Reconstruction of the vein of Labbé by using a short saphenous vein bypass graft. Technical note

How do I: Venous reconstruction of accidentally injured superficial sylvian vein during the clipping of an unruptured cerebral aneurysm

BACKGROUND

The transsylvian approach is a versatile treatment method for aneurysms of the anterior circulatory system. Studies have shown that sylvian veins run in various patterns, suggesting the need for dissection between veins to obtain appropriate surgical corridor. In case of inadvertent sylvian vein injury, serious complications such as venous congestion may occur.

METHOD

We herein describe the "side-to-side anastomosis reconstruction technique" of the resected superficial sylvian vein.

CONCLUSION

This technique can be effective for the reconstruction of other cortical veins, and indocyanine green videoangiography was effective in determining the indications for venous reconstruction.

Risk factors influencing cerebral venous infarction after meningioma resection

BACKGROUND

Cerebral venous infarction (CVI) is a serious complication after meningioma resection. The risk factors of postoperative cerebral venous infarction after surgical resection of meningioma can be determined through large samples and this study can add evidence to the literature.

METHODS

The clinical and imaging data of 1127 patients with intracranial meningiomas who underwent resection in our hospital were retrospectively collected and analyzed. CVI was evaluated by postoperative imaging and clinical manifestations. Univariate and multivariate analyses were performed to identify risk factors associated with CVI.

RESULTS

Overall, 4.7% (53/1127) of patients experienced CVI after meningioma resection. Multivariate analysis revealed superficial meningioma, moderate to severe peritumoral edema, peritumoral critical vein and WHO grade II-III as independent predictors of a postoperative CVI. After timely intervention, the symptoms were clearly alleviated in one month, and the prognosis was good, but injury to key veins could cause irreversible neurological disorders.

CONCLUSIONS

Intraoperative protection of veins is the primary way to prevent CVI. The present study identified several significant and independent risk factors for postoperative venous infarction, thereby enabling the identification of high-risk patients who require special attention during clinical and surgical management.

Usefulness of venous catheter as an intraluminal stent for end-to-end venous anastomosis

BACKGROUND

Venous anastomosis is one of the most difficult techniques in vascular neurosurgery.

METHOD

We present a simple technique of end-to-end venous anastomosis for reconstruction of accidentally injured vein. A venous catheter was used for the stent during the end-to-end anastomosis.

RESULTS

The venous catheter as the stent facilitated confirmation of the ostium of the vein. The venous end-to-end anastomosis was successfully performed.

CONCLUSIONS

Accidental venous injury can be reconstructed with the present simple technique.

Technique for rerouting a bridging vein that hinders the anterior interhemispheric approach: a technical note

BACKGROUND

The frontal bridging vein, which is the venous drainage route of the frontal cortex into the superior sagittal sinus (SSS), sometimes poses an obstacle in the anterior interhemispheric approach during surgery for anterior cerebral artery aneurysms. Although severe complications including venous infarction or edema due to damage to the bridging vein are well known, only a few reports have discussed how to avoid venous injury when we must sacrifice the bridging vein to obtain an appropriate surgical field. This report describes a microvascular technique performed in two patients who underwent rerouting of the bridging vein to obtain an appropriate anterior interhemispheric surgical corridor to treat a ruptured anterior cerebral artery aneurysm. The hindering bridging vein was resected from the entrance to the SSS and anastomosed toward the adjacent cortical vein.

METHODS

A 65-year-old male and a 43-year-old male were admitted to our hospital for sudden headache. Computed tomography, magnetic resonance angiogram, or digital subtraction angiography demonstrated a subarachnoid hemorrhage and an anterior cerebral artery aneurysm in both patients. In both cases, a relatively robust bridging vein, which appeared problematic to sacrifice, was draining into the SSS, resulting in a limited surgical corridor. Thus, we performed cortical vein reconstruction, and the aneurysms were successfully clipped under a wider surgical view.

RESULTS

We confirmed completed clipping without postoperative venous complications. One patient demonstrated patency of reconstructed venous flow by digital subtraction angiography. No apparent cognitive impairment was seen in either patient.

