Minimal Brain Retraction Research Articles

AB087. Rectosigmoid approach for cerebellopontine angle tumors: what have we learned so far?

The cerebellopontine angle (CPA) is a multifaceted triangular region bordered by the brainstem medially, the cerebellum superiorly and posteriorly, and the temporal bone laterally. Tumors located in the CPA comprise 5% to 10% of all intracranial neoplasms, with vestibular schwannomas being the most prevalent, followed by meningiomas and epidermoid tumors. Various surgical approaches exist for removing these lesions, which consistently present challenges for neurosurgeons in effectively managing them. This study presents a case of a CPA tumor successfully treated via the retrosigmoid approach, followed by an assessment of the approach's efficacy and surgical outcomes. A comprehensive literature search was conducted using electronic databases, including PubMed, ScienceDirect, and Google Scholar, to gather studies on surgically managed CPA tumors. In addition to reviewing the literature, we present a case study of a patient with CPA tumor who underwent surgery using the retrosigmoid approach. The literature review revealed that the retrosigmoid approach emerged as a commonly utilized technique, particularly for tumors in the CPA region. Analysis of the collected data indicated that the retrosigmoid approach offers several advantages, including excellent exposure of the CPA, minimal brain retraction, and reduced risk of injury to critical neurovascular structures. Moreover, studies consistently reported favorable surgical outcomes, with low rates of morbidity and mortality associated with this approach. In our case study, we successfully employed the retrosigmoid approach to resect a CPA tumor in a patient presenting with typical symptoms of spasticity in all four extremities and progressive hearing loss. In conclusion, the retrosigmoid approach remains a valuable surgical technique for the management of CPA tumors. This approach enhances the exposure of the CPA and increases the surgical angle of maneuverability. In most literature, the retrosigmoid approach provides adequate access that is safe and effective, with a low rate of postoperative complications. However, further prospective studies and comparative analyses are warranted to validate these findings and refine surgical techniques for optimizing patient outcomes.

Minimally invasive keyhole craniotomies for microsurgical clipping of cerebral aneurysms: comparative meta-analysis of the mini-pterional and supraorbital keyhole approaches.

Axel Perneczky is responsible for conceptualizing the "keyhole" philosophy as a new paradigm of minimal invasiveness within cranial neurosurgery. Keyhole neurosurgery aims to limit approach-related traumatization and minimize brain retraction while still enabling the neurosurgeon to achieve operative goals. The supraorbital keyhole craniotomy (SOKC) and minipterional (pterional keyhole, PKC) approaches have become mainstays for clipping intracranial aneurysms. While studies have compared these approaches to the traditional pterional craniotomy for clipping cerebral aneurysms, head-to-head comparisons of these workhorse keyhole approaches remain limited. The authors queried three databases per PRISMA guidelines to identify all studies comparing the SOKC to the PKC for microsurgical clipping of cerebral aneurysms. Of 148 unique studies returned on initial query, a total of 5 studies published between 2013 and 2019 met inclusion criteria. Where applicable, quantitative meta-analysis was performed via the Mantel-Haenszel method using Review Manager v5.4 (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Risk of bias (ROB) was assessed using the Cochrane ROBINS-I tool, and all studies were assigned a Level of Evidence (I-V). Across all five studies, the mean age ranged from 53.0 to 57.5 years old, and the cohort consisted of more females (n = 403, 60.6%) than males. The proportion of patients presenting with ruptured aneurysmal SAH was comparable between the SOKC and PKC cohorts (p = 0.43). Clipping rate [defined as the rate of successful aneurysm clip deployment with successful intraoperative occlusion] (OR 1.52 [0.49, 4.71], I2 = 0%, p = 0.47), final occlusion rates (OR 1.27 [0.37, 4.32], p = 0.70), and operative durations (SMD 0.33 [-0.83. 1.49], I2 = 97%, p = 0.58) were comparable regardless of approach used. Furthermore, rates of intraoperative rupture (OR 1.51 [0.64, 3.55], I2 = 0, p = 0.34), postoperative hemorrhage (OR 1.49 [0.74, 3.01], I2 = 0, p = 0.26), postoperative vasospasm (OR 0.94 [0.49, 1.80], I2 = 63, p = 0.86), and postoperative infection (OR 0.70 [0.16, 2.99], I2 = 0%, p = 0.63) were equivocal across SOKC and PKC cohorts. The PKC and SOKC approaches appear to afford comparable outcomes when used for open microsurgical clipping of cerebral aneurysms in select patients with both ruptured and unruptured aneurysms. Both are associated with excellent clipping and occlusion rates, minimal perioperative complication profiles, and favorable postoperative neurologic outcomes. Further investigations are merited so clinicians can further parse out the indications and contraindications for each keyhole approach.

