Search

Long-term effects of endoscopic endonasal transsphenoidal intracapsular debulking and adjuvant somatostatin analogs (SSAs) were evaluated in patients with growth hormone- (GH) secreting pituitary macroadenomas. We retrospectively reviewed the medical records of 45 patients with acromegalic macroadenoma who underwent endonasal endoscopic transsphenoidal intracapsular debulking and received adjuvant SSAs (octreotide) between 2006 and 2015 who had >1 year of follow-up. To evaluate the predictive factors for 1 year and long-term biochemical outcomes, univariate and multivariate analyses were performed. Biochemical remission was achieved in 1 year in 20 of the 45 (44.4%) patients, and in 31 of the 45 patients after long-term adjuvant SSA treatment. Tumor control was achieved in 43 of the 45 (93.3%) patients. The univariate analysis showed age (≥55 years), tumor size (diameter ≤1.5 cm), premedication GH levels (≤2.8 ng/mL), premedication insulin-like growth factor 1 levels (≤2-fold of upper limit of normal range), cavernous sinus invasion (Knops grades 2, 3, and 4), and near-total tumor resection were associated with long-term outcomes. The multivariate analysis showed near-total resection was a significant predictor for long-term outcomes (P = 0.019). There were no new pituitary dysfunctions. The observed complications included one case of cerebrospinal fluid leakage and one case of epistaxis requiring intervention. Intracapsular debulking and adjuvant SSAs are a safe and viable treatment for patients with GH secreting pituitary macroadenoma to achieve biochemical remission and tumor control. Although adjuvant SSA treatment enhances residual tumor control, cavernous sinus invasion impedes the remission of endocrine tumors. [ABSTRACT FROM AUTHOR]

Aneurysmal bone cysts (ABCs) are a rare, vascular, rapidly growing, benign, osteolytic lesions. Most ABCs involve the metaphysis of long bones, vertebrae, or flat bones. In this study, we review the literature to better understand the natural history, clinical presentation, and treatments. A 34-year-old man who presented with left intermittent otorrhea for months. Yellowish, pus-like discharge was noted. Mild tinnitus, hearing loss, and occasional headache was also found. The initial impression was chronic otitis media and ear drops were prescribed. However, his symptoms did not improve in the following months. The brain MRI with gadolinium enhancement revealed an extra-axial mixed signal intensity lesion on the T2-weighted image, multiloculated cystic components and rim enhancement was noted over the left middle cranial fossa. Left fronto-temporal craniotomy for tumor removal was performed. The pathological reports revealed an aneurysmal bone cyst. Typically, ABCs present with localized swelling and pain due to their rapid growth and expansion, with concomitant signs corresponding with the anatomical location of the lesion. MRI studies can reveal the cystic components of the lesion and multiple fluid levels within multiloculated cysts resulting from unclotted blood, separated from the soft tissue and medullary bone. Histopathologic diagnosis of ABC is the presence of multiple blood-filled cystic spaces separated by fibrous septa. The fibrous septa are composed of spindle-celled fibroconnective tissue with occasional osteoclast-type giant cells. ABCs are a rare, osteolytic lesions that rarely involve the skull. When the MRI shows a lesion with soap-bubble appearance in the calvaria, an aneurysmal bone cyst should be considered in the differential diagnosis, even if it is an extremely rare entity or the patient is relatively old. Surgical resection of the tumor is the first choice for treatment. • Aneurysmal bone cysts are rare, vascular, rapidly growing, benign, osteolytic lesions that rarely involve the skull. • Preoperative diagnosis of ABCs from another osteolytic lesion of the cranium is difficult. However, MRI shows the characteristics of the tumor, which include a multiloculated, expansile bony lesion with fluid–fluid levels in one or more granular spaces and a hypointense circular rim surrounding the entire lesion, an aneurysmal bone cyst should be considered, even if it is an extremely rare entity or the patient is relatively old. • Complete surgical resection of the tumor is the first choice for treatment if its location is assessed. Possible reconstruction after resection and postoperative adjunctive therapy for the complex lesion is an important issue to prevent tumor recurrence and restore neurological function. [ABSTRACT FROM AUTHOR]

