Neuroendoscopic transnasal surgery for skull base tumors: basic approaches, avoidance of pitfalls, and recent innovations.
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Since the introduction of endoscopic technology in the neurosurgical field, the role of transnasal surgery has been dramatically enlarged. With this technique, we can approach the anterior cranial base, parasellar region, clivus, cavernous sinus, and craniovertebral junction, less invasively than with conventional microsurgery. This review describes the two major approach methods in endoscopic skull base surgery, the endonasal approach and the transseptal approach. The endonasal approach uses two nostrils without nasal specula and the mucosa on the sphenoid rostrum and the posterior margin of the nasal septum are removed. In the transseptal approach, only a single nostril is available, but using the nasal speculum, sufficient surgical field can be obtained with only a small incision on the septum. In either approach method, it is very important to avoid excessive mucosal damage and to select the appropriate approach for each patient. The endoscopic skull base approach is one of the least invasive surgical procedures, which is a very promising therapeutic choice with potential for further advances. For better surgical outcomes and further progress, cooperation with rhinolaryngologists who have much more knowledge and experience about nasal surgery than neurosurgeons is essential. We believe this article will contribute to the development of safe and effective surgical procedures, and to the benefit of the patients suffering with intractable skull base lesions. (+info)
Clivus metastasis from gastric signet ring cell carcinoma after a 10-year disease-free interval--case report.
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A 64-year-old male presented with an extremely unusual case of solitary clivus metastasis from gastric cancer manifesting as mild headache and diplopia 10 years after radical excision of the primary tumor. The patient underwent surgical resection using an endoscopic transsphenoidal approach. Histological examination revealed typical signet ring cell carcinoma (SRC) which was identical to that of the previous gastric cancer. Why the late recurrence occurred such a long time after the first surgery and how it spread to the clivus remain unclear. The characteristics of SRC and the process of "tumor dormancy" may have been involved in the mechanism underlying late metastasis. (+info)
Combined endovascular and endoscopic surgery for acute epidural hematoma in a patient with poor health.
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A 74-year-old woman presented with right acute epidural hematoma (AEDH) associated with a skull fracture after a fall. Emergency craniotomy under general anesthesia could not be performed because of her poor medical condition. Therefore, transfemoral endovascular embolization and hematoma evacuation via a burr hole were performed using endoscopy under local anesthesia. The patient recovered and was discharged without neurological deficits. AEDH is a common traumatic disease often requiring emergency craniotomy to prevent death and restore neurological function. The present combined surgical approach was effective in treating AEDH that could not be treated under general anesthesia in a patient with poor medical condition. (+info)
Endoscopic third ventriculostomy for obstructive hydrocephalus caused by a large upper basilar artery aneurysm after coil embolization.
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A 76-year-old female presented with a large upper basilar artery (BA) aneurysm causing obstructive hydrocephalus after coil embolization manifesting as diplopia. Magnetic resonance (MR) imaging and MR angiography showed a large BA top aneurysm. Coil embolization was performed. More than 6 months after the first coil embolization, the aneurysm had re-grown and we performed a second coil embolization. Soon after that, obstructive hydrocephalus at the aqueduct of the midbrain occurred. MR imaging was performed to evaluate whether there was enough space at the prepontine cistern for a third ventriculostomy and also to verify the posterior direction of the aneurysm growth because of the risk of rupturing the aneurysm during the operative procedure. Then, we performed an endoscopic third ventriculostomy (ETV) via a left-sided approach. We could easily identify the infundibular recess, mamillary bodies, and tuber cinereum in the third ventricular floor. We detected a pulsating upper BA aneurysm that appeared to have caused a reddish color change in the right mammillary body and the right side of the thalamus and midbrain. If there is sufficient space in the prepontine cistern for the surgical procedure, ETV is a good choice for the treatment of obstructive hydrocephalus associated with cerebral aneurysms. (+info)
The long-term psychological effects of surgical treatment using neuroendoscopic techniques and Orbis Sigma shunt implantation in children suffering from hydrocephalus.