SupraPetrous InfraTemporal Approach: A Supplemental Approach to Supracerebellar Infratentorial for Inferior Amygdala and Hippocampal Head Access-A Cadaveric Study With Case Illustrations.

Access to the amygdala and hippocampus (A/H) is complex. To address the limitations and invasiveness of traditional approaches, including the Transsylvian, Subtemporal, and Supracerebellar infratentorial approaches, we developed the suprapetrous infratemporal (SPIT) approach. This study describes the nuances of this approach in both cadaveric studies and clinical cases. Three unilateral exposures were performed using microscopic and endoscopic methodologies in the SPIT approach. After cadaveric investigation, this approach was successfully implemented in representative clinical cases. The SPIT approach enabled direct access to the inferior A/H, circumventing the requirement for temporal lobe retraction and detachment of the temporal lobe from the dura through a subtemporal route by drilling the upper part of the mastoid, consequently mitigating tension on the vein of Labbé. This enabled a bottom-up view because one would gain with a zygomatic osteotomy and forward projection like a mini-posterior petrosal view by using a transmastoid view, without cutting down the zygomatic arch and opening the dura subtemporally, limiting patient pain and preventing case comorbidity. The SPIT approach was performed in 2 cases of mesial temporal cavernoma presenting with seizures. The lesion was visualized intraoperatively and was successfully removed in these cases. The postoperative course was excellent with no complications, and gross total resection was radiographically confirmed with Engel Class 1a seizure freedom. The SPIT approach is a complementary approach for inferior A/H disease, combining the combined middle fossa approach modified for intradural pathology. Limited drilling of the upper aspect of the mastoid with a medial dural opening at the level of the arcuate eminence provides a direct trajectory with minimal brain retraction. Additional research encompassing a larger patient cohort and extended follow-up periods is required to substantiate the advantages of SPIT in the management of inferior A/H lesions.

The historical adventures of Takeshi Kawase: the mountaineer who explored the "no man's land" with love for art, nature, and humankind.

The anterior petrosal approach, or Kawase's approach, is a commonly used technique in skull base surgery to access the brainstem in the posterior fossa from the middle fossa, and has the advantages of minimizing brain retraction and preserving hearing. It was first successfully performed by the legendary Japanese neurosurgeon, Takeshi Kawase, for the clipping of a basilar artery aneurysm in 1981. To date, no historical article has shed light on Kawase's intriguing personal history. In this historical vignette, the authors depict Kawase's unique background, talent, passion, as well as struggles that ultimately shaped his career. By sharing Kawase's personal story from the hospital where he first successfully performed his original approach, the authors hope to pass on to future generations Kawase's spirit and philosophy that have impacted the global neurosurgical community.

Endoport-Guided Endoscopic Excision of Intraaxial Brain Tumors.

