Frontotemporal Approach for Spheno-Orbital Meningioma and Orbital Compartment Resection: Technical Case Instruction: 2-Dimensional Operative Video.

Background And Importance: Spheno-orbital meningiomas (SOMs) pose a challenge to the skull base neurosurgeon because of their variable presentation and involvement of critical structures within the orbit. There is no consensus on optimal management of these patients and how to achieve maximal safe resection. The authors share an illustrative case with an accompanying video to demonstrate their aggressive approach to resect SOMs and their intraorbital components.

Preservation of cranial nerve function in large and giant trigeminal schwannoma resection: a case series.

Background: Trigeminal schwannomas (TSs) are intracranial tumors that can cause significant brainstem compression. TS resection can be challenging because of the risk of new neurologic and cranial nerve deficits, especially with large (≥ 3 cm) or giant (≥ 4 cm) TSs. As prior surgical series include TSs of all sizes, we herein present our clinical experience treating large and giant TSs via microsurgical resection.

Half-and-Half Approach for Multiple Aneurysms at the Superior Cerebellar and Middle Cerebral Arteries.

Aneurysms at the superior cerebellar artery (SCA) are commonly treated endovascularly because of their location around the basilar artery, but they are not intimately related with thalamoperforators. Therefore in younger patients, those with wide-necked aneurysms, or those with multiple ipsilateral aneurysms, surgery remains a treatment option. We present a 52-year-old woman with dizziness in whom multiple, unruptured intracranial aneurysms were identified.

Combined retrosigmoid and middle fossa approach for a small, superiorly located petroclival meningioma: how I do it.

Background: Petroclival meningiomas pose significant surgical challenges because of their deep location and complex surrounding neurovasculature. The use of multiple surgical approaches can optimize safe tumor removal from multiple anatomic compartments.

Method: We describe a patient with a growing superior petroclival meningioma centered at the posterior clinoid with extension into Meckel's cave that was successfully removed with a combined retrosigmoid and subtemporal middle fossa approach.

Multiple approaches to a spheno-orbital and deep face meningioma: how I do it.

Background: The integration of multiple approaches is sometimes needed for the safe resection of complex multicompartment skull base tumors.

Method: We present the case of a spheno-orbital and deep face meningioma that required a staged resection strategy using transnasal, transoral, transfacial, and transcranial approaches for airway protection and maximal safe tumor removal.

Conclusion: Limitations in individual skull base approaches for complex tumors can be anticipated and overcome by combining approaches.

Combined and staged retrosigmoid, extended middle fossa, and endoscopic transnasal approach to a petroclival chondrosarcoma: how I do it.

Background: Tumors of the petroclival region with multicompartment extension can be difficult to address with a single surgical approach.

Method: We present the case of a patient with a large chondrosarcoma centered at the right petroclival fissure with extension into the cavernous sinus, the region beneath the cavernous sinus, cerebellopontine angle with deformation of the pons, and prevertebral space. A staged complete resection was performed using a stage 1 single-incision combined right retrosigmoid craniotomy and extended middle fossa craniotomy, followed by a stage 2 endoscopic transnasal approach.

Closure of small skull base defects with muscle plug napkin ring technique: how I do it.

Background: Defects through the skull base into the paranasal sinuses can occur during anterior skull base procedures, risking cerebrospinal fluid leak and infection if not repaired.

Methods: We describe a muscle plug napkin ring technique for closure of small skull base defects, wherein a free muscle graft slightly bigger than the defect is packed tightly in the defect, half extracranially and half intracranially and sealed with fibrin glue. The technique is illustrated in the case of a 58-year-old woman with a large left medial sphenoid wing/clinoidal meningioma.

Treatment of a ruptured blister aneurysm of the left internal carotid artery with telescoping Pipeline Flex embolization devices with Shield Technology.

Ruptured blister aneurysms have significant rates of morbidity and mortality, but evidence of positive results with use of flow-diverting stents such as the Pipeline embolization device (PED) is growing. The authors describe the staged endovascular treatment of a ruptured left internal carotid artery blister aneurysm in a patient with a Hunt and Hess grade IV subarachnoid hemorrhage. PED placement was done via the common femoral artery using a triaxial delivery system.

Modified lateral orbitotomy approach for resection of anterior temporal cavernous malformation.

Background: The lateral orbitotomy approach (LOA) provides a direct and minimally invasive corridor to orbital apex, cavernous sinus, and middle cranial fossa (MCF) lesions. Removal of the lateral orbital wall and retraction of the orbital contents, as performed with a traditional LOA, can cause diplopia and enophthalmos and affect visual acuity. The modified LOA (mLOA) preserves the lateral orbital wall to limit this morbidity.

