Subfrontal Approach Research Articles

MR画像（MRAおよびT2WI）による未破裂中大脳動脈分岐部瘤に対する手術アプローチの選択

We performed clipping surgeries for patients with unruptured middle cerebral artery (MCA) bifurcation aneurysms and used preoperative magnetic resonance (MR) imaging (T2-weighted image; T2WI) and MR angiography (MRA), intraoperative findings, and postoperative computed tomographic scans to investigate 1) whether the subfrontal approach (SFA) with frontal lobe retraction or the transsylvian approach (TSA) can secure a minimum surgical field by less invasive procedures and 2) which site in the Sylvian fissure (SyF) is it the most effective for entering via TSA. TSA is classified into 1) the transproximal Sylvian approach (proximal TSA) by opening the proximal SyF, 2) transmiddle Sylvian approach (middle TSA) by opening the middle SyF, and 3) transdistal Sylvian approach (distal TSA) by opening the distal SyF. Determinants of selecting each approach are not only the length of the horizontal portion of the MCA (M1) and size and location of aneurysms in the deep SyF, but also the width of the anterior operculoinsular compartment (A-OpIC) of the SyF exposed by resection of the sphenoidal ridge and deep sphenoidal compartment (SphC) of the SyF. In conclusion, 1) the SFA is speculated to be appropriate for cases wherein M1 is hidden by aneurysms deeply located inside the narrow SphC; 2) the proximal TSA, for cases wherein M1 and aneurysms are located at the border of the wide SphC and A-OpIC; 3) the middle TSA, for cases wherein M1 and aneurysms are located at the lateral part of the wide A-OpIC; and 4) the distal TSA, for cases wherein long M2 and aneurysms are located in the OpIC.

Microsurgical strategy of invasive pituitary adenomas

Objective To analyze the efficacy of different surgical approach for invasive pituitary adenoma and to raise the rational microsurgical strategy. Methods We retrospectively analyzed the clinical data of 441 patients with invasive pituitary adenomas at the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from July 2012 to June 2015. The clinical manifestation, imaging data, surgical methods, microsurgical skills and prognosis were reviewed. Suprasellar invasive was identified in 310 patients, parasellar was in 293 patients and the sellar floor was in 187 patient. 318 patients underwent transsphenoidal surgery, while 123 patients were treated by craniotomy. In the cases of patients treated by craniotomy, the number of patients undergoing the subfrontal approach, the frontal lateral approach, the frontal temporal approach, the anterior interhemispheric approach and the callosal interforniceal approach was respectively 31, 50, 22, 11 and 9. Univariate analysis and Logistic regression analysis were used to evaluate the influencing factors of surgical approach for invasive pituitary adenoma. Results The suprasellar (P 15 cm3 (P<0.001) were the main factors to choose craniotomy, while the sellar floor (P<0.001) is the main factor to use transsphenoidal approach. The options of subfrontal approach, frontal lateral approach or frontal temporal approach were related to the parasellar (P<0.001) and width of the tumor (P=0.001). The height of the tumor (P<0.001) was associated with the selections of the subfrontal approach, the anterior interhemispheric approach or the callosal interforniceal approach. Conclusions The options of the surgical approach of invasive pituitary adenomas should be on the basis of preoperative patient status and imaging findings. Transsphenoidal surgery has unique advantages for excising the tumor which pushes the internal wall of the cavernous sinus - false tumor invasion . The frontal lateral approach takes a advantage of the subfrontal approach and the frontal temporal approach to remove the tumor in the cavernous sinus. The options of the anterior interhemispheric approach to remove tumor involving suprasellar space avoid the disconnection syndrome after the operation though the callosal interforniceal approach, and the gross-total resection rate is higher. Key words: Pituitary adenoma; Neurosurgical procedures; Surgical approach; Prognosis

Influence of preventive use of vasopressin tannate on diabetes insipidus and serum sodium at the early postoperation of craniopharyngioma