Transcortical approaches using a spatula-based retraction system have traditionally been used for the microsurgical resection of deep-seated intraventricular and parenchymal brain tumors. Recently, transparent cylindrical or tubular retractors have been developed to provide a stable corridor to access deeper brain lesions and perform bimanual microsurgical resection. The flexible endoports minimize brain retraction injury during surgery and, along with the superior vision of endoscopes, offer several advantages over standard microsurgery. In this chapter, we describe the surgical technique of the endoport-guided endoscopic excision of deep-seated intraaxial brain tumors. The endoscopic endoport technique that we use at our institution for the surgical management of intraventricular and intraparenchymal brain tumors has been described in detail with illustrative cases. Results from the literature review of intraventricular and intraparenchymal port surgery were analyzed, and the feasibility and safety of this technique were discussed. Surgical complication avoidance and management were highlighted. The port technique offers numerous potential advantages, including (1) reducing focal brain injury by distributing retraction forces homogenously, (2) minimizing white matter disruption and the risk of fascicle injury during cannulation, (3) ensuring the stability of the surgical corridor during the procedure, (4) preventing inadvertent expansion of the corticectomy and white fiber tract dissection throughout surgery, and (5) protecting the surrounding tissues against iatrogenic injuries caused by instrument entry and reentry. The endoport-assisted endoscopic technique is safe and offers an effective alternative option for the resection of intraventricular and intraparenchymal lesions.

The Endoscopic Lateral Transorbital Approach for the Removal of Select Sphenoid Wing and Middle Fossa Meningiomas. Surgical Technique and Short-Term Outcomes.

The endoscopic lateral transorbital approach (eLTOA) is a relatively new approach to the skull base that has only recently been applied in vivo in the management of complex skull base pathology. Most meningiomas removed with this approach have been in the spheno-orbital location. We present a series of select purely sphenoid wing and middle fossa meningiomas removed through eLTOA. The objective here was to describe the selection criteria and results of eLTOA for a subset of sphenoid wing and middle fossa meningiomas. This is a retrospective study based on a prospectively maintained database of consecutive cases of eLTOA operated on at our institution by the lead author. The cohort's clinical and radiographic characteristics and outcome are presented. Five patients underwent eLTOA to remove 3 sphenoid wing and 2 middle fossa meningiomas. The mean tumor volume was 11.9 cm 3 . Gross total resection was achieved in all cases. There were no intraoperative complications. Postoperatively, there was one case of subretinal hemorrhage, which was corrected by open vitrectomy repair, and one case of cerebrospinal fluid leak, which resolved with lumbar drainage. Three patients presented with visual impairment, 1 improved, 1 remained stable, and 1 worsened, but returned to stable after vitrectomy repair. All patients have been free of disease at a median follow-up of 8.9 months. eLTOA provides a direct minimal access corridor to certain well-selected sphenoid wing and middle fossa meningiomas. eLTOA minimizes brain retraction and provides a high rate of gross total resection. Meningiomas appropriately selected based on size, type, and location of dural attachment, and the eLTOA is a safe, rapid, and highly effective procedure with acceptable morbidity.

Standard Orbitozygomatic Craniotomy versus Mini Orbitozygomatic Craniotomy via an Eyebrow Incision for Microsurgical Treatment of Anterior Communicating Artery Aneurysms.

Background Skull base approaches are utilized to improve microsurgical treatment of cerebral aneurysms. Advantages include early proximal and distal control, increased visualization, and minimal brain retraction. Orbitozygomatic (OZ) craniotomies via pterional incision are commonly used for the treatment of anterior communicating artery (ACoA) aneurysms. A smaller, less invasive OZ craniotomy performed through an eyebrow incision may provide several advantages over a standard OZ approach. Objective We compare surgical outcomes of the standard and eyebrow OZ for the treatment of ACoA aneurysms. Design All patients who underwent microsurgical treatment for ACoA aneurysms by a single surgeon over an 8-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. Participants Thirty-seven consecutive patients were identified, with 15 receiving eyebrow OZ and 22 receiving standard OZ. Main Outcome Measures Data were collected on patient demographics, pathology, intraoperative and perioperative data, and 30-day morbidity. Results A total of 100% of the eyebrow OZ group and 95.5% of the standard OZ group had complete aneurysmal occlusion. Four eyebrow OZ and six standard OZ patients had an intraoperative rupture. All were managed without complication. Two eyebrow OZ and one standard OZ patient died within 30 days of surgery. No patients in either group had aneurysm recurrence, required retreatment, or were limited intraoperatively by exposure. Conclusions The OZ approach via an eyebrow incision has similar outcomes to a standard OZ approach and is a safe option for the treatment of ACoA aneurysms.