CONCLUSIONS

This technique may be useful for obtaining an appropriate surgical corridor when the frontal bridging vein may be damaged.

Venous sinus stenting for idiopathic intracranial hypertension is not associated with cortical venous occlusion

Background

The effect of dural venous sinus stenting has been investigated for the treatment of idiopathic intracranial hypertension (IIH) but the effect of stenting on the long-term patency of the cortical draining veins, especially the vein of Labbé (VOL), remains unknown.

Methods

We reviewed our database of 38 patients with IIH with 41 stented dural venous sinuses between October 2006 and December 2014. Demographic, clinical, and radiological data were reviewed. Follow-up catheter angiographic data were included when available.

Results

Stent placement spanned the ostium of the VOL in 35 patients (92.1%), with no immediate effect on the drainage of the VOL. Follow-up angiography (mean 35.1 months, range 1.7–80.7 months) was available in 24 patients, 21 of whom had stents spanning the VOL ostium. The VOL remained patent without occlusion or drainage alteration in all 21 patients. There were no immediate or long-term intracranial complications.

Conclusions

Dural venous sinus stenting for patients with IIH does not affect the immediate or long-term patency of the VOL and is not associated with intracranial complications.

[Posterior petrosal approach - analysis of the surgical technique in cadavers simulation]

The aim of the study was to present consecutive stages of the posterior petrosal approach (PPA). Eighteen simulations of PPA were performed on non-fixed human cadavers without any known pathologies in the head and neck. The consecutive stages of the procedure were documented with photographs and schemes. The starting point for PPA is a temporal craniotomy, suboccipital craniectomy and mastoidectomy with keeping the bony labyrinth intact. Approach to the middle part of the clivus is achieved by raise of the temporal lobe and section of the superior petrosal sinus and tentorium and by mobilization the sigmoid sinus. Posterior petrosal approach is a reproducible technique, which provides surgical penetration of the middle clivus and related regions. It reduces the operating distance and allows to limit the cerebellum and temporal lobe traction and to preserve the anatomic integrity of the brain stem and cranial nerves of the cerebellopontine angle.

Analysis of venous drainage from sylvian veins in clinoidal meningiomas

OBJECTIVE

To categorize clinoidal meningiomas according to their venous drainage patterns, and use each category as a guideline to establish an appropriate surgical strategy.

METHODS

We performed a retrospective analysis of 22 consecutive surgically treated patients with clinoidal meningioma who underwent preoperative digital subtraction angiography to examine the characteristics of the venous drainage system. These patients were categorized into: 1) cortical type in which the sylvian vein did not drain medially but drained to cortical veins, 2) sphenobasal type in which the sylvian vein drained into the pterygoid plexus, or 3) cavernous type in which the sylvian vein drained into the cavernous sinus directly through the sphenoparietal sinus. We tailored the surgical strategy to preserve these draining veins.

RESULTS

Preoperative angiographic evaluation demonstrated 14 patients (63.6%) with cortical type, 6 patients (27.3%) with sphenobasal type, and 2 patients (9.1%) with the cavernous type. In most cases, no restriction from the venous structure was observed because the sylvian vein belonged to the cortical type. However, in the case of the sphenobasal or sphenoparietal type, the surgical strategy seemed to be tailored to preserve the venous drainage system.

CONCLUSIONS

The surgical risk from venous complication in the treatment of clinoidal meningiomas appears to be low; however, there are likely to be patients that require a tailored surgical approach to avoid venous complications. Detailed preoperative assessment of anatomic structure and consideration of the optimal surgical strategy are critical to improve treatment outcomes.

Reconstruction of vein of Labbé in temporo-occipital meningioma invading transverse sinus: technical report

OBJECTIVE AND IMPORTANCE

Meningiomas invading major venous sinuses and veins are not uncommon. However, meningiomas involving both the transverse sinus and vein of Labbé are exceedingly rare. Venous reconstruction can be challenging after radical removal of the meningioma which invades major venous sinuses and veins. In this report, we present reconstruction of vein of Labbé in the surgery of temporo-occipital meningioma invading the transverse sinus.

