12 research outputs found
Surgical corridors to foramen magnum meningiomas: a mini-review
Gross-total resection of foramen magnum meningiomas remains the gold standard of treatment and should be performed whenever possible. The transcondylar approach (and its variations) represents the most used approach for meningiomas located in the lateral or anterior borders of the foramen magnum. Endoscopic transclivus approaches represent a useful option in selected cases of anterior midline foramen magnum meningiomas, to be performed in centers with advanced experience in endoscopic skull base surgery, with the caveats of increased risk of postoperative cerebrospinal fluid leak. Alternatively, radiosurgery remains an option for well-selected cases, especially for the management of asymptomatic patients with small enlarging tumors. Advances in molecular profiling, as well as genetic analysis, may guide adjuvant treatment
Anatomía ventricular para tercer ventriculostomía endoscópica
El conocimiento de la anatomía de las estructuras cerebrales en relación con los ventrículos cerebrales representa la capacidad para poder respetarlas durante una tercer ventriculostomía endoscópica (TVE), lo cual es indispensable para evitar complicaciones relacionadas al procedimiento. El propósito de este trabajo es hacer una revisión sobre la anatomía ventricular endoscópica, tomas ventriculares y vías de acceso para hacer una TVE. Se revisaron los puntos relevantes de la técnica quirúrgica y de la anatomía ventricular en nuestra experiencia institucional con el fin de hacer una descripción gráfica de la anatomía ventricular endoscópica para fenestración del piso del tercer ventrículo. Se mostrarán imágenes y videos relacionados con este abordaje.Knowledge of anatomy of brain structu-res in relation to the cerebral ventricles represents the capacity to respect them during an Endoscopic Third Ventriculostomy (ETV), which is essential to prevent complications related to the procedure. The purpose of this paper is to review the ventri-cular endoscopic anatomy, ventricular outlets and access roads to make a successful ETV. The relevant points of the surgical technique and of the ventri-cular anatomy in our institutional experience in or-der to make a graphic description of the anatomy for endoscopic ventricular floor fenestration of the third ventricle were reviewed
Cerebral ventricular system embryology
El Sistema Ventricular Cerebral se desarrolla de forma paralela al resto del Sistema Nervioso Central, facilitando la circulación del Líquido Cefalorraquídeo, desde su separación del líquido amniótico a nivel embrionario. Este desarrollo es necesario para entender correctamente la anatomía ventricular y facilitar el abordaje para patologías intraventriculares. El objetivo de esta revisión es reconocer los puntos más importantes en la embriología ventricular para facilitar el aprendizaje de la anatomía quirúrgica ventricularThe cerebral ventricular system is developed in parallel with the rest of the central nervous system, facilitating the circulation of cerebrospinal fluid, from the amniotic fluid separation in the embryonic phases. This development is necessary to correctly understand the ventricular anatomy and facilitate approach to intraventricular pathologies. The objective of this review is to recognize the most important points in the ventricular embryology and in the intraventricular endoscopic vision to facilitate learning of the ventricular surgical anatom
A history of Colombian neurosurgery : events, persons, and outcomes that have shaped the specialty in the country
Q1Q1The history of Colombian neurosurgery is a collective legacy of neurosurgeon-scientists, scholars, teachers, innovators, and researchers. Anchored in the country’s foundational values of self-determination and adaptability, these pioneers emerged from the Spanish colonial medical tradition and forged surgical alliances abroad. From the time of Colombian independence until the end of World War I, exchanges with the French medical tradition produced an emphasis on anatomical and systematic approaches to the emerging field of neurosurgery. The onset of American neurosurgical expertise in the 1930s led to a new period of exchange, wherein technological innovations were added to the Colombian neurosurgical repertoire. This diversity of influences culminated in the 1950s with the establishment of Colombia’s first in-country neurosurgery residency program. A select group of avant-garde neurosurgeons from this period expanded the domestic opportunities for patients and practitioners alike. Today, the system counts 10 recognized neurosurgery residency programs and over 500 neurosurgeons within Colombia. Although the successes of specific individuals and innovations were considered, the primary purpose of this historical survey was to glean relevant lessons from the past that can inform present challenges, inspire new opportunities, and identify professional and societal goals for the future of neurosurgical practice and specialization.https://orcid.org/0000-0001-9087-1392Revista Internacional - IndexadaA1N
Brain fascicles volumetry in healthy population
Objetivo Desde la aparición de la tractografía, al tratarse de una técnica no invasiva y
que usa la ampliamente conocida resonancia magnética (RM), el estudio de la sustancia
blanca se ha facilitado. A partir de eso, se han logrado grandes descubrimientos en
cuanto a fascículos cerebrales involucrados en funciones cognitivas. Sin embargo, su
evaluación sigue siendo subjetiva y depende de la experiencia y entrenamiento del
evaluador, razón por la cual se ha limitado su aplicabilidad en la práctica clínica. En ese
sentido, es conveniente parametrizar volúmenes cerebrales de sustancia blanca en
población sana a través de una herramienta electrónica que se pueda reproducir y así
poderlo aplicar en enfermos.
