World Neurosurg
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Treatment of aneurysms at the origin of the posterior inferior cerebellar artery (PICA) is challenging. Surgery is difficult due to the deep location and proximity to cranial nerves and endovascular treatment is complicated due to the often tortuous anatomy of the PICA and its small diameter. The purpose of this study is to report our experience with the endovascular treatment of aneurysms at the origin of the PICA. ⋯ Though aneurysm and parent vessel characteristics were challenging successful occlusion was achieved in a high rate of treatments, often with standalone coiling. Adjunctive techniques like retrograde stenting seem promising to further enhance endovascular results. Interestingly aneurysms arising solely from the origin of the PICA without the V4-segment involved presented with SAH significantly more often and wide-neck aneurysms presenting with SAH had a significantly higher periinterventional rupture rate.
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Tumors of the optic pathway and/or hypothalamus are uncommon, and the majority occur in patients with neurofibromatosis type 1.1,2 These lesions can be managed with a "watch-and-wait" approach; however, when treatment is indicated, the optimal strategy is wholly case dependent. We present a 22-year-old female patient with neurofibromatosis type 1 who had a partially cystic mass within the right mamillary body (Video 1). The mass was present on prior imaging but had increased in size and was newly enhancing with evidence of mass effect on the right optic tract. ⋯ Of note, the patient did experience mildly elevated postoperative sodium and was treated with desmopressin for transient diabetes insipidus. Twelve- and 24-month follow-up imaging showed no recurrence. The extended transsphenoidal approach used here offers a safe and suitable working corridor to achieve total resection of hypothalamic lesions without injury to the pituitary gland.
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In an ample armamentarium in neurosurgery, the semi-sitting position has produced debate regarding its benefits and risks. Although the position is apparently intuitive, many have abandoned its use since its initial inception, because of reported complexity and potential complications, leading to impracticality. However, through standardization, it has been shown not only to be safe but to carry with it many advantages, including less risk of secondary neurovascular injuries and better visualization of the surgical field. As with any surgical technical nuance, the semi-sitting position has advantages and disadvantages that must be weighed before the decision is made to adopt it or not, not only in a case-by-case scenario but also from a departmental standpoint. As we attempt to show, the advantages from a standardized approach for the semi-sitting position in experienced institutions may be more than sufficient to significantly outweigh the disadvantages, making it the preferable option for most, although not all, posterior fossa surgical interventions. ⋯ Although several of the steps described are also relevant and integral parts of other surgical positioning, we intend to create a protocol, in a stepwise fashion, to allow facilitated following, to be easily implemented in departments with different levels of experience. The steps comprise nursing care through to electrophysiologic and anesthesiologic approaches, along with neurosurgical cooperation, making it a team approach, not only to avoid position-related complications but also to optimize preoperative standardization, constructing a safe, efficient, and patient-centered scenario, to set the best possible stage for the next step: the intraoperative part of the intervention.
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The horizontal fissure of the cerebellum, which is the largest and most prominent fissure, has received less interest from anatomists and neurosurgeons. Hence, the current study aims to provide comprehensive detail about the horizontal fissure and its anatomic and surgical relationship with deeper structures such as the dentate nucleus and middle cerebellar peduncle for the benefit of the neurosurgeon. ⋯ The anatomic measurements and relationships provided in this description of the horizontal fissure will serve as a tool for surgery selection and planning, as well as an aid to improve microneurosurgical techniques, with the final goal being better patient outcomes.
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At craniotomy, the dura shrinks due to the drying effect of illumination and air exposure, rendering its primary closure difficult. When the opening is narrow, it can be patched with autologous grafts. However, tissue harvesting and meticulous suturing take time. As the cost-effectiveness of using dural substitutes is poor, we developed a new technique that involves dural scratching for the primary closure of dural openings. ⋯ Dural scratching is simple, safe, requires no special instrumentation, facilitates primary closure of the shrunken dura by stretching, and reduces the need for patch grafting.