World Neurosurg
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There has been marked evolution in techniques in skull base surgery including the development of minimally invasive endoscopic supraorbital, transnasal, and more recently, transorbital approaches. These have been typically described as isolated, rather than concerted approaches. It is possible that rather than using these approaches alone, they could be combined with transnasal approaches to provide improved manipulation angles, shorter working distances, and optimal visualization of the pathology. The primary objective of this study is therefore to determine whether these pathways can be combined in "multiportal" approaches to further improve the surgeon's ability to access and manipulate pathology in the central anterior cranial fossa. ⋯ The precaruncular transorbital approach provided rapid, direct, coplanar access to the clivus, sella, and suprasellar/parasellar regions. The supraorbital minicraniotomy augmented access to the planum sphenoidale, sella, tuberculum sella, and suprasellar regions. These approaches provided shorter working distances, improved visualization, and working angles that offer more direct access to the pituitary gland, suprasellar region, clivus, medial and lateral cavernous sinus than the endoscopic transnasal approach alone. The combination of endoscopic approaches to the central anterior skull base significantly improved instrument access, particularly to lateral targets, as well as better visualization of the vital structures in these regions. These ports provide the surgeon with a more expansive surgical field and improved the ability to perform two-handed microsurgical dissections.
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Randomized Controlled Trial
Efficacy of low-dose tissue-plasminogen activator intracisternal administration for the prevention of cerebral vasospasm after subarachnoid hemorrhage.
Vasospasm is one of the important factors associated with the functional prognosis after subarachnoid hemorrhage (SAH). Intracisternal administration of thrombolytic agents to dissolve subarachnoid clots may be responsible for bleeding complications. The efficacy and safety of cisternal irrigation therapy using low-dose tissue plasminogen activator were evaluated. ⋯ Cisternal irrigation therapy using low-dose tissue plasminogen activator is effective and safe. Intermittent injection is most effective and may decrease the risk of symptomatic vasospasm in patients with SAH.
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Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis has been used in moyamoya disease (MD) and non-moyamoya ischemic stroke (non-MD). It is important to monitor hemodynamic changes caused by bypass surgery for postoperative management. We evaluated the bypass blood flow during STA-MCA anastomosis by using indocyanine green (ICG) fluorescence angiography. ⋯ ICG angiography with injection of ICG into the bypass artery allowed quantitative assessment of bypass blood flow. The bypass supplies blood flow to a greater extent in MD than in non-MD during surgery. This might be caused by a larger pressure gradient between the anastomosed STA and recipient vessels in MD. These observations indicate that MD requires careful control of systemic blood pressure after surgery to avoid cerebral hyperperfusion syndrome. ICG angiography is considered useful for facilitating safe and accurate bypass surgery and providing information for postoperative management.
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Case Reports
Metastatic gliosarcoma mass extension to a donor fascia lata graft harvest site by tumor cell contamination.
Brain glioblastoma multiforme is a malignant and highly aggressive entity that rarely shows extracranial and extraneural invasion. In the past 70 years, only eight cases of subcutaneous metastases have been reported. ⋯ Contaminated surgical tools and instruments can facilitate the distant spread of tumor cells. Therefore, the renewal of the surgical tools and instruments and irrigation of the surgical area after primary tumor resection is emphasized.
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Microsurgical treatment of large and giant paraclinoid internal carotid artery (ICA) aneurysms often requires the use of the retrograde suction decompression (RSD) technique to facilitate clipping. Surgical results, functional outcomes at discharge, and technique limitations based on single institution series are presented. ⋯ Surgical clipping with the RSD method remains a treatment of choice with acceptable outcomes for patients not amenable for endovascular treatment.