Conventional Craniotomy Research Articles

Mini-craniotomy for intra-axial brain tumors: a comparison with conventional craniotomy in 306 patients harboring non-dural based lesions

The use of a mini-craniotomy approach involving linear skin incision and a bone flap of about 3cm has been reported for several neurosurgical diseases, such as aneurysms or cranial base tumors. More superficial lesions, including intra-axial tumors, may occasionally raise concerns due to insufficient control of the tumor boundaries. The convenience of a minimally invasive approach to intrinsic brain tumors was evaluated by comparing 161 patients who underwent mini-craniotomy (MC) for intra-axial brain tumors with a group of 145 patients operated on by the same surgical team through a conventional craniotomy (CC). Groups were propensity-matched for age, preoperative condition, size and location of the tumor, and pathological diagnosis. Results were analyzed focusing on operative time, the extent of resection, clinical outcome, hospitalization time, and time to start adjuvant therapy. Mini-craniotomy was equally effective in terms of extent of resection (GTR: 70.9% in the MC group vs 70.5% in the CC group) but had shorter operative time (average: 165min in the MC group vs 205min in the CC group p < 0.001) and lower rate of postoperative complications both superficial (1.03% vs 6.5% in the CC group p = 0.009) and deep (4% in the MC group vs 5.5% in the CC group p = 0,47). No relationship was found between the size or location of the tumor and resection rate. The MC group had reduced hospitalization time (average: 5.8days vs 7.6 in CC group p < 0.001) and faster access to adjuvant therapies. 92.5% of the MC patients, which were scheduled for treatment, started radiotherapy within 8weeks after surgery as opposed to 84.1% in the CC group (p = 0.04). These findings support the increasing use of mini-craniotomy for intra-axial brain tumors.

Chronic recording of cortical activity underlying vocalization in awake minipigs

BackgroundInvestigating brain dynamics underlying vocal production in animals is a powerful way to inform on the neural bases of human speech. In particular, brain networks underlying vocal production in non-human primates show striking similarities with the human speech production network. However, despite increasing findings also in birds and more recently in rodents, the extent to which the primate vocal cortical network model generalizes to other non-primate mammals remains unclear. Especially, no domestic species has yet been proposed to investigate vocal brain activity using electrophysiological approaches. New methodIn the present study, we introduce a novel experimental paradigm to identify the cortical dynamics underlying vocal production in behaving minipigs. A key problem to chronically implant cortical probes in pigs is the presence and growth of frontal sinuses extending caudally to the parietal bone and preventing safe access to neural structures with conventional craniotomy in adult animals. ResultsHere we first show that implantations of soft ECoG grids can be done safely using conventional craniotomy in minipigs younger than 5 months, a period when sinuses are not yet well developed. Using wireless recordings in behaving animals, we further show activation of the motor and premotor cortex around the onset of vocal production of grunts, the most common vocalization of pigs. ConclusionThese results suggest that minipigs, which are very loquacious and social animals, can be a good experimental large animal model to study the cortical bases of vocal production.

Is There a Higher Frequency of Postoperative Depression in Patients Undergoing Awake Craniotomy for Brain Tumors?: A Prospective Study.

