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Nathal E, Serrano-Rubio A, Benavides-Burbano CA, Rodríguez-Rubio HA. Paraclinoid aneurysms clipping through an extradural sphenoid ridge keyhole approach. Acta Neurochir (Wien) 2023; 165:2837-2841. [PMID: 37676506 PMCID: PMC10541827 DOI: 10.1007/s00701-023-05760-x] [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: 05/18/2023] [Accepted: 08/06/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Paraclinoid aneurysms represent a challenge for neurosurgeons due to the anatomical complexity of this region. Then, innovative techniques such as the extradural sphenoid ridge approach are suitable for a safe microsurgical clipping. METHOD A description of the surgical technique was made by the senior author, a vascular neurosurgeon experienced with the use of this approach in the management of paraclinoid aneurysms exemplified through a clinical case. CONCLUSION Microsurgical clipping through an extradural sphenoid ridge keyhole approach for small and midsize paraclinoid aneurysms is an excellent treatment modality with good clinical and surgical results.
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Affiliation(s)
- Edgar Nathal
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Universidad Nacional Autonoma de México (UNAM), Insurgentes Sur 3877, Tlalpan, Mexico City, 14263 Mexico
| | - Alejandro Serrano-Rubio
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Universidad Nacional Autonoma de México (UNAM), Insurgentes Sur 3877, Tlalpan, Mexico City, 14263 Mexico
| | - Camilo Armando Benavides-Burbano
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Universidad Nacional Autonoma de México (UNAM), Insurgentes Sur 3877, Tlalpan, Mexico City, 14263 Mexico
| | - Héctor A. Rodríguez-Rubio
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Universidad Nacional Autonoma de México (UNAM), Insurgentes Sur 3877, Tlalpan, Mexico City, 14263 Mexico
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Parikh KA, Yagmurlu K, Michael LM. Commentary: Transcavernous Surgical Approach for the Treatment of Carotid-Cavernous Fistula: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e216-e217. [PMID: 36701553 DOI: 10.1227/ons.0000000000000575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 01/27/2023] Open
Affiliation(s)
- Kara A Parikh
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kaan Yagmurlu
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Semmes Murphey Clinic, Memphis, Tennessee, USA
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Matoušek P, Cvek J, Čábalová L, Misiorzová E, Krejčí O, Lipina R, Krejčí T. Does Endoscopic Transnasal Optic Nerve Decompression Followed by Radiosurgery Improve Outcomes in the Treatment of Parasellar Meningiomas? MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081137. [PMID: 36013604 PMCID: PMC9414861 DOI: 10.3390/medicina58081137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/06/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Abstract
Introduction: The clinical management of parasellar meningiomas (PM) is challenging due to their intimate association with critical neurovascular structures. Consensus regarding the recommended treatment protocol is lacking. This study will evaluate patients’ visual outcomes following endoscopic transnasal optic nerve decompression (ETOND) and will investigate the possibility of reducing the rate of complications associated with stereotactic radiosurgery (SRS). Methods: Retrospective analysis was conducted on all patients who underwent ETOND for PM between 2013 and 2020. The study comprised 12 patients (7 women and 5 men aged 36–75 years; mean, 55.2 years; median, 57.6 years) in which 14 optic nerve decompression procedures were carried out. Patients were followed up for 6 to 86 months (mean, 29.3 months; median, 25 months). There were five cases of spheno-orbital meningioma, four cases of cavernous sinus meningioma, and one case each of petro-clival meningioma, optic nerve sheath meningioma, and planum sphenoidale/tuberculum sellae meningioma. Visual outcome was evaluated and any postoperative complications noted. Results: Improvements in visual acuity were noted in 10 of 14 eyes (71.4%) 3 to 6 months postoperation. Visual acuity remained stable in the remaining four eyes. No deterioration of visual acuity was noted during the follow-up period. In total, 9 of the 12 patients underwent SRS. No tumor growth was determined, while reduction in tumor volume was noted in five patients following SRS. No complications associated with SRS or the surgical procedure were noted. Conclusions: ETOND appears to be a promising technique for increasing rates of improved visual function, while reducing the risk of post SRS-related complications. In combination with subsequent SRS, it is an ideal treatment modality in the management of parasellar meningiomas. Confirmation of our findings would require a larger, prospective multicenter study.
