Unedited microneurosurgery of a pineal region neuroepithelial cyst

Background: Neuroepithelial cysts are benign, well-circumscribed, nonenhancingPeer reviewe

"Squeeze Maneuver" Assisted by Indocyanine Green Videoangiography : Simple Technique to "Resuscitate" Partially Occluded Bridging Veins During Microneurosurgical Operations

OBJECTIVE: The preservation of normal peri/intralesional bridging veins is extremely important in every micro-neurosurgical operation. The purpose of our study was to describe the "squeeze maneuver"assisted by indocyanine green videoangiography (ICGV), a simple technique to "resuscitate" partially occluded bridging veins during microneurosurgical operations. METHODS: When a bridging vein is inadvertently stretched up to its collapse during microneurosurgical procedures, a precise identification of the partially occluded zone is carried out under high magnification (10-153), as well as with the aid of the ICGV. If a continuous irrigation with isotonic saline solution does not allow one to reestablish the venous flow, the "squeeze maneuver" is carried out. This consists of squeezing and sliding with the bipolar forceps the occluded vessel along the normal venous flow direction. This procedure is repeated several times, while a continuous saline irriga-tion is applied. The ICGV is performed to confirm an adequate patency of the vein. RESULTS: This maneuver permits to restore the normal diameter of the vein and blood flow inside it. CONCLUSION: The "squeeze maneuver"assisted by ICGV represents a safe, clean, fast, and even cheap method for restoring the flow of partially occluded bridging veins during microneurosurgical operations.Peer reviewe

Hernesniemi's 1001 and More Microneurosurgical Videos : Videobook of Neurosurgery

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Seven Cerebral Aneurysms : A Challenging Case from the Andean Slopes Managed with 1-Stage Surgery

BACKGROUND: Treatment of multiple intracranial aneurysms is particularly demanding and even more so in a developing country where access to specialized centers may be prevented by different factors. METHODS: Single-stage surgical treatment of 7 cerebral aneurysms was performed in a 58-year-old woman from the northern Peruvian Andes. RESULTS: All 7 aneurysms were successfully and safely clipped through 2 lateral supraorbital craniotomies. The double clip technique was used in 3 aneurysms to prevent any residual aneurysmai neck. CONCLUSIONS: Good teamwork and correct application of microsurgical principles may allow effective treatment in complex neurosurgical cases even in resourcechallenged environments.Peer reviewe

Moyamoya Disease in an 8-Year-Old Boy : Direct Bypass Surgery in a Province of Peru

BACKGROUND: Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors. CASE DESCRIPTION: Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patient's motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru. CONCLUSIONS: The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.Peer reviewe

Surgical Outcome of Very Small Intracranial Aneurysms Utilizing the Double Clip Technique

OBJECTIVES: To report the outcome of patients with very small intracranial aneurysm (VSIA) undergoing surgical clipping using a double-clip technique. METHODS: This cross-sectional study was conducted in Namazi Hospital, the main referral neurovascular center in Southern Iran during a 6-year period from September 2010 to March 2016. All patients with VSIAs ( RESULTS: Operations were performed on 32 VSIAs in 26 patients with a mean +/- SD age of 55.7 +/- 10.1 years. Middle cerebral artery was the most common location for VSIA (50.0%). There was no neck remnant, and the complete occlusion rate was 100%. The rate of intraoperative aneurysm rupture was 30.8%, and none of the patients experienced rebleeding. The 6-month mortality rate was 0% in ruptured VSIAs and 6.25% in unruptured VSIAs. Most of the patients had favorable outcomes (88.5%), and the overall mortality rate was 11.5%. The rate of permanent neurologic deficit was 10.0% in ruptured and 12.5% in unruptured VSIAs. Multivariate logistic regression analysis revealed no association between baseline and clinical characteristics and outcome in this series. CONCLUSION: VSIAs are difficult to treat because of their small sizes; therefore, with a double-clip technique, one can reduce complications related to the treatment of small aneurysms.Peer reviewe

