One burr-hole craniotomy: Suboccipital midline approach to the fourth ventricle in Helsinki neurosurgery

Duraplasty with autologous nuchal ligament fascia to reduce postoperative complications in pediatric patients undergoing neoplasia resection with a suboccipital midline approach

OBJECTIVE

The authors sought to explore the safety and efficacy of an autologous nuchal ligament for dural repair in pediatric patients undergoing tumor resection through a suboccipital midline approach.

METHODS

Pediatric patients diagnosed with posterior fossa neoplasia who underwent surgery through a suboccipital midline approach were retrospectively reviewed. The patients were divided into artificial graft and autograft groups according to whether artificial duraplasty material or autologous nuchal ligament was used to repair the dura. Postoperative complications were reviewed and analyzed, including CSF leak, pseudomeningocele, and meningitis, during hospitalization and follow-up. Univariate and multivariate logistic regression analyses were used to investigate the relationship between duraplasty material and postoperative complications, as well as other risk factors for postoperative complications. Furthermore, multinomial logistic regression analysis was used to clarify which postoperative complications the autologous nuchal ligament tended to reduce.

RESULTS

This retrospective study included 66 pediatric patients who underwent tumor resection through a suboccipital midline approach. The clinical baseline characteristics were comparable between the two groups. The results showed that the autograft group had significantly fewer postoperative complications, especially pseudomeningocele, compared with the artificial graft group. Moreover, the time required to repair the dura in the autograft group was significantly less than that in the artificial graft group. Further results revealed that the duraplasty material, ependymoma, preoperative severe hydrocephalus requiring an external ventricular drain (EVD), and postoperative hydrocephalus exacerbation were independent risk factors for postoperative complications. In particular, the autologous fascia of the nuchal ligament tended to reduce pseudomeningocele more than CSF leak and meningitis. However, compared with pseudomeningocele and CSF leak, both ependymoma and postoperative hydrocephalus exacerbation were more likely to increase the occurrence of meningitis. In contrast, preoperative severe hydrocephalus requiring EVD led to increased rates of postoperative complications.

CONCLUSIONS

For pediatric patients with intracranial tumors who need to undergo resection through a suboccipital midline approach, dural repair using the nuchal ligament is safe, cost-effective, and time saving and significantly reduces postoperative complications.

Surgical Management of Brain Cavernous Malformations

Surgical removal of accessible lesions is the only direct therapeutic approach for cerebral cavernous malformations (CCMs). The approach should be carefully evaluated according to clinical, anatomical, and neuroradiological assessment in order to both select the patient and avoid complications. In selected cases, a quantitative anatomical study with a preoperative simulation of surgery could be used to plan the operation. Neuronavigation, ultrasound, and neurophysiologic monitoring are generally required respectively to locate the CCMs and to avoid critical areas. The chapter describes all the possible surgical approaches for supratentorial, infratentorial, deep seated and brain stem CCMs. In any case before performing surgery, the physicians should always consider the benign nature of the lesions and the absolute necessity to avoid not only neurological deficits, but also a neuropsychological impairment that could affect the quality of life of the patients.