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BACKGROUND: Hydrocephalus, which is the most common disease of the central nervous system in children, has a diverse etiology and clinical picture. Children suffering from hydrocephalus are often treated either by using a neuroendoscopic procedure or by Orbis Sigma shunt implantation. OBJECTIVES: To evaluate the long-term psychological effects of neuroendoscopic surgical treatment on the mental development and cognitive abilities of children suffering from hydrocephalus, in comparison with the results following Orbis Sigma shunt implantation, and to assess the impact of the kind of hydrocephalus on the outcome of the treatment. MATERIAL AND METHODS: The study involved 78 patients treated surgically for chronic noncommunicating hydrocephalus: 39 patients who had undergone neuroendoscopic surgery (average age: 12 years, SD +/- 7 years), and 39 who had undergone implantation of a ventriculo-peritoneal shunt (average age: 14 years +/- 5 years). The psychomotor development of the two groups was analyzed using psychomotor development tests including the Brunet-Lezine test, the Terman-Merrill test, Raven's Standard Progressive Matrices, Raven's Colored Progressive Matrices, the Benton Visual Retention Test, the Bender Visual Motor Gestalt Test, the Rey Fifteen-Item Memory Test, lateralization tests and a questionnaire. RESULTS: In the shunt group there were statistically significant prevalences hydrocephalus diagnosed perinatally and in the first year of life (p = 0.0291), epileptic seizures (p = 0.0181), intellectual disability (p = 0.0049) and gait disturbances (p = 0.006). There were statistically significant differences between two groups in the relative changes of linear measurements of the cerebral ventricle depending on the type of treatment: Relative Frontal Horn Index (RFHI): 0.93 following endoscopy and 0.64 following shunt implantation; Relative Evans' ratio (RER): 0.93 following endoscopy and 0.62 after shunt implantation; Relative Frontal and Occipital Horn Ratio (RFOHR): 0.89 after endoscopy and 0.69 after shunt implantation. The time treatment was undertaken and the incidence of mental retardation did not differ significantly between the two groups. CONCLUSIONS: The analysis of cerebral ventricle enlargement expressed in linear ventricular enlargement measurements revealed statistically important differences in the intellectual, cognitive and motor development between the groups treated with the two neurosurgical techniques. (+info)
Effect of thrombin concentration on the adhesion strength and clinical application of fibrin glue-soaked sponge.
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Fibrin glue-soaked gelatin sponge (FGGS) has been used for tissue sealing in neurosurgical practice, but too rapid clotting of fibrin glue occasionally prevents good fixation of FGGS. Dilution of thrombin may provide adequate manipulation time between mixing fibrinogen and thrombin on gelatin sponge and application into the tissue defects. The present study characterized the effect of thrombin dilution on the adhesion strength of FGGS and retrospectively assessed the clinical usage of the dilution for filling dead space or sealing arachnoid defect in 255 cases who underwent transsphenoidal surgery for the last 66 months. FGGS was prepared using three different concentrations of thrombin: 250 (standard), 50 (1:5 dilution), and 25 (1:10 dilution) units/ml, and incubated for three different periods (5, 20, and 60 seconds). FGGSs were applied over two adjacently positioned porcine skins placed on two metallic plates. The adhesion strength was evaluated by measuring maximum tensile strength during pulling out the sliding plate at a constant rate of displacement. The maximum adhesion strength was greater for FGGS with 1:10 diluted thrombin solution than for FGGS prepared with higher concentrations (p < 0.05). Adhesion strength did not decay for 20 seconds after the mixture. Only four of 255 cases (1.6%) required second reconstruction of sella floor due to the cerebrospinal fluid leakage. FGGS prepared with diluted thrombin solution can provide adequate adhesion strength for clinical use. (+info)
Enhancement of withstanding pressure of fibrin sealant by modified mixing ratio of fibrin sealant components for skull base reconstruction: technical note.
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A method to enhance the withstanding pressure of fibrin sealant in gasket-seal closure to prevent cerebrospinal fluid (CSF) leakage after extended transsphenoidal surgery (ETSS) was investigated by adjusting the mixing ratio of the components. A plastic chamber (200 ml) was constructed with a lid made of hydroxyapatite with a hole 10 mm in diameter. The chamber could be pressurized via an opening in the side wall. The hole in the hydroxyapatite lid was covered with a Gore-Tex sheet, 15 mm in diameter. The margin of the sheet was free. Solutions A (fibrinogen 80 mg/ml) and B (thrombin 250 units/ml) of fibrin sealant were mixed in volume ratios of 1:1, 2:1, and 5:1, and applied to the Gore-Tex sheet, then water was introduced to cover the fibrin sealant. The pressure was measured at which air leakage occurred from the side of the Gore-Tex sheet. The pressure values for A/B ratios of 1:1, 2:1, and 5:1 were 117 +/- 23.8 mmH(2)O (mean +/- standard error) (n = 5), 234 +/- 38.8 mmH(2)O (n = 5), and 345 +/- 36.4 mmH(2)O (n = 5), respectively, in the acute phase (5 minutes after application of fibrin sealant). Pressures were increased after 24 hours, and that for 5:1 was the highest (373 +/- 40.4 mmH(2)O, n = 5). The use of devices such as syringes specially designed to mix solutions A and B in the ratio of 5:1 can easily enhance the preventive effect of fibrin sealant against CSF leakage in ETSS. (+info)