World Neurosurg
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Normal skull base structures are destroyed either by the skull base pathology itself or during surgery that results in cerebrospinal fluid (CSF) leak. Skull base repair is usually performed transnasally by using a nasal septal flap. But when NSF is not available and failed repeated transnasal repair, a cranionasal repair with frontal pericranial flap (PF) can be attempted to achieve the highest successful chance. We performed a dual layer/split PF repair of a skull base defect using cranionasal approach and here we describe the technique. ⋯ We introduced the cranionasal dual layer/split PF technique to repair anterior skull base and successfully stopped the CSF leak in a patient after multiple EEA surgeries. This technique should only be considered in specific difficult situation where usual repair by EEA is impossible.
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We explored the factors affecting the surgical outcomes of Hirayama disease (HD). ⋯ The main side of the symptoms in patients with HD corresponded with ipsilateral spinal cord atrophy found on MRI. Also, atrophy of the spinal cord in the neutral position MRI study and the ability of the spinal cord to recover were significantly related to the surgical outcome. These factors might be used as potential indications for surgery of HD.
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Case Reports
Challenges in the management of a ruptured bihemispheric posterior inferior cerebellar artery aneurysm.
Bihemispheric posterior inferior cerebellar artery (PICA) is a rare anatomic variant wherein a single PICA supplies both cerebellar hemispheres. Inasmuch as it is the only PICA, treatment of aneurysms arising from this anatomic variant is more complex. We present a case of a ruptured bihemispheric PICA aneurysm and the challenges encountered in its management. ⋯ In dissecting aneurysms of a bihemispheric PICA, isolated endosaccular occlusion provides uncertain protection from a rebleed, whereas a more reliable treatment with PVO carries an unpredictable risk of ischemic complications. The risks of a PVO may be rationalized as a life-saving measure; however, the subsequent threshold for posterior fossa decompression should be low.
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Trigeminal ganglion stimulation can be effective for trigeminal neuralgia. For patients who respond well to neurostimulation delivered percutaneously through the foramen ovale but require extensive revision and removal of instrumentation, a subtemporal approach for stimulation of the trigeminal ganglion is an alternative option as a salvage procedure. ⋯ The subtemporal approach for salvage placement of the trigeminal ganglion stimulating electrode was effective in this patient and minimized risks given her history of erosion and multiple operations. This suggests that the subtemporal approach is a viable salvage operation for trigeminal ganglion stimulation for trigeminal neuropathic pain.
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Comparative Study
Neurosurgical Resection and Stereotactic Radiation Versus Stereotactic Radiation Alone in Patients with a Single or Solitary Brain Metastasis.
Brain metastases commonly manifest in patients with cancer, with ∼20%-50% presenting with 1 intracranial lesion. Among patients with 1, small brain metastasis and controlled or absent extracranial disease, it remains unclear whether aggressive intracranial management using neurosurgical resection plus cavity stereotactic radiosurgery/stereotactic radiotherapy (SRS/SRT) rather than SRS/SRT alone is beneficial. In patients with controlled or absent extracranial disease and 1 brain metastasis ≤2 cm in size, we evaluated the effect of surgery plus SRS/SRT compared with SRS/SRT on oncologic outcomes, including overall survival. ⋯ Aggressive, local therapy, including neurosurgical resection, might benefit patients with 1 brain metastasis in the context of controlled or absent systemic disease, even if the lesion in question is small. Further studies are needed to evaluate these associations.