IntroductionBrain tumor resection under awake settings may cause significant psychological stress, which may lead to perioperative anxiety and depression. We conducted a prospective study to compare postoperative depression in patients undergoing awake craniotomy (AC) for tumor resection and compare it with patients undergoing tumor resection under general anesthesia (GA).MethodsWe conducted a prospective study at a tertiary care hospital. Non-probability consecutive sampling was performed, and patients with a preoperative diagnosis of depression or with any other medical comorbidities that could precipitate depression were excluded. Two separate questionnaires, the Patient Health Questionnaire-9 (PHQ-9) Scale and the Karnofsky Performance Score (KPS), were used to screen depression and assess functional status, respectively.ResultsNinety-six patients met the inclusion criteria and were included in the study. Out of these, 37 (38.1%) had undergone awake craniotomy and 59 (60.8%) had undergone conventional craniotomy (CC) (under general anesthesia) for brain tumor resection. To standardize our method, we ensured that the demographic variables, including mean age, gender, educational status, marital status, and socioeconomic conditions, were comparable between both groups. Postoperative functional status fared better in patients who underwent awake craniotomy (p = 0.03). The total number of patients suffering from postoperative clinical depression, according to the PHQ-9 Scale, was 41 (42.7%), of which 12 (12.5%) were in the awake craniotomy group and 29 (30.2%) were in the conventional craniotomy group. The median PHQ-9 Scale score in the awake craniotomy group was 6 (range: 3-10), which was less than the median score in the conventional craniotomy group, which was 9 (range: 4-12). This difference, however, was not statistically significant (p = 0.06).ConclusionResection of brain tumors under awake conditions is not likely associated with any additional incidence of postoperative depression when compared with resection of tumors under general anesthesia.

Stereotactic laser interstitial thermal therapy corpus callosotomy for the treatment of pediatric drug-resistant epilepsy.

ObjectiveCorpus callosotomy is a safe and effective procedure for reducing the frequency of drop attacks. MR‐guided laser interstitial thermal therapy (MRgLITT) offers a minimally invasive alternative to conventional open craniotomy for callosotomy. We hypothesized that MRgLITT callosotomy could be safely performed in pediatric patients with similar seizure control.MethodsWe present an institutional case series of 11 procedures in 10 patients for the treatment of drop attacks in drug‐refractory primary generalized epilepsy. MRgLITT was used for complete callosotomy, anterior two‐thirds, posterior, or ablation of residual callosal fibers following prior callosotomy (open or MRgLITT). We retrospectively reviewed clinical course, operative details, radiographic imaging, clinical outcomes, and complications.ResultsOperative time ranged from 4‐8 hours, and median hospitalization was 2 days. No complications were encountered. Among the 7 patients with at least 3 months of follow‐up, 71% experienced freedom from drop attacks at longest follow‐up and 57% of cases showed improvement in their other seizure semiologies as well (Engel Class II: 28%, Class III: 28%, Class IV: 43%).SignificanceMR‐guided LITT callosotomy is safe and effective modality in the management of pediatric patients with medically intractable epilepsy characterized by drop attacks. While this is among the largest pediatric series to date, further studies are required to delineate its safety and efficacy among such patients.

Resting-State Functional Magnetic Resonance Imaging Networks as a Quantitative Metric for Impact of Neurosurgical Interventions.

Objective: Resting-state functional MRI (rs-fMRI) has been used to evaluate brain network connectivity as a result of intracranial surgery but has not been used to compare different neurosurgical procedures. Laser interstitial thermal therapy (LITT) is an alternative to conventional craniotomy for the treatment of brain lesions such as tumors and epileptogenic foci. While LITT is thought of as minimally invasive, its effect on the functional organization of the brain is still under active investigation and its impact on network changes compared to conventional craniotomy has not yet been explored. We describe a novel computational method for quantifying and comparing the impact of two neurosurgical procedures on brain functional connectivity.Methods: We used a previously described seed-based correlation analysis to generate resting-state network (RSN) correlation matrices, and compared changes in correlation patterns within and across RSNs between LITT and conventional craniotomy for treatment of 24 patients with singular intracranial tumors at our institution between 2014 and 2017. Specifically, we analyzed the differences in patient-specific changes in the within-hemisphere correlation patterns of the contralesional hemisphere.Results: In a post-operative follow-up period up to 2 years within-hemisphere connectivity of the contralesional hemisphere after surgery was more highly correlated to the pre-operative state in LITT patients when compared to craniotomy patients (P = 0.0287). Moreover, 4 out of 11 individual RSNs demonstrated significantly higher degrees of correlation between pre-operative and post-operative network connectivity in patients who underwent LITT (all P < 0.05).Conclusion: Rs-fMRI may be used as a quantitative metric to determine the impact of different neurosurgical procedures on brain functional connectivity. Global and individual network connectivity in the contralesional hemisphere may be more highly preserved after LITT when compared to craniotomy for the treatment of brain tumors.