Pituicytomas are low-grade glial tumors in the sellar and suprasellar region. They may be easily confused with pituitary lesions. We review the literature in order to better understand and categorize the natural history, clinical presentations, and treatments. A 45-year-old female patient who complained of left eye blurred vision for 2 months. The imaging study revealed a solid sellar tumor with marked homogeneous enhancement following intravenous administration of gadolinium, and compression of the optic chiasm. Thus, under the preoperative diagnosis of pituitary macroadenoma, the patient underwent endoscope-assisted surgery via the transsphenoidal approach. The patient recovered well after surgery. The histopathological diagnosis was pituicytoma, WHO grade I. Pituicytomas are defined as a circumscribed low-grade glial tumor arising from the neurohypophysis or infundibulum with bipolar spindle cells arranged in a fascicular or storiform pattern (a cartwheel). The clinical symptoms are variable depending on the tumor size and location. They usually present due to mass effect. The radiographic characteristics are not nonspecific. The diagnosis of pituicytoma is based on histopathological evidence. Pituicytomas consist of a solid proliferation of elongated spindle cells arranged in interlacing fascicles and/or in a "storiform" pattern. In immunohistochemical studies, pituicytomas was strongly expressed in TTF-1. Pituicytomas are benign, slow-growing glial tumors. It is difficult to diagnosed before operation as its clinical presentations and imaging studies resemble those of non-functional pituitary adenomas. The best chance of successful treatment is gross total resection by the endoscopic approach or transcranial approach. • Pituicytomas are rare benign tumors arising from the neurohypophysis or infundibulum. • They are often mistaken for pituitary adenomas which have a similar clinical presentations and imaging findings. • The diagnosis of pituicytoma is based on histopathological evidence. In immunohistochemical studies, pituicytomas was strongly expressed in TTF-1. • Complete resection of the tumor is the main treatment for pituicytoma. The choice of surgical route used may depended on the tumor size, whether invasion to other structures has occurred, and the technique of the surgeon. [ABSTRACT FROM AUTHOR]

Several meningioma cases arising through Meckel's cave (MC) at the middle and posterior fossa have been reported. However, few relevant meningiomas have been observed with a dumbbell shape. We report a rare case of a 36-year-old woman with a meningioma of MC with a typical dumbbell-shaped, schwannoma-like presentation on magnetic resonance imaging (MRI), resulting in a misleading differential diagnosis. In this case report, we discuss the characteristics of meningioma of MC observed on MRI and our surgical approach to this condition. This tumor was able to mimic a trigeminal schwannoma both clinically and radiographically. This case report has been reported in line with the SCARE 2020 criteria [1]. • A dumbbell-shaped meningioma of MC was able to mimic a trigeminal schwannoma both clinically and radiographically. • An endoscope-assisted keyhole approach to the skull base is a more promising approach due to the improved visualization with a small incision. [ABSTRACT FROM AUTHOR]

Intracranial collision tumors are rare diseases in which two distinct neoplasms are found at the same location. We present an unusual case of an intracranial collision tumor composed of atypical meningioma (WHO grade II) and glioblastoma. The case was a 56-year-old woman hospitalized due to generalized weakness and dizziness. Imaging survey revealed a right frontal lobe extra-axial mass with significant perilesional edema. The patient underwent a one-stage craniotomy for tumor removal. The pathology revealed collision brain tumors of clear cell atypical meningioma (WHO grade II) and glioblastoma. The patient had an uneventful postoperative recovery. The mechanism behind collision brain tumors remains unclear, and some experts consider these tumors sporadic events. Further research is needed to optimize preoperative diagnosis and surgical strategy for collision brain tumor patients. Surgeon should consider intracranial collision tumors when brain image indicated unusual perilesional edema of meningioma. Though there is no standard treatment for these patients, it seems one-staged surgical treatment is feasible. To our knowledge this is the first case of collision tumors with clear cell atypical meningioma (WHO grade II) and glioblastoma. • Intracranial collision tumors are very rare disease that two different histological types are in the same location • We present a case of collision brain tumor composed of two malignancies with clear cell type atypical meningioma (WHO grade II) and glioblastoma • Brain MRI showing an extradural lesion with disproportionate perilesional edema, collision tumor should be considered • Intraoperative frozen section diagnosis can be confused if not aware of the disease [ABSTRACT FROM AUTHOR]

