Orbital Surgical Guidelines: Pediatric Considerations

xlomafota13 shared this article with you from Inoreader Orbital Surgical Guidelines: Pediatric Considerations Via Journal of Neurological Surgery Part B: Skull Base J Neurol Surg B Skull Base DOI: 10.1055/s-0040-1722637 Pediatric orbital and skull base surgery comprises a wide array of tumors. An understanding of the location of the lesion, nature of the disease, and surrounding anatomy is paramount to surgical planning in these small spaces. The goals of pediatric skull base surgery are to avoid injury to the surrounding structures, minimize cosmetic deformities, and remove some or all of the tumors based on anticipated pathology and biologic cost of removal. Safe surgery on many of these tumors requires an understanding of the location of the lesion relative to the optic nerve or orbit. This is particularly challenging because the dimensions of the orbital confines change continuously as one navigates from rostral to caudal. Management of these tumors may require a multidisciplinary approach including orbital surgery, neurosurgery, otolaryngology, oral maxillofacial surgery, plastic surgery, and interventiona l neuroradiology. [...] Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Article in Thieme eJournals: Table of contents  |  Abstract  |  Full text View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Facial Nerve Function Outcome and Risk Factors in Resection of Large Cystic Vestibular Schwannomas

xlomafota13 shared this article with you from Inoreader Facial Nerve Function Outcome and Risk Factors in Resection of Large Cystic Vestibular Schwannomas Via Journal of Neurological Surgery Part B: Skull Base J Neurol Surg B Skull Base DOI: 10.1055/s-0041-1725028 Objective Cystic vestibular schwannomas (VS) in contrast to solid VS tend to have accelerated growth, larger volume, rapid/atypical presentation, lobulated/adherent surface, and unpredictable course of the cranial nerves. Cystic VS are surgically challenging, with worse clinical outcomes and higher rate of subtotal resection (STR). Methods We retrospectively analyzed postoperative outcomes of 125 patients with cystic VS, operated between years 2005 and 2019 in our center. We confronted the extent of the resection and House-Brackmann (HB) grade of facial palsy with the results of comparable cohort of patients with solid VS operated in our center and literature review by Thakur et al.1 Results Translabyrinthine approach was preferred for resection of large, cystic VS (97.6%). Gross-total resection (GTR) was achieved in 78 patients (62.4%), near-total resection (NTR) with remnant (<4 × 4 × 2 mm) in 43 patients (34.4%), and STR in 4 patients (3.2%). NTR/STR were significantly associated with higher age, tumor volume >5 cm3, retrosigmoid approach, high-riding jugular bulb, tumor adherence to the brain stem, and facial nerve (p = 0.016; 0.003; 0.005; 0.025; 0.001; and <0.00001, respectively).One year after the surgery, 76% of patients had HB grades 1 to 2, 16% had HB grades 3 to 4, and 8% had HB grades 5 to 6 palsy. Worse outcome (HB grades 3 to 6) was associated with preoperative facial palsy, tumor volume >25 cm3, and cyst over the brain stem (p = 0.045; 0.014; and 0.05, respectively). Comparable solid VS operated in our center had significantly higher HB grades 1 to 2 rate than our cystic VS (94% versus 76%; p = 0. 03). Comparing our results with literature review, our HB grades 1 to 2 rate was significantly higher (76% versus 39%; p = 0.0001). Tumor control rate 5 years after surgery was 95.8%. Conclusion Our study confirmed that microsurgery of cystic VS has worse outcomes of facial nerve preservation and extent of resection compared with solid VS. Greater attention should be paid to the above-mentioned risk factors. [...] Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Article in Thieme eJournals: Table of contents  |  Abstract  |  Full text View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Orbital Surgery: Evolution and Revolution

