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Resection of Oculomotor Nerve Lesions Using Continuous Stimulation of the Oculomotor Nerve Proximal to the Lesion: A Technical Report. World Neurosurg 2021; 152:56-60. [PMID: 34139352 DOI: 10.1016/j.wneu.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND We describe a continuous monitoring method aimed at preserving nerve function during biopsy of lesions on the oculomotor nerve using stimulation of the oculomotor nerve proximal to the lesion. CASE DESCRIPTION A 5-year-old girl with a recurrent left oculomotor nerve palsy and contrast-enhancing left oculomotor nerve mass on magnetic resonance imaging underwent a biopsy of the lesion to aid in its diagnosis. At the time of surgery, needle electrodes were inserted into the superior and inferior rectus muscles percutaneously, and cotton-covered electrodes were implanted into the oculomotor nerve proximal to the lesion. Compound muscle action potentials of the oculomotor nerve were measured continuously by monopolar stimulation. The lesion was mapped by direct stimulation, and the unresponsive area was excised. The amplitude of the compound muscle action potentials decreased during the resection but recovered postoperatively. After resection of the lesion, the compound muscle action potentials remained the same as they were preoperatively. No obvious postoperative oculomotor nerve palsy was observed. CONCLUSIONS This method of continuous monitoring of the function of the oculomotor nerve is simple to use and is suitable for lesions in close proximity to the oculomotor nerve.
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Ius T, Tel A, Minniti G, Somma T, Solari D, Longhi M, De Bonis P, Scerrati A, Caccese M, Barresi V, Fiorentino A, Gorgoglione L, Lombardi G, Robiony M. Advances in Multidisciplinary Management of Skull Base Meningiomas. Cancers (Basel) 2021; 13:2664. [PMID: 34071391 PMCID: PMC8198762 DOI: 10.3390/cancers13112664] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 12/18/2022] Open
Abstract
The surgical management of Skull Base Meningiomas (SBMs) has radically changed over the last two decades. Extensive surgery for patients with SBMs represents the mainstream treatment; however, it is often challenging due to narrow surgical corridors and proximity to critical neurovascular structures. Novel surgical technologies, including three-dimensional (3D) preoperative imaging, neuromonitoring, and surgical instruments, have gradually facilitated the surgical resectability of SBMs, reducing postoperative morbidity. Total removal is not always feasible considering a risky tumor location and invasion of surrounding structures and brain parenchyma. In recent years, the use of primary or adjuvant stereotactic radiosurgery (SRS) has progressively increased due to its safety and efficacy in the control of grade I and II meningiomas, especially for small to moderate size lesions. Patients with WHO grade SBMs receiving subtotal surgery can be monitored over time with surveillance imaging. Postoperative management remains highly controversial for grade II meningiomas, and depends on the presence of residual disease, with optional upfront adjuvant radiation therapy or close surveillance imaging in cases with total resection. Adjuvant radiation is strongly recommended in patients with grade III tumors. Although the currently available chemotherapy or targeted therapies available have a low efficacy, the molecular profiling of SBMs has shown genetic alterations that could be potentially targeted with novel tailored treatments. This multidisciplinary review provides an update on the advances in surgical technology, postoperative management and molecular profile of SBMs.
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Affiliation(s)
- Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy
| | - Alessandro Tel
- Maxillofacial Surgery Department, Department of Medicine, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.T.); (M.R.)
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100 Siena, Italy;
- IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, 80125 Naples, Italy; (T.S.); (D.S.)
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, 80125 Naples, Italy; (T.S.); (D.S.)
| | - Michele Longhi
- Unit of Radiosurgery and Stereotactic Neurosurgery, Department of Neurosciences, Azienda Ospedaliera Universitaria Integrata (AOUI), 37128 Verona, Italy;
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant’ Anna University Hospital, 44124 Ferrara, Italy; (P.D.B.); (A.S.)
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44124 Ferrara, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant’ Anna University Hospital, 44124 Ferrara, Italy; (P.D.B.); (A.S.)
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44124 Ferrara, Italy
| | - Mario Caccese
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy; (M.C.); (G.L.)
| | - Valeria Barresi
- Department of Diagnostics and Public Health, University of Verona, 37134 Verona, Italy;
| | - Alba Fiorentino
- Radiation Oncology Department, Advance Radiation Therapy, General Regional Hospital F. Miulli, 70021 Acquaviva delle Fonti, Italy;
| | - Leonardo Gorgoglione
- Department of Neurosurgery, Hospital “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy;
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCCS, 35128 Padua, Italy; (M.C.); (G.L.)
| | - Massimo Robiony
- Maxillofacial Surgery Department, Department of Medicine, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy; (A.T.); (M.R.)