Abstract: This study used a biodegradable composite containing genipin-cross-linked gelatin annexed with β-tricalcium phosphate ceramic particles (genipin-gelatin-tricalcium phosphate, GGT), developed in a previous study, as a nerve guide conduit. The aim of this study was to analyse the influence of a large-area irradiated aluminium–gallium–indium phosphide (AlGaInP) diode laser (660nm) on the neural regeneration of the transected sciatic nerve after bridging the GGT nerve guide conduit in rats. The animals were divided into two groups: group 1 comprised sham-irradiated controls and group 2 rats underwent low-level laser (LLL) therapy. A compact multi-cluster laser system with 20 AlGaInP laser diodes (output power, 50mW) was applied transcutaneously to the injured peripheral nerve immediately after closing the wound, which was repeated daily for 5min for 21 consecutive days. Eight weeks after implantation, walking track analysis showed a significantly higher sciatic function index (SFI) score (P <0.05) and better toe spreading development in the laser-treated group than in the sham-irradiated control group. For electrophysiological measurement, both the mean peak amplitude and nerve conduction velocity of compound muscle action potentials (CMAPs) were higher in the laser-treated group than in the sham-irradiated group. The two groups were found to be significantly different during the experimental period (P <0.005). Histomorphometric assessments revealed that the qualitative observation and quantitative analysis of the regenerated nerve tissue in the laser-treated group were superior to those of the sham-irradiated group. Thus, the motor functional, electrophysiologic and histomorphometric assessments demonstrate that LLL therapy can accelerate neural repair of the corresponding transected peripheral nerve after bridging the GGT nerve guide conduit in rats. [Copyright &y& Elsevier]

Abstract: In 1995 a government-supported Universal National Health care system was implemented in Taiwan, which in 2008 was available to 98% of the population. This system offers affordable, rapid medical attention. A multi-center retrospective study was conducted to assess the prognosis of malignant glioma patients under this system. In 2005 and 2006, patients at 14 independent neuro-oncology centers with newly diagnosed malignant glioma were enrolled. The patient profile, pathology, treatment modalities, and prognosis were collected by questionnaire at each center. The Taiwan Neuro-Oncology Society was responsible for the data analysis. The overall median survival period, 1-year survival rate, and 2-year survival rate for patients with World Health Organization grade III glioma were 33.8 months, 81.4%, and 58.2%, respectively, and 15 months, 57.3%, and 33.9% in patients with grade IV glioma. The median survival period, 1-year survival rate, and 2-year-survival rate in patients receiving temozolomide adjuvant therapy was 36 months, 84.2%, and 61.8%, respectively, for patients with grade III glioma and 19.8 months, 73.1%, and 43.7%, for patients with grade IV glioma. The universal health care system in Taiwan offers a comparable prognosis with an affordable premium relative to other large series in developed countries. [Copyright &y& Elsevier]