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Affiliation(s)
- Petr Matoušek
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Ostrava, 70852 Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Jakub Cvek
- Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
- Department of Oncology, University Hospital Ostrava, 70852 Ostrava, Czech Republic
| | - Lenka Čábalová
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Ostrava, 70852 Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Eva Misiorzová
- Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
- Department of Neurosurgery, University Hospital Ostrava, 70852 Ostrava, Czech Republic
| | - Ondřej Krejčí
- Department of Neurosurgery, University Hospital Ostrava, 70852 Ostrava, Czech Republic
| | - Radim Lipina
- Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
- Department of Neurosurgery, University Hospital Ostrava, 70852 Ostrava, Czech Republic
| | - Tomáš Krejčí
- Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
- Department of Neurosurgery, University Hospital Ostrava, 70852 Ostrava, Czech Republic
- Correspondence:
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Heng L, Wang H, Zhang S, Jiang X, Qu Y. Pretreating cavernous sinus with hemostatic agent injection molding during endoscopic endonasal pituitary surgery: technical note. Acta Neurochir (Wien) 2022; 164:2105-2114. [PMID: 35687171 DOI: 10.1007/s00701-022-05267-x] [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: 02/05/2022] [Accepted: 04/22/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To clarify the technical pearls of cavernous sinus molding technique with hemostatic agent injection during endoscopic endonasal pituitary surgery. METHODS All patients pretreated with cavernous sinus hemostatic agent injection molding technique for hemostasis in endoscopic endonasal surgery for pituitary adenoma resection between November 2017 and June 2021 were included. A small incision was made in the cavernous sinus wall before intracavernous manipulation. The hemostatic agent was injected with gentle pressure. It spread along the venous channels and established partial molding of the cavernous sinus. Intraoperative bleeding, surgical field score, and complications were evaluated. RESULTS Thirty-eight patients with pituitary adenoma requiring cavernous sinus manipulation were pretreated with this technique. Technically, the tailored thin blunt metal tube with its 1 cm head end bended up 45° were the best instrument to accomplish injection. Multi-spot injections were preferred to control different compartments of the cavernous sinus, which both had a better effect in bleeding control and helped to reduce the influence of trigemino-cardiac reflex. Postoperative complications, including temporal lobe edema, hemorrhage, and exophthalmos were not observed. CONCLUSION Pretreating cavernous sinus with hemostatic agent injection molding technique during endoscopic endonasal pituitary surgery is a practical, effective and safe method for intracavernous bleeding control.
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Affiliation(s)
- Lijun Heng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Hang Wang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Shuo Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Xue Jiang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi, China.
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Andrade-Barazarte H, Chen Z, Feng C, Srinivasan VM, Furey CG, Lawton MT, Hernesniemi J. Case Report: Internal Carotid Artery Thrombosis: A Rare Complication After Fibrin Glue Injection for Cavernous Sinus Hemostasis. Front Surg 2021; 8:730408. [PMID: 34796197 PMCID: PMC8593815 DOI: 10.3389/fsurg.2021.730408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/27/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Fibrin glue injection within the cavernous sinus (CS) is a demonstrably safe and simple technique to control venous bleeding with a low complication rate. However, this technique does have inherent risks. We illustrate 2 cases of internal carotid artery (ICA) thrombosis after fibrin glue injection in the CS for hemostasis. Methods: After encountering this complication recently, we conducted a retrospective review of the surgical database of 2 senior neurosurgeons who specialize in cerebrovascular and skull base surgery to identify patients with any complications associated with the use of fibrin glue injection for hemostasis. Approval was given by respective institutional review boards, and patient consent was obtained. Results: Of more than 10,000 microsurgery procedures performed by 2 senior neurosurgeons with a combined experience of 40 years, including procedures for aneurysms and skull base tumors, 2 cases were identified involving ICA thrombosis after fibrin glue injection in the CS for hemostasis. Both cases involved severe ischemic complications as a result of the ICA thrombosis. In this article, we present their clinical presentation, characteristics, management, and outcomes. Conclusion: Direct injection of fibrin glue into the CS for hemostasis can effectively control venous bleeding and facilitate complex dissections. However, it can be associated with ICA thrombosis, with subsequent serious ischemia and poor prognosis. Although this complication appears to be rare, increased awareness of this problem should temper the routine use of fibrin glue in anterior clinoidectomy and transcavernous approaches.