To explore the influence of preventive use of vasopressin tannate on diabetes insipidus and serum sodium at the early postoperation of craniopharyngioma. Methods: The data of 83 patients, who underwent unilateral sub-frontal approach resection of craniopharyngioma between 2010 and 2014 by the same senior neurosurgeon, were retrospectively analyzed. The patients were divided into a vasopressin tannate group (used group) and a control group. The diabetes insipidus and serum sodium changes were compared between the two groups. Results: Compared with the control group, the incidence of diabetes insipidus decreased at the early postoperation in the vasopressin tannate group (P<0.05). There was high incidence of diabetes insipidus in patients with pituitary stalk excision and tumor close adhesion to the third ventricle floor at the early postoperation (P<0.05). Under such conditions, the incidence of diabetes insipidus in the vasopressin tannate group was decreased compared with the control group (P<0.05). Postoperative hypernatremia occurred in 37 patients (44.6%), and hyponatremia occurred in 60 patients (72.3%), the average time of the occurrence of hpernatremia and hyponatremia was 1.4 and 3.7 days after surgery. Postoperative high serum sodium and low serum sodium appeared alternately in 19 patients (22.9%). There was significant difference in the serum sodium distribution in the first day after surgery in both groups (P<0.05), and the percent of hpernatremia in the vasopressin tannate group was significantly less than that in the control group (P<0.05). Conclusion: Preventive use of vasopressin tannate can effectively reduce diabetes insipidus and hypernatremia incidence at the early postoperative stage after microsurgery for craniopharyngioma.

Extraventricular neurocytoma of the sellar region: case report and literature review.

Introduction The extraventricular neurocytoma of the sellar region (EVNSR) is a rare disease, it is difficult to make exact diagnosis of and operate on patients. Retrospectively analysed the clinical manifestations, image features, therapy methods and outcomes among patients with EVNSR, to investigate the epidemiological characteristics, image features, diagnosis, treatment and prognosis.Case descriptionA 25-year-old man man with 7-month worsening vision of left eye, was confirmed EVNSR after subtotally resection from the neurosurgical department of Deji hospital.Discussion and evaluationNine cases of EVNSR were reported from this article and elsewhere. Ages of these patients were ranging from 25 to 66 (with an average of 45.67). The male–female ratio was 1–2. All EVNSR patients had visual damage. Images showed the tumors were in the sellar and suprasellar regions. Preoperatively, all patients were misdiagnosed as other diseases: such as pituitary tumor, craniopharyngioma, and meningioma. For tumor removal treatment, five patients received transpterional approach, one received subfrontal approach and three received transnostril–transsphenoidal approach. EVNSR was confirmed by pathological tests. The tumor was completely removed in one patient. During the 12–24 month postoperative follow up period, the recurrence or metastasis of the tumor was found in two patients.ConclusionsEVNSR is a rare disease. It occurs mostly in middle-aged women. EVNSR is likely to be misdiagnosed as pituitary adenoma preoperatively. The histological examination would help confirm the diagnosis. Using transpterional approach to remove tumor will help the prognosis, especially among patients with normal pituitary function. Both postoperative radiotherapy and long-term follow-up are recommended.

Combined surgical and medical treatment of giant prolactinoma: case report

Abstract The operative management of giant pituitary prolactinoma represents a significant challenge for neurosurgeons, due to the degree of local tumor infiltration into adjacent structures such as cavernous sinus. The degree of parasellar tumor extension can be classified according to the Knosp grading system’ while suprasellar extension is qualified in accordance with the modified Hardys classification system. This report describes the case of a male patient with a giant pituitary prolactinoma in which a partial tumor resection via a subfrontal approach was achieved. Typically, resection rates of less than 50% have been reported following surgery on giant pituitary adenomas. Prolactin levels were very high, consistent with invasive giant prolactinoma. Our patient was treated with Cabergoline which eventually normalized the prolactin level and significantly reduced the size of the residual tumor. This case serves to illustrate that in the presence of significant suprasellar and parasellar extension, multi-modal treatment strategies with surgery and dopamine agonist, is the gold standard in the management of locally aggressive pituitary prolactinomas.