Endoscopic Assisted Supraorbital Approach for Tumors of Anterior and Middle Skull Base

Background Data: The supraorbital eyebrow approach is a minimally invasive keyhole technique that offers wide access to the anterior skull base and parasellar region using the subfrontal corridor, with assistances of neuroendoscopy The approach through the eyebrow permits access to a number of lesions in the subfrontal corridor with minimal brain retraction and a much smaller area of potential injury of main structures.
 Study Design: This study is a follow up study.
 Objective: To evaluate the role of supraorbital endoscopic approach for tumors of anterior and middle skull base.
 Patients and Methods: All the operations were performed at Suez Canal University hospitals, in about 24 months, the first 30 patients having tumors of anterior and middle skull base fulfilling the inclusion criteria were included in this prospective study.
 Results: Endoscopy can play an important role in improving visualization through the keyhole corridor. With the use of neuroendoscopy, the reach of this approach may be extended even further to include the pituitary fossa, the top third of the clivus, the interpeduncular cistern, the anterior third ventricle, and the medial and anterior temporal lobe and middle fossa.The major advantage of the supraorbital over the endonasal route is a simplified skull base closure and reduced risk of postoperative CSF leak. It is a valuable approach for selected patients. Neuromonitoring may further increase surgical safety.
 Conclusion: The approach through the eyebrow permits access to a number of lesions in the subfrontal corridor With the use of the assisstence of neuroendoscopy, with minimal brain retraction and a much smaller area of potential injury of anatomical structures.

Hybrid Fluoroscopic and Neurophysiological Targeting of Responsive Neurostimulation of the Rolandic Cortex.

Precise targeting of cortical surface electrodes to epileptogenic regions defined by anatomic and electrophysiological guideposts remains a surgical challenge during implantation of responsive neurostimulation (RNS) devices. To describe a hybrid fluoroscopic and neurophysiological technique for targeting of subdural cortical surface electrodes to anatomic regions with limited direct visualization, such as the interhemispheric fissure. Intraoperative two-dimensional (2D) fluoroscopy was used to colocalize and align an electrode for permanent device implantation with a temporary in Situ electrode placed for extraoperative seizure mapping. Intraoperative phase reversal mapping technique was performed to distinguish primary somatosensory and motor cortex. We applied these techniques to optimize placement of an interhemispheric strip electrode connected to a responsive neurostimulator system for detection and treatment of seizures arising from a large perirolandic cortical malformation. Intraoperative neuromonitoring (IONM) phase reversal technique facilitated neuroanatomic mapping and electrode placement. In challenging-to-access anatomic regions, fluoroscopy and intraoperative neurophysiology can be employed to augment targeting of neuromodulation electrodes to the site of seizure onset zone or specific neurophysiological biomarkers of clinical interest while minimizing brain retraction.

A new simple and free tubular device for microscopic transcortical approach to deep-seated lesions: technical note and case example.

Surgery for deep-seated brain tumors remains challenging. Transcortical approaches often require brain retraction to ensure an adequate surgical corridor, thus possibly leading to brain damage. Various techniques have been developed to minimize brain retraction such as self-retaining retractors, endoscopic approaches, or tubular retractor systems. Even if they evenly distribute the mechanical pressure over the parenchyma, rigid retractors can also cause some degree of brain damage and have significant disadvantages. We propose here a soft cottonoid retractor for microscopic resection of deep-seated and ventricular lesions. Through a small corticectomy, a channel route with a blunt cannula is developed until the lesion is reached. Then, a "balloon-like system" made with a surgical glove is progressively inflated, dilatating the surgical corridor. A mini-tubular device, handmade by suturing a surgical cottonoid, is positioned into the corridor, unfolded, and sutured to the edge of the dura, to prevent it from being progressively expelled from the working channel. This allows a good visualization of the lesion and surrounding structures under the microscope. Advantages of this technique are the softness of the tube walls, the absence of rigid arm to hold the tube, and the possibility for the tube to follow the movements of the instruments and to modify its orientation according to the working area. This simple and inexpensive tubular working channel for microscopic transcortical approach is a valuable alternative technique to traditional self-retaining retractor and rigid tube for the microsurgical resection of deep-seated brain tumors.