CLINICAL PRESENTATION

A 55-year-old woman was admitted to our institution with a 13-year history of focal epilepsy in the form of transient aphasia with vertigo. Cranial magnetic resonance imaging revealed a homogeneously contrast enhancing lesion measuring 40 mm in diameter in the left temporo-occipital area. Cerebral magnetic resonance venography and venous phase of cerebral digital subtraction angiography revealed invasion of the upper wall of left transverse sinus and total occlusion of the lumen of the vein of Labbé.

TECHNIQUE

After removal of all the tumors except the piece attached to the transverse sinus and vein of Labbé with standard neurosurgical techniques, the left transverse sinus lumen and vein of Labbé lumen were explored. The tumor tissue inside the transverse sinus and vein of Labbé were removed along with tumor-invaded venous wall. Venous reconstruction of the transverse sinus and vein of Labbé was performed using autologous dura mater as a patch for the defect.

CONCLUSION

This is the first report in the literature in which the vein of Labbé was reconstructed in the surgery of temporo-occipital meningioma invading the vein of Labbé and transverse sinus together.

Microvascular repair of an injured cortical draining vein

BACKGROUND

Cortical venous injury can occur during any intracranial procedure with potentially severe consequences. We describe a simple technique that allowed for successful repair of a large cortical draining vein.

CASE DESCRIPTION

A 43-year-old, right-handed woman presented with 6 months of headaches and progressive difficulty with right-sided hemiparesis. She had significant loss of hand coordination and writing ability. Computed tomography and MR imaging revealed a parasagittal meningioma in the left, posterior frontal region. The patient underwent craniotomy with resection of the lesion.

CONCLUSION

When a cortical vein is injured, collateral drainage pathways may prevent the development of a clinical problem. Because of the unpredictability of these collateral channels, venous reconstruction may be feasible and even straightforward in some cases.

Significance of preserving the vein of Labbé in epilepsy surgery involving temporal lobe resection

OBJECT

Preservation of the vein of Labbé is recommended to prevent temporal lobe infarction after skull base surgery. However, the importance of preserving the vein in epilepsy surgery involving resection of the temporal lobe is unclear.

METHODS

Retrospective analysis was performed in 47 cases, in which patients underwent temporal lobe resection, out of 148 cases in which patients underwent surgery for intractable seizures over a 5-year period. Standard temporal lobe resection anterior to the vein of Labbé was performed in 11 patients. In 24 patients, the temporal lobe resection extended posterior to the vein of Labbé; the vein was preserved in eight patients, who underwent surgery prior to 2002, and resected in the other 16 patients, who underwent surgery after 2002. Twelve patients underwent a temporoparietooccipital resection. There was no significant difference in the pattern of venous anatomy (based on analysis of the relative size of veins [chi-square test, p = 0.1] and the number of superficial veins draining the temporal lobe [p = 1]) in patients in whom the vein was resected compared with those in whom it was preserved. No patient experienced postoperative infarction.

CONCLUSIONS

The authors conclude that the vein of Labbé may be safely resected in epilepsy surgery involving temporal lobe resection. The decision whether to resect the vein need not be based on the surface venous drainage pattern or number of veins draining the temporal lobe.

Posterior subtemporal transtentorial approach to intraparenchymal lesions of the anteromedial region of the superior cerebellum

Object. To overcome the limitations associated with surgical approaches that have been described for accessing intraparenchymal lesions of the anteromedial region of the superior cerebellum, the authors used a posterior subtemporal transtentorial approach to remove tumors in this region. In this paper they describe the surgical technique that they used as well as the operative findings and clinical outcomes observed in patients who underwent resection of tumors in the anteromedial superior cerebellum.

Methods. The consecutive patients with anteromedial superior cerebellar tumors who underwent resection performed using the posterior subtemporal transtentorial approach at the National Institutes of Health were included in this study. Clinical, neuroimaging, and operative results were analyzed.

