Surgical Strategy in Midline Tumours of the Anterior Cranial Fossa

Midline tumors of the anterior cranial fossa (ACF) are mostly represented by olfactory groove menigiomas (OGM). There are many different approaches to this complex anatomical area but only a few that allow from the beginning dural implant removal: purely endoscopic transnasal (EA), transcranial/transfrontal sinus (TFA), and combined EA-TFA (CA) approach. Despite the improvement of EA, the optimal treatment strategy for the surgical treatment of OGM is still a matter of debate. The most advocate advantages of the EA are the absence of cerebral retraction and the possibility to resect the dural implant of the tumor, thus reducing its vascularization. On the other hand, it presents several limits: an important sinonasal morbidity, the loss of olfaction as default, increased risk of postoperative CSF leakage (5-10% in referral centers), especially in anteriorly located tumors. Moreover, the EA is contraindicated in case of lateral (above the orbital floor) or anterior extension (posterior wall of frontal sinus), cerebral parenchima involvment, or in case of major nerves or artery encasement. Consequently, only little tumors extended to the tuberculum sellae or planum sphenoidalis could be safely resected through a purely EA. The TFA is performed by a bicoronal incision, creating a craniotomy on the anterior wall of the frontal sinus and drilling the posterior wall of the frontal sinus. It gives direct access to the dural attachment of the tumor and avoids any cerebral retraction. In case of bulky or far posterior tumors, the interhemispheric route is usually very effective. The TFA permits to remove OGM of any dimension, to deal with nerves of vessel encasement, and to respect meningohypophyseal arteries. The incidence of postoperative CSF leakage is minimal since the closure with the galea is of the utmost effectiveness (0% in our experience). In case of sinonasal involvement, a CA is usually preferred

Use of a neuro-evacuation device for the endoscopic removal of third ventricle colloid cysts

BackgroundColloid cysts are benign tumors usually located at the level of the foramen of Monro and account for approximately 1% of all intracranial tumors. Endoscopic surgical treatment represents the approach of choice for removal of these tumors and is usually preferred over transcortical or transcallosal microsurgical approaches. Our purpose is to demonstrate the feasibility of endoscopic removal of colloid cysts using a novel aspiration and fragmentation system, currently designed for evacuation of cerebral hematomas.MethodsWe performed an evaluation of the results obtained in patients with symptomatic colloid cysts of the third ventricle operated on using an endoscopic neuroevacuation system (Artemis Neuro Evacuation Device, Penumbra, Alameda, California, USA) between April 2020 and April 2022. Instrumentation and surgical technique are described in detail. All patients underwent postoperative MRI to assess the extent of cyst removal.ResultsFive patients were included in our study. The predominant symptom at onset was headache. No intraoperative complications related to the technology in use occurred. The surgical time for the cyst removal was significantly shorter than removal via a standard endoscopic technique (80 vs. 120 min). Removal was complete, both content and capsule of the cyst, in all patients. In all cases there was a complete regression of the previously complained symptoms.ConclusionThe Artemis Neuro Evacuation Device has proved to be effective and safe in removal of colloid cysts of the third ventricle and may be proposed as a possible alternative or as a complement of the standard instruments routinely used in neuroendoscopy