The Dural Dark-Side Approach for falcine and tentorial meningioma: A surgical series of five patients

IntroductionFalcine or tentorial meningioma can be complex to resect. When large meningiomas are located in eloquent areas, a direct ipsilateral surgical approach may cause brain injury and postoperative neurological deficits. In this series, 5 patients were surgically treated using a contralateral transfalcine or transtentorial approach to minimize brain retraction. This strategy was called the Dural Dark-Side Approach (DDSA). The aim was to analyze the quality of tumor resection and postoperative outcome. Material and methodsIn our department, from June 2018 to January 2020, 5 patients underwent microsurgical DDSA for resection of 4 falcine and 1 tentorial meningioma. All tumors were selected on the following two criteria: large>40mm diameter tumor, with surrounding functional cortex. Clinical and radiologic data were retrospectively analyzed. Results and discussionMean follow-up was 20 months. No patients required use of a rigid retractor during surgery. Gross total resection was performed in 3 patients and near-total resection in 2. All patients had favorable neurologic outcome. Postoperative MRI showed no ipsilateral or contralateral brain lesions. ConclusionThis series suggested that meticulous DDSA allows excellent resection in selected large falcine or tentorial meningioma. The approach offered a safe and effective surgical corridor without injuring the surrounding healthy parenchyma.

Anatomical justification and types of transorbital endoscopic approaches (review)

Transcranial and transnasal approaches are the most common techniques for treatment of diseases and injuries of the eye socket and the base of the skull. However, development of endoscopic technology, microsurgical devices and minimally invasive techniques promotes increased interest in transorbital endoscopic approaches which allow to perform manipulations in the eye socket and structures of the base of the skull, namely, the anterior and middle cranial fossa. There are 4 types of such approaches: pre-caruncular, superior transpalpebral, lateral retro-canthal and inferior preseptal. Currently, precise indications for transorbital approaches are not formulated, and there are no algorithms for approach selection. The article describes the results of using these approaches in treatment of diseases and injuries of the orbit and the base of the skull. In injuries and tumors of the orbit and the base of the skull, cerebrospinal liquid leakage, infectious diseases, endocrine ophthalmopathy, transorbital endoscopic techniques provide good functional and cosmetic results. Among the advantages of these approaches are larger orbitotomy area and preservation of nasal structures, absence of large neurovascular bundles in the way of the approach, small incision, minimal brain retraction, good visibility and illumination of the structures. Transorbital endoscopic approaches to the base of the skull aren’t associated with significant neurological or vascular complications, hemorrhage, hematomas, infections. Diplopy, ptosis, enophthalmia are also quite rare. In literature, there are no descriptions of cases of loss of vision or postoperative cerebrospinal liquid leakage.