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Eibl T, Hammer A, Yakubov E, Blechschmidt C, Kalisch A, Steiner HH. Medulloblastoma in adults - reviewing the literature from a surgeon's point of view. Aging (Albany NY) 2021; 13:3146-3160. [PMID: 33497354 PMCID: PMC7880386 DOI: 10.18632/aging.202568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Medulloblastoma is a common primary brain tumor in children but it is a rare cancer in adult patients. We reviewed the literature, searching PubMed for articles on this rare tumor entity, with a focus on tumor biology, advanced neurosurgical opportunities for safe tumor resection, and multimodal treatment options. Adult medulloblastoma occurs at a rate of 0.6 per one million people per year. There is a slight disparity between male and female patients, and patients with a fair skin tone are more likely to have a medulloblastoma. Patients present with cerebellar signs and signs of elevated intracranial pressure. Diagnostic efforts should consist of cerebral MRI and MRI of the spinal axis. Cerebrospinal fluid should be investigated to look for tumor dissemination. Medulloblastoma tumors can be classified as classic, desmoplastic, anaplastic, and large cell, according to the WHO tumor classification. Molecular subgroups include WNT, SHH, group 3, and group 4 tumors. Further molecular analyses suggest that there are several subgroups within the four existing subgroups, with significant differences in patient age, frequency of metastatic spread, and patient survival. As molecular markers have started to play an increasing role in determining treatment strategies and prognosis, their importance has increased rapidly. Treatment options include microsurgical tumor resection and radiotherapy and, in addition, chemotherapy that respects the tumor biology of individual patients offers targeted therapeutic approaches. For neurosurgeons, intraoperative imaging and tumor fluorescence may improve resection rates. Disseminated disease, residual tumor after surgery, lower radiation dose, and low Karnofsky performance status are all suggestive of a poor outcome. Extraneural spread occurs only in very few cases. The reported 5-year-survival rates range between 60% and 80% for all adult medulloblastoma patients.
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Affiliation(s)
- Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Eduard Yakubov
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Cristiane Blechschmidt
- Department of Neuropathology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Kalisch
- Department of Oncology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
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Bovo N, Momjian S, Gondar R, Bijlenga P, Schaller K, Boëx C. Sensitivity and Negative Predictive Value of Motor Evoked Potentials of the Facial Nerve. J Neurol Surg A Cent Eur Neurosurg 2021; 82:317-324. [PMID: 33477186 DOI: 10.1055/s-0040-1719026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective of this study was to determine the performance of the standard alarm criterion of motor evoked potentials (MEPs) of the facial nerve in surgeries performed for resections of vestibular schwannomas or of other lesions of the cerebellopontine angle. METHODS This retrospective study included 33 patients (16 with vestibular schwannomas and 17 with other lesions) who underwent the resection surgery with transcranial MEPs of the facial nerve. A reproducible 50% decrease in MEP amplitude, resistant to a 10% increase in stimulation intensity, was applied as the alarm criterion during surgery. Facial muscular function was clinically evaluated with the House-Brackmann score (HBS), pre- and postsurgery at 3 months. RESULTS In the patient group with vestibular schwannoma, postoperatively, the highest sensitivity and negative predictive values were found for a 30% decrease in MEP amplitude, that is, a criterion stricter than the 50% decrease in MEP amplitude criterion, prone to trigger more warnings, used intraoperatively. With this new criterion, the sensitivity would be 88.9% and the negative predictive value would be 85.7%. In the patient group with other lesions of the cerebellopontine angle, the highest sensitivity and negative predictive values were found equally for 50, 60, or 70% decrease in MEP amplitude. With these criteria, the sensitivities and the negative predictive values would be 100.0%. CONCLUSION Different alarm criteria were found for surgeries for vestibular schwannomas and for other lesions of the cerebellopontine angle. The study consolidates the stricter alarm criterion, that is, a criterion prone to trigger early warnings, as found previously by others for vestibular schwannoma surgeries (30% decrease in MEP amplitude).
