Microsurgical dissection of Sylvian fissure-short technical videos of third generation cerebrovascular neurosurgeons

Background Multiple intracranial pathologies, including aneurysms of the middle cerebral artery, distal basilar artery, and suprasellar pathologies require the microsurgical opening of the Sylvian fissure. Delicate splitting of the arachnoid and safe microdissection of the veins, arteries, and brain parenchyma is the key to successful surgery through the Sylvian fissure corridor. We hypothesize that the geographical and historical environment in which neurosurgeons learn their operative skills is subject to a number of extrinsic influences, including cultural nuances of surgical techniques. Here we try to illustrate some cultural differences and technical aspects of the opening of the Sylvian fissure by four "third generation" cerebrovascular neurosurgeons from three different continents. Methods In the video analysis, various microsurgical aspects, including the opening style of the Sylvian fissure, handedness, use of sharp or blunt microinstruments, use of retractors, use of high magnification, and handling of bridging veins are presented. Results The video illustrates the two distinct Sylvian fissure opening styles, namely sharp and blunt microdissection, as well as the extent of the opening namely a wide and focal splitting. Conclusion The edited video underlines nuances and differences of a few major technical aspects that are perhaps typical to certain surgical environments and cultures. These microsurgical nuances and styles are useful pearls that can be mastered with training by any novice neurosurgeon.Peer reviewe

In Memoriam: A Memoir for Our Fallen "Heroes"

This article is made available for unrestricted research re-use and secondary analysis in any form or be any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: “When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session—all these require surgical judgment which is a matter of long experience.” It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us. This memorial is intended to commemorate our colleagues who succumbed during the first 4 months

Surgical Treatment of Pediatric Unilateral Tinnitus Due to Cochleovestibular Nerve Compression by Intrameatal Anterior Inferior Cerebellar Artery Loop

OBJECTIVES: Cochleovestibular nerve compression syndrome due to intra-meatal anterior inferior cerebellar artery (AICA) that causes tinnitus is an extremely rare condition with special therapeutic challenges and implications. Here we present the first surgically treated pediatric case of tinnitus showing microvascular conflict of the cochleovestibular nerve and intrameatal AICA loop. METHODS: A pediatric case of tinnitus is described, and a surgical technique is elaborated with video material. A PubMed literature search was performed to identify surgically treated pediatric cases of intrameatal compression of the eighth nerve with an AICA loop. RESULTS: Tinnitus was completely resolved and hearing was intact immediately after surgical decompression. The patient was free from further symptoms after a short follow-up of 12 weeks. Microsurgical decompression including opening of the internal auditory canal and transposition of the AICA was an effective treatment option in this case. CONCLUSION: Decompression of the cochleovestibular nerve including opening of the internal auditory canal and transposition of the AICA appears to be an effective treatment option for cases with radiologically confirmed intrameatal vascular compression of the eighth nerve causing unilateral pulsatile tinnitus.Peer reviewe