Discussion on Comparison of Clinical Effect and Improvement of GCS Score between Large Craniotomy and Conventional Craniotomy for Severe Craniocerebral Injury

Discussion on Comparison of Clinical Effect and Improvement of GCS Score between Large Craniotomy and Conventional Craniotomy for Severe Craniocerebral Injury

Hematoma Evacuation via Image-Guided Para-Corticospinal Tract Approach in Patients With Spontaneous Intracerebral Hemorrhage

Background: Corticospinal tract injury from conventional craniotomy might influence the outcomes of intracerebral hemorrhage (ICH). The aim of the study was to evaluate the safety and efficacy of hematoma evacuation via image-guided para-corticospinal tract approach. Methods: Seventy-five ICH patients who underwent the image-guided para-corticospinal tract approach were retrospectively collected into surgery group. Diffusion tensor imaging (DTI) or CT angiography (CTA) was performed to identify the relationship of important white matter tracts and hematoma. The neuronavigation system where the preoperative imaging data is loaded was used to identify the burr hole location, and depth of insertion. The approach was introduced into the sulcus under navigation guidance and parallel to the CST into the hematoma along the trajectory chosen. Hematoma was removed under the image-guided para-corticospinal tract approach. Seventy-five age-, sex-, hematoma site- and volume-matched ICH patients who underwent conservative treatment were randomly selected as controls. Demographical, clinical, radiological and treatment-related data of patients were analyzed retrospectively. Functional outcome was evaluated by modified Rankin Scale at 90 days. Findings: 150 patients were retrospectively collected. The median Glasgow Coma Scale (GCS) score on admission was 11 (range, 5-15). The percent of thalamus/basal ganglion regions were 86.7% (130 patients). The mean hematoma volume was 47 ± 19 mL. A higher proportion of favorable patients was observed in surgery group than conservative treatment group (32.0% versus 17.4%; P=0.037). Interpretation: Hematoma evacuation via image-guided para-corticospinal tract approach seems to be safe in ICH patients with a relatively high functional independence. Funding: The ministry of science and technology of China and Southwest Hospital. Declaration of Interest: All authors declare that they have no conflicts of interest. Ethical Approval: This retrospective trial was approved by the Southwest Hospital. Ethics approval was obtained from the Ethics Committee of the Southwest Hospital of Third Military Medical University.

Effects of STC on postoperative recovery of disturbance of consciousness in traumatic multiple intracranial hematoma patients.

Objective:The study explored the therapeutic value of standard trauma craniectomy (STC) for the treatment of traumatic multiple intracranial hematoma.Methods:Clinical data of traumatic multiple intracranial hematoma patients who underwent surgical treatment in 2014 and 2015 were collected. The STC group and a control group according to the surgical mode, 48 and 30 cases were randomly selected from each group, respectively. Statistical analysis was performed on the change in the Glasgow coma scale (GCS) score from before the operation to 1 day, 1 week and 1 month postoperatively through repeated analysis of variance and Wilcoxon rank-sum analysis.Results:Significant differences in the GCS were observed at different time points for the two operative modes (P < .01), and an interaction was observed between time and treatment groups (P < .05). The rates of change of the GCS score for the two surgical modes were most obviously different at 3 days and 1 week postoperatively (P ≤ .001, P < .01). No statistically significant differences were observed in the rates of change of the GCS at 1 month postoperatively (P > .05).Conclusions:Compared to conventional craniotomy, STC has obvious effects on the recovery after disturbance of consciousness at 1 week postoperatively but does not result in a significant improvement in recovery at 1 month postoperatively.