Can the angle between optic nerves indicate whether optic chiasm is prefixed, normofixed or postfixed? An anatomical study with radiologic and neurosurgical implications.

The objective of this study was to measure the angle (Interneural angle, INA) between intracranial segments of optic nerves (ISON), and to look for any relation between it and the relative anteroposterior location (RAPL) of the optic chiasm (OC)-viz. prefixed, normofixed and postfixed. The sample comprised of 100 autopsy specimens from South Indian population. INA was measured using software-aided processing of digital photographs. Length of the ISON was measured on each side using Vernier calipers. RAPL of the OC was noted during dissection. These were analysed with statistical methods. RAPL of OC was found to be prefixed in 24%, normofixed in 65% and postfixed in 11%. The INA had an overall mean of 69.9° (SD 9.29°). ANOVA confirmed statistically significant difference in INA among different groups; the corresponding mean value for the group was as follows: 79.61° (prefixed), 68.10° (normofixed) and 59.48° (postfixed). ROC curve was plotted for the use of various 'cut off' values of INA to 'diagnose' prefixed OC; an INA≥71.4° was seen to diagnostically correlate with prefixed OC with 83.3% sensitivity and 75% specificity. The INA is wider when OC is prefixed, intermediate when normofixed and narrowed when postfixed. This observation throws light on the possibility of using INA as a marker of RAPL of OC. As INA can be measured in axial MRI sections, it can be used in differentiation of the cases with prefixed OC from others during pre-operative work up for pituitary surgeries and to identify individuals 'at risk' during subfrontal approach for pituitary lesions.

Microsurgical Management of Craniopharyngiomas via a Unilateral Subfrontal Approach: A Retrospective Study of 177 Continuous Cases

To evaluate the outcomes of 177 cases of craniopharyngioma (CP) treated via a unilateral subfrontal approach. A total of 177 continuous microscopic surgeries were performed by the senior author (Y.X.). The tumors were divided into 6 groups using the diaphragm sellae and the third ventricle floor as the anatomic references. The preoperative, postoperative, and long-term follow-up data were analyzed to evaluate the extent of tumor resection, recurrence, and functional status. The subfrontal-basal approach was used in 169 (91.4%) cases. Total resection was achieved in 167 (94.4%) cases. A total of 158 patients were followed from 6 to 130 months. There were 3 perioperative and 23 delayed deaths. Twenty-two patients had tumor recurrence (12.7%). The progression-free survival was 80% at 5 years and 72% at 10 years. The overall survival was 84.0% at 2.5 years and 83.2% at 10 years. There was a significant increase of pituitary dysfunction after total resection. Neurologic function was stable in most patients. Rate of hypothalamic dysfunction and mortality were higher in patients with intraventricular CPs. Of the surviving patients, 91.8% were living independently with acceptable morbidities at the end of the study. Most CPs extend along the intrasellar-suprasellar-third ventricle axis. A subfrontal-basal approach is a simple, safe, and effective approach to resecting CPs extending along the vertical axis. A translamina terminalis approach is an ideal corridor to resect intraventricular CP. The benefit of radical resection remains controversial, especially for CPs involving the infundibulotuberal region.

