Paraclinoid aneurysms represent a true microsurgical challenge for resolution 1,2 due to the proximity with neurovascular structures of the skull base 3–5. We present a case: a 42-year-old woman with ...headache, detecting left paraclinoid aneurysm in angiography. A left pterional approach plus exposure of the internal carotid at the cervical level were performed. Also, an arciform durotomy with the opening of the sylvian fissure to the carotid cistern, were done. The anterior clinoid process was exposed, observing the aneurysm originating from the clinoid segment of the carotid artery, being impossible the clipping without anterior clinoidectomy 4,5. The dura was cut medially from the optic canal to the clinoid process. Drilling was performed at the base of the clinoid process to expose the distal carotid dural ring.
The carotid was released in the clinoid segment through the section of the distal dural ring to mobilize it. After identifying the distal and proximal neck of the aneurysm, the reconstruction was started by placing a 90 degrees clip in the anteroposterior direction; then, a second clip in the posteroanterior direction and puncturing the aneurysm, showing that the aneurysmal flow is present. A third and fourth clip, were placed in tandem from the proximity to the internal carotid to the dome of the aneurysm. Finally, a fifth curved clip was placed on the previous ones to give them greater closing pressure. Postoperative angiography shows a complete exclusion of the aneurysm with adequate carotid permeability. The postoperative period was excellent, without any neurological deficit. The patient consented with publication of her images and videos.
Among the posterolateral corridors to the ventral foramen magnum (FM), the transcondylar fossa (supracondylar transjugular tubercle) approach (TCFA) is indicated for lesions lying anteriorly to the ...dentate ligament and above the jugular foramen and hypoglossal canal.1-13 It involves the drilling of the condylar fossa, namely the exocranial surface of the jugular tubercle. Despite the anatomic variability of the condyle and posterior condylar emissary vein,14,15 they are important landmarks for the TCFA. The extradural jugular tuberculectomy has no risk of iatrogenic mechanical instability compared with the transcondylar approach. This 2-dimensional operative video (Video 1) aims to show the key technical aspects of the TCFA through the case description of an anterolateral FM meningioma. A 35-year-old male patient with a left anterolateral FM meningioma underwent TCFA in a semisitting position. Drilling of the condylar fossa led to an extradural resection of the jugular tubercle. Posterior condylar emissary veins connecting the sigmoid sinus/jugular bulb with the vertebral venous plexus marked the lateral limit of the approach. Through a suprahypoglossal working corridor, the meningioma was debulked and dissected. Postoperative magnetic resonance imaging confirmed complete resection of the tumor, and the patient was discharged neurologically intact on the third postoperative day. TCFA is a valuable technical option for selected anterolateral FM meningiomas. The perfect knowledge and intraoperative use of specific anatomic landmarks are critical to safely perform the TCFA while maximizing the exposure of the surgical target and decreasing the risk of postoperative mechanical instability of the craniovertebral junction.
Intraaxial tumors of the central lobe are challenging lesions to deal with because of the high eloquence of this anatomic area.1,2 Diffusion tensor imaging magnetic resonance imaging and fluorescein ...(F) have proven to be useful in the planning and execution, respectively of glioma surgery.3-9 Nevertheless, the advantages of intraoperative use of augmented reality (AR) with diffusion tensor imaging−based high-definition fiber tractography (HDFT) are still underestimated.
In the AR HDFT-F technique reported by our group, the integration of AR into the microscope comes through the BrainLAB Curve navigation platform (BrainLAB AG, Munich Germany), Smartbrush software (BrainLAB AG), KINEVO 900 surgical microscope (Carl Zeiss, Oberkochen, Germany), and YELLOW 560 filter (Carl Zeiss).9 The microscope establishes a wired autodetection of the navigation platform, and the eyepiece functions as a “see-through display” of the AR images, which are overlapped onto the surgical field.
Video 1 shows the technical key aspects of the intraoperative use of the AR HDFT-F technique in the maximal safe anatomic resection of a postcentral gyrus high-grade glioma.
Parkinson's disease is a neurodegenerative disease whose progression and clinical characteristics have a close bidirectional and multilevel relationship with the process of neuroinflammation. In this ...context, it is necessary to understand the mechanisms involved in this neuroinflammation-PD link. This systematic search was, hereby, conducted with a focus on the four levels where alterations associated with neuroinflammation in PD have been described (genetic, cellular, histopathological and clinical-behavioral) by consulting the PubMed, Google Scholar, Scielo and Redalyc search engines, including clinical studies, review articles, book chapters and case studies. Initially, 585,772 articles were included, and, after applying the inclusion and exclusion criteria, 84 articles were obtained that contained information about the multilevel association of neuroinflammation with alterations in gene, molecular, cellular, tissue and neuroanatomical expression as well as clinical-behavioral manifestations in PD.
Sellar arachnoidocele is a term used to define the herniation of the subarachnoid space to the sella.1 This is a rare radiologic finding that, in most cases, does not require treatment.2-5 When ...symptoms appear, the term empty sella syndrome is used. Two varieties exist: primary and secondary empty sella syndrome.2
The aim of this 3-dimensional operative video (Video 1) is to demonstrate the extradural microsurgical remodeling of the sellar fossa with autologous bone in 2 cases of primary empty sella syndrome. Both patients signed an informed consent for the procedures and agree with the use of their images for research purposes.
In both cases, magnetic resonance imaging scans showed herniation of the subarachnoid space into the pituitary fossa and an anchor-like silhouette on coronal view.