NIMG-19. USING FUNCTIONAL ULTRASOUND (FUS) TO MAP BRAIN FUNCTIONALITY AND TUMOR VASCULATURE WITH MICROMETER-MILLISECOND PRECISION

Abstract OBJECTIVE In the early 20th century, Dr. Cushing first demonstrated the use of electrical stimulation mapping (ESM) to define motor and sensory cortices during neurosurgical procedures. Essentially, little has changed in what guides a neurosurgeon’s intra-operative decision-making since. Inherent limitations of ESM such as limited depth penetration and risk of seizure elicitation, warrant the development of new image-guided resection tools. Here, we present functional Ultrasound (fUS)-imaging as a new, high-resolution tool to guide intra-operative decision-making during awake tumor removal. METHODS fUS relies on high-frame-rate ultrasound, which offers images at thousands of frames-per-second. As such, fUS is sensitive to very small motions caused by vascular dynamics (µDoppler), allowing measurements of changes in cerebral blood volume (CBV). This facilitates the possibility to 1) detect functional response, as CBV-changes reflect changes in metabolism of activated neurons through neurovascular coupling and 2) visualize high-resolution vascular morphology of tumor and healthy tissue. During conventional awake craniotomy surgery, n= 10 patients were asked to perform 60s functional tasks to elicit cortical responses. Simultaneously, a conventional 5 MHz ultrasound probe connected to an experimental acquisition system, was placed over ESM-defined functional areas. After image acquisition, correlation analyses with the corresponding tasks revealed functional and non-functional areas. In addition, 3D vascular maps were reconstructed from subsequent 2D-Power Doppler Images (PDIs). RESULTS fUS was able to detect functional areas as activated using conventional motor tasks, as well as complex language-related tasks. In addition, both 2D-PDIs and 3D-reconstructions revealed the ability of fUS to detect unique high-resolution onco-vascular characteristics in high- and low-grade malignancies. In all cases, images were acquired with micrometer-millisecond (300 µm, 1.5-2.0 msec) precision at imaging depths &amp;gt; 5 cm. CONCLUSIONS Applying fUS-imaging successfully in this awake craniotomy series serves as a clear demonstration of the technique’s revolutionary potential for maximizing safe tumor removal.

Advantages of Small Bone-Window Craniotomy Under Microscope Combined Postoperative Intracranial Pressure Monitoring in the Treatment of Hypertensive Intracerebral Hemorrhage.

The aim of this study is to analyze the clinical effect of small bone-window craniotomy with microscope combined postoperative ICP monitoring, and further explore an appropriate treatment for HICH patients. One hundred fifty patients with HICH were selected according to inclusion and exclusion criteria and divided into 3 groups at random, 50 each group. Patients in 3 groups were treated with conventional craniotomy, small bone-window craniotomy and small bone-window craniotomy combined ICP monitoring respectively. The surgical efficiency, treatment effect and outcomes were recorded and analyzed. The intraoperative blood loss and operation time of small window groups were significantly less than that of conventional group, and the hematoma clearance rate in small window groups were significantly higher than in conventional group (P < 0.05). Compared with conventional group, the hospital stays and mannitol dose used were less in small window groups and least in small window combined ICP monitoring group (P < 0.05). The complication rate in small window combined ICP monitoring group was 10%, which was significantly lower than in conventional group (26%, P < 0.05), while no significant difference was found between small window group (18%) compared with the other 2 groups respectively (P > 0.05). The difference of morality rate between 3 groups wasn't significant (P > 0.05). Three treatment significantly increased the Barthel index score, and the improvement of small window combined ICP monitoring group was significantly higher than in other 2 groups respectively (P < 0.05), while the difference between this two groups wasn't significant (P > 0.05). Small bone-window craniotomy is more efficient and convenient than conventional craniotomy in the treatment of HICH. In the meantime, small bone-window craniotomy simultaneous with ICP monitoring significantly improved clinical effect and treatment outcomes of HICH patients.

Minipterional craniotomy for surgical clipping of anterior circulation aneurysms: compatibility between the feasibility, safety and efficiency.

ObjectiveThe aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms.MethodsA retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry.ResultsTotal 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy.ConclusionsWe suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.