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Affiliation(s)
- Hugo Andrade-Barazarte
- "Juha Hernesniemi" International Center of Neurosurgery, Cerebrovascular Diseases, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Zhongcan Chen
- "Juha Hernesniemi" International Center of Neurosurgery, Cerebrovascular Diseases, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Chenyi Feng
- "Juha Hernesniemi" International Center of Neurosurgery, Cerebrovascular Diseases, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Visish M Srinivasan
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Charuta G Furey
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Juha Hernesniemi
- "Juha Hernesniemi" International Center of Neurosurgery, Cerebrovascular Diseases, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
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6
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Volovici V, Dammers R. How I do it: proximal control in parkinson's triangle for a very large paraclinoid aneurysm. Acta Neurochir (Wien) 2021; 163:2967-2971. [PMID: 34389909 PMCID: PMC8520508 DOI: 10.1007/s00701-021-04961-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/31/2021] [Indexed: 11/30/2022]
Abstract
Background Paraclinoid aneurysms, especially when they are large, can be quite difficult to treat, both endovascularly and through microsurgical clip reconstruction. There are many possibilities to approach this region surgically, and most hinge on total or partial removal of the anterior clinoid process. Gaining proximal control may be a challenge when space is limited, which is why Parkinson’s triangle may be a viable alternative in some cases. Methods We describe in a stepwise fashion the steps used to reconstruct a very large paraclinoid aneurysm. We first attempted to gain proximal control in the carotid cave and later in Parkinson’s triangle because of limited manoeuvrability. Conclusion Proximal control in Parkinson’s triangle can be a safe alternative when the post-clinoidal segment of the internal carotid artery (ICA) is short and working space is limited in paraclinoid aneurysm microsurgical clip reconstruction. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-04961-6.
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Affiliation(s)
- Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Basma J, Krisht KM, Lee P, Cai L, Krisht AF. Temporary Clipping of the Intracavernous Internal Carotid Artery: A Novel Technique for Proximal Control. Oper Neurosurg (Hagerstown) 2021; 20:E91-E97. [PMID: 33313919 DOI: 10.1093/ons/opaa302] [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: 02/10/2020] [Accepted: 07/11/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Securing proximal control in complex paraclinoid aneurysm surgery through traditional techniques may be challenging and risky in certain situations. Advancements of anatomical knowledge of the cavernous sinus (CS) and hemostasis have made it more accessible as a surgical option. OBJECTIVE To describe the technique of temporary clipping of the horizontal segment of the intracavernous internal carotid artery (IC-ICA) in preparation for permanent clipping of complex paraclinoid aneurysms. METHODS Through an extradural pretemporal approach, the lateral wall of the CS is exposed. The dura between the trochlear nerve and V1 is opened, and access is made to the horizontal segment of the IC-ICA. After circumferential dissection, the temporary clip can be introduced to the artery, and the extradural clinoidectomy can be continued under secured proximal control. RESULTS Seven patients with complex paraclinoid aneurysms were treated between May 2013 and May 2016 by the senior author. Temporary clipping of the IC-ICA was performed in all cases. Average time to achieve proximal control was 22.6 min (22.6 ± 13.8). One patient developed transient oculomotor palsy postoperatively. There were no other complications. CONCLUSION When the exposed clinoidal segment of the internal carotid artery does not offer sufficient proximal space for temporary clipping, the extradural approach can be extended to the horizontal portion of the IC-ICA. In our experience, this technique is a quick, reliable, and safe alternative to the classical modalities of temporary occlusion.
