1,2 The internal carotid artery is most frequently involved; kissing aneurysms rarely affect the distal anterior cerebral artery (DACA). By dint of the close proximity of the aneurysm fundus, these aneurysms can pose unique operative challenges.3,4 A highly fragile aneurysm dome with a high intraoperative rupture rate is a unique management challenge in DACA aneurysms.5 The stakes are higher when there is an aneurysm rupture in the setting of kissing DACA aneurysms requiring an anterior interhemispheric approach. The negotiation of a tight interhemispheric fissure in between the bridging veins and prevention of a premature aneurysm rupture at a narrow space become vital in these situations. ⋯ The patient in Video 1 presented with an acute subarachnoid hemorrhage with severe headache of sudden onset and nuchal rigidity (World Federation of Neurological Surgeons grade II). Both aneurysms were located at the A3-A4 junction and successfully clipped through a right-sided anterior interhemispheric approach. She made a satisfactory postoperative recovery (modified Rankin Scale score of 1 at 6-week follow-up and 0 at 6-month follow-up) with an excellent angiographic outcome.
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Navigated pedicle screw placement can be particularly challenging for cervical and upper thoracic levels in obese patients. This technical challenge can be compounded by smaller-diameter tools, which can be flexible and therefore confound navigation. It is imperative to avoid excessive manipulation of surrounding tissues to maintain navigation accuracy in the mobile cervical spine.1 Robotic-assisted spinal approaches use firm guides to aid drilling and screw placement but are hindered by high costs with equipment acquisition.2,3 Here, we propose a technical nuance that combines robotic surgical principles with tools that are more readily available in many surgical departments (Video 1). ⋯ Imaging showed multilevel degenerative disease and a solid prior C5-7 anterior cervical diskectomy and fusion with grade I anterolisthesis at C7-T1 due to severe facet degeneration with severe left-sided foraminal stenosis. Given failure of conservative management, the patient was brought to the operating room for left C7-T1 foraminotomy and C7-T1 posterior instrumented fusion. Here, we show the use of a tubular retractor fixed to the surgical bed for solid and reproducible trajectory for all tools to minimize the risk of surrounding tissue manipulation and its effect on navigation accuracy.