Abstract: We compared the preliminary outcomes of cervical fusion performed using radiolucent cages containing either cancellous bone or hydroxyapatite graft. From July 2004 to June 2006, 45 consecutive patients presented with a total of 109 levels of degenerative disc disease between the C2 and C7 levels. Each patient underwent anterior cervical discectomy and fusion (ACDF) for each affected cervical disc. The retrospective analysis of the cage fillers was divided into group 1 (23 patients with 56 affected cervical levels) who received cages packed with cancellous bone marrow, and group 2 (22 patients with 53 affected cervical levels) who received cages packed with hydroxyapatite graft. Bone marrow was harvested from the anterior iliac crest. The Prolo scale was used to assess both the economic and functional status postoperatively. The Yates’ correction to test independence in a contingency was used to compare the fusion rate of both groups post-operatively at day 1 and at 1, 3 and 6 month follow-up. At a mean follow-up of 12 months, the fusion rates observed in groups 1 and 2, respectively, were 21.4% and 13.2% after 1month, 76.8% and 64.2% after 3 months, and 98.2% and 96.2% after 6 months. Functional and economic status were better in group 2, with a statistical significance (p<0.05) observed at the 3-month follow-up. Although hydroxyapatite graft is an osteoconductive, rather than osteoinductive, material, when used as a cage filler it is a safe and efficient substitute for cancellous bone. [Copyright &y& Elsevier]

Abstract: Ganglion cysts of the spine are uncommon. They occur mostly in the dorsolateral trunk and arise with the greatest frequency in the lumbar spine. However, they are rarely symptomatic. We report a rare case of a patient with a ganglion cyst of the lower cervical spine presenting with acute Brown-Sequard syndrome. The patient had no history of trauma. Magnetic resonance imaging of the cervical spine showed a cystic lesion connecting to the synovial joint C6–7 and compressing the posterior aspect of the spinal cord. The patient underwent emergent C6–7 laminectomy with total removal of the cyst. Neurological function recovered completely 4 months after operation. Ganglion cysts should be considered in the differential diagnosis of an extradural mass of the cervical spine. Magnetic resonance imaging provides a rapid and correct diagnosis, and laminectomy with removal of the cyst results in good neurological recovery. [Copyright &y& Elsevier]

Summary: Interleukin-6 (IL-6) is frequently produced in gliomas and has been implicated as a mediator of growth control in several human neoplasms. In this study, IL-6 expression was examined in 11 surgically resected glioblastomas and a cell line U87MG by immunohistochemical staining and quantitative real-time RT-PCR. The relationships between IL-6 expression level and clinical presentation, survival, imaging findings, age and preoperative Karnofsky performance status were analyzed. The median survival times were 16 months in patients with negative IL-6 expression and 7 months in those with positive IL-6 expression (P =0.075). Three of these patients with a relatively longer survival time (>1 year) did not express IL-6 in the tumor. Relatively more severe peri-focal edema on imaging was also noted in the glioblastomas with IL-6 expression. IL-6 was also found in the cytoplasm of endothelial cells of newly formed vessels and infiltrating inflammatory cells. These preliminary results implicate IL-6 expression as a possible prognostic indicator in glioblastoma. This cytokine may also play a role in tissue edema, angiogenesis and inflammation of this tumor, but whether IL-6 expression promotes malignancy is uncertain. [Copyright &y& Elsevier]

Summary: A 53-year-old female with a functioning pituitary adenoma was found to also have an unruptured asymptomatic aneurysm in the cavernous sinus portion of the internal carotid artery on MRI. The adenoma had a suprasellar extension with optic chiasm compression and extended into the right cavernous sinus. An aneurysm-like flow-void adjacent to the left internal carotid artery in the sella and embedded in the adenoma was also found. The aneurysm was confirmed by conventional angiography. We used a right fronto-pterional approach to clip the aneurysm and to remove the pituitary tumor in a one-stage procedure. The outcome was good on long-term follow-up. It is important to thoroughly evaluate the anatomic relations around the sella turcica prior to procedures with limited exposure, including transsphenoidal surgery, to avoid unrecognized complications and morbidity. [Copyright &y& Elsevier]