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Affiliation(s)
- Jaafar Basma
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Khaled M Krisht
- Department of Neurological Surgery, CHI St. Vincent Arkansas Neuroscience Institute, Sherwood, Arkansas
| | - Paul Lee
- Department of Neurological Surgery, CHI St. Vincent Arkansas Neuroscience Institute, Sherwood, Arkansas
| | - Li Cai
- Department of Neurological Surgery, CHI St. Vincent Arkansas Neuroscience Institute, Sherwood, Arkansas
| | - Ali F Krisht
- Department of Neurological Surgery, CHI St. Vincent Arkansas Neuroscience Institute, Sherwood, Arkansas
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Sellin JN, Srinivasan VM, Navarro JC, Batjer HH, Van Loveren H, Duckworth EA. Transcavernous Approach to the Basilar Apex: A Cadaveric Prosection. Cureus 2018; 10:e2192. [PMID: 29682431 PMCID: PMC5908389 DOI: 10.7759/cureus.2192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The transcavernous approach to the basilar artery, as initially described by Dolenc, is one of the most common and elegant approaches to the region. It affords a generous working and viewing angle, but it can be technically challenging and requires attention to detail at each step. We investigate this approach in this report via a cadaveric prosection with a focus on the value of each of the component steps in improving surgical view and exposure. The transcavernous approach steps are divided into extradural stages: orbitozygomatic osteotomy (a modern adjunct to Dolenc's original description), drilling of the lesser sphenoid wing, and anterior clinoidectomy; and intradural stages: wide splitting of the Sylvian fissure, unroofing of the oculomotor and trochlear nerves, and posterior clinoidectomy. The surgical windows afforded by each step in the approach are illustrated using microscopic images taken during the cadaveric prosection of a donor who happened to harbor a basilar apex aneurysm. An illustrative case and artist illustrations are used to emphasize the relative value of each step of the transcavernous exposure.
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Affiliation(s)
| | | | - Jovany C Navarro
- Department of Anesthesiology, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Hunt H Batjer
- Department of Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Harry Van Loveren
- Department of Neurosurgery, University of South Florida Morsani College of Medicine
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Abstract
The lesions involving cavernous sinus (CS) and lateral sellar region includes tumors, vascular lesions, infection, inflammation, and trauma. Tumors associated with CS cause significant distortion of the microanatomy posing an additional surgical challenge to the neurosurgeons. The surgical approach and microsurgical anatomy with respect to the origin and growth of the tumor within the CS region have not been comprehensively described in recent years. We conducted a review of literature concerning CS and associated tumors, complied through MEDLINE/OVID and using cross-references of articles on PubMed with the keywords cavernous sinus, CS tumors, pituitary adenoma, meningioma, schwannoma, chordoma, CS hemangiomas, extradural, interdural, intradural, skull base, gamma knife radiosurgery, endoscopic endonasal approach. Based on the tumor origin and growth pattern, the tumors associated with CS can be classified into three categories: Type-I: tumor originating from CS, Type-II: originating from lateral wall of CS, and Type-III: extraneous origin and occupying CS. The review focuses on approach to a tumor within each type of tumor in the CS region. The emphasis is that the tumor growth pattern and significant distortion of the CS anatomy caused by the tumor growth should be considered while planning the optimal surgical approach for tumors in this region to ensure complete tumor resection with minimal neurovascular morbidity.