单侧额下入路显微切除嗅沟脑膜瘤

目的：探讨单侧额下入路显微切除嗅沟脑膜瘤的技巧和疗效。方法：在2004年1月至2015年5月采用经单侧额下入路显微切除巨大嗅沟脑膜瘤45例，其中男11例，女34例；平均年龄49.2岁(22~78岁)。肿瘤最大直径平均4.9 cm (2.2 cm~8.1 cm)。回顾性分析所有患者的临床数据、影像特征、手术记录和预后，采用非配对资料χ2检验结果连续性校正法分析预后影响因素。结果：全切(Simpson grade I/II/III)41例(91.1%)，少许残留4例(8.9%)，其中1例行伽玛刀治疗。主要并发症：颅内感染3例，额叶挫伤5例(11.1%)，其中伴血肿需手术清除1例。新增嗅觉损失9例(20.0%)，额叶损伤症状3例，脑脊液漏2例，视力减退1例，脑肿胀1例，癫痫发作1例，脑积水1例。出院后3~6个月，预后良好38例(84.4%)，中残6例(13.3%)，重残1例(2.2%)术前KPS评分 ≤ 70与不良预后相关(χ2 = 5.139, P = 0.023)。41例(91.1%)获随访，平均随访时间42.6个月(3~107个月)，KPS计分85.2分；3例(7.3%)复发，均行伽玛刀治疗，1例再手术。结论：应用适宜手术技巧，单侧额下入路显微切除巨大嗅沟脑膜瘤疗效确切，并发症较少；术前KPS ≤ 70分是嗅沟脑膜瘤手术不良预后因素。 Objective: To investigate the techniques and clinical effects for removal of olfactory groove meningiomas (OGMs) via unilateral subfrontal approach. Methods: Between January 2004 and May 2015, a total of 45 OGM patients were operated on via the unilateral subfrontal approach. There were 11 male patients and 34 female patients. Their mean age was 49.2 (22~78) years. The average maximal tumor diameter was 4.9 cm (2.2 cm - 8.1 cm)). The clinical data, radiological findings, surgical records and outcome of patients were retrospectively analyzed, and the prognostic factors were analyzed by using of the unpaired χ2 test with continuity correction. Results: Apparent complete tumor removal was achieved in 41 patients (91.1%). Four patients (8.9%) had minimal residual tumors, 3 of which had gamma knife radiosurgery. There was no surgical mortality. The main operative complications included new anosmia (9 cases), intracranial infection (3 cases), frontal contusion (5 cases), frontal mental changes (3 cases), cerebrospinal fluid leakage (2 cases), and visual deficits\brain swelling\seizures and hydrocephalus (1 case) respectively. At 3 - 6 months after discharge, 38 (84.4%) patients had a good recovery, 6 (13.3%) were moderately disabled and 1 (2.2%) was severely disabled. The preoperative KPS ≤ 70 was the cause of unfavorable prognosis (χ2 = 5.139, P = 0.023). During the mean follow-up of 42.6 months (range, 3 - 107 months) for 41 patients, the average KPS was 85.2. Tumor recurred in 3 cases, all being treated with gamma knife radiosurgery, one of which required reoperation. Conclusion: By using optimal operative techniques, OGMs can be removed safely via the unilateral subfrontal approach with relatively low morbidity. The preoperative KPS ≤ 70 is an unfavorable prognostic factor for OGM resection.

The Anterior Subcallosal Approach to Third Ventricular and Suprasellar Lesions: Anatomical Description and Technical Note

Surgical access to the third ventricle is challenging, given the depth of the operative field and close proximity of vital neural structures that must be traversed. For anterior third ventricular lesions, approach options include anterior transcallosal or transcortical, subfrontal, frontotemporal, or endonasal. The subcallosal approach, a translamina terminalis approach, is unique in that the surgical corridor is just below the corpus callosum, minimizes retraction and preserves corpus callosum integrity. Case examples are provided, and an anatomical study delineating the dimensions of the surgical corridor is performed. Two latex-injected cadaver heads were used to describe the subcallosal corridor. A magnetic resonance imaging scan was obtained and registered with neuronavigation for correlative anatomical illustration. Depth, dimensions, and cross-sectional area were measured for the subcommunicating and supracommunicating corridors. The surgical depth for anterior transcallosal, subcallosal, and subfrontal approaches was 7.5 cm, 7.7 cm, and 7.6 cm respectively. The average corridor dimensions for the subcallosal approach were 14.75 × 6.63 mm compared with 8.88 × 5.38 mm for the subcommunicating corridor. Cross-sectional area of the subcommunicating corridor was 30.62 mm(2) compared with 80.42 mm(2) for supracommunicating. This was easily enlarged to 156.62 mm(2) with gentle retraction. The anterior subcallosal approach is a safe approach for lesions of the third ventricle that avoids splitting the corpus callosum and resecting unnecessary brain and minimizes brain retraction. This corridor is superior to the traditional subfrontal approach in terms of working space and compares favorably to the anterior transcallosal approach without disrupting the corpus callosum.

