Short-Burst Bipolar Coagulation for Repairing Partially Damaged Brain Arteries Preserving Their Flow: Technical Note

Comparative Assessment of Thermal Damage Induced by Bipolar Forceps in a Bovine Liver

BACKGROUND AND OBJECTIVES

Bipolar electrocautery systems in neurosurgical procedures may induce thermal damage to adjacent tissues, especially neural tissues. Therefore, it is crucial to control thermal spread from the tips of bipolar forceps into adjacent tissues. The goal of this study was to compare the thermal damage induced in unintended adjacent tissues during coagulation with 6 different bipolar forceps.

METHODS

Fresh ex vivo bovine liver tissues were coagulated with 6 different bipolar forceps: Aesculap® nonstick, Atlas Choice™, ISOCOOL®, SilverGlide®, Spetzler™-Malis®, and VersaTru® (45 trials per bipolar forceps). For all forceps, coagulation was performed with a power setting of 35 Malis units, 1-mm tip spacing, and 3-second activation time. Tissue samples were evaluated for the extent of thermal damage (30 trials per bipolar forceps). Tissue temperatures were measured with thermocouples placed in the tissues (15 trials per bipolar forceps). The area and maximum depth of thermal damage were measured manually with image analysis software.

RESULTS

The injury area induced by ISOCOOL® and Atlas Choice™ bipolar forceps was significantly less than that of the Aesculap® nonstick ( P < .001), SilverGlide® ( P < .001), Spetzler™-Malis® ( P < .001), and VersaTru® ( P < .001). The areas of thermal injury caused by the ISOCOOL® and Atlas Choice™ forceps were not statistically significantly different from each other ( P = .08). Lesions from the ISOCOOL® and Atlas Choice™ forceps showed significantly less depth of injury than the Aesculap® nonstick ( P = .001), SilverGlide® ( P < .001), Spetzler™-Malis® ( P < .001), and VersaTru® ( P < .001). There was no statistically significant difference in the depth of thermal injury between the ISOCOOL® and Atlas Choice™ forceps ( P = 1.0).

CONCLUSION

Bipolar forceps that effectively limit excessive thermal dissipation reduce the risk of unintended injury to adjacent or peripheral tissues. In an ex vivo bovine liver model, coagulation tests with ISOCOOL® and Atlas Choice™ bipolar forceps resulted in less depth and lower mean injury areas compared with other forceps.

Management and outcomes of internal carotid artery, anterior cerebral artery, or middle cerebral artery injury during microsurgical approach of the anterior and middle cranial skull base: insights from a systematic review and a case series

Injury of the internal carotid artery (ICA), anterior cerebral artery (ACA), and middle cerebral artery (MCA) are rare but devastating complications during microsurgery of the anterior and middle cranial skull base. We systematically reviewed the current knowledge on ICA, ACA, and MCA injury during skull base microsurgery and performed a multicentric data collection to refine their management. A systematic review of ICA, ACA, and MCA injuries during direct microsurgical approaches to the anterior and middle cranial skull base was performed, using PRISMA-IPD guidelines and using a multicentric case collection. Literature search (French and English languages, PubMed/MEDLINE) was performed from January 1946 to July 2024. 76 adult patients were included (65 adult from literature review, 11 from multicentric case collection). The injury involved the ICA, ACA, and MCA in 38.2%, 39.5%, and 22.3% of cases, respectively. Death related to the artery injury occurred in 22.4% of cases. Injury of the ICA and intraoperative management by occlusive clipping were independent predictors of death related to the arterial injury. Permanent neurological deficit related to the artery injury occurred in 46.1% of cases. Injury of the ICA and permanent artery occlusion were independent predictors of permanent neurological deficit related to the arterial injury. Arterial injury during anterior or middle cranial skull base microsurgery is a dramatic complication. Salvage techniques resulting in the occlusion of the injured artery have higher rates of death and of permanent neurological deficit. Non-occlusive techniques should be preferred, whenever feasible, to manage the injury.