Short-Burst Bipolar Coagulation for Repairing Partially Damaged Brain Arteries Preserving Their Flow : Technical Note

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Virtual Reality Glasses and "Eye-Hands Blind Technique" for Microsurgical Training in Neurosurgery

OBJECTIVE: Microsurgical skills and eye-hand coordination need continuous training to be developed and refined. However, well-equipped microsurgical laboratories are not so widespread as their setup is expensive. Herein, we present a novel microsurgical training system that requires a high-resolution personal computer screen, smartphones, and virtual reality glasses. METHODS: A smartphone placed on a holder at a height of about 15-20 cm from the surgical target field is used as the webcam of the computer. A specific software is used to duplicate the video camera image. The video may be transferred from the computer to another smartphone, which may be connected to virtual reality glasses. RESULTS: Using the previously described training model, we progressively performed more and more complex microsurgical exercises. It did not take long to set up our system, thus saving time for the training sessions. CONCLUSION: Our proposed training model may represent an affordable and efficient system to improve eye-hand coordination and dexterity in using not only the operating microscope but also endoscopes and exoscopes.Peer reviewe

Lesión difusa de médula espinal, ¿cirugía o tratamiento paliativo?: a propósito de un caso

Diffuse spinal cord injuries are rare and pose a diagnostic challenge. Low-grade gliomas are the most prevalent type, with primary astrocytomas being the most frequent subtype. We present the case of a 36-year-old man with a 13-year history of squeezing neck pain, which progressed with right hemiparesis and later with severe paraparesis and loss of sphincter control. A whole spine MRI scan showed diffuse neoproliferative lesions that spread throughout all the spinal cord segments. An open biopsy of the lesion in the T1-T2 segment was performed. The pathology report stated low-grade glioma. Treatment is controversial, so surgery was ruled out due to high morbidity. Radiotherapy and chemotherapy were chosen because they play an important role in controlling the disease.Las lesiones difusas de médula son raras y un reto diagnóstico. Los gliomas de bajo grado son los de mayor prevalencia y los astrocitomas primarios, el subtipo más frecuente. Presentamos el caso de un varón de 36 años, con tiempo de enfermedad de 13 años de dolor cervical insidioso, progresa con hemiparesia derecha y, posteriormente, paraparesia severa con pérdida de control de esfínteres. Mediante una RMN total de columna se evidenciaron lesiones neoproliferativas difusas abarcando todos los segmentos medulares. Se realizó una biopsia a cielo abierto en segmento T1-T2, la patología diagnosticó glioma de bajo grado. El tratamiento es controversial y se descartó la cirugía por la alta morbilidad. Se optó por radioterapia y quimioterapia por su rol importante en el control de la enfermedad

Modified Pure Endoscopic Approach to Pineal Region : Proof of Concept of Efficient and Inexpensive Surgical Model Based on Laboratory Dissections

OBJECTIVE: In recent decades endoscopic techniques have been increasingly used in neurosurgery as they may offer a valuable close-up view of the working area through a minimally invasive surgical corridor. Herein, we present an inexpensive and efficient endoscopic surgical model using a borescope, which was used for a "modified pure endoscopic approach" to the pineal region. METHODS: A borescope video camera was connected to a 16-inch personal computer monitor. A standard midline suboccipital craniotomy was performed on 2 cadaveric heads in the Concorde position. Then, a "borescopic" supracerebellar infratentorial approach was executed, thus reaching the pineal region, which was exposed through an extensive arachnoid dissection. RESULTS: Using the previously described model, we were able to provide excellent exposure of the main neurovascular structures of the pineal region, as shown by the intraoperative videos. In 1 specimen we identified an incidental pineal cyst that was meticulously dissected and removed. CONCLUSIONS: Our proposed "borescopic" surgical model may represent an inexpensive and efficient alternative to conventional endoscopic techniques and could be used for training purposes, as well as even for clinical procedures, after a proper validation, particularly in economically challenging environments.Peer reviewe