World Neurosurg
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Endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus in carefully selected patients.1 Studies have shown that larger ostomy size may be associated with higher ETV success and reduced ostomy closure in pediatric and adult patients.2-5 Therefore dilation of the ostomy is a key step in this procedure, which is traditionally accomplished with a balloon catheter, leaving behind loose redundant tissue at the ostomy site. In this 2-dimensional endoscopic operation (Video 1), we demonstrate the technique of using an aspiration device to enlarge the ETV ostomy in a controlled and efficient manner while eliminating redundant tissue. The patient is a 6-month-old girl with newly developed triventricular hydrocephalus seen on head ultrasound, manifested as upward gaze palsy, fontanelle fullness, and rapidly increasing head circumference. ⋯ No intraoperative or postoperative complication occurred. Postoperative magnetic resonance imaging demonstrated an 8.4-mm ostomy on the third ventricular floor, nearly twice the size of a typical ETV ostomy.5 The key considerations in using this device include setting a low aspiration limit to avoid oversuction and using only mediolateral motion to avoid damage to the basilar artery. Future comparative studies are needed to investigate the efficacy, safety, and long-term outcome in aspirator-assisted ETV versus traditional techniques, as well as to evaluate ostomy size as an independent variable for long-term ETV success.
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Intraoperative rupture is the most important complication of aneurysm surgery1-5 and occurs in 3 different stages: premature (before dissection), dissection, and clipping.5 We present a video of premature rupture and its management (Video 1). A 45-year-old patient presented with subarachnoid hemorrhage originating from a dorsal internal carotid artery (ICA) aneurysm of the communicating segment. Due to our sufficient experience, we preferred direct clipping in this case. ⋯ In the literature review including 10,540 cases,1 the mean incidence of IOR is 16.6%. Therefore every neurosurgeon should be prepared for this important complication and know its management well. This case reminds us once again the golden rule of aneurysm surgery: proximal control first.
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Successful surgery for epilepsy hinges on identification of the epileptogenic focus. Stereoelectroencephalography (sEEG) is the most effective way to identify most seizure foci. There are multiple methods of inserting depth electrodes, including frame-based, frameless, and robot-assisted techniques. Studies have shown the accuracy of frame-based and robotic-assisted techniques to be statistically similar, while only one study has detailed the frameless sEEG insertion technique. ⋯ VarioGuide frameless stereotaxy for sEEG placement is comparable to frame-based and robotic-assisted techniques with statistically similar rates of epileptic focus identification. Lead placement accuracy is slightly lower and time per lead is slightly higher relative to robot-assisted surgeries. When a robot system is unavailable, surgeons can consider using a frameless stereotactic technique for sEEG insertion, allowing patients to benefit from a similarly high rate of epileptic zone identification.
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Case Reports
Tractography Navigated Endoscopic En-bloc Excision of Pediatric Giant Choroid Plexus Tumor.
Giant choroid plexus (CP) tumors in children pose a formidable surgical challenge due to extensive vascularity/blood loss, tumor size impeding early visualization of the pedicle, hydrocephalus/mass effect distorting cerebral localization, considerable prevalence of atypical tumors and carcinoma demanding excision without tumor spillage, and retraction-associated morbidity. However, total resection of CP papilloma has excellent potential for cure. This is probably the first report in the literature of diffusion tensor imaging navigation-guided tumor pedicle targeting, endoscopic devascularization and division of pedicle followed by en bloc delivery in optimally tackling most of these challenges in a 6-year-old girl presenting with a giant lateral ventricular CP tumor. ⋯ Ventricle was entered perpendicular to the sulcus through the roof of the atrium, with least cortical transgression and avoiding injury to laterally placed optic radiation and speech areas.6 A 30-degree, 4-mm endoscope was inserted anterolateral to the tumor and fixed. The wide-angled vision offered by endoscopes enhancing meticulous dissection is the likely cause of better neurological outcomes, as noted in other ventricular lesions.7 Pedicular attachment of the tumor is coagulated thoroughly and cut, ensuring initial sparing of venous drainage. The draining vein is then coagulated and divided. 'En-bloc' excision is also known in other vascular lesions to decrease the risk of bleeding.8 The angled optics & panoramic visualization helps to identify any possible tumor seedlings.9 This is probably the first report of endoscopic en-bloc excision of a giant choroid plexus tumor in literature.
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Butterfly glioblastoma (bGB) poses significant surgical challenges, yet recent findings have highlighted the potential of surgical decompression in extending patient survival.1-10 The selection of a surgical strategy for bGB varies across studies. Generally, the side with a larger tumor volume is a preferred approach route, and the nondominant hemisphere is preferred when both tumors are similar in size. The contralateral tumor is removed via the resection cavity of the ipsilateral side,11 with successful utilization of endoscopic-assisted techniques.8 In the case of deep-seated bGB covered with a thick intact brain, accessing the tumor requires creating an invasive corridor, therefore minimizing the damage to the intact brain is ideal. ⋯ We conducted the same technique for another deep-seated anterior bGB case, both resulting in postoperative Karnofsky performance status improvements (Video 1). Tailoring the surgical approach to the unique characteristics of each bGB case is important. The patients consented to the procedure and the publication of their images.