Materiales y métodos Se reportan 10 sujetos sanos desde el punto de vista
neurológico. Para cada sujeto, se adquirieron imágenes ponderadas por difusión y
los resultados se visualizaron mediante FiberNavigator (http://scilus.github.io/
fibernavigator). Finalmente, esa misma herramienta fue utilizada para purificar los
fascículos objeto de estudio y realizar el conteo de las fibras.
Resultados Se obtuvieron valores de volumetría del fascículo longitudinal superior
(FLS), fascículo longitudinal inferior (FLI), fascículo frontoccipital inferior (FFI), fascículo
uncinado (FU) y fascículo del cíngulo (FC), identificando que no existen diferencias
estadísticamente significativas entre el número de fibras que componen los fascículos
cerebrales.
Discusión Los resultados alcanzados de la anatomía y la direccionalidad de fibras de
los fascículos cerebrales de este estudio coinciden con el resto de la evidencia publicada
hasta el momento, sin encontrar diferencias en cuanto a su organización y recorrido.
Conclusión Aunque esos resultados no sirven como valores de referencia para ser
aplicados en pacientes con patología neurológica, brindamos información inexistente
hasta el momento, con ese equipo en específico y la reproducción entre los distintos
usuarios y el software.Objective Since the appearance of tractography, as it is a non-invasive technique and
uses the widely known magnetic resonance (MR), the study of white matter has been
facilitated. After this, great discoveries have been made regarding the brain fascicles
involved in cognitive functions. However, its evaluation continues to be subjective and
depends on the evaluator’s experience and training. That the reason why its
applicability has been limited in clinical practice. Because of this, it is convenient to
parametrize cerebral volumes of white matter in healthy population through an
electronic, reproducible tool that could be applied in patients.
Materials and Methods Ten neurologically healthy subjects are reported, for each
subject we acquired images weighted by diffusion and the results were visualized by
means of FiberNavigator (http://scilus.github.io/fibernavigator). Finally, this same tool
was used to purify the fascicles under study and perform the fiber count.
Results Volumetric values of the upper longitudinal fasciculus, inferior longitudinal
fasciculus, inferior frontoccipital fasciculus, uncinated fasciculus and cingulate
fasciculus were obtained, identifying that there are not statistically significant
differences in the number of fibers that make up the cerebral fascicles.
Discussion The results achieved of the anatomical and fiber directionality of the
cerebral fascicles of this study, coincide with the rest of the evidence published up to
now, without finding differences regarding its organization and route.
Conclusion Although these results do not serve as reference values to be applied in
patients with neurological pathology, do we provide nonexistent information so far,
with this specific equipment and the reproducibility between the different users and
the software
Micromirrors in Neurosurgery: Technical Overview and Benefits Assessment
Aim: To weight the benefits and limitations of intraoperative use of micromirrors in neurosurgery. Material and methods: Surgical cases where micromirrors were employed were retrospectively selected from the surgical database of five different surgeons in different hospitals. Complications directly attributable to the micromirrors were assessed intraoperatively and confirmed with postoperative neuroimaging studies. Results: Fourteen patients were selected. The site of the lesion was as follows: posterior fossa (43%), frontal lobe (22%), temporal lobe (14%), parietal lobe (7%), insula (7%), and basal ganglia (7%). Five tumors (35%) were gliomas, 3 (21%) epidermoid, and 3 (21 %) supratentorial metastases. Two patients underwent microvascular decompression for neurovascular conflict, and 1 harbored a brain arteriovenous malformation. A gross total resection was achieved in all the tumors and the AVM, while an effective decompression was successfully performed in both patients with conflict. No complications directly attributable to the use of the micromirror occurred. A relatively easy learning curve was noted. Conclusion: Micromirrors proved to be useful in enhancing the visualization of neurovascular structures and pathology residuals within deep-seated surgical fields without the need for fixed brain retraction. Their cost-effectiveness and easy learning curve constitute solid reasons for advocating a revitalization of this ?old but gold? tool in neurosurgery
Endoscopic endonasal resection of epidermoid cysts involving the ventral cranial base
OBJECTIVE Epidermoid cysts (ECs) commonly extend to involve the ventral cisterns of the cranial base. When present,
symptoms arise due to progressive mass effect on the brainstem and adjacent cranial nerves. Historically, a variety
of open microsurgical approaches have been used for resection of ECs in this intricate region. In recent years, the
endoscopic endonasal approach (EEA) has been proposed as an alternative corridor that avoids crossing the plane of
the cranial nerves. To date, there is a paucity of data in the literature regarding the safety and efficacy of the EEA in the
treatment of ECs of the ventral cranial base.
