Neurosurgery
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Recent advances in microsurgical techniques facilitate surgical resection of brainstem lesions that were previously considered inoperable. In this article we present, for the first time, the tonsillouveal transaqueductal approach to access a progressively symptomatic cavernoma within the depth of the tegmentum of the mesencephalon. ⋯ This report shows, for the first time, direct surgical removal of a cavernous hemangioma in the mesencephalic tegmentum via the aqueduct. This approach adds to contemporary microneurosurgery, respecting functional anatomy and minimizing neurological deficits.
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Case Reports
Primary dural repair during minimally invasive microdiscectomy using standard operating room instruments.
Minimally invasive microdiscectomies are commonly being performed for disc herniations. Although inadvertent dural tears are not common, they do occur. Present management of many dural tears includes fibrin glue or other adhesive substances over the dura, tight closure of the fascia and skin, and possibly bedrest. Because these surgeries are usually performed through a small tube, a primary dural repair can be prohibitively difficult. One reason for the difficulty in a primary closure is that the small tube limits the use of proper opening and closing of standard dural repair instruments as well as the proper angulation of the instruments. ⋯ Primary dual repair during minimally invasive microdiscectomy can be performed using standard operation room instruments, including a standard micropituitary ronguer, 5-0 Prolene suture (Ethicon, Inc., Somerville, NJ), and a laparoscopic knot pusher.
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Although a few studies have quantified errors in the implantation of deep brain stimulation electrodes into the subthalamic nucleus (STN), a significant trend in error direction has not been reported. We have previously found that an error in axial plane, which is of most concern because it cannot be compensated for during deep brain stimulation programming, had a posteromedial trend. We hypothesized that this trend results from a predominance of a directionally oriented error factor of brain origin. Accordingly, elimination of nonbrain (technical) error factors could augment this trend. Thus, implantation accuracy could be improved by anterolateral compensation during target planning. ⋯ Elimination of the technical factors of error during STN deep brain stimulation implantation can result in a consistent posteromedial error. Implantation accuracy may be improved by compensation for this error in advance.
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To introduce a novel surgical technique for the dissection of the greater superficial petrosal nerve (GSPN) in the middle fossa approach. ⋯ The temporal dura can be elevated safely with a front-to-back technique to preserve the GSPN and to help maintain the physiological integrity of the facial nerve.
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Several variations on the supraorbital craniotomy via a forehead or eyebrow incision have been described in the literature in recent years. A modification of this approach, the transciliary orbitofrontozygomatic approach, has been used by the authors as a minimally invasive method of approaching certain intracranial pathologies. The authors present their experience with this technique in 105 consecutive patients with tumors or aneurysms of the anterior cranial fossa. ⋯ This approach was used in 105 consecutive patients who underwent operation for either tumors or aneurysms via an eyebrow incision. The transciliary orbitofrontozygomatic approach is associated with low surgical morbidity. Although experience with this technique is still limited, it is a viable alternative in cases in which the pathology resides in the midline or anterior fossa.