Patients evolved favorably, improving their visual deficit after the surgery, as can be observed in the postoperative visual field study.
If surgery is indicated due to visual loss, the procedure is known as chiasmapexy. Recently, Guinto et al3 described a technique for chiasmapexy. Our team considers this procedure to be useful, technically simple, and low cost. Being autologous, rejection possibilities are almost null. This 3D video serves as a complement to illustrate the technique.
The exact molecular pathways underlying the multifactorial natural history of intracranial aneurysms (IAs) are still largely unknown, to the point that their understanding represents an imperative ...challenge in neurovascular research. Wall shear stress (WSS) promotes the genesis of IAs through an endothelial dysfunction causing an inflammatory cascade, vessel remodeling, phenotypic switching of the smooth muscle cells, and myointimal hyperplasia. Aneurysm growth is supported by endothelial oxidative stress and inflammatory mediators, whereas low and high WSS determine the rupture in sidewall and endwall IAs, respectively. Angioarchitecture, age older than 60 years, female gender, hypertension, cigarette smoking, alcohol abuse, and hypercholesterolemia also contribute to growth and rupture. The improvements of aneurysm wall imaging techniques and the implementation of target therapies targeted against inflammatory cascade may contribute to significantly modify the natural history of IAs. This narrative review strives to summarize the recent advances in the comprehension of the mechanisms underlying the genesis, growth, and rupture of IAs.
Carotid–ophthalmic aneurysms arise from the internal carotid artery between the distal dural ring and the origin of the posterior communicating artery. The surgical treatment of these aneurysms ...usually requires anterior clinoidectomy. However, this procedure is not without complications. In the present report, we have described optic nerve mobilization after optic foraminotomy as an alternative to anterior clinoidectomy to clip superior carotid–ophthalmic aneurysms.
We have reported the cases of 3 patients with superior carotid–ophthalmic aneurysms who had undergone surgical clipping. Instead of an anterior clinoidectomy, the optic nerve was mobilized after performing optic foraminotomy. The optic canal was carefully unroofed with a 3-mm, high-speed, diamond drill under constant cold saline irrigation to avoid thermal damage to the optic nerve. After incision of the falciform ligament and optic sheath, the optic nerve was gently mobilized with a No. 6 Penfield dissector, facilitating aneurysmal neck exposure and clipping through a widened opticocarotid triangle.
The postoperative course was uneventful for all 3 patients, without any added visual defect. Optic nerve mobilization allowed us to safely widen the opticocarotid triangle and dissect the aneurysm off the optic nerve, without the need for clinoidectomy. This alternative technique permitted, not only early decompression of the optic nerve, but also dissection of the arachnoid between the inferior surface of the optic nerve and the superior surface of the ophthalmic–carotid artery and aneurysm dome.
Optic nerve mobilization after optic foraminotomy proved to be a safe and relatively easy technique for exposing and treating superior carotid–ophthalmic aneurysms.
•The cavernous sinus and anterior clinoid process are challenging structures.•The meningo-orbital band tethers the fronto-temporal dura.•The detachment of the meningo-orbital band is a key step to ...expose these structures.•We proposed a method for the safe and effective detachment of the meningo-orbital band.
The meningo-orbital band (MOB) is the most superficial dural band that tethers the fronto-temporal dura to the periorbita. It is usually encountered when performing a pterional or fronto-temporo-sphenoidal approach, and it disrupts surgical access to deeper regions.
Our objective was to perform a detailed anatomy study and a stepwise method to successfully detach the MOB using cadaveric specimens. We used six formalin‐fixed, silicone‐injected cadaveric heads. On each side, we performed a pterional approach plus mini‐peeling of the anterior third of the middle fossa and/or extradural anterior clinoidectomy. We also applied this technique in three clinical cases to prove its safety and efficacy. The detachment of the MOB consists in four steps, 1) detachment of the temporal and frontal dura, 2) cutting of the MOB, 3) exposure and drilling of the anterior clinoid process, and 4) pealing of the lateral wall of the cavernous sinus. Using clinical cases, we explain how to adapt the technique depending on the localization of the lesion. The detachment of the MOB is the key to safely expose the cavernous sinus and the anterior clinoid process. The authors proposed a step-by-step method for the safe and effective detachment of the MOB. It is recommended, particularly to less experienced neurosurgeons that are starting with skull base surgery, and also to experts that want to expand their knowledge.
Intracranial trigeminal schwannomas are rare tumors that may extend into multiple cranial compartments and may emerge from the root, ganglion, or intracranial portion of any of its branches.1-6 The ...aim of this 3-dimensional operative video is to present a single-stage complete removal of a dumbbell-shaped trigeminal schwannoma through a pretemporal approach (Video 1). Informed consent was given by the patient for use of images and the surgical video. We describe the case of a 43-year-old female presenting with chronic headaches and left facial pain in the trigeminal territory of V2 and V3. Magnetic resonance imaging showed a tumoral lesion located within the cerebellopontine angle, petroclival region, and middle fossa. Due to the patient’s symptoms, tumor size, and growth on sequential imaging, single-stage surgical removal was determined through a frontotemporal approach. There were no adverse outcomes posterior to the surgery, and the patient evolved favorably without neurologic deficits. Postoperative imaging showed complete resection of the tumoral lesion. Presurgical planning is essential for an effective and safe surgical strategy. For cases of trigeminal schwannomas with extension to the middle and posterior fossa, single-stage surgery is feasible for complete and safe removal.
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