Experimental Study on Targeting Brain Tumor with Ultrasound Nanoparticles Across Blood Brain Barrier

Glioma is a malignant tumor that originates in the brain and accounts for more than half of all brain tumors. The disease is associated with a high fatality rate. Satisfactory treatment cannot be achieved through conventional craniotomy. We use carboxymethyl chitosan-coated Fe3 O4 composite nanoparticles (CMCS-Fe3 O4 NPs) as a drug delivery platform, and installed transferrin (TRF) with a targeting function on the platform. The anticancer drug methotrexate (MTX) is loaded onto the composite nanomaterial to complete a new delivery system for nano-drug targeted treatment of glioma. The composite nanoparticle is not toxic to cells in vitro, but after loading with it is loaded with MTX, it significantly inhibits proliferation of C6 cells. In vivo experiments show that CMCS-Fe3 O4NPs-TRF-MTX has a marked therapeutic effect on glioma in mouse models. The nano complex quickly penetrates the blood-brain barrier and enters brain tissues. An aggregation effect is not obvious. MRI monitoring for up to 4.0 h shows that CMCS-Fe3 O4 NPs-TRF-MTX slowly releases drug molecules over an extended period, thus increasing the duration of drug activity.

Observation on the effect of craniotomy with large bone flaps on acute craniocerebral trauma and its influence on stress response of patients

Objective To investigate the effect of large bone flap craniotomy on acute craniocerebral trauma and its influence on stress response. Methods From January 2015 to December 2018, 80 patients with acute craniocerebral trauma were randomly divided into control group (40 cases) and observation group (40 cases) by random number table method.The patients in the control group were treated with conventional craniotomy and decompression, while the patients in the observation group were treated with craniotomy with large bone flaps.The changes of intracranial pressure, Glasgow coma index (GCS score), stress response index, prognosis and complications after 6 months were compared between the two groups before treatment and 2 weeks after treatment. Results Two weeks after treatment, the intracranial pressure in the observation group [(8.48±2.10)mmHg] was lower than that in the control group [(11.86±1.74) mmHg], while the GCS score[(10.35±1.87)points] was higher than that in the control group [(7.69±1.15)points](t=19.434, 7.663, all P<0.05). Two weeks after treatment, the serum levels of ACTH [(35.19±5.46)mg/L] and cortisol [(17.41±4.56)mg/L] in the observation group were lower than those in the control group [(48.91±4.95)mg/L and (28.93±7.48)mg/L] (t=11.774, 8.317, all P<0.05). Six months after treatment, the prognosis of the observation group(60.00%) was better than that of the control group (32.50%) (χ2=6.084, P<0.05). The incidence of complications of the observation group (5.00%) was lower than that of the control group (22.50%) (χ2=5.165, P<0.05). Conclusion Craniotomy with large bone flaps has good effect in the treatment of patients with acute craniocerebral trauma, and can reduce stress response and with fewer complications, which is worthy of clinical reference. Key words: Craniotomy; Decompression, surgical; Craniocerebral trauma; Intracranial pressure; Glasgow coma index; Stress response

Efficacy and safety of four interventions for spontaneous supratentorial intracerebral hemorrhage: a network meta-analysis

ObjectTo investigate the efficacy and safety of four interventions of spontaneous intracerebral hemorrhage simultaneously.MethodsPubMed, EmBase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for randomized...

Neurocritical Management of Traumatic Acute Subdural Hematomas.

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Clinical Study on Minimally Invasive Liquefaction and Drainage of Hypertensive Putaminal Hemorrhage through Frontal Approach

