Complications: skull base and cerebrovascular.

Neurosurgical complications are a rich source for learning, but they are grossly underutilized for the purpose of surgeon education. Details of the complications, which make them all the more powerful as teaching tools, are restricted to morbidity and mortality conferences behind closed doors, and open discussions of the topic are blurred by hypotheticals in order to shield the presenters from medicolegal risks. In this issue of Neurosurgical Focus, 9 neurosurgeons were invited to present complications they encountered along with the details and specific lessons they learned.

Virtual and Augmented Reality in Neurosurgery.

In this chapter, we explore the role of mixed reality (MxR), a synergy of virtual reality (VR) and augmented reality (AR), in neurosurgery. MxR marks a significant advancement in surgical planning and execution, enhancing precision, safety, and outcomes. We trace the evolution of neurosurgical techniques, positioning MxR as the latest innovation in a series of technological advancements aimed at improving surgical accuracy and patient safety.

Transorbital Approach Clipping of Middle Cerebral Artery Aneurysm: A Virtual Reality Morphometric Anatomic Study.

Background: The transorbital approach (TOA) has a unique advantage to the more common lateral approaches as it provides direct access to the anterior middle fossa and medial sylvian fissure (SF) without significant dissection or retraction. However, when to use the TOA for surgical treatment of middle cerebral artery (MCA) aneurysms remains unclear. This study details the feasibility of clipping unruptured MCA aneurysms via the TOA by highlighting the anatomic features that either facilitate or hinder the approach.

Minimally Invasive Lateral Transorbital Approach for Clipping of Right Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video.

The lateral transorbital approach is a minimally invasive approach that was first described for accessing the cavernous sinus.1 Although other minimally invasive approaches have been broadly applied to aneurysm surgery,2 the use of transorbital keyholes for this is still quite rare.3,4 We present a 72-year-old man with an incidentally discovered 5-mm middle cerebral artery aneurysm.

Minimally Invasive Bilateral Duo-Keyhole Approach for Giant Falcine Meningioma: 2 Dimensional Operative Video.

One of the key concepts behind minimally invasive keyhole cranial surgery is that as the operative corridor deepens, it also widens. The corridor should therefore be designed parallel to the long-axis of the tumor to optimize visualization.1 These ideas were applied in a duo-keyhole operation for a falcine meningioma.

A Cadaveric Feasibility Study of the Biportal Endoscopic Transfrontal Sinus Approach: A Minimally Invasive Approach to the Anterior Cranial Fossa.

Background And Objectives: The trans-sinus transglabellar and bifrontal approaches offer direct access to the anterior cranial fossa. However, these approaches present potential drawbacks. We propose the biportal endoscopic transfrontal sinus (BETS) approach, adapting endoscopic endonasal approach (EEA) techniques for minimally invasive access to the anterior fossa, reducing tissue manipulation, venous sacrifice, and brain retraction.

Extended reality in cranial and spinal neurosurgery - a bibliometric analysis.

Purpose: This bibliometric analysis of the top 100 cited articles on extended reality (XR) in neurosurgery aimed to reveal trends in this research field. Gender differences in authorship and global distribution of the most-cited articles were also addressed.

Methods: A Web of Science electronic database search was conducted.

Feasibility of exoscopic keyhole surgery: case series.

Keyhole approaches, performed with the endoscope, microscope, or exoscope, aim to minimize tissue traumatization while maximizing surgical view. The exoscope can provide better ergonomics than the microscope without restricting the space inside of the keyhole, as when using the endoscope. However, a frequently quoted reason for intraoperative exoscope-to-microscope conversion is the absence of sufficient light.

Mixed reality in neurosurgery: redefining the paradigm for arteriovenous malformation planning and navigation to improve patient outcomes.

Objective: Brain arteriovenous malformations (AVMs) present significant challenges in neurosurgery, requiring detailed planning and execution. In this study, the authors aimed to evaluate the efficacy of mixed reality (MxR), a synergistic application of virtual reality (VR) and augmented reality (AR), in the surgical management of AVMs.

Methods: A retrospective review was conducted on 10 patients who underwent AVM resection between 2021 and 2023.

The TIGR triangle of the pineal region: a virtual reality anatomic study.

