360 Degrees Endoscopic Access to and Through the Orbit

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.

Ultrahigh-Definition-3-Dimensional Exoscope-Assisted Clipping of a Right Middle Cerebral Artery Unruptured Aneurysm with Indocyanine Green Video Angiography: Operative Video

Ultrahigh-definition 3-dimensional exoscopes represent an excellent technologic innovation in contemporary neurosurgery. They combine the advantages of operating microscopes and endoscopes, offering excellent magnification and lighting, maintaining a relatively small footprint and optimal ergonomic features.1-5 One of the most interesting employments of exoscopes in neurosurgery is represented by intracranial vascular surgery. Reports in this field are still limited, but recent experience has shown that ultrahigh definition 3-dimensional exoscopes for aneurysm surgery are noninferior to operating microscopes for surgery duration, complication rate, and patient outcomes.6 In addition, many intraoperative techniques such as the indocyanine green videoangiography (ICG-VA) have been successfully implemented to exoscope-based surgery.7 We present herein the case of a 66-year-old woman that came to our attention for the incidental finding of 3 unruptured brain aneurysms. After neurosurgical consultation, the one located at the right middle cerebral artery bifurcation was considered eligible for surgery.8,9 As shown in Video 1, ICG-VA was employed after permanent clipping to allow immediate quality assurance of occlusion and distal vessel integrity. Postoperative course was uneventful, and follow-up examinations demonstrated the complete occlusion of the aneurysm. This report highlights the feasibility of exoscopic-based ICG-VA in vascular neurosurgery, given its ease of use, ergonomics, and excellent quality of vision provided to both surgeons and operating staff.

Endoscopic Endonasal Excision of a Cavernous Hemangioma of the Orbital Apex with Cryoprobe Assistance: Two-Dimensional Surgical Video

Cavernous hemangiomas (CHs) represent the commonest benign orbital lesion in adults, accounting for nearly 6% of overall orbital tumors.1The most common presenting symptoms include unilateral visual deficits, diplopia, ocular muscle impairment, and nonpulsatile proptosis. CHs can be asymptomatic until they reach a considerable size, but when lodged deep in the orbital apex, even small masses may cause severe functional deficits.2 If found incidentally, a wait-and-scan policy is advised. Surgical treatment is indicated in patients with visual impairment or in cases of volumetric increase during the follow-up.3 Among the different surgical corridors to the orbital apex, in the last decade, the endoscopic-assisted approaches, both transpalpebral and endonasal, have emerged as minimally invasive and effective techniques in the skull base surgeon's armamentarium.4 If those lesions are located medially to the optic nerve, the endoscopic endonasal approaches (EEAs) offer several advantages compared with standard craniotomies or orbitotomies.5,6 A 45-year-old woman was admitted to our hospital with symptoms of progressive right visual impairment for 10 months, with radiologic finding of an encapsulated small roundish lesion at the right orbital apex. The mass was completely removed by means of EEA with intraoperative use of a dedicated cryoprobe (Video 1). Histopathologic examination confirmed the CH. At follow-up, the patient experienced complete resolution of her symptoms, with no residues or relapses on magnetic resonance imaging. This case sheds light on the advantages of EEA with the assistance of a cryoprobe, including optimal visualization of the target, lack of external incision, no brain retraction, and short hospital stays.

Endoscopic transventricular approach for the resection of a hemorrhagic cavernous malformation of the tectal plate: Operative video

Background

Cavernomas of the third ventricle are rare entities that provide significant therapeutic challenges. Because of the better view of the surgical field and the possibility to achieve a gross total resection (GTR), microsurgical approaches are more commonly used to target the third ventricle. Endoscopic transventricular approaches (ETVA), on the other hand, are minimally invasive procedures that can afford a straight corridor trough the lesion, avoiding bigger craniotomies. Moreover, these approaches have shown lower infectious risks and shorter hospitalization times.

Case Description

A 58-year-old female patient accessed the Emergency Department complaining of headache, vomiting, mental confusion, and syncopal episodes for the past 3 days. An urgent brain computed tomography scan revealed a hemorrhagic lesion of the third ventricle, conditioning triventricular hydrocephalus, so an external ventricular drainage (EVD) was placed in an emergency setting. An magnetic resonance imaging (MRI) showed a 10 mm diameter hemorrhagic cavernous malformation originating from the superior tectal plate. An ETVA was performed for the cavernoma resection, followed by an endoscopic third ventriculostomy. After proving shunt independence, the EVD was removed. No clinical nor radiological complications were assisted in the postoperative period, so the patient was discharged 7 days after. The histopathological examination was consistent with cavernous malformation. An immediate postoperative MRI showed GTR of the cavernoma with a little clot around the surgical cavity, which appeared completely reabsorbed 4 months later.