Endoscope-assisted transcranial surgery for anterior skull base meningiomas

Anterior skull base meningiomas are benign, dural-based tumors that originate from the tuberculum sellae, planum sphenoidale or olfactory groove. A multitude of traditional transcranial approaches have been effectively used for resection of these tumors. However, in the era of minimally invasive neurosurgery, the endoscopic endonasal and the endoscope-assisted or endoscope-controlled supraorbital keyhole eyebrow approaches stand out as the two main options utilized to resect these tumors. The supraorbital keyhole approach minimizes brain retraction, tissue dissection and length of the skin incision. Consequently, this approach is associated with a lower complication profile and much better cosmetic results in comparison to classic approaches. With endoscopic assistance or control, the approach provides an excellent view of anterior skull base meningiomas and enables optic nerve decompression when angled scopes are used. In our opinion, endoscopes will ultimately replace the surgical microscopes as the viewing tools in this type of surgery. A limited number of studies have directly compared the endoscopic endonasal approach versus the supraorbital keyhole one for resection of anterior cranial base meningiomas. In these studies, scores and algorithms have been suggested to help select the suitable approach. The practical value of these algorithms still needs to be validated by further research. Although the endoscope-assisted or -controlled supraorbital keyhole approach offers a minimally invasive and highly effective approach for excision of anterior cranial base meningiomas, the ideal approach should be tailored to the individual patient according to the tumor size, lateral extension, optic canal involvement, extent of vascular encasement and surgeon’s experience.

Translamina Terminalis Approach to the Hypothalamus Using Supraorbital Craniotomy: Technical Note and Comparison with Other Surgical Corridors.

Objectives:Approaches to the hypothalamus and anterior third ventricle are variable. We present a technical note on access of the hypothalamus using the trans-lamina terminalis approach by supraorbital craniotomy in a patient who had a hypothalamic cavernoma and presented to us with recurrent hemorrhage.Patients and methods:The trans-lamina terminalis approach, including anatomical landmarks and surgical steps through a supra-orbital craniotomy, is described and a comparison with other surgical corridors is discussed.Results:The supraorbital trans lamina terminalis approach allowed an effective access to the hypothalamic lesions. This approach provided a safe and minimally invasive corridor for gross total resection of the lesion since trespass of viable brain tissue is avoided. One clinical case illustrates the feasibility of the approach allowing complete removal of a cavernoma without surgery related neurological of endocrinological deficits.Conclusions:The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for hypothalamic lesions. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long and narrow surgical corridor requires some technical familiarization. The clinical outcomes are comparable to other surgical corridors.

The endoscopic supraorbital translaminar approach: a technical note.

Resection of lesions located within the third ventricle presents a surgical challenge. Several approaches have been developed in an attempt to obtain maximal resection, while minimizing brain retraction. In this work, we assess the surgical exposure and maneuverability of the endoscopic supraorbital translaminar approach (ESTA), a potential alternative to fenestrate the lamina terminalis and approach the third ventricle by using the endoscope through a keyhole supraorbital-eyebrow craniotomy. Five cadaveric heads were used to assess the corridor depth, area of exposure, and viewing angles offered by the ESTA. One additional utilized specimen provided a stepwise dissection of the approach. The ESTA was successfully performed in all specimens. Depth of the surgical corridor from the craniotomy to the ipsilateral internal carotid artery (ICA), lamina terminalis, and contralateral carotid were 70.7 ± 2.9mm, 73.2 ± 2.9mm, and 78.9 ± 4.1mm, respectively. Viewing angle referenced to the ipsilateral ICA was 6.5 ± 4.2°, while the viewing angle for the lamina terminalis was 25.8 ± 4.3°. The surgical exposure provided by the ESTA was 1655 ± 255mm2. The ESTA provides a wide surgical view of the lamina terminalis and may be potentially used to approach lesions located in the anterior third of the third ventricle. As a pure endoscopic approach, the ESTA requires minimal brain retraction, while affords good visualization of targeted lesions around the lamina terminalis. The ESTA uses an anterolateral approach and so provides a short and straightforward approach to these structures.

