Neurosurgery
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En bloc resection of chordomas is associated with increased patient survival. Achievement of en bloc resection, however, may present a great surgical challenge, particularly in the mobile spine. Novel multidisciplinary techniques may enable en bloc resection of lesions presenting in anatomically challenging locations. A combined simultaneous thoracoscopic and posterior approach in a patient with an upper thoracic chordoma is presented; en bloc resection was achieved. ⋯ A combined simultaneous thoracoscopic and posterior approach is safe and effective for en bloc resection of multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the tumor and the mediastinum, thus assisting with safe osteotomies via the posterior approach.
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A neurovascular flow diverter (FD), aiming at inducing embolic occlusion of cerebral aneurysms through hemodynamic changes, can produce variable mesh densities owing to its flexible mesh structure. ⋯ The emerging strategy of maximum FD compaction can double aneurysmal flow reduction, thereby accelerating aneurysm occlusion. Moreover, ultrahigh blood shear stress was observed through FD pores, which could potentially activate platelets as an additional aneurysmal thrombosis mechanism.
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Pontine cavernous malformations (CMs) located on a peripheral pontine surface or the fourth ventricular floor are resectable lesions, but those deep within the pons away from a pial surface are typically observed. However, the anterior bulge of the pons formed by the brachium pontis creates a unique entry point for access to deep pontine lesions from below, working upward through the pontomedullary sulcus. ⋯ The central pons remains difficult territory to access, and new surgical corridors are needed. The bulging underbelly of the pons allows access to pontine lesions deep to the pial surface from below. The far lateral TPMS approach is a novel and more direct alternative to the retrosigmoid transmiddle cerebellar peduncle approach. Unlike the retrosigmoid approach, the TPMS approach requires minimal parenchymal transgression and uses a brainstem entry point medial to most lower CNs. Favorable results demonstrate the feasibility of resecting pontine CMs that might have been previously deemed unresectable.
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Dedifferentiated chordomas are rare high-grade malignant spinal tumors for which there is minimal information to help guide treatment. ⋯ Dedifferentiated chordomas are aggressive malignant tumors with a higher risk of local recurrence, metastases, and early mortality than conventional chordomas. Tumor diameter >10 cm, marginal resection, and sacroiliac joint infiltration may be associated with increased risk of local recurrence and mortality. Those with a smaller burden of dedifferentiated disease (<1 cm) within the primary chordoma have a better prognosis. Patients should be counseled about these risks before surgery and should have regular follow-up for the detection of local recurrence and metastases.
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During surgery for intrinsic brain lesions, it is important to distinguish the pathological gyrus from the surrounding normal sulci and gyri. This task is usually tedious because of the pia-arachnoid membranes with their arterial and venous complexes that obscure the underlying anatomy. Moreover, most tumors grow in the white matter without initially distorting the cortical anatomy, making their direct visualization more difficult. ⋯ A 3-D reconstruction of the cortical surface can be easily created with free OsiriX software. This technique helps the surgeon perfect the mentally created 3-D picture of the tumor location to carry out cleaner, safer surgeries.