Intracranial Dural Arteriovenous Fistulas: The Sinus and Non-Sinus Concept

AbstractIntroduction: Dural arteriovenous fistulas (dAVFs) account for 10–15% of all intracranial arteriovenous lesions. Different classification strategies have been proposed in the course of the years. None of them seems to guide the treatment strategy. Objective: We expose the experience of the vascular group at Niguarda Hospital and we propose a very practical classification method based on the location of the shunt. We divide dAVF in sinus and non-sinus in order to simplify our daily practice, as this classification method is simply based on the involvement of the sinuses. Material and Methods: 477 intracranial dural arteriovenous fistulas have been treated. 376 underwent endovascular treatment and 101 underwent surgical treatment. Cavernous sinus DAVFs and Galen ampulla malformations have been excluded from this series as they represent a different pathology per se. 376 dAVFs treated by endovascular approach: 180 were sinus and 179 were non-sinus. 101 dAVFs treated with surgical approach: 15 were sinus and 86 were non-sinus. Discussion: Of the 477 intracranial dAVF the recorded mortality and severe disability was 3% and morbidity less than 4%. All patients underwent a postoperative DSA with nearly 100% of complete occlusion of the fistula. At a mean follow-up of 5 years in one case there was a non-sinus fistula recurrence, due to the presence of a partial clipping of "piè" of the vein. Conclusions: The sinus and non-sinus concept has guided our institution for years and has led to good clinical results. This paper intends to share this practical classification with the neurosurgical community

From Reparative Surgery to Regenerative Surgery: State of the Art of Porous Hydroxyapatite in Cranioplasty

Decompressive craniectomy is one of the most common neurosurgical procedures, usually performed after neuropathological disorders, such as traumatic brain injury (TBI), but also vascular accidents (strokes), erosive tumours, infections and other congenital abnormalities. This procedure is usually followed by the reconstruction of the cranial vault, which is also known as cranioplasty (CP). The gold-standard material for the reconstruction process is the autologous bone of the patient. However, this is not always a feasible option for all patients. Several heterologous materials have been created in the last decades to overcome such limitation. One of the most prominent materials that started to be used in CP is porous hydroxyapatite. PHA is a bioceramic material from the calcium phosphate family. It is already widely used in other medical specialties and only recently in neurosurgery. In this narrative review of the literature, we summarize the evidence on the use of PHA for cranial reconstruction, highlighting the clinical properties and limitations. We also explain how this material contributed to changing the concept of cranial reconstruction from reparative to regenerative surgery

Neurological Study of Radial Nerve Conduction During Endoscopic Radial Artery Harvesting:An Intra‐Operative Evaluation

Endoscopic radial artery harvesting (ERAH) is a feasible and attractive minimally invasive approach for conduit procurement, however there have been concerns about a potential neurological damage occurring at the harvest limb site secondary to injury of the radial nerve during endoscopic harvesting. We present a case of ERAH in which we evaluated intraoperatively the characteristics of radial nerve conduction by means of electroneuromyography (ENM) during harvesting. No pathological changes of nerve conduction were detected at the harvest limb site during surgery and postoperatively, thereby supporting the benefits of the endoscopic approach in terms of neurological outcomes following radial artery procurements with a less invasive approach

Acute Supratentorial Ischemic Stroke: When Surgery Is Mandatory

Acute occlusion of middle cerebral artery (MCA) leads to severe brain swelling and to a malignant, often fatal syndrome. The authors summarize the current knowledge about such a condition and review the main surgical issues involved. Decompressive hemicraniectomy keeps being a valid option in accurately selected patients

Lactotroph PitNET/adenoma associated to granulomatous hypophysitis in a patient with Crohn's disease: A case report

Granulomatous hypophysitis is a rare and poorly understood condition. Although certain cases are treated as primary pituitary autoimmune disorders, rare cases may be associated with pituitary neuroendocrine tumours (PitNETs) and systemic inflammatory diseases. Here, we report a case of a 47-year-old man that underwent endoscopic trans-sphenoidal excision of a pituitary mass diagnosed as PitNET. On histologic evaluation, the neoplasm showed an admixture of granulomas with extensive inflammatory infiltrate and lactotroph PitNET/adenoma. Careful anamnestic examination revealed a diagnosis of Crohn's disease 20 years prior. Although rarely done, both PitNET and Crohn's disease may be associated with granulomatous hypophysitis, and our patient had both conditions. During the 6-year follow-up, PitNETs and hypophysitis did not recur, while Crohn's disease was only partially controlled by medical therapy. To our knowledge, this is the first description of association of granulomatous hypophysitis, PitNET and Crohn's disease