World Neurosurg
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Review
Factors that Affect Physiologic Tremor and Dexterity during Surgery: a Primer for Neurosurgeons.
All individuals have a physiologic tremor that may become more pronounced in periods of stress, stimulant use, or caffeine. There are few publications measuring the effects of these factors on surgeons or trainees and no comprehensive reviews. We sought to review the representative literature. ⋯ The literature evaluating tremor and its relationship to surgical performance is limited. Surgeons wishing to optimize surgical dexterity may benefit from avoiding caffeine use or fasting before operating and avoiding sleep deprivation or alcohol use the night before procedures. Those surgeons prone to anxiety or stress-related tremor may obtain a benefit from certain beta-blockers. Finally, the use of appropriate surgical ergonomics with hand or wrist steadying may improve surgical tremor and reduce fatigue.
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The resection of planum sphenoidale and tuberculum sellae meningiomas is challenging. A universally accepted classification system predicting surgical risk and outcome is still lacking. ⋯ An orbitotomy and early decompression of the involved optic canal are important for achieving gross total resection, maximizing visual improvement, and avoiding recurrence. The visual outcomes were excellent. A new classification system that can allow the comparison of different series and approaches and indicate cases that are more suitable for an endoscopic transsphenoidal approach is presented.
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Case Reports
Stent assisted coiling of aneurysm in a persistent primitive lateral vertebro basilar system.
Fenestrations of cerebral arteries are relatively common. Knowledge of their structure has recently gained clinical significance with increasing awareness of fenestration aneurysms. Persistent primitive lateral vertebrobasilar (PPLVB) anastomoses are an extreme end of the embryologic mishaps causing these fenestrations, and their occurrence has only been reported twice. ⋯ The unique anatomy of these aneurysms and relation with important perforators and brainstem make surgery extremely difficult and require advanced endovascular techniques like balloon remodeling and stent assistance. Three-dimensional rotational angiography can help in providing clarity to the aneurysmal anatomy and planning treatment. The purpose of this case report is to bring to notice the possibility of such aneurysms and use the unique anatomy to understand various tools available in the endovascular surgeon's armamentarium.
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Case Reports
Encountering a basal vein of Rosenthal variant during the anterior transpetrosal approach.
The basal vein of Rosenthal (BVR) is important in intracranial surgery, including skull base surgery. We report a case of petroclival meningioma in which a BVR variant drained into the tentorial sinus. ⋯ To our knowledge, this is the first study to describe surgery using the ATPA and involving a BVR variant, in which the vein was imaged successfully preoperatively using sliding-thin-slab MIP.
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During brain surgery, there are difficulties associated with identifying subcortical fibers with no clear landmarks. We evaluated the usefulness of cortical evoked potentials with subcortical stimuli (subcortico-cortical evoked potential [SCEP]) in identifying subcortical fibers intraoperatively. ⋯ SCEP was useful for identifying subcortical fibers and confirmed the preservation of these fibers. This technique is expected to contribute to the effectiveness and safety of resective surgery in patients with lesions close to eloquent areas.