Lateral medullary vascular compression manifesting as paroxysmal hypertension

Neurovascular compression of the rostral ventrolateral medulla (RVLM) has been described as a possible cause of refractory essential hypertension. We present the case of a patient affected by episodes of severe paroxysmal hypertension, some episodes associated with vago-glossopharyngeal neuralgia. Classical secondary forms of hypertension were excluded. Imaging revealed a neurovascular conflict between the posterior inferior cerebellar artery (PICA) and the ventrolateral medulla at the level of the root entry zone of the ninth and tenth cranial nerves (CN IX-X REZ). A MVD of a conflict between the PICA and the RVLM and adjacent CN IX-X REZ was performed, resulting in reduction of the frequency and severity of the episodes. Brain MRI should be performed in cases of paroxysmal hypertension. MVD can be considered in selected patients.

Combined petrosal approach: a systematic review and meta-analysis of surgical complications

Transpetrosal approaches are known to be associated with a significant risk of complications, including CSF leak, facial palsy, hearing impairment, venous injury, and/or temporal lobe injury. We aimed to evaluate the morbidity of the standard combined petrosal approach (CPA), defined as a combination of the posterior (retrolabyrinthine) and the anterior petrosal approach. We performed a systematic review and meta-analysis of articles reporting on clinical series of patients operated on for petroclival meningiomas through CPA. Studies that used the terminology "combined petrosal approach" without matching the aforementioned definition were excluded as well as clinical series that included less than 5 patients. A total of 8 studies were included involving 160 patients. The pooled complication rates were 3% (95% CI, 0.5-5.6) for CSF leak, 8.6% (95% CI, 4.1-13.2%) for facial palsy, 8.2% (95% CI, 3.9-12.6%) for hearing impairment, 2.8% (95% CI, 0.9-6.5%) for venous complications, and finally 4.8% (95%, 1.2-8.4%) for temporal lobe injury. Contrary to the general belief, CPA is associated with an acceptable rate of complications, especially when compared to alternative approaches to the petroclival area. In view of the major advantages like shorter trajectory, multiple angles of surgical attack, and early tumor devascularization, CPA remains an important tool in the armamentarium of the skull base surgeon.

Anterolateral (juxtacondylar) approach with limited mastoidectomy to resect a jugular foramen meningioma

BACKGROUND

The anterolateral (juxtacondylar) approach with limited mastoidectomy is a suitable option to expose the postero-inferior part of the jugular foramen (JF). It is particularly indicated for tumors extending in the neck beyond the jugular foramen, especially in those cases necessitating both neck control as well as control of the mastoid segment of facial nerve.

METHOD

We describe here the steps to safely perform an anterolateral approach with mastoidectomy along with a brief description of its indications and limits.

CONCLUSION

This approach represents a valid option to reach the JF. Its knowledge can improve the process of optimal approach selection when dealing with complex pathology involving the JF.

Basal Cisternostomy for Severe TBI: Surgical Technique and Cadaveric Dissection

Introduction

Cisternostomy is emerging as a novel surgical technique in the setting of severe brain trauma. Different surgical techniques have been proposed with a variable degree of epidural bone work. We present here the surgical technique as it is currently performed in our Institution.

Methods

Anatomical dissection of one adult cadaveric head, injected and non-formalin fixed was perfomed. A large right fronto-temporo-parietal craniotomy was accomplished. Extradural sphenoidal drilling till opening of the superior orbital fissure was performed. The microsurgical anatomy of basal cisternostomy was then explored.

Results

A step by step description of the surgical technique, enriched with cadaveric and intraoperative images, was made.

Conclusion

Basal cisternostomy is a promising surgical technique that does not necessarily include complex surgical maneuvers. Trained neurosurgeon can safely implement it in their clinical practice.

Vestibular schwannoma: care for soft tissues and subperineural dissection: how I do it

BACKGROUND

Recognition of the right surgical cleavage plane of a vestibular schwannoma is mandatory to preserve the facial nerve function.

METHOD

We describe here our surgical technique that is focused on soft tissues preservation and on subperineural dissection, avoiding direct exposure of the acoustico-facial complex in order to preserve facial nerve function.

CONCLUSION

Soft tissue dissection helps in reducing patient's postoperative discomfort. Meticulously keeping a subperineural plan of dissection enables to preserve facial nerve function while offering satisfying resection rates.