METHODS The authors reviewed a prospectively acquired database of EEAs for resection of ECs over 8 years at Weill
Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior authors. Standardized clinical and
radiological parameters were assessed before and after surgery. Statistical tests were used to determine the impact of
previous surgery and tumor volume on extent of resection and recurrence as well as the method of closure on rate of
CSF leak.
RESULTS Between January 2009 and February 2017, 7 patients (4 males and 3 females; age range 16–70 years) underwent
a total of 8 surgeries for EC resection utilizing the EEA. Transplanum and transclival extensions were performed
in 3 and 5 patients, respectively. Methods of closure incorporated a gasket seal in 6 of 8 procedures and a nasoseptal
flap in 7 of 8 procedures. Gross-total resection (GTR) was achieved in 43% of patients, and near-total resection (> 95%)
was obtained in another 43%. Complications included diabetes insipidus (n = 2), postoperative CSF leak (n = 2), transient
third cranial nerve palsy (n = 1), and epistaxis (n = 1). With a mean follow-up of 43.5 months, recurrence has been
observed in 2 of 7 patients. In 1 case, reoperation for recurrence was required 71 months following the initial surgery.
Use of the gasket-seal technique with nasoseptal flap coverage significantly correlated with the absence of postoperative
CSF leakage (p = 0.018). GTR was achieved in 25% of the patients who had prior surgeries and in 50% of patients
without previous resections. The mean volume of cysts in which GTR was achieved (4.3 ± 1.8 cm3) was smaller than that
in which subtotal or near-total resection was achieved (12.2 ± 11 cm3, p = 0.134).
CONCLUSIONS The EEA for resection of ECs of the ventral cranial base is a safe and effective operative strategy that
avoids crossing the plane of the cranial nerves. In the authors’ experience, gasket-seal closure with nasoseptal flap coverage
has been associated with a decreased risk of postoperative CSF leakage
Structural and functional connectivity of ascending reticular activating system in a patient with impaired consciousness after a cardiac arrest. A case report
Abstract
Rationale: Diffusion tensor imaging (DTI), diffusion tensor tractography (DTT), as well as resting-state-functional magnetic
resonance imaging (rsfMRI) are promising methods for assessing patients with disorders of consciousness (DOCs).
Patient concerns: This work describes the main findings using DTI, DTT, and rsfMRI in a patient with a DOC secondary to an
anoxic encephalopathy who had a fatal outcome. She was an 85-year-old woman who presented a cardiac arrest and underwent
cardiopulmonary resuscitation for 20 minutes then returning to spontaneous circulation. After sedation withdrawal, 2 days after the
event, she remained with a Glasgow Coma Scale score of 3/15 and with an absence of brainstem reflexes.
Diagnoses: DOC secondary to an anoxic encephalopathy after cardiovascular resuscitation.
Interventions: A complete brain MRI scan was performed 72 hours after the initial event, including DTI, DTT, and rsfMRI. DTT
demonstrated disruption of both ventral and dorsal tegmental tracts bilaterally. DTI showed a reduction of fractional anisotropic level
in the mesencephalic nuclei. Moreover, changes in the number of fiber tracts were not evidenced in any portions of the ascending
reticular activating system (ARAS). Finally, an increase in the anticorrelated and correlated association among the nuclei in the ARAS
and the cortex was evidenced.
Outcomes: Patient deceased.
Lessons: Neuroimaging demonstrated low FA values in the ARAS, destruction of dorsal and ventral tegmental tracts, as well as
hyper-connective (highly correlated or anti-correlated) association among ARAS and cortical nuclei compared with 3 healthy control
subjects.
Abbreviations: AAN = Arousal Network Atlas, ADC = apparent diffusion coefficient, ARAS = ascending reticular activating
system, BOLD = blood-oxygen-level dependent imaging, DIPY = Diffusion Imaging in Python, DOC = disorder of consciousness, DTI
= diffusion tensor imaging, DTT = diffusion tensor tractography, DWI = diffusion weighted imaging, FA = fractional anisotropy, FC =
functional connectivity, FSL = FMRIB Software Library, ODF = orientation distribution function, ROI = region of interest, rsfMRI =
resting-state functional magnetic resonance imaging, TBI = traumatic brain injury
Functional Neuroanatomy of the Glasgow Coma Scale
Introducción: La escala de coma de Glasgow (ECG) es una escala mundialmente reconocida para la clasificación de pacientes
con trauma craneoencefálico de acuerdo a su compromiso neurológico. Esta escala evalúa la apertura ocular, la respuesta
verbal y la respuesta motora. La neuroanatomía funcional representa un compromiso secuencial para el descenso en el
puntaje de cada uno de estos ítems. El objetivo de esta revisión es describir la anatomía del sistema reticular activador
ascendente (SRAA), la anatomía funcional del lenguaje, la anatomía del tallo cerebral y de las vías motoras que representan
cada ítem evaluado por la ECG.