Far Lateral Approach (Transcondylar, Transtubercular) for Bypass and Trapping of a Ruptured, Dissecting PICA Aneurysm

Aneurysms of the posterior circulation pose a unique challenge due to higher rupture rates, higher recurrence rates following endovascular treatment, and extended open cranial base approaches required to reach the ventrally located brainstem circulation. While endovascular therapy has made tremendous strides in successful treatment for most posterior circulation aneurysms, open microscopic approaches remain essential in specific circumstances. Here, we present a case of a patient who presented with acute, severe headache, and sixth nerve palsies, and who was found to have hydrocephalus and a dissecting aneurysm at the anterolateral medullary segment of the posterior inferior cerebellar artery (PICA). Interestingly, this patient had a history of alpha-1 antitrypsin deficiency that has been linked with spontaneous aortic and cervical arterial dissections. The fusiform geometry of the dissecting aneurysm was deemed suboptimal for endovascular treatment, so an open microsurgical approach for occipital artery to PICA bypass and aneurysm trapping was planned. Because this patient had cerebral edema in the setting of a ruptured aneurysm and hydrocephalus, a far lateral craniotomy combined with drilling of the occipital condyle and jugular tubercle was critical to enhance exposure of the first segment of the PICA and to minimize brain retraction. In this video, we highlight the key steps and nuances for harvest of the occipital artery, achieving control of the extracranial vertebral artery, performing the transcondylar and transtubercular far lateral approach, and bypass with trapping technique for these challenging posterior circulation aneurysms. The link to the video can be found at: https://youtu.be/dqgblwX6t0Q .

Minimally invasive resection of intracranial lesions using tubular retractors: a large, multi-surgeon, multi-institutional series.

Lesions located in subcortical areas are difficult to safely access. Tubular retractors have been increasingly used successfully with low complication profile to access lesions by minimizing brain retraction trauma and distributing pressure radially. Both binocular operative microscope and monocular exoscope are utilized for lesion visualization through tubular retractors. We present the largest multi-surgeon, multi-institutional series to determine the efficacy and safety profile of a transcortical-transtubular approach for intracranial lesion resections with both microscopic and exoscopic visualization. We reviewed a multi-surgeon, multi-institutional case series including transcortical-transtubular resection of intracranial lesions using either BrainPath (NICO, Indianapolis, Indiana) or ViewSite Brain Access System (VBAS, Vycor Medical, Boca Raton, Florida) tubular retractors (n=113). One hundred thirteen transtubular resections for intracranial lesions were performed. Patients presented with a diverse number of pathologies including 25 cavernous hemangiomas (21.2%), 15 colloid cysts (13.3%), 26 GBM (23.0%), two meningiomas (1.8%), 27 metastases (23.9%), 9 gliomas (7.9%) and 9 other lesions (7.9%). Mean lesion depth below the cortical surface was 4.4cm, and mean lesion size was 2.7cm. A gross total resection was achieved in 81 (71.7%) cases. Permanent complication rate was 4.4%. One patient (0.8%) experienced one early postoperative seizure (<1week postop). No patients experienced late seizures (>1week follow-up). Mean post-operative hospitalization length was 4.1days. Tubular retractors provide a minimally invasive operative corridor for resection of intracranial lesions. They provide an effective tool in the neurosurgical armamentarium to resect subcortical lesions with a low complication profile.

Expanded transnasal approaches to the skull base in the Middle East: Where do we stand?