Abstract: Background: Intracranial lipomas are thought to be congenital in origin and are very rare, representing 0.1% to 1.7% of all intracranial tumors. Most ICLs are located at midline. Lipomas at sylvian fissure are extremely rare. They are slow growing, and biological course is favorable even without surgical treatment. A Medline search of the literature from 1965 to 2007 revealed only 13 cases of sylvian fissure lipomas reported. Of 9 patients with sylvian fissure lipoma diagnosed during life, 6 patients were operated on with no mortality and got improvement of symptoms. Surgical intervention should be considered if there are problems such as compressive effect or resistance to anticonvulsive medical treatment. Case Description: We report a 57-year–old woman with a sylvian fissure lipoma presenting with persistent intractable headache. Imaging study showed a lobular nonenhanced lesion associated with abnormal vessels in the right sylvian fissure. The patient underwent minimally invasive pterion keyhole approach, and the lipoma was successfully and totally removed. Headache and subsided postoperatively. Conclusions: There are only few cases of sylvian fissure lipomas in which surgical excision has been attempted. Because of improvement of microsurgical techniques, direct surgical approach with total removal of lipomas, via a minimally invasive pterion keyhole approach, is feasible. Therefore, it should be kept in mind that the primary goal of the surgery is adequate decompression; and total removal may be achieved if the lesion permits. [Copyright &y& Elsevier]

Glioblastoma is the most common and most aggressive primary brain malignancy. The multimodality treatments for this tumor including surgery, radiotherapy, and chemotherapy, are still not completely satisfied. Phenethyl isothiocyanate (PEITC), one member of the isothiocyanate family, has been shown to induce apoptosis in many human cancer cells. In this study, we investigate the pro-apoptotic effects caused by PETIC in human brain glioblastoma multiforme GBM 8401 cells. In our data, PEITC induced the cell morphological changes and decreased the cell viability of GBM8401 cells in a dose- and time-dependent manner. Moreover, the analysis of cell cycle distribution detected by flow cytometry showed that PEITC induced significantly sub-G1 phase (apoptotic population) in GBM 8401 cells. In addition, PEITC promoted the production of reactive oxygen species (ROS) and increase in [Ca2+]I, but decreased the mitochondrial membrane potential (ΔΨm) in treated cells. PEITC also induced caspases activities in GBM 8401 cells. Results from Western blot analysis indicated that PEITC promoted Fas, FasL, FADD, TRAIL, caspase-8, -9, -3, increased the pro-apoptotic protein (Bax, Bid and Bak), and inhibited the anti-apoptotic proteins (Bcl-2 and Bcl-xl) in GBM 8401 cells. Furthermore, PEITC promoted the release of cytochrome c, AIF and Endo G. GADD153, GRP 78, XBP-1 and IRE-1α, Calpain I and II in GBM 8401 cells. PEITC also promoted the expression of associated protein with endoplasmic reticulum (ER) stress. PEITC induces apoptosis through the extrinsic (death receptor) pathway, dysfunction of mitochondria, ROS induced ER stress, intrinsic (mitochondrial) pathway in GBM 8401 cells. The possible molecular mechanisms and signaling pathways of the anti-cancer properties of PEITC for human brain glioblastoma cells were postulated. [ABSTRACT FROM AUTHOR]