QOL-15QUALITY OF LIFE IN MASSIVE OPTICOHYPOTHALAMIC GLIOMA. AN ANALYSIS OF AN EXPERIENCE IN 73 CASES TREATED OVER 18 YEARS

BACKGROUND: Visual pathway gliomas represent 1% to 5% of childhood brain tumors. About 43% occur in children <10 years old. Although benign, opticohypothalamic chiasmatic gliomas can have aggressive course in young children. PATIENTS AND METHODS: Seventy-three cases of opticohypothalamic chiasmatic were surgically treated in our department over the past 18 years (1990-2011). A retrospective analysis is presented. A semi-structured interview for disease domain specific quality of life (QOL) was performed in a focused group of 30 patients to elicit themes to provide a thematic analysis. RESULTS: The average age of presentation was 14.8 years and duration of complaints was 3 months. Headaches, vomiting and dimunition of vision were the most common complaints. The average size of the tumor was 7.4 cm. All patients underwent only biopsy of the tumor. The subfrontal approach was used in all patients. Ventriculoperitoneal shunt was required in 19 patients postoperatively. The average follow-up period was 7 years. Nonsymptomatic recurrence was noted in 8 patients. Overall, the median time to tumor progression was 55 months. The 5- and 10-year survival probabilities were 93 and 74%, respectively. The functional activity assessed by Barthel's Index is maintained in children with low grade optochiasmal gliomas treated with conformal RT. The decline in functional activity is seen in patients with tumor recurrence and in complications. However, there was improvement of functional activity after RT due to tumour control and rehabilitative support. The maximum improvement was seen in visually impaired patients. CONCLUSION: Barthel's Index is a simple, reproducible, quick and easy to perform. It is especially applicable for older children and adolescents and may be used as an outcome measure tool in clinics with resource limitations. The approach towards quality of life issues should be more aggressive including psychosocial intergration. There is a need for more objective and better quality of life studies.

Minimally invasive subfrontal route for the resection of medial temporal region intrinsic tumors.

The mesial temporal region (MTR) comprises important components of the limbic system, as well as vital neurovascular structures. Because of its important functional role, as much healthy brain tissue as possible must be preserved while targeting resection of MTR lesions. A frontal minicraniotomy is used to access the MTR through a subfrontal approach. By opening the most medial part of the Sylvian fissure, the uncus-amygdala complex is exposed, and through this, the head of the hippocampus can be reached and removed as well. This approach is extremely suitable for MTR lesions, as it provides the advantage of sparing the most important functional structures of the temporal lobe, the temporal stem, and the limen insulae, as well as the optic radiations and the fronto-occipital connections.

Ethmoidal meningoencephalocele and CSF leak after posthaemorrhagic ventricular dilatation in a newborn child

Rhinoliquorrhoea suggests a communication between the subarachnoid space and the sinonasal tract. Clinical presentation includes clear nasal discharge, headache, pneumocephalus, meningitis or brain abscess. Cerebrospinal fluid (CSF) leaks are mostly of traumatic origin (skull base fractures), iatrogenic (secondary to endoscopic endonasal surgery) or associated with tumour aetiology. Occasionally, hydrocephalus has been the cause of rhinoliquorrhoea in adults, presumably secondary to the chronically raised intracranial pressure with skull base erosion and meningocele. To our knowledge, the association of hydrocephalus and ethmoid meningoencephalocele/CSF leak has not been previously reported in a newborn child. We present the case of a 9-month-old girl who was referred for rhinorrhoea. She had a history of posthaemorrhagic ventricular dilatation. Brain computed tomography (CT) and magnetic resonance imaging (MRI) showed a left ethmoidal meningoencephalocele and small ventricular size. The meningoencephalocele was surgically repaired using an intradural subfrontal approach. During the postoperative period, after the transient lumbar drain was withdrawn, she developed symptomatic hydrocephalus. Ventriculoperitoneal shunting was required. Progressive ventricular dilatation may arise from a meningoencephalocele/CSF leak in paediatric patients. Early identification and repair of the meningoencephalocele are critical to avoid development of complications.