ABSTRACTBACKGROUND: Endoscopic transnasal surgery has gained rapid global acceptance over the last two decades. The growing literature and understanding of anterior skull base endoscopic anatomy, in addition to new dedicated endoscopic instruments and tools, have helped to expand the use of the transnasal route in skull base surgery.OBJECTIVE: Report our early experience in expanded endoscopic transnasal surgery (EETS) and approach to skull base neoplasms.DESIGN: Descriptive, retrospective case series.SETTING: Major tertiary care center.PATIENTS AND METHODS: A retrospective case review was conducted at King Saud University Medical City between December 2014 and August 2019. Cases with skull base neoplasms that underwent EETS were included. EETS was defined as endoscopic surgical exposure that extended beyond the sellar margins (prechiasmatic sulcus superiorly, clival recess inferiorly, cavernous carotid lines laterally). Routine transsphenoidal pituitary neoplasms, neoplasms of sinonasal origin and meningoencephaloceles were excluded.MAIN OUTCOME MEASURES: Preoperative clinical assessment, imaging results, surgical approach, and hospital course were all retrieved from the patient electronic charts. Clinical follow-up, perioperative complications, and gross residual tumor rates were documented and reviewed.SAMPLE SIZE AND CHARACTERISTICS: 45 cases of EETS, 13 males and 32 females with mean age of 39.0 (17.7) years (range 2–70 years).RESULTS: The series comprised a wide range of pathologies, including giant pituitary adenoma (8 cases), meningioma (23 cases), craniopharyngioma (4 cases), chordoma (4 cases), optic pathway glioma (2 cases), epidermoid neoplasms (2 cases), astrocytoma (1 case), and teratoma (1 case). For the entire series, gross total resection was achieved in 25/45 operations (55.5%). Postoperative cerebrospinal fluid leak was the most common complication observed in 9 patients (20%) which were all managed endoscopically. Major vascular complications occurred in 2 patients (4.4%) and are described. Other complications are outlined as well. No mortality was observed.CONCLUSIONS: EETS to the skull base can be done with results comparable to traditional approaches. More work is needed to expand our experience, improve outcomes, and educate the public and medical community in our region about the usefulness of this approach.LIMITATIONS: Sample size and study design.CONFLICT OF INTEREST: None.

Anatomic Study on Neuroendoportal Transcortical Approach to Lateral Ventricles

Resection of intraventricular lesions remains a challenge for modern neurosurgery. Endoscopy has provided great advantages in ventricular surgery, even if limited in terms of operability, due to the restricted working channel and impossibility for bimanual surgical manipulation. Tubular approaches have been considered as an option, enabling the use of microsurgical techniques, minimizing violation of brain tissue. The aim of our study was to describe and critically evaluate the use of portal surgery to access lateral ventricles in terms of surgical exposure and operability. A microanatomic laboratory cadaver study was conducted with a stepwise description of the surgical technique. The operability score was applied for quantitative analysis of surgical operability, and an illustrative case is reported. Through the anterior approach, the neuroport provides maximal operability at the foramen of Monro and the posterior aspect of the frontal horn, while through the posterior approach maximal operability is achieved in the paratrigonal area. Endoscopic assistance does not affect operability but provides adjunctive exposure in blind spots, as the roof of the frontal horn, the most anterior aspect of the temporal and occipital horn. Ventricular tubular systems provide adequate visualization, with minimal brain retraction, improving operability as compared with endoscopy. Endoscopic assistance critically widens surgical exposure in blind spots without providing concomitant significant advantage in terms of surgical operability.

Endoscopic Management of Supratentorial Ventricular Tumors

Background: Intraventricular tumors are ideal indications for neuroendoscopic surgery. Because intraventricular tumors often cause cerebrospinal fluid (CSF) pathway obstruction, resulting in ventricular dilation and sufficient space for maneuvering with the endoscopes is available. Objective: The aim of this study was retrospectively and antrospectively evaluation of the role and outcome of use of endoscope in intraventricular tumors in term of: 1-Diagnostic of the deep lesions. 2- Management of increased intra-cranial pressure (ICP). 3-Excision of tumor depends on the type. Patients and Methods: This prospective and retrospective study was carried on 30 patients who sought medical advice for intra ventricular tumor from 2015 to 2019 in Al-Hussein University Hospital. Tumors are removed or biopsied with or without ETV and septum pellucidostomy. Results: According to our study, we found that endoscopic removal of intraventricular tumors has low rate of complications. There were 25 cases with no complications (83.3%) and better outcome. There were 15 cases (50%) very good outcome and 10 cases (33.3%) were good outcome, as there was minimal dissection and brain retraction. Conclusion: Regarding endoscopic treatment of intra ventricular tumors, there are many advantages of the endoscopic approach as low rate of complications, minimal dissection, better outcome, brain retraction, rapid access to the target and excellent visualization of the lesion and surrounding structures. Endoscopic approach also has the ability of treatment of the associated hydrocephalus at the same session with low rate of failure or recurrence.