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Affiliation(s)
- Silky Chotai
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yi Liu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Hwang J, Seol HJ, Nam DH, Lee JI, Lee MH, Kong DS. Therapeutic Strategy for Cavernous Sinus-Invading Non-Functioning Pituitary Adenomas Based on the Modified Knosp Grading System. Brain Tumor Res Treat 2016; 4:63-69. [PMID: 27867914 PMCID: PMC5114194 DOI: 10.14791/btrt.2016.4.2.63] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/09/2016] [Accepted: 06/29/2016] [Indexed: 12/05/2022] Open
Abstract
Background Non-functioning pituitary adenomas (NFPA) invading into the cavernous sinus are surgically challenging. To decrease recurrence rate, surgeon makes a strong endeavor to resect tumor gross totally. However, gross total resection (GTR) is difficult to achieve with cavernous sinus invasion. Recently, a new classification system for cavernous invasion of pituitary adenomas was suggested. The aim of this study is to validate this new classification system and to identify limitations and considerations in designing treatment strategies for patients with NFPA involving the cavernous sinus. Methods Between January 2000 and January 2012, 275 patients who underwent operation for NFPA were enrolled in the study. Median age was 50 years (15–79 years). There were 145 males and 130 females. The median follow-up duration was 4 years (range 1–12.5 years). Results Related to extent of tumor removal, GTR was obtained in 184 patients (66.9%), near total resection (NTR) was obtained in 45 patients (16.3%), and sub-total resection (STR) was obtained in 46 patients (16.7%) of a total 275 patients. There were statistically significant differences between the extent of resection and the new Knosp classification (p<0.001). In the high-grade group of the new Knosp classification, there was no difference in recurrence between patients who underwent GTR or NTR only and those who underwent STR with adjuvant radiation therapy (p=0.515). Conclusion In case of high risk of surgical complications, STR with adjuvant radiation therapy can be considered as an alternative strategy for safe treatment of cavernous-invading adenomas.
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Affiliation(s)
- Juyoung Hwang
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Ho Lee
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Tavanaiepour D, Jernigan S, Abolfotoh M, Al-Mefty O. Fibrin Glue Injection for Cavernous Sinus Hemostasis Associated with Cranial Nerve Deficit: A Case Report. J Neurol Surg Rep 2015; 76:e72-4. [PMID: 26251815 PMCID: PMC4520999 DOI: 10.1055/s-0034-1543977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 11/10/2014] [Indexed: 10/25/2022] Open
Abstract
Fibrin glue injection has been used to control intraoperative cavernous sinus (CS) venous bleeding. There have been no reported complications related to this maneuver. We present a case where a patient developed a sensory trigeminal nerve deficit after injection of fibrin glue into the posterior CS during resection of a petrosal meningioma. We believe that this deficit was due to the compression of the trigeminal ganglion similar to balloon compression procedures. Although fibrin glue injection may achieve satisfactory cavernous sinus homeostasis, the volume and rate of injection should be kept in mind to avoid a compressive lesion on traversing cranial nerves and surrounding structures, or retrograde filling of the venous tributaries.
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Affiliation(s)
- Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Sarah Jernigan
- Department of Neurosurgery, University of Miami, Miami, Florida, United States
| | | | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard School of Medicine, Boston, Massachusetts, United States
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12
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Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, McCoul ED, Anand VK, Schwartz TH. Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg 2014; 120:1086-94. [PMID: 24527820 DOI: 10.3171/2014.1.jns131228] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This study details the extent of resection and complications associated with endonasal endoscopic surgery for pituitary tumors invading the cavernous sinus (CS) using a moderately aggressive approach to maximize extent of resection through the medial CS wall while minimizing the risk of cranial neuropathy and blood loss. Tumor in the medial CS was aggressively pursued while tumor in the lateral CS was debulked in preparation for radiosurgery. METHODS A prospective surgical database of consecutive endonasal pituitary surgeries with verified CS invasion on intraoperative visual inspection was reviewed. The extent of resection as a whole and within the CS was assessed by an independent neuroradiologist using pre- and postoperative Knosp-Steiner (KS) categorization and volumetrics of the respective MR images. The extent of resection and clinical outcomes were compared for medial (KS 1-2) and lateral (KS 3-4) lesions. RESULTS Thirty-six consecutive patients with pituitary adenomas involving the CS who had surgery via an endonasal endoscopic approach were identified. The extent of resection was 84.6% for KS 1-2 and 66.6% for KS 3-4 (p = 0.04). The rate of gross-total resection was 53.8% for KS 1-2 and 8.7% for KS 3-4 (p = 0.0006). Six patients (16.7%) had preoperative cranial neuropathies, and all 6 had subjective improvement after surgery. Surgical complications included 2 transient postoperative cranial neuropathies (5.6%), 1 postoperative CSF leak (2.8%), 1 reoperation for mucocele (2.8%), and 1 infection (2.8%). CONCLUSIONS The endoscopic endonasal "medial-to-lateral" approach permits safe debulking of tumors in the medial and lateral CS. Although rates of gross-total resection are moderate, particularly in the lateral CS, the risk of permanent cranial neuropathy is extremely low and there is a high chance of improvement of preexisting deficits. This approach can also facilitate targeting for postoperative radiosurgery.