xlomafota13 shared this article with you from Inoreader Orbital Surgery: Evolution and Revolution Via Journal of Neurological Surgery Part B: Skull Base J Neurol Surg B Skull Base DOI: 10.1055/s-0040-1722704 This article traces the development of orbital surgery and its subsequent modifications. It also points out the importance of defining one's goal before embarking on orbital surgery. Although generally considered part of ophthalmology, surgery on the orbit has been relatively neglected and not routinely practiced. This article reviews the history of development of orbital surgery, both the revolutionary ideas and the evolutionary changes. There are multiple orbital lesions that do not need to be treated with surgery at all. These days chemotherapy, radation therapy, or even immunotherapy may be more appropriate. The most common orbital pathology, that is thyroid orbitopathy, the physician needs to decide whether or not the orbit needs to be decompressed or whether there are problems related to motility that can be dealt with by eye muscle surgery. [...] Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Article in Thieme eJournals: Table of contents  |  Abstract  |  Full text View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Delayed Craniospinal Metastasis of Aggressive Nonfunctioning Pituitary Adenomas as Pituitary Carcinomas

xlomafota13 shared this article with you from Inoreader Delayed Craniospinal Metastasis of Aggressive Nonfunctioning Pituitary Adenomas as Pituitary Carcinomas Via Journal of Neurological Surgery Part B: Skull Base J Neurol Surg B Skull Base DOI: 10.1055/s-0041-1725024 Background Clinical behavior of pituitary neoplasms is peculiar and notoriously difficult to predict. While aggressive tumors are common, metastasis is very rare, can be highly delayed, and there are no histological or clinical features to meaningfully predict this happening. Endocrinologically silent tumors are particularly difficult, as there is less opportunity to detect early metastasis. Together, this amounts to a situation of uncertainty over the appropriate management of such tumors before and after metastasis. Case Description The authors report two cases of nonfunctioning aggressive pituitary adenoma (APA) each requiring two transsphenoidal surgeries, a transcranial resection and radiotherapy. Both these tumors subsequently metastasized caudally along the neuraxis, years later, as a null cell carcinoma associated with a germline CHEK2 mutation and a silent Crooke's cell carcinoma. The former represents a novel oncogenetic association. Conclusion Delayed drop dural metastasis of pituitary carcinoma is becoming increasingly recognized. Surgical resection of the distant disease to confirm the diagnosis and relieve the mass effect, followed by temozolomide chemotherapy, is the current treatment of choice. The need for both long-term follow-up in patients with APA, and a high degree of suspicion toward dural-based radiographic findings is emphasized. [...] Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Article in Thieme eJournals: Table of contents  |  Abstract  |  Full text View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Multimodal Microvascular Mapping for Head and Neck, Skull Base Research and Education: An Anatomical Donor Study

xlomafota13 shared this article with you from Inoreader Multimodal Microvascular Mapping for Head and Neck, Skull Base Research and Education: An Anatomical Donor Study Via Journal of Neurological Surgery Part B: Skull Base J Neurol Surg B Skull Base DOI: 10.1055/s-0041-1725026 Objective This study was aimed to develop a method combining computed tomography (CT) and fluorescence imaging, allowing identification of microvasculature in anatomical donors and facilitating translational research and education. Methods We investigated homogeneity and radiopacity of 30 different mixtures including radiopaque substances povidone–iodine (Betadine), barium sulfate (BaSO4), and bismuth subsalicylate (Pepto-Bismol) varying in suspension and dilution with agar, latex, or gelatin. Three candidate mixtures were selected for testing the extent of perfusion in renal vasculature to establish methodology. From these candidate mixtures, two were selected for mixture with fluorescein and infusion into cadavers based on their ability to perfuse renal vasculature. The extent to which these two candidate mixtures combined with fluorescein were able to perfuse vasculature in a cadaver head was used to determine which mixture was superior. Results BaSO4 and bismuth subsalicylate–based mixtures demonstrated superior opacity in vials. In terms of solidifying agents, gelatin-based mixtures demonstrated increased friability and lower melting points compared with the other agents, so only latex and agar-based mixtures were used moving forward past the vial stage. Combinations of BaSO4 and latex and BaSO4 and 3% agar were found to perfuse kidneys superiorly to the mixture containing bismuth subsalicylate. Finally, in cadaver heads, the mixture containing BaSO4, agar, and fluorescein was found to perfuse the smallest vasculature. Conclusion A final combination of BaSO4, 3% agar, and fluorescein proves to be a powerful and novel combination enabling CT imaging, fluorescence imaging, and dissection of vasculature. This paves the way for future translational research and education. [...] Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Article in Thieme eJournals: Table of contents  |  Abstract  |  Full text View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Long-Term Outcomes of the Electrically Unresponsive, Anatomically Intact Facial Nerve Following Vestibular Schwannoma Surgery