Conclusion

ETVA provides a straight corridor to the third ventricle, excellent visualization of the relevant anatomical structures, safe resection of the lesion, and treatment of the concomitant hydrocephalus by ETV.

Clinical and oncological outcomes in single-stage versus staged surgery for pediatric craniopharyngiomas: a multicenter retrospective study

PURPOSE

Craniopharyngiomas (CPGs) are aggressive brain tumors responsible of severe morbidity in children. The best treatment strategies are under debate. Our study evaluates surgical, pituitary, and hypothalamic outcomes of a tailored staged-surgical approach compared to a single-stage radical approach in children with CPGs.

METHODS

Multicenter retrospective study enrolling 96 children treated for CPGs in the period 2010-2022. The surgical management was selected after a multidisciplinary evaluation. Primary endpoint includes the inter-group comparison of preservation/improvement of hypothalamic-pituitary function, the extent of resection, and progression-free survival (PFS). Secondary endpoints include overall survival (OS), morbidity, and quality of life (QoL).

RESULTS

Gross Total Resection (GTR) was reached in 46.1% of cases in the single-stage surgery group (82 patients, age at surgery 9 ± 4.7 years) and 33.3% after the last operation in the staged surgery group (14 patients age 7.64 ± 4.57 years at first surgery and 9.36 ± 4.7 years at the last surgery). The PFS was significantly higher in patients addressed to staged- compared to single-stage surgery (93.75% vs 70.7% at 5 years, respectively, p = 0.03). The recurrence rate was slightly higher in the single-stage surgery group. No significant differences emerged in the endocrinological, visual, hypothalamic outcome, OS, and QoL comparing the two groups.

CONCLUSIONS

In pediatric CPGs' surgical radicality and timing of intervention should be tailored considering both anatomical extension and hypothalamic-pituitary function. In selected patients, a staged approach offers a safer and more effective disease control, preserving psychophysical development.

Frameless neuronavigation-assisted brain biopsy with electromagnetic tracking: how I do it?

BACKGROUND

In recent years, thanks to several technological innovations, stereotactic cerebral biopsies have evolved from frame-based to frameless neuronavigation-assisted techniques.

METHODS

The authors provide herein a detailed step-by-step description of the technique, shedding light on surgical tips and how to avoid complications. The practical application of the technique is demonstrated with a high-quality video.

CONCLUSION

The neuronavigation-assisted brain biopsy with electromagnetic tracking is a "true frameless" procedure. It represents a simple, safe, and effective innovation for frameless biopsy of cerebral lesions. This technique is time efficient, offering a high degree of accuracy required for the establishment of a definitive diagnosis, enabling optimal further treatment, and thus improving patient outcome.

Quantitative Anatomic Comparison of Endoscopic Transnasal and Microsurgical Transcranial Approaches to the Anterior Cranial Fossa

BACKGROUND

Several microsurgical transcranial approaches (MTAs) and endoscopic transnasal approaches (EEAs) to the anterior cranial fossa (ACF) have been described.

OBJECTIVE

To provide a preclinical, quantitative, anatomic, comparative analysis of surgical approaches to the ACF.

METHODS

Five alcohol-fixed specimens underwent high-resolution computed tomography. The following approaches were performed on each specimen: EEAs (transcribriform, transtuberculum, and transplanum), anterior MTAs (transfrontal sinus interhemispheric, frontobasal interhemispheric, and subfrontal with unilateral and bilateral frontal craniotomy), and anterolateral MTAs (supraorbital, minipterional, pterional, and frontotemporal orbitozygomatic approach). An optic neuronavigation system and dedicated software (ApproachViewer, part of GTx-Eyes II-UHN) were used to quantify the working volume of each approach and extrapolate the exposure of different ACF regions. Mixed linear models with random intercepts were used for statistical analyses.

RESULTS

EEAs offer a large and direct route to the midline region of ACF, whose most anterior structures (ie, crista galli, cribriform plate, and ethmoidal roof) are also well exposed by anterior MTAs, whereas deeper ones (ie, planum sphenoidale and tuberculum sellae) are also well exposed by anterolateral MTAs. The orbital roof region is exposed by both anterolateral and lateral MTAs. The posterolateral region (ie, sphenoid wing and optic canal) is well exposed by anterolateral MTAs.

