Operative Technique and Complication Avoidance in Supraorbital Endoscopic Keyhole Craniotomy

Objective: The aim of the current study is to describe the technical details of the endoscopic supraorbital keyhole craniotomy and how to avoid complications related with it.Material and Methods: In this cross sectional observational study nine preserved human cadavers from TheSkull Base Lab of Weill Cornell Medical College, Cornell University, New York, USA were used. Total number of18 endoscopic supraorbital keyhole craniotomies were performed. Distances between the different targetedanatomical constructs were looked at and measured.Results: A supraorbital craniotomy was performed with details on the technique of the surgery. The secondmajor part of the results comprised of per-operative complications and how to avoid these complications.Conclusion: To treat anterior and middle skull base pathologies, the endoscopic supraorbital keyholecraniotomy is an effective, valuable and minimal access surgical choice

Feasibility and safety of GliaSite brachytherapy in treatment of CNS tumors following neurosurgical resection

Purpose: To investigate feasibility and safety of GliaSite brachytherapy for treatment of central nervous system (CNS) tumors following neurosurgical resection. We report mature results of long-term follow-up, outcomes and toxicity. Materials and Methods: In the period from 2004 to 2007, 10 consecutive adult patients with recurrent, newly diagnosed, and metastatic brain malignancies underwent GliaSite brachytherapy following maximally safe neurosurgical resection. While 6/10 (60%) patients were treated for recurrence, having previously been treated with external beam radiotherapy (EBRT), 4/10 (40%) received radiotherapy (RT) for the first time. A median dose of 52.0 Gy (range, 45.0 - 60.0 Gy) was prescribed to 0.5 cm - 1.0 cm from the balloon surface. Radiation Therapy Oncology Group (RTOG) criteria were used to assess toxicities associated with this technique. Follow-up was assessed with MRI scans and was available on all enrolled patients. Results: Median follow-up was 38 months (range, 18 - 57 months). Mean size of GliaSite balloon was 3.4 cm (range, 2.0 - 4.0 cm). Median survival was 14.0 months for the entire cohort after the treatment. The 17.6 and 16.0 months average survival for newly diagnosed and recurrent high grade gliomas (HGG), respectively, translated into a three-month improvement in survival in patients with newly diagnosed HGG compared to historical controls (P = 0.033). There were no RTOG grades 3 or 4 acute or late toxicities. Follow-up magnetic resonance imaging (MRI) imaging did not identify radiation necrosis. Conclusions: Our data indicate that treatment with GliaSite brachytherapy is feasible, safe and renders acceptable local control, acute and long-term toxicities. We are embarking on testing larger numbers of patients with this treatment modality

The rectus capitis lateralis and the condylar triangle: important landmarks in posterior and lateral approaches to the jugular foramen

OBJECTIVE The rectus capitis lateralis (RCL) is a small posterior cervical muscle that originates from the transverse process of C-1 and inserts onto the jugular process of the occipital bone. The authors describe the RCL and its anatomical relationships, and discuss its utility as a surgical landmark for safe exposure of the jugular foramen in extended or combined skull base approaches. In addition, the condylar triangle is defined as a landmark for localizing the vertebral artery (VA) and occipital condyle. METHODS Four cadaveric heads (8 sides) were used to perform far-lateral, extended far-lateral, combined transmastoid infralabyrinthine transcervical, and combined far-lateral transmastoid infralabyrinthine transcervical approaches to the jugular foramen. On each side, the RCL was dissected, and its musculoskeletal, vascular, and neural relationships were examined. RESULTS The RCL lies directly posterior to the internal jugular vein-only separated by the carotid sheath and in some cases cranial nerve (CN) XI. The occipital artery travels between the RCL and the posterior belly of the digastric muscle, and the VA passes medially to the RCL as it exits the C-1 foramen transversarium and courses posteriorly toward its dural entrance. CNs IX-XI exit the jugular foramen directly anterior to the RCL. To provide a landmark for identification of the occipital condyle and the extradural VA without exposure of the suboccipital triangle, the authors propose and define a condylar triangle that is formed by the RCL anteriorly, the superior oblique posteriorly, and the occipital bone superiorly. CONCLUSIONS The RCL is an important surgical landmark that allows for early identification of the critical neurovascular structures when approaching the jugular foramen, especially in the presence of anatomically displacing tumors. The condylar triangle is a novel and useful landmark for identifying the terminal segment of the hypoglossal canal as well as the superior aspect of the VA at its exit from the C-1 foramen transversarium, without performing a far-lateral exposure