Three patients (two men and one woman) with anteromedial superior cerebellar tumors (two hemangioblastomas and one pilocytic astrocytoma) underwent resection via this approach. All the tumors were larger than 3 cm in diameter (range 3.1–3.5 cm). This approach provided excellent surgical access and permitted complete tumor resection in each case. The patients remained neurologically unchanged compared with preoperative baseline findings at the last follow-up examination (conducted at 4, 18, and 42 months postoperatively). One patient displayed a mild transient confusion immediately after surgery, but it resolved within 6 days.

Conclusions. The posterior subtemporal transtentorial approach provides excellent access to the anteromedial superior cerebellar region. This approach permits resection of large lesions in this location, while avoiding many of the limitations associated with other approaches to this site.

Cerebral revascularization

During the last 10 years, there has been a revival of interest in cerebral revascularization procedures. Not only have significant progressions in surgical techniques been published, the use of more advanced diagnostic methods has led to a widening of the indications for cerebral bypass surgery. The purpose of this review is to outline the current techniques for extracranial-to-intracranial (EC/IC) and intracranial-to-intracranial (IC/IC) bypass surgery, as well as to identify the current indications for revascularization procedures based on the available literature. The excimer laser-assisted non-occlusive anastomosis (ELANA) technique is described in more detail because we think that this technique almost completely eliminates the risk of cerebral ischemia due to the temporary vessel occlusion which is currently used in conventional anastomosis techniques.

The preservation and reconstruction of cerebral veins and sinuses

Although cerebral veins and venous sinuses are very important to the neurosurgeon, they have received adequate attention only recently. The consequences of cerebral venous occlusion are well known. When the venous outflow is compromised due to a lack of adequate collateral circulation, venous infarction follows, with swelling, haemorrhage and neuronal death. The clinical consequences will depend upon the region of involvement of the brain and the site of the infarcted tissue. The symptoms may include seizures, hemiplegia, aphasia, coma and death. Similarly, the consequences of cerebral venous sinus occlusion depend upon the availability of collateral circulation. When such collaterals are not available, papilledema and visual loss and a pseudotumour cerebri syndrome are observed in milder cases, whereas, severe diffuse brain swelling, coma and death may be observed in severe cases. Acute venous or venous sinus occlusion is potentially very dangerous, whereas slow and chronic venous or venous sinus occlusion is better tolerated. Even in such patients, some neurological manifestations may follow, when the collaterals are poor.

Venous consideration in petrosal approach: microsurgical anatomy of the temporal bridging vein

OBJECTIVE

The technical difficulty of using the petrosal approach and the likelihood of encountering venous complications depend on the particular temporal venous anatomy. To reduce such potential risks, neurosurgeons must have adequate knowledge of the variations in the anatomy of the temporal venous drainage system, particularly of the temporal bridging veins.

METHODS

In 20 cadaveric specimens, the temporal bridging veins were examined with the aid of an operating microscope. The anatomic location of their termination and of the tributaries of these bridging veins was noted.

RESULTS

Forty-four terminations and 109 tributaries of the temporal bridging veins were identified in our specimens. The temporal bridging veins were divided into three groups according to the anatomic location of their terminations: 1) the transverse sinus group (seen in all 20 hemispheres), with drainage into the lateral part of the cerebellar tentorium, to which most of the vein of Labbé belongs; 2) the tentorial group (seen in 50% of the 20 hemispheres), with drainage into the medial part of the tentorium, which is composed mainly of the middle and posterior temporobasal veins; and 3) the petrosal group (seen in 55% of the 20 hemispheres), with entry around the superior petrosal sinus, which may limit mobility of the temporal lobe in the petrosal approach. On the basis of this anatomic information, we propose a new classification of the temporal venous drainage system and discuss the clinical implications of these findings.

CONCLUSION

In planning the petrosal approach, great care should be taken not only with the vein of Labbé but also with the petrosal bridging veins. Knowledge of this venous anatomy can reduce venous complications during the lateral cranial base approach.