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Affiliation(s)
- Graeme F Woodworth
- Department of Neurological Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and
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Mishra S, Leão B, Rosito DM. Extradural anterior clinoidectomy: Technical nuances from a learner's perspective. Asian J Neurosurg 2014; 12:189-193. [PMID: 28484528 PMCID: PMC5409364 DOI: 10.4103/1793-5482.145544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Extradural removal of the anterior clinoid process (ACP) is a crucial step in the proper surgical exposure of various pathologies in and around the central skull base. Since the pioneering description by Dolenc, the technique of extradural clinoidectomy has undergone several refinements in the light of improved understanding of microsurgical anatomy and maturation of neurosurgical techniques. Mastery of the surgical nuances involved in performing this surgical exercise will allow the young neurosurgeon to execute this step without undue reluctance and trepidation. Objective: This paper is an attempt to describe in detail, from a learner's viewpoint, the sequence of maneuvers involved in extradural removal of the ACP. Materials and Methods: The standard pterional approach and extradural anterior clinoidectomy was performed on four sides of two formalin fixed and latex injected cadaver heads. Important steps were photographed through the surgical microscope. Conclusion: An accurate understanding of the microsurgical anatomy of this region and the surgical nuances relevant to extradural clinoidectomy helps simplify the complexity of this surgical step.
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Affiliation(s)
- Shashwat Mishra
- Department of Neurosurgery, Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Baltazar Leão
- Department of Neurosurgery, Arkansas Neuroscience Institute, St. Vincent's Infirmary, Little Rock, AR 72205, USA
| | - Diego Mendez Rosito
- Department of Neurosurgery, Arkansas Neuroscience Institute, St. Vincent's Infirmary, Little Rock, AR 72205, USA
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List RJ, Thomas SPH, Shenouda E, Lang D, Davis A, Mathad N. Fibrin Sealant Injection: An Aid to Reduce Venous Bleeding during Jugular Bulb and Sigmoid Sinus Dissection in Glomus Jugulare (Jugulotympanic Paraganglioma) Surgery. Skull Base 2012; 21:309-12. [PMID: 22451831 DOI: 10.1055/s-0031-1284212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Glomus jugulare (jugulotympanic paraganglioma) surgery requires tumor dissection in the region of the jugular bulb, upper internal jugular vein, and sigmoid sinus. Despite ligation or external compression of the sigmoid sinus proximally and ligation of the internal jugular vein distally, troublesome venous bleeding can arise from the inferior petrosal sinus or condylar veins at the medial wall of the jugular bulb. Excessive packing in this area can place the integrity of the lower cranial nerves at risk. We report a technique in which Tisseel(®) fibrin sealant is injected into the ligated sigmoid sinus and internal jugular vein. This forms an internal cast around the tumor in the sigmoid-jugular complex and helps seal the inferior petrosal sinus and condylar veins. This allows for safer dissection with reduced venous bleeding. Our experience in five cases has shown this technique to be effective.