Endoscope-assisted anterolateral approach to a recurrent cervical spinal chordoma

BACKGROUND

The anterolateral approach (ALA) enables to access the craniovertebral junction (CVJ), lower and middle clivus, jugular foramen, and cervical spine from a lateral perspective. It is particularly indicated when dealing with extradural bone tumors. Other rare indications are represented by spondylotic myeloradiculopathy and vascular diseases.

METHOD

We describe here the steps to safely perform an anterolateral approach along with a brief description of its indications and limits.

CONCLUSION

ALA represents a valid option to treat cervical spine and CVJ bone tumors such as chordomas. Its knowledge can improve the process of approach selection when dealing with such complex cases.

Neuroendoscopic septostomy: Indications and surgical technique

BACKGROUND

Endoscopic septostomy is the treatment of choice for monolateral obstruction of the foramen of Monro. Common causes of this condition include: neoplasms, hemorrages, infections, congenital atresia, idiopathic occlusion.

METHOD

All the steps for performing a safe endoscopic pellucidotomy are presented. A brief discussion about the most common technical variations and their rationale is added.

CONCLUSION

Endoscopic pellucidotomy is a safe and effective treatment when a thorough understanding of anatomy is achieved.

Pituitary apoplexy: considerations on a single center experience and review of the literature

PURPOSE

To present a single-center experience on pituitary tumor apoplexy and a review of literature focusing on predisposing and precipitating factors.

METHODS

Clinical presentation of our series of cases. Contemporary published literature is also reviewed.

RESULTS

The definition of this syndrome has not been consistent although now the majority of authors agree to definite it as an acute condition caused by hemorrhage or infarction of a pre-existing pituitary adenoma. Different predisposing and precipitating factors have been described in literature; among these antithrombotic and anticoagulant drugs, seem to play relevant roles. The clinical cases observed in our clinic confirm these data and suggest a probable association between elderly patients taking anticoagulant therapy and pituitary apoplexy adenoma.

CONCLUSION

Pituitary tumor apoplexy remains a challenging disease in relation to difficulties in correct diagnosis and thus in appropriate treatment. Antithrombotic/anticoagulant therapy may have an important role as precipitating factor. When a pituitary disorder is known, great care should be taken in the prescription of anticoagulant therapy.

Role of preoperative embolization of intramedullary hemangioblastoma

OBJECT

Hemangiobastomas (HB) are rare lesions accounting for 1 to 5% of all spinal cord tumors. Due to their hypervascular nature, an angiography may be proposed preoperatively in order to identify tumoral vascular anatomy. Preoperative embolization may be indicated to reduce intraoperative bleeding, thus facilitating tumor resection and minimizing surgical risk. The aim of this paper is to report our experience of preoperative embolization in intramedullary hemangioblastomas.

METHODS

We performed a retrospective analysis of all patients operated on for intramedullary hemangioblastomas between 1995 and 2014 who had undergone embolization before surgery.

RESULTS

Seven patients were analyzed: there were 6 females and 1 male, mean age 43years, 6 patients had Von Hippel-Lindau disease. Four tumors were located in the cervical spine and three in the dorsal spine. The average maximum sagittal diameter was 19mm (range 8-32mm), while the average maximum axial diameter was 11.5mm (range 6-21mm). The embolic agent used was Histoacryl (NBCA). Endovascular embolization was routinely performed the day before surgery. One patient experienced a major preoperative complication with a vertebrobasilar infarctus with consequent unilateral cerebellar syndrome and gait instability. Minor extravasation of embolic agent was observed in two cases. In one of these two cases, there was also the penetration of the embolic agent in the tumor; the resection was impossible due to the hard consistency of the tumor. In the other 6 patients, the resection was total. Six patients had identical preoperative and postoperative McCormick score and one patient shifted to a better score at follow-up.

CONCLUSION

Preoperative endovascular embolization is an effective adjunct treatment. It is useful in reducing the surgical bleeding and thus the operative risks. The procedure is not always safe and complications could occur. We recommend preoperative embolization in selected cases.

Intramedullary ependymoma: Microsurgical resection technique

Spinal ependymomas are predominantly slow-growing lesions constituting approximately 30-88% of primary spinal intramedullary tumors. They usually present as circumscribed lesions, with regular margins and a clear surgical plane. Gross-total resection is often feasible and potentially curative but neurosurgeons should keep in mind that the ultimate goal of surgery is the preservation of spinal cord function. We present the surgical technique to safely resect an intramedullary ependymoma using a posterior median sulcus approach. A brief description of current management of this pathology is also presented.