Materiales y métodos: Se hizo una revisión narrativa bibliográfica de las principales vías para cada ítem de la ECG.
Resultados: Las principales vías en relación con la apertura ocular se concentran en las vías del SRAA, las vías de la respuesta
verbal incluyen las vías del lenguaje y las vías que provienen del putamen y del cerebelo que regulan la emisión del lenguaje,
mientras que las vías que regulan la respuesta motora principalmente se relacionan con la vía piramidal, el sistema rubroespinal y vestíbulo-espinal.
Conclusiones: El descenso del puntaje en los tres ítems que evalúa la ECG se relacionan con vías específicas que predominan
en los ganglios basales y en el tallo cerebralIntroduction: The Glasgow Coma Scale (GCS) is a globally recognized scale for the classification of patients with traumatic
brain injury according to their neurological impairment. This scale evaluates the ocular opening, the verbal response and the
motor response. Functional neuroanatomy represents a sequential decrease in the score of each of these items. The objective
of this review is to describe the anatomy of the ascending reticular activating system (ARAS), the functional anatomy of the
language, and the anatomy of the brainstem and the motor pathways that represent each item evaluated by the GCS.
Materials and methods: A narrative literature review of the main routes for each item of the scale was performed.
Results: The main pathways in relation to the ocular opening are concentrated in the ARAS, the verbal response pathways
include the language pathways and the connections that come from the putamen and the cerebellum that regulate the
production of the language, while the pathways that regulate the motor response mainly relate to the pyramidal tract, the rubrospinal and vestibulo-spinal systems.
Conclusions: The decline of the score in the three items that evaluates the GCS is related to specific pathways that
predominate in the basal ganglia and in the brainstem
Endonasal endoscopic transsphenoidal resection of intrinsic third ventricular craniopharyngioma: surgical results
OBJECTIVE
Intrinsic third ventricular craniopharyngiomas (IVCs) have been reported by some authors to “pose the greatest surgical challenge” of all craniopharyngiomas (CPAs). A variety of open microsurgical approaches have historically been used for resection of these tumors. Despite increased utilization of the endoscopic endonasal approach (EEA) for resection of CPAs in recent years, many authors continue to recommend against use of the EEA for resection of IVCs. In this paper, the authors present the largest series to date utilizing the EEA to remove IVCs.
METHODS
The authors reviewed a prospectively acquired database of the EEA for resection of IVCs over 14 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital. Preoperative MR images were examined independently by two neurosurgeons and a neuroradiologist to identify IVCs. Pre- and postoperative endocrinological, ophthalmological, radiographic, and other morbidities were determined from retrospective chart review and volumetric radiographic analysis.
RESULTS
Between January 2006 and August 2017, 10 patients (4 men, 6 women) ranging in age from 26 to 67 years old, underwent resection of an IVC utilizing the EEA. Preoperative endocrinopathy was present in 70% and visual deterioration in 60%. Gross-total resection (GTR) was achieved in 9 (90%) of 10 patients, with achievement of near-total (98%) resection in the remaining patient. Pathology was papillary in 30%. Closure incorporated a “gasket-seal” technique with nasoseptal flap coverage and either lumbar drainage (9 patients) or a ventricular drain (1 patient). Postoperatively, complete anterior and posterior pituitary insufficiency was present in 90% and 70% of patients, respectively. In 4 patients with normal vision prior to surgery, 3 had stable vision following tumor resection. One patient noted a new, incongruous, left inferior homonymous quadrantanopsia postoperatively. In the 6 patients who presented with compromised vision, 2 reported stable vision following surgery. Each of the remaining 4 patients noted significant improvement in vision after tumor resection, with complete restoration of normal vision in 1 patient. Aside from the single case (10%) of visual deterioration referenced above, there were no instances of postoperative neurological decline. Postoperative CSF leakage occurred in 1 morbidly obese patient who required reoperation for revision of closure. After a mean follow-up of 46.8 months (range 4–131 months), tumor recurrence was observed in 2 patients (20%), one of whom was treated with radiation and the other with chemotherapy. Both of these patients had previously undergone GTR of the IVC.
CONCLUSIONS
The 10 patients described in this report represent the largest number of patients with IVC treated using EEA for resection to date. EEA for resection of IVC is a safe and efficacious operative strategy that should be considered a surgical option in the treatment of this challenging subset of tumors