Subfrontal approach for nasal⁃cranial communicans tumor resection with nasal endoscope: analysis of 12 cases

Objective To explore the methods and effects of operation via subfrontal approach with nasal endoscope for removing nasal⁃cranial communicans tumor. Methods Clinical data of 12 patients who underwent operation for nasal⁃cranial communicans tumor via subfrontal approach with nasal endoscope were analysed retrospectively. The lesions included chordoma in 6 cases (extradural, 5; intradural ⁃ extradural, 1), meningioma in 5 cases (intradural ⁃ extradural) and inverted papilloma in one case (extradural). Bilateral frontal coronal incision and frontal craniotomy were performed. Frontal lobe was detached for exposing anterior skull base. Tumor in cranial part was removed by neurosurgeon with microscope, and residual neoplasm in nasal cavity was removed by otorhinolaryngologist with nasal endoscope. Results The tumors were totally removed in 11 cases. Greater part incision was performed in one case. Postoperative complications were mental symptom (one case), cerebrospinal rhinorrhea (2 cases), and hyposmia or anosphrasia (3 cases). Conclusion The subfrontal approach and nasal endoscope is more safe and effective for removing nasal⁃cranial communicans tumor. DOI：10.3969/j.issn.1672-6731.2010.06.013

Clinical analysis of transcranial orbitotomy approach on cranio-orbital tumors.

The aims of this study were to investigate 21 cases of transcranial orbitotomy for cranio-orbital tumors and evaluate the clinical value of the surgical approach. A retrospective study was done on 21 patients with cranio-orbital tumors. According to the tumors' location, shape, boundary, and invasion on the images, coronal scalp flap approach, subfrontal approach, or pterion approach for transcranial orbitotomy was performed. The surgical route was coronal scalp flap approach in 7 cases (including 3 cases combined with lateral orbitotomy), subfrontal approach in 6 cases, or pterion approach in 8 cases (including 1 case combined with evisceration of orbit). Tumors were en bloc resection in 4 cases, block resection or curettage in 13 cases, and incomplete resection in 4 cases. Postoperatively, the mean reduction in exophthalmos was 4 mm; maximum reduction was 11 mm. Ocular movement restriction was made better in 10 of 14 patients, whereas there was no change in 4 of 14 patients. Ophthalmoplegia occurred in 2 cases, complete ptosis occurred in 3 cases, and mydriasis occurred in 3 cases. No vision loss or cerebrospinal fluid leak was observed. Fourteen patients were followed up, including 2 patients with metastatic carcinoma who died dead because of systemic metastasis; 2 patients had a recurrence (schwannoglioma and meningioma). No recurrence was found in the other 10 patients. Cranio-orbital tumors can be removed effectively through transcranial orbitotomy, whereas operative approach is convenient to the surgical procedure and can offer better exposure. Being familiar with the tumors' location, adhesion, and invasion, coupled with the skilled surgical techniques, would improve the results and reduce serious complications.

Outcome Assessment After Surgical Treatment of Tuberculum Sellae Meningiomas- A Preliminary Report.

To evaluate the endocrinological and ophthalmological results of the tuberculum sellae meningioma surgery. MATRRIAL and METHODS: A total of 18 patients diagnosed with tuberculum sellae meningioma received surgical treatment at Neurosurgery Clinic at Military Medical Institute in Warsaw from January 2010 to July 2012. This analyzed group of patients included 15 females and 3 males at a mean age of 50.5 years (ranging from 30 to 73; SD ± 13.4). In the pre-operative and post-operative periods, all patients underwent magnetic resonance imaging of the head according to a uniform protocol, eye examinations with assessment of visual acuity and field of vision, as well as endocrine tests to evaluate the hypothalamic-pituitary axis (including urine specific gravity and osmolality as well as blood cortisol, TSH, fT3, and fT4 levels). All patients underwent surgical treatment of the tumor via unilateral subfrontal craniotomy, achieving macroscopically complete tumor removal (Simpson grade II resection). The use of the unilateral subfrontal approach helped improve vision in 88% of the treated patients. Endocrine tests revealed no hypothalamic-pituitary axis dysfunction. The most commonly diagnosed meningiomas of the area were meningothelial (77%) and transitional (12%) meningiomas. Surgical treatment of tuberculum sellae meningiomas via the unilateral subfrontal approach is a safe technique with no significant complications. Visual improvement was observed in 88% of the patients who had received this treatment. There were no hormonal disturbances in patients operated via the subfrontal approach either prior to or after the procedure, which suggests that surgical treatment of tuberculum sellae meningiomas has no effect on pituitary endocrine function.