Background Hypertensive intracerebral hemorrhage is one of the most common cerebrovascular diseases with high mortality and high disability rate. The aim of this study was to observe the curative effect of minimally invasive liquefaction and drainage of hypertensive putaminal hemorrhage (HPH) through frontal approach. Methods This study retrospectively reviewed the clinical data of 66 HPH patients who underwent surgery from January 2012 to January 2017 including 35 males and 31 females, aged 51 to 82 years, with an average age of 61.6 ± 7.32 years. All patients were treated in the first people's hospital of Kunshan. They were divided into two groups: puncture thrombolysis and drainage therapy (PTDT) group and conventional craniotomy (CC) group. Result The pulmonary infection rate in PTDT group was 13.8%, significantly lower than that of 27.7% in CC group ( p < 0.05). One year after onset, the modified Rankin scale (mRS) score of surviving patients was evaluated. The mRS score of the PTDT group with 30 to 60 mL of preoperative bleeding was 1.91 ± 0.82, which was significantly better than that of the CC group (2.21 ± 0.83) ( p < 0.05). There was no significant difference in mRS score between PTDT group (2.59 ± 0.62) and CC group (2.88 ± 0.87) with preoperative bleeding > 60 mL ( p > 0.05). In patients with Glasgow coma scale (GCS) 5 to 8 scores, the mRS of PTDT and CC groups were 2.73 ± 0.72 and 2.94 ± 0.96, respectively ( p > 0.05). In patients with GCS 9 to 13 scores, the mRS score of PTDT group was 1.83 ± 0.69, which was significantly better than that of CC group (2.06 ± 0.74) ( p < 0.05). Conclusion HPH can be treated effectively through PTDT. PTDT group has lower lung infection rate than CC group. And it can significantly improve the prognosis of patients with preoperative bleeding volume of 30 to 60 mL and preoperative GCS score of 9 to 13.

Comparison of the Surgical Approaches for Frontal Traumatic Intracerebral Hemorrhage

Purpose: Recent developments in minimally invasive techniques have the potential to reduce surgical morbidity, promote patient recovery, accelerate surgical procedures, and thus improve cost-effectiveness in case management. In this study, we compared the treatment efficacy and results of supraorbital keyhole approach (SOKA) with those of conventional unilateral frontal craniotomy (CUFC) for traumatic intracerebral hemorrhage (TICH) in the frontal lobe. Methods: We analyzed the data of 38 patients who underwent CUFC (n=30) and SOKA (n=8) and retrospectively reviewed their medical records and radiological findings. Furthermore, we tried to identify the best surgical method for such lesions by including patients who underwent burr hole aspiration and drainage (BHAD) (n=9) under local anesthesia due to various circumstances. Results: The difference in the initial Glasgow coma scale score, operative time, and length of hospitalization between the CUFC and SOKA were statistically significant. All radiological features between the two groups including associated skull fracture, amount of pre- and postoperative hematoma, percentage of complete hematoma removal, pre- and postoperative midline shifting of the hematoma, and development of postoperative delayed hematoma were not statistically significant. Our experience of 46 patients with TICH in the frontal lobe with any of the three different surgical methods including BHAD enabled us to obtain valuable findings. Conclusions: Although it is difficult to insist that one particular approach is more useful than the other, we are confident that SOKA will have more advantages over CUFC in carefully selected patients with frontal TICH depending on the surgical experience of a neurosurgeon.

Stereotactic Catheter Drainage Versus Conventional Craniotomy for Severe Spontaneous Intracerebral Hemorrhage in the Basal Ganglia

Intracerebral hemorrhage (ICH) is one of the most devastating forms of cerebrovascular pathology. However, its treatment remains a matter of debate among neurosurgeons and neurologists. The study was to explore the efficacy of minimally invasive surgery (stereotactic catheter drainage, SCD) for patients with severe intracerebral hemorrhage (Glasgow Coma Scale, GCS) score ≤ 8 and hematoma volume ≥ 30 cm3) and to determine predisposing factors for good clinical outcome. A total of 75 patients with severe ICH were included in this retrospective study. Patients were assigned to the SCD group (n=38) or the conventional craniotomy group (n=37). Patients were followed up for 12 months postoperatively, and their clinical parameters were compared. During the operation, the SCD group exhibited a lower bleeding volume (p<0.001) and shorter operating time (p<0.001) than the conventional craniotomy group. For postoperative efficacy, the rates of pneumonia and tracheotomy were lower (p=0.002 and p=0.027, respectively), and the duration of hospital and neurosurgery intensive care unit (NSICU) in days were significantly shorter in the SCD group (p=0.046 and p=0.047, respectively). Furthermore, patients in the SCD group showed improved modified Rankin Scale (mRS) scores at discharge (p<0.018) and at 12-month follow up (p<0.001). Predisposing factors for good clinical outcomes were hematoma volume (<50 cm3, 95% confidence interval (CI): 1.043–1.956, p<0.046), initial GCS score (>6, 95% CI: 3.248–187.466, p<0.001), hypertension (none, 95% CI: 1.440–2.922, p<0.001), and treatment modality (SCD, 95% CI: 1.422–3.226, p<0.001). Taken together, SCD surgery is safe and effective in patients with severe ICH and has fewer complications and better clinical outcomes than conventional craniotomy.