Subaxial cervical foraminal chondromas: case-based discussion on surgical management

Cervical foraminal chondromas are benign lesions that may require surgical resection when symptomatic due to radicular and/or spinal cord compression. The aim of surgery is to achieve gross tumor removal while preserving neurological function and spine stability. The authors describe a case of subaxial foraminal chondroma with a systematic review of the literature on patients with cervical chondromas. In the reported case, the authors used a retrojugular approach to remove a C6-C7 right chondroma without the need for spinal stabilization. Literature review identified a total of 11 patients who underwent surgery for subaxial foraminal chondroma. The mean age at diagnosis is 33.6 years (range: 10-73). Most patients report neurological symptoms at the time of diagnosis. The most frequently involved vertebral level is C4-C5 (54.6%, 6/11). Preoperative foraminal enlargement is present in 63.6% (7/11) of patients. Surgical resection is performed via an anterior approach in 18.2% (2/11) of patients, with vertebral body resection and concomitant cervical instrumentation. The anterolateral approach is selected in 27.2% (3/11) of patients, and the posterior approach in 54.6% (6/11) of patients, with only one patient requiring both anterior and posterior instrumentation. The choice of surgical access for subaxial foraminal chondroma can be challenging due to the anatomical location of the tumor in relation to the cervical nerve roots and spinal cord. Accurate approach selection is key to achieving complete tumor removal while preserving cervical spine stability.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution

BACKGROUND

 Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution.

METHODS

 Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details.

RESULTS

 There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging.

CONCLUSIONS

 Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.

Vascular Lesions of the Pineal Region: A Comprehensive Review of the Therapeutic Options

OBJECTIVE

Vascular lesions of the pineal region comprise aneurysms of the pineal region, arteriovenous malformations, cavernous malformations, and vein of Galen malformations. In the present report, we have offered an extensive review of each vascular pineal region lesion.

METHODS

We performed an extensive literature review, focusing on the current therapeutic options available for the different vascular lesions of the pineal region.

RESULTS

Vascular lesions of the pineal region are rare. Microneurosurgery remains a valid treatment of cavernomas, arteriovenous malformations, and aneurysms. Endovascular treatments seem to be the first option for the vein of Galen malformations, followed by microneurosurgery. Radiosurgery seems beneficial for small-size arteriovenous malformations. Complex and large vascular lesions will require a combination of multiple treatments.

CONCLUSIONS

Vascular lesions of the pineal region are complex, uncommon diseases. Thus, definitive therapeutic modalities for these lesions require further research.

Repair of damaged cortical artery by direct micro-suture in surgical treatment of acute subdural hematoma: technical note

BACKGROUND

In surgical treatment of acute subdural hematoma (ASDH), neurosurgeons frequently encounter bleeding from cortical arteries, which is usually controlled with bipolar coagulation. However, bipolar coagulation is associated with a risk of sacrificing the cortical artery, which may affect the prognosis of neurological symptoms when these cortical arteries supply critical areas. In this article, we describe microsurgical repair of damaged cortical arteries using a 10-0 nylon micro-suture in patients with arterial-origin ASDH.

METHODS

After removal of the subdural hematoma, the exact bleeding point of the cortical artery was identified, and the 10-0 nylon suture stitches were placed on the arterial tear under a microscope. After completion of the micro-suture, vascular patency was confirmed by indocyanine green (ICG) videoangiography.

RESULTS

From June 2015 through February 2017, microsurgical repair was performed for seven cortical arteries in six patients. All damaged arteries were located near the Sylvian fissure, and all tears were pinhole tears. The average blood flow occlusion time was 8 min (range, 0-15 min). The patency of all seven repaired arteries was successfully confirmed by ICG videoangiography. Postoperative cerebral infarction was not observed except in one patient with cerebral contusion and a history of severe head trauma.

CONCLUSIONS

The present report demonstrates that repair of a cortical artery by the 10-0 nylon micro-suture is a simple and safe method with a low risk of sacrificing the artery. This technique may be a good option in the surgical treatment of arterial-origin ASDH, especially when the accompanying cerebral contusion is minimal.