The Olfactory Groove Schwannoma Attached to the Cribriform Plate: A Case Report

The olfactory groove schwannoma is a quite rare tumor. We report a case of a 49-year-old woman with an olfactory groove schwannoma attached to the cribriform plate without olfactory dysfunction. She had no specific neurological symptoms other than a headache, and resection of the tumor showed it to be a schwannoma. About 19 months after the operation, a follow-up MRI showed no evidence of tumor recurrence. Surgical resection through subfrontal approach could be one of the curative modality in managing an olfactory groove schwannoma. An olfactory groove schwannoma should be considered in the differential diagnosis of anterior skull base tumors.

Clipping of bilateral MCA aneurysms and a coiled ACOM aneurysm through a modified lateral supraorbital craniotomy

We showcase the microsurgical clipping of a left middle cerebral artery (MCA) aneurysm-(B) done through a modified right lateral supraorbital craniotomy, as well as clipping of a previously coiled anterior communicating (ACOM) artery aneurysm-(C) and a bilobed right MCA aneurysm-(A). Splitting of the right sylvian fissure is initially performed following which a subfrontal approach is used to expose and dissect the contralateral sylvian fissure. The left MCA aneurysm is identified and clipped. The ACOM aneurysm is then clipped following multiple clip repositioning based on flow measurements. The right MCA aneurysm is then identified and each lobe is clipped separately. The first picture showcased in this video is a side to side right and left ICA injection in AP projection. In this picture, (A) points to the bilobed right MCA aneurysm, (B) to the left middle cerebral artery (MCA) aneurysm, and (C) to the previously coiled anterior communicating (ACOM) artery aneurysm. The red dotted line shows that both MCA aneurysms lie within the same plane which makes it easier to clip both of them, through one small craniotomy. The video can be found here: http://youtu.be/4cQC7nHsL5I .

The outcome of bilateral subfrontal approach of large olfactory groove meningioma

Objective The aim of the study was to evaluate the value of bilateral subfrontal approach for management of olfactory groove meningioma focused on preoperative and postoperative investigations for ophthalmologic disturbance. Background Olfactory groove meningiomas arise in the midline along the dura of the cribriform plate and may reach a large size before producing symptoms. There are many surgical approaches such as bilateral subfrontal, unilateral subfrontal, and pterional approaches for this lesion. Patients and methods Over a 3-year period, 20 patients with olfactory groove meningiomas more than 4.5 cm in diameter were operated upon using the bilateral subfrontal approach. Data related to clinical history, symptoms, signs, and outcome were obtained by review of the patient's clinical notes, operative reports, histopathological records, follow-up records, and radiological images. Operative and postoperative events were noted with a follow-up period of 6 months. Results Twenty patients with olfactory groove meningiomas were approached by bilateral subfrontal approach. The most common presenting symptom was headache, which was seen in 16 patients (80%). On admission, five patients (25%) had mental status changes, nine patients (45%) presented with associated visual complaints, and two patients (20%) had epilepsy at presentation. Within the first month after surgery, the postoperative visual acuity was improved in two patients, whereas in seven patients it remained unchanged. In two patients, visual field defects improved and in one patient the defects resolved completely. Conclusion Visual deficits can be improved in patients with olfactory groove meningiomas after a bifrontal approach, after 6 months follow-up period without additional neurological deficits.

Third ventricular cavernoma: Report of two cases.