Safety and Efficacy of Minimally Invasive Stereotactic Aspiration with Multicatheter Insertion Compared with Conventional Craniotomy for Large Spontaneous Intracerebral Hemorrhage (≥50 mL)

Conventional craniotomy (CC) is generally favored for treating large intracerebral hemorrhage (ICH), but the feasibility of minimally invasive stereotactic aspiration for large ICH is controversial. We investigated the efficacy and safety of stereotactic aspiration with multicatheter insertion (SAMCI) for large ICH (≥50 mL). In January 2014, we implemented SAMCI for large ICH. The inclusion criteria for SAMCI were as follows: 1) spontaneous supratentorial ICH, 2) ICH volume ≥50 mL, 3) Glasgow Coma Scale score ≥5, and 4) no bilateral fixed dilated pupils. Forty-seven patients who underwent SAMCI from January 2014 to July 2018 composed the SAMCI group, and 34 patients who underwent CC between January 2010 and December 2013 and retrospectively met the inclusion criteria for SAMCI composed the control group (CC group). The mean preoperative ICH volume in the SAMCI and CC groups was 73.1 ± 22.8 and 72.4 ± 21.5 mL, respectively. There were no significant differences between the groups in baseline characteristics except for ICH location. The deep portion of the ICH was higher in the SAMCI group than in the CC group. Postoperative mortality and rebleeding rates were significantly lower in the SAMCI group than in the CC group (4.3% vs. 26.5% and 0% vs. 14.7%, respectively; P < 0.05). Logistic regression analysis showed that SAMCI contributed to a decrease in the mortality rate (odds ratio, 0.04; P= 0.008). SAMCI is a feasible therapeutic option for large ICH and has low complication rates.

Reappraising the neurosurgical significance of the pterion location, morphology, and its relationship to optic canal and sphenoid ridge and neurosurgical implications.

Frontolateral craniotomy procedures have advanced from conventional craniotomy to mini-craniotomy, and to contemporary keyhole surgery. In this context, it is important for the neurosurgeon to precisely locate the pterion. The distance of the pterion center from midpoint of zygomatic arch and posterolateral margin of frontozygomatic suture was studied bilaterally in 50 whole adult skulls in Indian ethnic group. The depth of optic canal and sphenoid ridge from the pterion was recorded bilaterally in fifty cut adult skulls and fifteen three-dimensional computed tomography scans. The suture length, thickness, and morphology were studied. The data were analyzed using SPSS software, two-tailed Student's t test, binary logistic regression and receiver operating characteristic curve for sexual dimorphism. The pterion center was located at a mean distance of 37.02 mm above the midpoint of zygomatic arch, 28.20 mm behind the posterolateral margin of frontozygomatic suture, 42.73 mm lateral to the optic canal and 10.59 mm from the sphenoid ridge. The location did not exhibit sexual dimorphism. In 20% cases the pterion center was 40 mm or more above the midpoint of the zygomatic arch and in 5% cases 35 mm or more posterior to the posterolateral margin of frontozygomatic suture. The mean suture length was 10±3 mm. The mean thickness at the center of the pterion was 3.52±1.45 mm. The commonest variety was sphenoparietal followed by frontotemporal, epipteric, and stellate types. A thorough knowledge of these dimensions has innumerable neurosurgical implications in resection of sellar, parasellar, and paraclinoid tumors and circulatory aneurysms.