Acta neurochirurgica
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Acta neurochirurgica · Oct 2012
Transphenoidal surgery without steroid replacement in patients with morning serum cortisol below 9 μg/dl (250 Nmol/l).
Adrenal insufficiency is a feared complication in patients undergoing transphenoidal surgery (TSS). Using the insulin tolerance test (ITT) for the preoperative assessment of hypothalamic-pituitary-adrenal (HPA) status is less than ideal, and the morning serum cortisol (MSC) is often used as a proxy for ITT. However, neither the ITT nor the MSC level has been validated to indicate HPA sufficiency compared to a physiological gold standard such as patients' ability to withstand transphenoidal surgery. ⋯ This study suggests that TSS can be performed safely in patients with preoperative MSC less than 9 μg/dl (250 nmol/l) in closely monitored settings without intraoperative cortisol administration. Further studies are warranted.
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Acta neurochirurgica · Oct 2012
Management of C2 fractures using Iso-C(3D) guidance: a single institution's experience.
About 20 % of cervical fractures involve the C2 vertebra. Many surgical techniques have been proposed according to the type of fracture. However, morbidity and mortality of these procedures is often high, which can be attributed to the old age and significant co-morbidities of the affected population and the complex anatomy of C2. To target the latter, several authors have applied iso-C(3D) guidance for most of the common techniques. We here present our experience using a fixed protocol and iso-C(3D) guidance in all cases of traumatic C2 fractures. ⋯ Iso-C(3D) guidance is a safe and straightforward technique for anterior and posterior screw placement in the upper cervical spine.
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Acta neurochirurgica · Oct 2012
Case ReportsSingle stage transcranial exposure of large dural venous sinuses for surgically-assisted direct transvenous embolization of high-grade dural arteriovenous fistulas: technical note.
High-grade dural arteriovenous fistulas (DAVFs) with retrograde cortical leptomeningeal drainage are formidable lesions because of their risk for intracranial hemorrhage. Treatment is aimed at occluding venous outflow to achieve obliteration of the fistula. In DAVFs that involve a large dural venous sinus (transverse sigmoid sinus or superior sagittal sinus), occluding venous outflow can be accomplished endovascularly with transvenous embolization. However, in some cases of DAVFs with reflux into cortical leptomeningeal veins, there may be venous restrictive disease downstream, such as occlusive thrombosis, which can prohibit endovascular access via the transfemoral or transjugular routes. In these instances, a transcranial approach can be performed to expose the large dural venous sinus distal to the site of occlusion for direct catheterization of the venous outflow for transvenous embolization. This combined surgical and endovascular strategy provides direct access to the venous outflow and bypasses the site of thrombotic obstruction. ⋯ Our technique of surgically-assisted direct transvenous embolization of high-grade DAVFs can be successfully performed as a single stage in the operating room with intraoperative angiography and stereotactic image guidance.
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Acta neurochirurgica · Oct 2012
Transvertebral anterior key hole foraminotomy without fusion for the cervicothoracic junction.
Various surgical procedures have been used to repair disc herniations and osteophytes at the cervicothoracic junction. Among these procedures, transvertebral anterior foraminotomy without fusion is a relatively less invasive, safe and useful method, although the majority of spinal surgeons remain unfamiliar with this method. We describe the surgical procedure for a transvertebral anterior keyhole foraminotomy without fusion at the cervicothoracic junction, and we assess the middle-term clinical and radiological outcomes. ⋯ This procedure allows for direct access to the pathology and is less invasive. In this study, we clarified that this technique yields excellent radiological and clinical outcomes.
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Acta neurochirurgica · Oct 2012
Near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT): are they complementary or competitive imaging techniques in aneurysm surgery?
In this pilot study we compared advantages and drawbacks of near-infrared indocyanine green videoangiography (ICGVA) and intraoperative computed tomography (iCT) to investigate if these are complementary or competitive methods to acquire immediate information about blood vessels and potential critical impairment of brain perfusion during vascular neurosurgery. ⋯ A combination of ICGVA and iCT is feasible, with very good diagnostic imaging quality associated with short acquisition time and little interference with the surgical workflow. Both techniques are complementary rather than competing analysing tools and help to assess information about local (ICGVA/iCTA) as well as regional (iCTA/iCTP) blood flow and cerebral perfusion immediately after clipping of intracranial aneurysms.