CONCLUSION

Anterior and anterolateral MTAs play a pivotal role in the exposure of most anterior and posterolateral ACF regions, respectively, whereas midline regions are well exposed by EEAs. Furthermore, certain anterolateral approaches may be most useful when involvement of the optic canal and nerves involvement are suspected.

Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma

Objective  We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach.

Design  Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots ( Fig. 1 ). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy.

Setting  The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy.

Participants  Skull base team was participated in the study.

Main Outcome Measures  A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus ( Fig. 2 ) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap.

Results  No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus ( Fig. 1 ). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion.

Conclusion  Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved.

The link to the video can be found at: https://youtu.be/TsqXjqpuOws .

Lessons learned during covid-19 pandemic, a worldwide survey: evolution of global neurosurgical practice

BACKGROUND

During the COVID-19 pandemic, a multitude of surveys have analyzed the impact virus spreading on the everyday medical practice, including neurosurgery. However, none have examined the perceptions of neurosurgeons towards the pandemic, their life changes, and the strategies they implemented to be able to deal with their patients in such a difficult time.

METHODS

From April 2021 to May 2021 a modified Delphi method was used to construct, pilot, and refine the questionnaire focused on the evolution of global neurosurgical practice during the pandemic. This survey was distributed among 1000 neurosurgeons; the responses were then collected and critically analyzed.

RESULTS

Outpatient department practices changed with a rapid rise in teleservices. 63.9% of respondents reported that they have changed their OT practices to emergency cases with occasional elective cases. 40.0% of respondents and 47.9% of their family members reported to have suffered from COVID-19. 56.2% of the respondents reported having felt depressed in the last 1 year. 40.9% of respondents reported having faced financial difficulties. 80.6% of the respondents found online webinars to be a good source of learning. 47.8% of respondents tried to improve their neurosurgical knowledge while 31.6% spent the extra time in research activities.

CONLCUSIONS

Progressive increase in operative waiting lists, preferential use of telemedicine, reduction in tendency to complete stoppage of physical clinic services and drop in the use of PPE kits were evident. Respondents' age had an impact on how the clinical services and operative practices have evolved. Financial concerns overshadow mental health.

Endoscopic Endonasal Pituitary Hemi-Rotation Approach to the Upper Clivus: Anatomical Study and Clinical Report

AIM

To report on the endoscopic endonasal pituitary hemi-rotation approach (EPHRA) in a preclinical setting and in a preliminary clinical experience.

MATERIAL AND METHODS

EPHRA was performed in five fresh-frozen head and neck specimens (a total of 10 sides) and in a selected case of a right-sided dorsum sellae chordoma.

RESULTS

The approach described allowed exposure of the lateral part of the upper clivus in all the specimens and in the case reported. To evaluate the maximum possible degree of hypophyseal hemi-rotation, the hemi-rotation angle (HRA) of the approach was measured and reported for all sides of the specimens. In 9 out of 10 cadaver head sides, and in the clinical case, it was possible to avoid sectioning of the inferior hypophyseal artery. No complications occurred during or after the procedure.

CONCLUSION

EPHRA represents an addition to the techniques already described and finds indications in case of non-massive neoformations of the lateral upper clivus. Clinical applications and limitations still need to be clarified in further clinical studies.

Symptomatic ecchordosis physaliphora of the upper clivus: an exceedingly rare entity

OBJECTIVE

This paper highlights the management of 5 patients affected by symptomatic ecchordosis physaliphora (EP), treated via endoscopic endonasal transsphenoidal-transclival approach and contextual multilayer skull base reconstruction. A detailed analysis of each case is provided, along with the review of the current body of literature.

METHODS

A retrospective review of patients treated by means of endoscopic endonasal approach for EP from 2010 to 2020 in the Otolaryngology and Neurosurgery Departments of a tertiary-care referral center for endoscopic skull base surgery was analyzed. Only adult patients with a definitive histopathological and immunohistochemical diagnosis of EP were included in the study. A systematic literature review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed for EP.

RESULTS

Five cases of EP were retrieved and included in the study. Four patients presented with CSF leakage: in two cases after minor head trauma, in one case with associated bacterial meningitis, and in one case as only referred symptom. One patient complained diplopia due to VI cranial nerve palsy. No complications or recurrences of the disease were observed after a median follow-up of 37.2 months (range, 18-72 months). A total of 27 studies were identified with the systematic literature review, encompassing 30 patients affected by symptomatic EP who were addressed to surgical treatment. Twenty-five patients underwent complete surgical removal of the EP, while in 5 cases, only subtotal resection was performed.

