Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: Anatomic considerations - Part I

INTRODUCTION: Interest in using the extended endonasal transsphenoidal approach for management of suprasellar lesions, with either a microscopic or endoscopic technique, has increased in recent years. The most relevant benefit is that this median approach permits the exposure and removal of suprasellar lesions without the need for brain retraction. MATERIALS AND METHODS: Fifteen human cadaver heads were dissected to evaluate the surgical key steps and the advantages and limitations of the extended endoscopic endonasal transplanum sphenoidale approach. We compared this with the transcranial microsurgical view of the suprasellar area as explored using the bilateral subfrontal microsurgical approach, and with the anatomy of the same region as obtained through the endoscopic endonasal route. RESULTS: Some anatomic conditions can prevent or hinder use of the extended endonasal approach. These include a low level of sphenoid sinus pneumatization, a small sella size with small distance between the internal carotid arteries, a wide intercavernous sinus, and a thick tuberculum sellae. Compared with the subfrontal transcranial approach, the endoscopic endonasal approach offers advantages to visualizing the subchiasmatic, retrosellar, and third ventricle areas. CONCLUSION: The endoscopic endonasal transplanum sphenoidale technique is a straight, median approach to the midline areas around the sella that provides a multiangled, close-up view of all relevant neurovascular structures. Although a lack of adequate instrumentation makes it impossible to manage all structures that are visible with the endoscope, in selected cases, the extended endoscopic endonasal approach can be considered part of the armamentarium for surgical treatment of the suprasellar area

The Emerging Role of Microbial Biofilm in Lyme Neuroborreliosis

Lyme borreliosis (LB) is the most common tick-borne disease caused by the spirochete Borrelia burgdorferi in North America and Borrelia afzelii or Borrelia garinii in Europe and Asia, respectively. The infection affects multiple organ systems, including the skin, joints, and the nervous system. Lyme neuroborreliosis (LNB) is the most dangerous manifestation of Lyme disease, occurring in 10-15% of infected individuals. During the course of the infection, bacteria migrate through the host tissues altering the coagulation and fibrinolysis pathways and the immune response, reaching the central nervous system (CNS) within 2 weeks after the bite of an infected tick. The early treatment with oral antimicrobials is effective in the majority of patients with LNB. Nevertheless, persistent forms of LNB are relatively common, despite targeted antibiotic therapy. It has been observed that the antibiotic resistance and the reoccurrence of Lyme disease are associated with biofilm-like aggregates in B. burgdorferi, B. afzelii, and B. garinii, both in vitro and in vivo, allowing Borrelia spp. to resist to adverse environmental conditions. Indeed, the increased tolerance to antibiotics described in the persisting forms of Borrelia spp., is strongly reminiscent of biofilm growing bacteria, suggesting a possible role of biofilm aggregates in the development of the different manifestations of Lyme disease including LNB

Analisis Percepatan terhadap Waktu Proyek (Study Kasus : Kantor Dinas SKPD Gedung B3 di Tenayan Raya)

Project implementation have always refers to the construction assumption and forecast while time plans and schedule were made, Therefore, the contruction problem will arise if there is a discrepancy between plan and assumptions comparing to the actual project. Delays of project implementation is generally always lead to adverse consequences both for the owner and contractor. The project the (SKPD) Unit City Government of Pekanbaru in Riau is having a delay of 75 days. The Best construction time acceleration is 45 days. Construction acceleration can be conducted by 3 alternatives solutions such as: overtime alternative, equipment and workers addition alternative, and shift system alternative. The analysis started from the critical path. Network project the analysis, was obtained from the cost due to delay stands at Rp. 4.761.786.975,00. Cost of construction acceleration caused by overtime alternative is Rp. 2.152.360.596,00 with a total 11.136 hours of extra work for workers, cost of construction acceleration by the workers and equipments additionionally for alternative result Rp. 2.434.965.492,00 with a total 14 new workers, with additional of 2 new equipment units. Cost of construction acceleration from shift alternative is Rp. 2.434.965.492,00 with a total of 14 new workers, a total 2 of equipment units. In conclusion, the most effective construction acceleration method is overtime alternative, obtained the minimum financial loss and recommended to use for the construction acceleration

Production of lead metal by molten-salt electrolysis with energy-efficient electrodes