Background: In this morphometric study, we describe the anatomy of the TIGR triangle, which is bordered by the tentorial surface of the cerebellum, the internal cerebral vein and vein of Galen complex, and the vein of Rosenthal. These structures define the window, or deep keyhole, to access the pineal region in non-midline supracerebellar infratentorial approaches.

Methods: The posterior fossa anatomy of 16 patients was studied in virtual reality (VR), and the TIGR triangles were defined and measured with special attention on its angular orientation in the posterior fossa.

Does Head Positioning After Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia Matter?

Background: Percutaneous glycerol rhizotomy (PGR) is a minimally invasive procedure for patients with trigeminal neuralgia who are not candidates for microvascular decompression. PGR has widely varying success rates. It has been postulated that differences in post-injection head positioning might account for the various success rates.

The Paramedian Supracerebellar Infratentorial Approach: 2-Dimensional Operative Video.

Indications: The supracerebellar-infratentorial approach uses the plane between the tentorium and the superior surface of the cerebellum to expose the pineal region.

Anatomic Essentials: The bone opening is just underneath the level of the transverse sinus, and so its position must be noted preoperatively. The anatomy of the internal cerebral veins and the veins of Galen and Rosenthal should be examined as well.

Transorbital Surgical Corridor: An Anatomic Analysis of Ocular Globe Retraction and the Associated Exposure for the Transpalpebral Orbital Rim Preserving Endoscopic Orbitotomy (TORPEDO) Approach.

Background And Objectives: The transorbital approach varies by the extent of bony removal and the target. Orbital rim-sparing transorbital approach with removal of only the orbit's posterior wall provides optimal cosmetic results, without the need for reconstruction. The size of this corridor, limited by the medial globe retraction, has not yet been defined and is difficult to determine in cadavers because of postmortem tissue desiccation.

The Inaugural "Century" of Mixed Reality in Cranial Surgery: Virtual Reality Rehearsal/Augmented Reality Guidance and Its Learning Curve in the First 100-Case, Single-Surgeon Series.

Background And Objective: Virtual reality (VR) refers to a computer-generated three-dimensional space in which a surgeon can interact with patient-specific anatomic models for surgical planning. Augmented reality (AR) is the technology that places computer-generated objects, including those made in VR, into the surgeon's visual space. Together, VR and AR are called mixed reality (MxR), and it is gaining importance in neurosurgery.

Anterior Transpetrosal Approach: 2-Dimensional Operative Video.

Indications Corridor And Limits Of Exposure: The anterior transpetrosal approach uses the subtemporal corridor to access the Meckel cave and the upper petroclival region from the dorsum sellae down to the cerebellopontine angle.

Anatomic Essentials Need For Preoperative Planning And Assessment: The boundaries of posteromedial triangle of the middle fossa must be adequately visualized for the anterior petrosectomy. They are V3 anteriorly, the petrous ridge medially, GSPN laterally, and the meatal plane posteriorly.

Middle cerebellar peduncle approach for Nocardia brainstem abscess: illustrative case.

Background: Nocardia cyriacigeorgica represents a rare cause of cerebral abscesses. Rarer still are brainstem abscesses caused by this bacterial species in immunocompetent hosts. In fact, only one such brainstem abscess case has been described in the neurosurgical literature to our knowledge to date.

Augmented-reality template guided transorbital approach for intradural tumors.

For "minimally invasive" approaches to a deep-lying skull base lesion, the bone opening must be precisely placed and adequately wide to accomplish the surgical goal. Surgical rehearsal in virtual reality (VR) can generate navigation-integrated augmented reality (AR) templates to ensure precise surgical openings. In this video, the authors used AR templates for the transpalpebral, transorbital approach for intradural tumors.

The Virtual Vision of Neurosurgery: How Augmented Reality and Virtual Reality are Transforming the Neurosurgical Operating Room.

Background: In this era of imagination and technological innovation, mixed reality systems such as virtual reality (VR) and augmented reality (AR) are contributing to a wide array of neurosurgical care, from the betterment of surgical planning and surgical comfort to novel treatments and improved resident education. These systems can augment procedures that require high-level dexterity such as minimally invasive surgery and tumor excisions, as well as peripheral and neurovascular surgery. We define and compare the technological features, indications, and characterized outcomes of VR and AR systems in the context of neurosurgery through a review of the literature to date.