CONCLUSIONS

EP might result in a "locus minoris resistentiae" of the skull base, predisposing, in rare cases, to CSF leakage and meningitis, spontaneously or after minor trauma. In cases of symptomatic EP, endoscopic endonasal transsphenoidal-transclival approach represents a safe and effective technique for both EP resection and contextual skull base reconstruction.

Neurosurgeons on the front line: experience from the center of the storm in Italy

In this tumultuous time, the entire world has been shaken up by the COVID-19 outbreak. Italy has had one of the highest infection-related mortality rates. Bergamo, a city in eastern Lombardy, was among the most affected. Here, the authors describe the main healthcare actions taken at their institution to stem the crisis, with particular concern regarding the fate of their neurosurgery department. Among the different topics, the authors particularly focus on the retraining of neurosurgeons, organization of activities, and what should be the role of neurosurgeons during a pandemic.

An Uncommon Case of Neuroenteric Cyst Located at the Lateral Cerebellomedullary Cistern

We present the case of a 42-year-old woman with a 5-week history of headache, progressive dysphagia, dysphonia, and hoarseness. A brain magnetic resonance imaging revealed an extra-axial cyst of the left lateral cerebellomedullary cistern. The subsequent histopathologic examination diagnosed a neuroenteric cyst. This case sheds light on the pivotal role of histologic identification of neuroenteric cyst, which could be crucial for further diagnostic investigations, especially in pediatric patients.

The endoscopic diving technique in endonasal transsphenoidal surgery: how I do it

BACKGROUND

The endoscopic diving technique (EDT) is a procedure utilized in endonasal endoscopy, which consists of irrigating the surgical cavity during tumor removal, with a continuous flow of pressurized saline solution.

METHODS

The authors provide a detailed step-by-step description of the technique, shedding light on surgical tips and pitfalls. Advantages, disadvantages, and the most useful application of the technique are clarified and showed with a high-quality endoscopic video.

CONCLUSION

EDT represents an effective and safe procedure. It allows a wide exploration of the surgical cavity, providing tumor hydro-dissection, assisting in bleeding control, and optimizing the efficacy of endoscopic transsphenoidal surgery.

How I do it: step-by-step BacJac™ posterior interspinous spacer placement

BACKGROUND

BacJac™ is a posterior interspinous spacer for selected cases of degenerative lumbar spine diseases. It blocks the metameric vertebral segment in terminal extension, restoring foraminal heights.

METHODS

The authors provide a detailed step-by-step description of the surgical technique, shedding light on surgical tips and pitfalls of this procedure. An accurate pre-operative patient selection is analyzed, defining meticulously surgical indications. A high-quality video of the surgical procedure is provided.

CONCLUSION

BacJac™ interspinous device allows a safe, mini-invasive, and effective treatment of selected cases of degenerative lumbar spine disease.

Endoscopic Endonasal Odontoidectomy Preserving Atlantoaxial Stability: a Pediatric Case

Objectives  We illustrate endoscopic endonasal odontoidectomy for the Chiari-I malformation respecting craniovertebral junction (CVJ) stability.

Design  Case report of a 12-year-old girl affected by the Chiari-I malformation. Magnetic resonance imaging (MRI) showed tonsillar herniation, basilar invagination, and dental retroversion, causing angulation and compression of the bulbomedullary junction. Patient underwent endoscopic third ventriculostomy (ETV) with reduction of ventricular size and resolution of gait disturbances, but she complained the Valsalva-induced headaches, hiccup, and dysesthesias in the lower limbs. Endoscopic endonasal odontoidectomy was chosen to decompress the cervicomedullary junction.

Setting  The research was conducted at University Hospital “Ospedale di Circolo,” Department of Neurosurgery at Varese in Italy.

Participants  Patients were from neurosurgical and ENT (ear, nose, and throat) skull base team.

Main Outcome Measures  A bilateral paraseptal approach was performed, using a four-hand technique. After resection of posterior edge of the nasal septum, the choana is entered and a rhinopharynx muscle–mucosal flap is dissected subperiosteal and transposed in oral cavity. The CVJ is exposed and, using neuronavigation and neuromonitoring, odontoidectomy is fulfilled until dura is reached, preserving the anterior arch of C1. Reconstruction is obtained suturing the flap previously harvested.