Double bypass for mycotic middle cerebral artery aneurysm.

Background: Ruptured intracranial mycotic aneurysms have high morbidity and mortality and present unique surgical challenges because of vessel friability.[1] Flow-preserving strategies are needed for more proximal lesions that cannot be treated with vessel sacrifice.

Case Description: A 33-year-old man with no medical history who presented with fevers and peripheral septic emboli was found to have infective cardiac valve vegetations.

Staged and Combined Approach for Resection of Giant Posterior Fossa and Temporal Bone Schwannoma.

Vestibular schwannomas have an estimated incidence of 1.09/100,000 people, representing 6%-10% of intracranial tumors. Rarer giant vestibular schwannomas are defined by an extrameatal diameter of ≥4 cm and can be difficult to treat because of displacement and compression of local neurovasculature and the potential for multicompartment involvement.

Cranio-Orbital Approach for Single-Stage En Bloc Resection of Optic Nerve Glioma: Technical Note.

Background And Importance: There is no consensus on the optimal surgical approach for managing optic nerve gliomas. For solely intraorbital tumors, a single-stage lateral orbitotomy approach for resection may be performed, but when the nerve within the optic canal is affected, two-stage cranial and orbital approaches are often used. The authors describe their technique to safely achieve aggressive nerve resection to minimize the probability of recurrence that might affect the optic tracts, optic chiasm, and contralateral optic nerve.

Right frontotemporal craniotomy for ECA-to-MCA direct and indirect bypass and occipital artery indirect bypass to the posterior circulation: case report.

Moyamoya is an uncommon disease that presents with stenoocclusion of the major vasculature at the base of the brain and associated collateral vessel formation. Many pediatric patients with moyamoya present with transient ischemic attacks or complete occlusions. The authors report the case of a 9-year-old girl who presented with posterior fossa hemorrhage and was treated with an emergency suboccipital craniotomy for evacuation.

Cervical Laminoplasty for Resection of Hemorrhagic Cavernous Malformation Using a Biportal Technique.

This Video 1 presents the surgical management of a 36-year-old woman who presented with progressive weakness in her right arm associated with a pins-and-needles sensation. Magnetic resonance imaging of the cervical spine revealed a likely hemorrhagic cavernous malformation of the spinal cord at the C3-4 level. The lesion was wholly intramedullary with no presentation to the surface of the spinal cord.

Minimally invasive oblique interbody fusion for correction of iatrogenic lumbar deformity.

Spinal instability may arise as a consequence of decompressive lumbar surgery. An oblique lumbar interbody fusion combined with pedicle screw fixation can provide indirect decompression on neural elements, stabilization of mobile spondylolisthesis, and restoration of segmental lordosis. Minimally invasive techniques may facilitate a shorter hospitalization and faster recovery than a traditional open revision operation.

Staged transarterial endovascular embolization of a malignant dural arteriovenous fistula using Onyx and n-butyl cyanoacrylate.

Dural arteriovenous fistulae (dAVFs) are vascular anomalies formed by abnormal connections between branches of dural arteries and dural veins or dural venous sinus(es). These pathologic shunts constitute 10%-15% of all intracranial arteriovenous malformations. The hallmark of malignant dAVFs is the presence of cortical venous drainage, a finding that increases the likelihood of nonhemorrhagic neurologic deficit, intracranial hemorrhage, and mortality if left unaddressed.

Anterior two-thirds corpus callosotomy via stereotactic laser ablation.

Anterior two-thirds corpus callosotomy is a common palliative surgical intervention most commonly employed in patients with atonic or drop seizures. Recently, stereotactic laser ablation of the corpus callosum without a craniotomy has shown promise in achieving similar outcomes with fewer side effects and shorter hospitalizations. The authors demonstrate ablation of the anterior two-thirds corpus callosum in a patient with Lennox-Gastaut syndrome and drug-resistant drop seizures.

GoPro Hero Cameras for Creation of a Three-Dimensional, Educational, Neurointerventional Video.

Neurointerventional education relies on an apprenticeship model, with the trainee observing and participating in procedures with the guidance of a mentor. While educational videos are becoming prevalent in surgical cases, there is a dearth of comparable educational material for trainees in neurointerventional programs. We sought to create a high-quality, three-dimensional video of a routine diagnostic cerebral angiogram for use as an educational tool.

Expanding neurosurgery.

The history of medicine is replete with innovations in neurosurgery that have spurred further developments across the medical spectrum. Surgeons treating pathologies in the head and spine have broken ground with new approaches, techniques, and technologies since ancient times. Neurosurgeons occupy a vital nexus in patient care, interfacing with the clinical symptoms and signs afflicting patients, the pathology at surgery, and imaging studies.