xlomafota13 shared this article with you from Inoreader Long-Term Outcomes of the Electrically Unresponsive, Anatomically Intact Facial Nerve Following Vestibular Schwannoma Surgery Via Journal of Neurological Surgery Part B: Skull Base J Neurol Surg B Skull Base DOI: 10.1055/s-0041-1725034 Objective The study aimed to determine long-term outcomes in patients with intraoperative electrical conduction block in an anatomically intact facial nerve (FN). Patients and Methods Single center retrospective review of prospectively collected database of all vestibular schwannoma surgeries between January 1, 2008 and August 25, 2015. Operative notes were reviewed and patients with anatomically intact FNs, but complete conduction block at the end of surgery were included for analysis. Results In total, 371 patients had vestibular schwannoma surgery of which 18 met inclusion criteria. Mean follow-up was 34.28 months and average tumor size was 28.00 mm. Seventeen patients had House-Brackmann Grade VI facial palsy immediately postoperatively and one patient was grade V. At 1 year, three patients remained grade VI (17%), two improved to grade V (11%), seven to grade IV (39%), six to grade III (33%), and one patient to grade II (6%). On extended follow-up, five patients (28%) had additional 1 to 2 score improvement in facial function. Subset analysis revealed no correlation of tumor size, vascularity, adherence to nerve, operative approach, extent of resection, splaying of FN, and recurrent tumor or sporadic tumors to the extent of FN recovery. Conclusion Intraoperative conduction block does not condemn a patient to permanent FN palsy. There is potential for a degree of recovery comparable with those undergoing nerve grafting. Our data do not clearly support a policy of same-surgery or early-postoperative primary nerve grafting in the event of a complete conduction block, and instead we favor monitoring for recovery in an anatomically intact nerve. [...] Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Article in Thieme eJournals: Table of contents  |  Abstract  |  Full text View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.

Prevention of Superior Petrosal Vein Injury during Microvascular Decompression for Trigeminal Neuralgia: Operative Nuances

xlomafota13 shared this article with you from Inoreader Prevention of Superior Petrosal Vein Injury during Microvascular Decompression for Trigeminal Neuralgia: Operative Nuances Via Journal of Neurological Surgery Part B: Skull Base J Neurol Surg B Skull Base DOI: 10.1055/s-0041-1725036 Background The superior petrosal vein (SPV) often obscures the surgical field or bleeds during microvascular decompression (MVD) for the treatment of trigeminal neuralgia. Although SPV sacrifice has been proposed, it is associated with multiple complications. We have performed more than 4,500 MVDs, including approximately 400 cases involving trigeminal neuralgia. We aimed to describe our operative technique and nuances to avoid SPV injury. Methods We have provided a detailed description of our institutional protocol, including the anesthesia technique, neurophysiologic monitoring, patient positioning, surgical approach, and SPV management. The surgical outcomes and treatment-related complications were retrospectively analyzed. Results No SPVs were sacrificed intentionally or accidentally during our MVD protocol for trigeminal neuralgia. In the 344 operations performed during 2006 to 2020, 269 (78.2%) patients did not require medication postoperatively, 58 (16.9%) tolerated the procedure with adequate medication, and 17 (4.9%) did not respond to MVD. Postoperatively, 35 (10.2%), 1 (0.3%), and 0 patients showed permanent trigeminal, facial, or vestibulocochlear nerve dysfunction, respectively. Wound infection occurred in five (1.5%) patients, while cerebrospinal fluid leaks occurred in three (0.9%) patients. Hemorrhagic complications appeared in four (1.2%) patients but these were unrelated to SPV injury. No surgery-related mortalities were reported. Conclusion MVD for the treatment of trigeminal neuralgia can be achieved safely without sacrificing the SPV. A key step is positioning the patient's vertex at a 10-degree elevation from the floor, which can ease venous return and loosen the SPV, making it less fragile to manipulation and providing a wider surgical corridor. [...] Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany Article in Thieme eJournals: Table of contents  |  Abstract &nbs p;|  Full text View on the web Inoreader. Take back control of your news feed. Follow us on Twitter and Facebook.