Affordability impacts therapeutic intensity of acute management of severe traumatic brain injury patients:An exploratory study in Tanzania

Introduction: Quality health care in low and middle-income countries (LMICs) is constrained by financing of care. Research question: What is the effect of ability to pay on critical care management of patients with severe traumatic brain injury (sTBI)? Material and Methods: Data on sTBI patients admitted to a tertiary referral hospital in Dar-es-Salaam, Tanzania, were collected between 2016 and 2018, and included payor mechanisms for hospitalization costs. Patients were grouped as those who could afford care and those who were unable to pay. Results: Sixty-seven patients with sTBI were included. Of those enrolled, 44 (65.7%) were able to pay and 15 (22.3%) were unable to pay costs of care upfront. Eight (11.9%) patients did not have a documented source of payment (unknown identity or excluded from further analysis). Overall mechanical ventilation rates were 81% (n=36) in the affordable group and 100% (n=15) in the unaffordable group (p=0.08). Computed tomography (CT) rates were 71.6% (n=48) overall, 100% (n=44) and 0% respectively (p<0.01); Surgical rates were 16.4% (n=11) overall, 18.2% (n=8) vs. 13.3% (n=2) (p=0.67) respectively. Two-week mortality was 59.7% overall (n=40), 47.7% (n=21) in the affordable group and 73.3% (n=11) in the unaffordable group (p=0.09) (adjusted OR 0.4; 95% CI: 0.07-2.41, p=0.32). Discussion and Conclusion: Ability to pay appears to have a strong association with the use of head CT and a weak association with mechanical ventilation in the management of sTBI. Inability to pay increases redundant or sub-optimal care, and imposes a financial burden on patients and their relatives

Feasibility and safety of GliaSite brachytherapy in treatment of CNS tumors following neurosurgical resection

Purpose: To investigate feasibility and safety of GliaSite brachytherapy for treatment of central nervous system (CNS) tumors following neurosurgical resection. We report mature results of long-term follow-up, outcomes and toxicity. Materials and Methods: In the period from 2004 to 2007, 10 consecutive adult patients with recurrent, newly diagnosed, and metastatic brain malignancies underwent GliaSite brachytherapy following maximally safe neurosurgical resection. While 6/10 (60%) patients were treated for recurrence, having previously been treated with external beam radiotherapy (EBRT), 4/10 (40%) received radiotherapy (RT) for the first time. A median dose of 52.0 Gy (range, 45.0 - 60.0 Gy) was prescribed to 0.5 cm - 1.0 cm from the balloon surface. Radiation Therapy Oncology Group (RTOG) criteria were used to assess toxicities associated with this technique. Follow-up was assessed with MRI scans and was available on all enrolled patients. Results: Median follow-up was 38 months (range, 18 - 57 months). Mean size of GliaSite balloon was 3.4 cm (range, 2.0 - 4.0 cm). Median survival was 14.0 months for the entire cohort after the treatment. The 17.6 and 16.0 months average survival for newly diagnosed and recurrent high grade gliomas (HGG), respectively, translated into a three-month improvement in survival in patients with newly diagnosed HGG compared to historical controls (P = 0.033). There were no RTOG grades 3 or 4 acute or late toxicities. Follow-up magnetic resonance imaging (MRI) imaging did not identify radiation necrosis. Conclusions: Our data indicate that treatment with GliaSite brachytherapy is feasible, safe and renders acceptable local control, acute and long-term toxicities. We are embarking on testing larger numbers of patients with this treatment modality