"The U.S. Bureau of Mines investigated electrode designs for electrowinning lead metal from a LiCl-KCl-PbCl2 electrolyte at 450 deg C. The major objective of this investigation was to decrease the energy requirement for lead electrowinning. Electrolysis was performed in a bench-scale cell using several graphite electrode assemblies. Such parameters as electrode spacing, current density, and chlorine gas removal from the anode were investigated in the bench-scale tests. An optimum electrode assembly, termed the sawtooth design, was scaled up and operated at 3,000 and 4,000 A. The sawtooth electrodes operating at 3,000 A produced lead for 0.66 Kw.H/kg. The electrodes were constructed by cutting large triangular grooves in the electrode surfaces. The electrodes were placed together such that the triangular peaks of one electrode projected into the triangular valleys of the other electrode. Chlorine did not build up on the anode with the sawtooth electrodes." - NIOSHTIC-2NIOSHTIC no. 10008548199

Surgical Freedom Evaluation During Optic Nerve Decompression. Laboratory Investigation

Background and objective: Various surgical routes have been used to decompress the intracanalicular optic nerve. Historically, a transcranial corridor was used, but more recently, ventral approaches (endonasal and/or transorbital) have been proposed, individually or in combination. The present study aims to detail and quantify the amount of bony optic canal removal that may be achieved via transcranial, transorbital, and endonasal pathways. In addition, the surgical freedom of each approach was analyzed. Methods: In 10 cadaveric specimens (20 canals), optic canals were decompressed via pterional, endoscopic endonasal, and endoscopic superior eyelid transorbital corridors. The surgical freedom and circumferential optic canal decompression afforded by each approach was quantitatively analyzed. Statistical comparison was carried using a nonpaired Student t test. Results: An open pterional transcranial approach allowed the greatest area of surgical freedom (transcranial, 109.4 ± 33.6 cm2; transorbital, 37.2 ± 4.9 cm2; endonasal homolateral, 10.9 ± 5.2 cm2; and endonasal contralateral, 11.1 ± 5.6 cm2) with widest optic canal decompression compared with the other 2 ventral routes (transcranial, 245.2; transorbital, 177.9; endonasal, 144.6). These differences reached, in many cases, statistical significance for the transcranial approach. Conclusions: This anatomic contribution provides a comprehensive evaluation of surgical access to the optic canal via 3 distinct, but complementary, approaches: transcranial, transorbital, and endonasal. Our results show that, as expected, a transcranial approach achieved the widest degree of circumferential optic canal decompression and the greatest surgical freedom for manipulation of surgical instruments. Further surgical experience is necessary to determine the proper surgical indication for the transorbital approach to this disease

Surgical management of adult Brainstem Gliomas: a systematic review and meta-analysis

The present review aims to investigate the survival and functional outcomes in adult high-grade brainstem gliomas (BGSs) by comparing data from resective surgery and biopsy. MEDLINE, EMBASE and Cochrane Library were screened to conduct a systematic review of the literature, according to the PRISMA statement. Analysis was limited to articles including patients older than 18 years of age and those published from 1990 to September 2022. Case reports, review articles, meta-analyses, abstracts, reports of aggregated data, and reports on multimodal therapy where surgery was not the primary treatment were excluded. The ROBINS-I tool was applied to evaluate the risk of bias. Six studies were ultimately considered for the meta-analysis. The resective group was composed of 213 subjects and the bioptic group comprised 125. The analysis demonstrated a survival benefit in those patients in which an extensive resection was possible (STR HR 0.59 (95% CI 0.42, 0.82)) (GTR HR 0.63 (95% CI 0.43, 0.92)). Although surgical resection is associated with increased survival, the significantly higher complication rate makes it difficult to recommend surgery instead of biopsy for BSGs. Future investigations combining volumetric data and molecular profiles could add important data to better define the proper indication between resection and biopsy

The role of inferior petrosal sinus sampling in ACTH-dependent Cushing's syndrome: review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology

In the management of adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome, inferior petrosal sinus sampling (IPSS) provides information for the endocrinologist, the neurosurgeon, and the neuroradiologist. To the endocrinologist who performs the etiological diagnosis, results of IPSS confirm or exclude the diagnosis of Cushing's disease with 80%-100% sensitivity and over 95% specificity. Baseline central-peripheral gradients have suboptimal accuracy, and stimulation with corticotropin-releasing hormone (CRH), possibly desmopressin, has to be performed. The rationale for the use of IPSS in this context depends on other diagnostic means, taking availability of CRH and reliability of dynamic testing and pituitary imaging into account. As regards the other specialists, the neuroradiologist may collate results of IPSS with findings at imaging, while IPSS may prove useful to the neurosurgeon to chart a surgical course. The present review illustrates the current standpoint of these 3 specialists on the role of IPSS

Bacterial and Viral Infection and Sepsis in Kidney Transplanted Patients

Kidney transplanted patients are a unique population with intrinsic susceptibility to viral and bacterial infections, mainly (but not exclusively) due to continuous immunosuppression. In this setting, infectious episodes remain among the most important causes of death, with different risks according to the degree of immunosuppression, time after transplantation, type of infection, and patient conditions. Prevention, early diagnosis, and appropriate therapy are the goals of infective management, taking into account that some specific characteristics of transplanted patients may cause a delay (the absence of fever or inflammatory symptoms, the negativity of serological tests commonly adopted for the general population, or the atypical anatomical presentation depending on the surgical site and graft implantation). This review considers the recent available findings of the most common viral and bacterial infection in kidney transplanted patients and explores risk factors and outcomes in septic evolution

Idiopathic Aqueductal Stenosis: Late Neurocognitive Outcome in ETV Operated Adult Patients

ObjectiveThe aim of the present study is to evaluate a neurocognitive outcome in patients affected by late-onset idiopathic aqueductal stenosis (LIAS) who underwent endoscopic third ventriculostomy (ETV). Materials and MethodsA prospective study was conducted between January 2015 and December 2017 in a series of 10 consecutive adult patients referred to the Neurosurgery Department of IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy. All the adult patients admitted with absence of CSF flow through the aqueduct in phase-contrast (PC)-MRI sequences or a turbulence void signal in T2-weighted images in midsagittal thin-slice MR sequences underwent a specific neuroradiological, neurological, and neurocognitive assessment pre- and postoperatively. ResultsAll patients affected by gait and sphincter disturbances improved after ETV. Attentive and executive functions as well as visuo-spatial memory and verbal executive functions improved in several patients. Similarly, the affective and behavioral scales improved in almost 50% of the patients. No major complications have been recorded, and no patients required a second surgery for shunt placement. ConclusionEndoscopic third ventriculostomy represents a safe and effective surgical procedure for the treatment of LIAS. In addition to neurological improvement, we demonstrated also postoperative neurocognitive improvement mainly in attentive and executive functions, visuo-spatial memory, verbal executive functions, and behavioral and affective domains

Biofilm is a major virulence determinant in bacterial colonization of chronic skin ulcers independently from the multidrug resistant phenotype

Bacterial biofilm is a major factor in delayed wound healing and high levels of biofilm production have been repeatedly described in multidrug resistant organisms (MDROs). Nevertheless, a quantitative correlation between biofilm production and the profile of antimicrobial drug resistance in delayed wound healing remains to be determined. Microbial identification, antibiotic susceptibility and biofilm production were assessed in 135 clinical isolates from 87 patients. Gram-negative bacteria were the most represented microorganisms (60.8%) with MDROs accounting for 31.8% of the total isolates. Assessment of biofilm production revealed that 80% of the strains were able to form biofilm. A comparable level of biofilm production was found with both MDRO and not-MDRO with no significant differences between groups. All the methicillin-resistant Staphylococcus aureus (MRSA) and 80% of Pseudomonas aeruginosa MDR strains were found as moderate/high biofilm producers. Conversely, less than 17% of Klebsiella pneumoniae extended-spectrum beta-lactamase (ESBL), Escherichia coli-ESBL and Acinetobacter baumannii were moderate/high biofilm producers. Notably, those strains classified as non-biofilm producers, were always associated with biofilm producer bacteria in polymicrobial colonization. This study shows that biofilm producers were present in all chronic skin ulcers, suggesting that biofilm represents a key virulence determinant in promoting bacterial persistence and chronicity of ulcerative lesions independently from the MDRO phenotype