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Affiliation(s)
- Nicolas Bovo
- Neurochirurgie, Université de Genève Centre Médical Universitaire, Geneva, Switzerland
| | | | - Renato Gondar
- Division of Neurosurgery, Neurosciences Cliniques, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Karl Schaller
- Department of Neurosurgery, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Colette Boëx
- Hôpitaux Universitaires de Genève, Geneva, Switzerland
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Jeong HN, Ahn SI, Na M, Yoo J, Kim W, Jung IH, Kang S, Kim SM, Shin HY, Chang JH, Kim EH. Triggered Electrooculography for Identification of Oculomotor and Abducens Nerves during Skull Base Surgery. J Korean Neurosurg Soc 2020; 64:282-288. [PMID: 33353290 PMCID: PMC7969041 DOI: 10.3340/jkns.2020.0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/10/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Electrooculography (EOG) records eyeball movements as changes in the potential difference between the negatively charged retina and the positively charged cornea. We aimed to investigate whether reliable EOG waveforms can be evoked by electrical stimulation of the oculomotor and abducens nerves during skull base surgery. METHODS We retrospectively reviewed the records of 18 patients who had undergone a skull base tumor surgery using EOG (11 craniotomies and seven endonasal endoscopic surgeries). Stimulation was performed at 5 Hz with a stimulus duration of 200 μs and an intensity of 0.1-5 mA using a concentric bipolar probe. Recording electrodes were placed on the upper (active) and lower (reference) eyelids, and on the outer corners of both eyes; the active electrode was placed on the contralateral side. RESULTS Reproducibly triggered EOG waveforms were observed in all cases. Electrical stimulation of cranial nerves (CNs) III and VI elicited positive waveforms and negative waveforms, respectively, in the horizontal recording. The median latencies were 3.1 and 0.5 ms for craniotomies and endonasal endoscopic surgeries, respectively (p=0.007). Additionally, the median amplitudes were 33.7 and 46.4 μV for craniotomies and endonasal endoscopic surgeries, respectively (p=0.40). CONCLUSION This study showed reliably triggered EOG waveforms with stimulation of CNs III and VI during skull base surgery. The latency was different according to the point of stimulation and thus predictable. As EOG is noninvasive and relatively easy to perform, it can be used to identify the ocular motor nerves during surgeries as an alternative of electromyography.
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Affiliation(s)
- Ha-Neul Jeong
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Myongji Hospital, Goyang, Korea
| | - Sang-Il Ahn
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Minkyun Na
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woohyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - In-Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Soobin Kang
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
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Cenzato M, Stefini R, Zenga F, Piparo M, Debernardi A, Costi I, Fava E. Cerebellopontine Angle Surgery Assisted by Continuous Mapping of the Facial Nerve Via the Ultrasonic Aspirator. J Neurol Surg A Cent Eur Neurosurg 2020; 82:369-374. [PMID: 33086423 DOI: 10.1055/s-0040-1709162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cerebellopontine angle (CPA) surgery carries the risk of lesioning the facial nerve. The goal of preserving the integrity of the facial nerve is usually pursued with intermittent electrical stimulation using a handheld probe that is alternated with the resection. We report our experience with continuous electrical stimulation delivered via the ultrasonic aspirator (UA) used for the resection of a series of vestibular schwannomas. METHODS A total of 17 patients with vestibular schwannomas, operated on between 2010 and 2018, were included in this study. A constant-current stimulator was coupled to the UA used for the resection, delivering square-wave pulses throughout the resection. The muscle responses from upper and lower face muscles triggered by the electrical stimulation were displayed continuously on multichannel neurophysiologic equipment. The careful titration of the electrical stimulation delivered through the UA while tapering the current intensity with the progression of the resection was used as the main strategy. RESULTS All operations were performed successfully, and facial nerve conduction was maintained in all patients except one, in whom a permanent lesion of the facial nerve followed a miscommunication to the neurosurgeon. CONCLUSION The coupling of the electrical stimulation to the UA provided the neurosurgeon with an efficient and cost-effective tool and allowed a safe resection. Positive responses were obtained from the facial muscles with low current intensity (lowest intensity: 0.1 mA). The availability of a resection tool paired with a stimulator allowed the surgeon to improve the surgical workflow because fewer interruptions were necessary to stimulate the facial nerve via a handheld probe.
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Affiliation(s)
- Marco Cenzato
- Department of Neurosurgery, Great Niguarda Hospital, Milano, Lombardia, Italy
| | - Roberto Stefini
- Department of Neurosurgery, Ospedale Civile di Legnano, Legnano, Lombardia, Italy
| | - Francesco Zenga
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Piemonte, Italy
| | - Maurizio Piparo
- Department of Neurosurgery, Great Niguarda Hospital, Milano, Lombardia, Italy
| | - Alberto Debernardi
- Department of Neurosurgery, Great Niguarda Hospital, Milano, Lombardia, Italy
| | - Ilaria Costi
- Department of Neurophysiology, Great Niguarda Hospital, Milano, Lombardia, Italy
| | - Enrica Fava
- Department of Neurosurgery, Great Niguarda Hospital, Università degli Studi di Milano BIOMETRA,, Milano, Lombardia, Italy
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