Venous air embolisms and sitting position in Helsinki pineal region surgery

Background

Nowadays, the sitting position has lost favor among neurosurgeons partly due to assumptions of increased complications, such as venous air embolisms (VAEs) and hemodynamic disturbances. The aim of our study is to describe the importance of some anesthetic considerations and the utility of antigravity trousers as well, together with a skillful neurosurgery and an imperative proper teamwork, in order to prevent the risk of severe VAE during pineal region surgery. We routinely use them for the variant of the sitting position we developed, the "praying position."

Methods

A retrospective review of 51 pineal lesions operated on in the "praying position" using antigravity trousers was carried out. In the "praying position" the legs of the patient are kept parallel to the floor. Hence, antigravity trousers are used to generate an adequate cardiac preload.

Results

VAE associated to persistent hemodinamic changes was nonexistent in our series. The rate of VAE was 35.3%. VAEs were diagnosed mainly by monitoring of the end-tidal CO₂ (83.33%). A venous system lesion was the cause in most of the cases. When VAE was suspected, an inmediate reaction based on a good teamwork was imperative. No cervical spine cord injury nor peripheral nerve damage were reported. The average microsurgical time was 48 ± 33 min.

Conclusions

The risks of severe VAE during pineal region surgery in the "praying-sitting position" may be effectively prevented by some essential anesthetic considerations and the use of antigravity trousers together with a skillful neurosurgery, and an imperative proper teamwork.

Praying Sitting Position for Pineal Region Surgery: An Efficient Variant of a Classic Position in Neurosurgery

BACKGROUND

The sitting position has lost favor among neurosurgeons partly owing to assumptions of increased complications, such as venous air embolisms and hemodynamic disturbances. Moreover, the surgeon must assume a tiring posture. We describe our protocol for the "praying position" for pineal region surgery; this variant may reduce some of the risks of the sitting position, while providing a more ergonomic surgical position.

METHODS

A retrospective review of 56 pineal lesions operated on using the praying position between January 2008 and October 2015 was performed. The praying position is a steeper sitting position with the upper torso and the head bent forward and downward. The patient's head is tilted about 30° making the tentorium almost horizontal, thus providing a good viewing angle. G-suit trousers or elastic bandages around the lower extremities are always used.

RESULTS

Complete lesion removal was achieved in 52 cases; subtotal removal was achieved in 4. Venous air embolism associated with persistent hemodynamic changes was nonexistent in this series. When venous air embolism was suspected, an immediate reaction based on good teamwork was imperative. No cervical spine cord injury or peripheral nerve damage was reported. The microsurgical time was <45 minutes in most of the cases. Postoperative pneumocephalus was detected in all patients, but no case required surgical treatment.

CONCLUSIONS

A protocolized praying position that includes proper teamwork management may provide a simple, fast, and safe approach for proper placement of the patient for pineal region surgery.

Moyamoya Disease in an 8-Year-Old Boy: Direct Bypass Surgery in a Province of Peru

BACKGROUND

Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors.

CASE DESCRIPTION

Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patient's motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru.

CONCLUSIONS

The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.

The open access video collection project "Hernesniemi's 1001 and more microsurgical videos of Neurosurgery": A legacy for educational purposes

BACKGROUND

Neurosurgical educational programs and courses are helpful to improve the quality of training. Moreover, nowadays, online activities may represent a very useful tool to globally enhance neurosurgical education. The "Hernesniemi's 1001 and more microneurosurgical videos" project aims to show the microsurgical style developed by the senior author and his TEAMs in more than 40 years of experience.

METHODS

More than 1100 high-definition videos of microneurosurgical operations performed by the senior author were carefully edited. These videos illustrate the philosophy of "simple, clean, fast and preserving the normal anatomy" while offering a step by step guide of different neurosurgical procedures.

RESULTS

All the aforementioned material is well organized in an electronic videobook, freely available in Surgical Neurology International. The book also includes comments of great current neurosurgeons and writings of the authors and editors.

CONCLUSION

We are sure that our project will be able to instill in and spread across the neurosurgical community the microneurosurgical style of the senior author, thus representing an efficient educational tool for surgeons all around the world.