Summary Background Cilengitide is a selective αvβ3 and αvβ5 integrin inhibitor. Data from phase 2 trials suggest that it has antitumour activity as a single agent in recurrent glioblastoma and in combination with standard temozolomide chemoradiotherapy in newly diagnosed glioblastoma (particularly in tumours with methylated MGMT promoter). We aimed to assess cilengitide combined with temozolomide chemoradiotherapy in patients with newly diagnosed glioblastoma with methylated MGMT promoter. Methods In this multicentre, open-label, phase 3 study, we investigated the efficacy of cilengitide in patients from 146 study sites in 25 countries. Eligible patients (newly diagnosed, histologically proven supratentorial glioblastoma, methylated MGMT promoter, and age ≥18 years) were stratified for prognostic Radiation Therapy Oncology Group recursive partitioning analysis class and geographic region and centrally randomised in a 1:1 ratio with interactive voice response system to receive temozolomide chemoradiotherapy with cilengitide 2000 mg intravenously twice weekly (cilengitide group) or temozolomide chemoradiotherapy alone (control group). Patients and investigators were unmasked to treatment allocation. Maintenance temozolomide was given for up to six cycles, and cilengitide was given for up to 18 months or until disease progression or unacceptable toxic effects. The primary endpoint was overall survival. We analysed survival outcomes by intention to treat. This study is registered with ClinicalTrials.gov , number NCT00689221 . Findings Overall, 3471 patients were screened. Of these patients, 3060 had tumour MGMT status tested; 926 patients had a methylated MGMT promoter, and 545 were randomly assigned to the cilengitide (n=272) or control groups (n=273) between Oct 31, 2008, and May 12, 2011. Median overall survival was 26·3 months (95% CI 23·8–28·8) in the cilengitide group and 26·3 months (23·9–34·7) in the control group (hazard ratio 1·02, 95% CI 0·81–1·29, p=0·86). None of the predefined clinical subgroups showed a benefit from cilengitide. We noted no overall additional toxic effects with cilengitide treatment. The most commonly reported adverse events of grade 3 or worse in the safety population were lymphopenia (31 [12%] in the cilengitide group vs 26 [10%] in the control group), thrombocytopenia (28 [11%] vs 46 [18%]), neutropenia (19 [7%] vs 24 [9%]), leucopenia (18 [7%] vs 20 [8%]), and convulsion (14 [5%] vs 15 [6%]). Interpretation The addition of cilengitide to temozolomide chemoradiotherapy did not improve outcomes; cilengitide will not be further developed as an anticancer drug. Nevertheless, integrins remain a potential treatment target for glioblastoma. Funding Merck KGaA, Darmstadt, Germany. [ABSTRACT FROM AUTHOR]

Abstract: Background: We performed endoscope-assisted MVD or fully endoscopic MVD for minimizing the risks of brain retraction and extensive dissection and got good results. In addition, we highlighted the value of endoscopy in the diagnosis and therapy for cranial nerve pathologic condition in the posterior fossa. Methods: Among 300 consecutive patients with microsurgically treated HFS, 32 patients underwent endoscope-assisted MVD or fully endoscopic MVD through the retromastoid approach between July 1998 and December 2002, at the Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC. The use of endoscopes is indicated for patients who had difficulty in identifying the nerve-vessel conflicts. Results: The procedure was successful in 96.9% of patients and improved in 3.1%. No failure or recurrence was noted. The postoperative complications were found in 2 patients who were treated by endoscope-assisted MVD. One patient (3.1%) showed delayed facial palsy on the seventh day but was fully recovered 2 months later. Hearing impairment was noticed in one patient (3.1%). There was no perioperative mortality. Conclusion: From our experience, we conclude that the endoscope''s superior visualization more accurately identifies neurovascular conflicts and provides a comprehensive evaluation of the completeness of the decompression. In addition, this method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. Endoscopes are good as an adjunctive imaging modality to confirm nerve-vessel conflicts identified by the microscope and to reveal others that escaped from microscopic survey. [Copyright &y& Elsevier]

Abstract: Background: Previous reports of the efficacy of percutaneous pulsed radiofrequency have been confounded by fewer case numbers, poor patient selection, and limited data on cervical or lumbar radicular pain. We used percutaneous pulsed radiofrequency for cervical and lumbar radicular pain, and the study has more than 100 cases for the analysis of the efficacy of percutaneous pulsed radiofrequency. Methods: We collected 154 cases of patients with lumbar or cervical radicular pain due to a herniated intervertebral disk or previous failed surgery. They underwent pulsed radiofrequency therapy in 2 to 4 spinal levels unilaterally. Follow-up period was from 1 week to 1 year postoperatively. Results: Twenty-six (53.06%) of 49 patients and 59 (50.86%) of 116 patients after cervical and lumbar pulsed radiofrequency stimulation, respectively, had an initial improvement of 50% or more in the first week of follow-up. Twenty-seven (55.10%) of 49 patients and 52 (44.83%) of 116 patients after cervical and lumbar pulsed radiofrequency stimulation, respectively, had pain relief of 50% or more at the follow-up period of 3 months. In the analysis of patients with pain relief of 50% or more for at least 1 month, the most effective period was during postoperation 1 month later. No complication was found among these patients. Conclusions: The results of this retrospective analysis showed that the application of pulsed radiofrequency is a safe and useful intervention for cervical and lumbar radicular pain. The satisfactory pain relief obtained by most of our patients justifies the start of this study for at least 6 months. Although pulsed radiofrequency appears to provide intermediate-term relief of pain, further studies with long-term follow-up are necessary. [Copyright &y& Elsevier]