Sir/Madam, Cerebral parenchyma is the most common site for a cavernoma in the nervous system. Intraventricular cavernomas are rare and constitute 2.5-10.8% of cerebral cavernomas.[1] Third ventricular cavernomas are even rare, only 25 cases have been reported in the literature.[2] We report two more cases of third ventricular cavernomas. The first patient was a 54-year-old man, who presented with acute headache and vomiting. He was unconscious on arrival in casualty. CT scan showed third ventricular hemorrhage [Figure 1a]. He underwent external ventricular drainage, followed by ventriculo-peritoneal (VP) shunt later. An MRI done at 10 days after ictus showed a mixed density lesion with hemorrhagic component occupying the third ventricle with broad base on the floor [Figure 1b]. He underwent tranacallosal-interhemispheric approach and total excision of the lesion. The tumor was arising from the floor of the third ventricle. Histopathology was cavernoma. After surgery the patient developed diabetes insipidus, which was managed with desmopressin. Figure 1 (a) CT scan showing hemorrhage in third ventricle. (b) MRI showing a heterogeneous lesion in the third ventricle with bleed The second patient was a 6-year-old girl who presented with headache and vomiting for 2 months. CT scan showed a calcified in third ventricle with hydrocephalus [Figure 2a]. MRI showed a heterogeneous lesion occupying the entire third ventricle [Figure 2b]. There was no evidence of recent hemorrhage. She underwent VP shunt followed by subfrontal approach, and only partial excision of the lesion as the lesion was densely adherent to the floor of the third ventricle. Histopathology was cavernoma. After surgery she developed transient hyponatremia, which was managed medically. Figure 2 (a) CT scan showing calcified tumor in third ventricle. (b) MRI showing a heterogeneous lesion in the third ventricle Third ventricular cavernomas can present with signs and symptoms of any third ventricular tumors, however they usually present with symptoms of hydrocephalus.[2] Presentation as intraventriuclar hemorrhage is uncommon, and only three cases have been reported.[2] Our first patient presented with hemorrhage, and second with hydrocephalus. They can arise from the suprachiasmatic region, foramen of Monroe, lateral wall or floor of third ventricle.[3] Both of our patients had cavernomas arising from floor of third ventricle. The imaging appearance is that of typical cavernomas. The close differential diagnosis in the absence of hemorrhage is third ventricular craniopharyngioma. The natural history of intraventricular cavernoma is not known. There is a risk of hemorrhage and acute hydrocephalus if the lesion is not excised completely. However, there is risk of hypothalamic damage in case of complete resection of lesion arising from floor of third ventricle, as it happened in our first case. It may be worthwhile doing only a VP shunt for hydrocephalus if the lesion is arising from the floor of the third ventricle.[4]

Endoscopic-Assisted Microsurgical Technique for Management of Anterior Cranial Fossa Lesions Using the Keyhole Supraorbital Approach

Introduction: The priority in neurosurgery is to achieve the greatest therapeutic effect while causing the least iatrogenic injury. The concept of keyhole surgery is based on preoperative study of diagnostic images to determine the anatomic windows that provide access to the pathological processes. The supraorbital subfrontal approach expose the suprasellar anatomic structures free for surgical dissection. The endoscope allows the “surgeon’s eye “to penetrate the depth and width of the access route. Methods: During a 17-year period between 1995 and 2012 we have performed endoscope-assisted microsurgical procedures for: aneurysm 274, anterior cranial fossa meningioma 137, craniopharyngiomas 68, arachnoid cysts 42, astrocytoma 24, epidermoids/dermoid 39, pituitary adenoma 58, germinoma 8, teratoma 11, hamartoma 5. Results: Postoperative complications associated with approach were: supraorbital hypesthesia 17, palsy of the frontal muscle 12, permanent hyposmia in 24, wound healing disturbances 3, CSF collection and leak 11 patients. Conclusion: The supraorbital craniotomy allows a wide exposure for deep-seated intracranial areas it offers equal surgical possibilities with less approach-related morbidity. The optical advantages of the endoscopic visualization in anatomical orientation and tumor removal improve the surgical outcome.