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Agarwal V, Velho V, Gosavi KS, Khobragade AA, Aher R, Binayke RS. Hemostatic effect of human fibrin glue on bleeding surface of the brain: An experiment on albino Wistar rats. INDIAN JOURNAL OF NEUROTRAUMA 2012. [DOI: 10.1016/j.ijnt.2012.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Son HE, Park MS, Kim SM, Jung SS, Park KS, Chung SY. The avoidance of microsurgical complications in the extradural anterior clinoidectomy to paraclinoid aneurysms. J Korean Neurosurg Soc 2010; 48:199-206. [PMID: 21082045 DOI: 10.3340/jkns.2010.48.3.199] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 07/27/2010] [Accepted: 09/15/2010] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Paraclinoid segment internal carotid artery (ICA) aneurysms have historically been a technical challenge for neurovascular surgeons. The development of microsurgical approach, advances in surgical techniques, and endovascular procedures have improved the outcome for paraclinoid aneurysms. However, many authors have reported high complication rates from microsurgical treatments. Therefore, the present study reviews the microsurgical complications of the extradural anterior clinoidectomy for treating paraclinoid aneurysms and investigates the prevention and management of observed complications. METHODS Between January 2004 and April 2008, 22 patients with 24 paraclinoid aneurysms underwent microsurgical direct clipping by a cerebrovascular team at a regional neurosurgical center. Microsurgery was performed via an ipsilateral pterional approach with extradural anterior clinoidectomy. We retrospectively reviewed patients' medical charts, office records, radiographic studies, and operative records. RESULTS IN OUR SERIES, THE CLINICAL OUTCOMES AFTER AN IPSILATERAL PTERIONAL APPROACH WITH EXTRADURAL ANTERIOR CLINOIDECTOMY FOR PARACLINOID ANEURYSMS WERE EXCELLENT OR GOOD (GLASGOWS OUTCOME SCALE : GOS 5 or 4) in 87.5% of cases. The microsurgical complications related directly to the extradural anterior clinoidectomy included transient cranial nerve palsy (6), cerebrospinal fluid leak (1), worsened change in vision (1), unplanned ICA occlusion (1), and epidural hematoma (1). Only one of the complications resulted in permanent morbidity (4.2%), and none resulted in death. CONCLUSION Although surgical complications are still reported to occur more frequently for the treatment of paraclinoid aneurysms, the permanent morbidity and mortality resulting from a extradural anterior clinoidectomy in our series were lower than previously reported. Precise anatomical knowledge combined with several microsurgical tactics can help to achieve good outcomes with minimal complications.
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Affiliation(s)
- Hee Eon Son
- Department of Neurosurgery, School of Medicine, Eulji University, Daejeon, Korea
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Fay LY, Wu JC, Huang WC, Shih YH, Cheng H. One-stage posterior resection is feasible for a holovertebral aneurysmal bone cyst of the axis: a case report and literature review. ACTA ACUST UNITED AC 2009; 72 Suppl 2:S80-5. [PMID: 19944829 DOI: 10.1016/j.wneu.2009.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND For cervical spine ABC, staged surgery and the combination of both anterior and posterior approaches are usually necessary for lesions involving all 3 (anterior, middle, and posterior) columns of the spine (holovertebral). CASE DESCRIPTION A 20-year-old young man presented with quadriplegia and acute urine retention lasting for 3 days in November 2006. The diagnosis of an ABC involving the C2 vertebral body, pedicles, laminae, and spinous process was made by MRI. One-stage surgery with intralesional injection of fibrin glue via the posterior approach only was able to deliver complete resection and spinal stabilization. His neurologic function recovered well, and he was able to walk independently 10 days postoperation. At the 1-year follow-up, image studies of the cervical spine demonstrated good bone fusion without recurrence of ABC. The C2 vertebral body also showed resolution of ABC and good trabeculation. CONCLUSIONS Intralesional injection of fibrin glue during the operation for holovertebral ABC can be beneficial to (1) avoid using an anterior approach for complete resection and reconstruction, which was usually required in previous reports, and (2) effectively decrease the blood loss during surgery.
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Affiliation(s)
- Li-Yu Fay
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Nuances and technique of the pretemporal transcavernous approach to treat low-lying basilar artery aneurysms. Neurosurg Rev 2009; 33:129-35; discussion 135. [DOI: 10.1007/s10143-009-0231-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 05/07/2009] [Accepted: 07/22/2009] [Indexed: 11/26/2022]
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