Results  Postoperative course was unremarkable and the patient experienced improvement of symptoms. Postoperative MRI documented the appearance of tight cerebrospinal fluid (CSF) film anterior to bulbomedullary junction and in retrotonsillar spaces, opening of the bulbomedullary angle, and slight tonsils reduction. No CVJ instability was occurred with any need of posterior fixation.

Conclusion  Endoscopic endonasal odontoidectomy is a feasible approach for CVJ malformation. In this case, bulbar decompression was achieved preserving CVJ stability and avoiding posterior fixation.

The link to the video can be found at: https://youtu.be/VIobocHfCuc .

Transsphenoidal surgery for pituitary adenomas in pediatric patients: a multicentric retrospective study

INTRODUCTION

Pediatric pituitary adenomas are rare lesions. Incidence is reported between 1 and 10% of all childhood brain tumors and between 3 and 6% of all surgically treated adenomas. Although pituitary adenomas present with symptoms of hormone hypersecretion or neurological disruptions secondary to mass effect, they are almost constantly benign. Characteristics of patients may vary in different studies according to age, gender, size of adenoma, hormonal activity, and recurrence rates.

METHODS

Data on consecutive pediatric patients who were operated for pituitary adenoma with endoscopic endonasal transsphenoidal surgery (EETS) and transsphenoidal microsurgery (TMS) in the Department of Neurosurgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey, in the Neurosurgical Unit of the San Matteo Hospital, Pavia, Italy, and in the Division of Neurological Surgery Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy, between July 1997 and May 2018, were analyzed. Twenty-seven patients (11 males and 16 females), who were 18 years old or younger at the time of surgery, were included in the study. Medical records, images, and operative notes of patients were retrospectively reviewed.

RESULTS

There were 16 females (59.3%) and 11 males (40.7%). Mean age was 15.3 ± 3.3 (4-18). Thirty-two surgical procedures were performed for 27 patients (6 children required second operation). Thirteen patients (48.14%) had Cushing's disease (CD), 5 patients (18.5%) had growth hormone (GH)-secreting adenoma, 5 patients (18.5%) had prolactinoma, and 4 patients (14.8%) had non-functional adenoma. Twenty-two patients (81.4%) met remission criteria, and 5 patients (18.5%) did not meet remission criteria. Four patients met remission criteria after the second operation.

CONCLUSION

Transsphenoidal approach affords effective release of mass effect and not only restoration but also perpetuation of normal endocrine functions in the majority of pediatric pituitary adenoma patients. Satisfactory results are reported with both EETS and TMS in the literature. Despite the technical difficulties in pediatric age, transsphenoidal resection of adenoma is still the mainstay treatment that provides cure in pediatric patients.

The Helmet-Visor Pericranial Flap as a Viable Option for Anterior Cranial Base Reconstruction in Complex Oncologic Cases

OBJECTIVE

To describe a novel bilaterally pedicled pericranial flap for anterior cranial base reconstruction after removal of complex frontobasal cancers extending to the frontal region, thus precluding the use of standard reconstructive techniques.

METHODS

In selected oncologic cranial base surgeries, the use of the standard galea frontalis pericranial flap for reconstructive purposes may be precluded by tumor infiltration. In such cases, dura mater reconstruction and exclusion of frontal sinuses from the intracranial space can be performed using a large superficial temporal artery bilaterally pedicled pericranial flap obtained from both temporoparietal regions. Surgical technique, indication, contraindication, complications, and degree of resection are recorded to evaluate the efficacy of this surgical method.

RESULTS

A 48-year-old man affected by a recurrence of frontobasal squamous cell carcinoma was surgically treated by combined transcranial and endoscopic endonasal resection. A large pericranial flap pedicled bilaterally on the parietal branches of the superficial temporal artery was obtained, transposed anteriorly, carefully watertight sutured to the dural defect, and used to exclude cranialized frontal sinuses as well. The reconstruction was successful, and the patient was discharged home on the tenth postoperative day without any complications and/or development of cerebrospinal fluid leak. Contrast-enhanced magnetic resonance imaging 3 months after surgery was clear from disease with consolidated surgical outcomes.

CONCLUSIONS

This novel pericranial flap seems to be easily obtained and effective for anterior cranial base reconstruction when the use of a traditional galea frontalis flap is precluded for oncologic reasons and there are concerns for the possible development of contaminations and cerebrospinal fluid leaks.