Abstract: Background: Spinal osteomyelitis and epidural abscess are complicated medical conditions. Diagnosis is often delayed because of cormorbidity. The time of instrumentation is still controversial. However, there is no doubting the indication of spinal hardware implantation when spinal fusion is needed. Long segment osteomyelitis and extended epidural abscess are rare. The treatment is challenging for neurosurgeons. We report a case of extended epidural abscesses and long segments of osteomyelitis. Methods: One-stage meticulous debridement, anterior cervical corpectomies, and spinal fusion with mesh cage and titanium plate were performed on the patient. Hyperbaric oxygenation and 6 weeks of intravenous antibiotics were prescribed as adjuvant therapy. Results: Both clinical presentations and imaging studies showed a good response to the treatment. The patient returned to his life 3 months later. Conclusions: This case illustrates that spinal instrumentation is not an absolute contraindication in the presence of epidural abscesses and vertebral osteomyelitis. Combined surgical debridement at a critical level, with adjuvant antibiotics and hyperbaric oxygenation, is a safe and effective therapy in those with neurologic deficits, spinal instability, and extended epidural abscess. [Copyright &y& Elsevier]

Hemifacial spasm caused by an elongated, tortuous, or enlarged vertebral artery (VA) can be difficult to treat. Greater rates of incomplete cure also have been noted. 1-6 In this video, we demonstrate the key steps of a simple and effective adjustable sling technique of an ectatic VA transposition for microvascular decompression. In this patient, an ectatic VA was stacked on the posterior inferior cerebellar artery, and together they compressed the root exit zone (REZ) of the facial nerve. We cut a suturable and unabsorbable artificial dural graft into a sling. The rougher side of the sling was used to wrap around the VA to obtain more friction and avoid sliding. Suitable width of the sling was determined to prevent prominent indentation on the VA. We wrapped the VA at a perforator-free zone and lifted the VA away from the REZ by pulling the sling in a lateral direction. At the same time, the anchor point for the aneurysm clip to hold the sling at the lateral skull base also was determined. We made a small dural incision at the anchor point, where an aneurysm clip was applied to hold the sling securely under tension but not to cause kinking of the VA/posterior inferior cerebellar artery. The patient had no hemifacial spasm immediately after the operation and thereafter. This adjustable sling technique provides an easy and strong hold to maintain an ectatic VA away from the REZ of the facial nerve (Video 1). [ABSTRACT FROM AUTHOR]

Abstract: Background: Gunshot accidents are not uncommon in Taiwan, but involvement limited to the ocular region and sphenoid sinus is rare. Minimal invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure should be considered if there are no additional injuries in the craniocerebral region. Case Description: A 39-year–old man had severe pain in the left eye with resulting blindness after being accidentally hit in the left eye by a gunshot pellet while walking in a wooded area. He was referred from another hospital with the impression of left eyeball rupture. There was no severe neurologic deficit except for blindness of the left eye when he arrived at the emergency department of our hospital. Brain and orbits CT scans showed a round metallic foreign body at the right sphenoid sinus without predominant damages of brain parenchyma. Endonasal transsphenoidal endoscopy-assisted procedure was used to remove the shotgun pellet, and the patient had good clinical outcomes. Conclusion: Herein we present this rare case to show the possibility of a shotgun pellet injury remaining in the sphenoid sinus. The role of radiological studies such as CT scans and intraoperative C-arm fluoroscope plain films in diagnosis and management of this case is affirmed. The strategy of minimally invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure for those limited injuries is a good choice for treatment. [Copyright &y& Elsevier]