Search

Objective The extent of the far-lateral approach (FLA) has not yet been quantified for the region of the vertebral and posterior inferior cerebellar arteries (VA-PICA). We quantitatively analyzed six main sequential steps of the FLA. Methods A modified small FLA (msFLA) and a classic large FLA (clFLA) were performed sequentially on both sides of five cadaveric heads. A frameless navigational system was used to quantify the angle of attack for the origin (T1) and lateral medullary segment (T2) of the PICA and the surgical area of exposure above and below the vagus nerve (cranial nerve [CN] X). Results The total area of exposure above CN X increased significantly (p 0.05) from the msFLA to the clFLA. However, the surgical exposure area below CN X did not change (p 0.05). C1 hemilaminectomy increased (p 0.05) the vertical angle of attack, and drilling the posteromedial third of the occipital condyle increased (p 0.05) the horizontal angle of attack to the origin of the PICA. Conclusions For the VA-PICA region, the msFLA offered a similar practical surgical working area and similar angles of attack when compared with the clFLA. The FLA should be tailored based on the location, size, and pathology of lesions and on the exposure required for effective surgical treatment.

Background: The risk of developing immediate postoperative seizures in patients undergoing supratentorial brain tumor surgery without anti-epileptic drug (AED) prophylaxis is 15-20%. Patients who present with pre-operative seizures and patients with supratentorial meningioma or supratentorial low grade gliomas are at significantly higher risk. There is little data on the efficacy of levetiracetam as a prophylactic AED in the immediate postoperative period (within 7 days of surgery) in these patients. Methods: We conducted a retrospective chart review of 165 adult patients classified as higher risk for postoperative seizures who underwent brain tumor resection at Duke University Hospital between time May 2010 and December 2011. All patients had received levetiracetam monotherapy in doses of 1000-3000 mg/day in the immediate postoperative period. Results: We identified 165 patients with following tumor locations: Frontal 83 (50.3%), Temporal 37 (22.4%), Parietal 30 (18.2%), Occipital 2 (1.2%) and 13 (7.8%) with single lesions involving more than one lobe. Histology revealed: Glioma 98 (59.4%), Meningioma 57 (34.5%) and Brain Metastases 6 (3.6%). Preoperatively, 88/165 (53.3%) patients had presented with seizures. 12/165 patients (7.3%) developed clinical seizures (generalized 10, partial 2) in the immediate post-operative period. Other than somnolence in 7 patients (4.2%), no major side-effects were noted. Conclusions: The incidence of seizures was significantly lower in patients treated with levetiracetam (7.3%) when compared with the expected (15-20%) rate without AED prophylaxis based on the previous literature. Levetiracetam appears effective and safe for seizure prevention in patients undergoing brain tumor resection and who are at significantly higher risk of developing post-operative seizures. These findings warrant confirmation in a prospective randomized trial.

Background: Oculomotor nerve palsy (OMNP) is a well-recognized complication of posterior communicating artery (PCOM) aneurysms. Only a few comparative studies have assessed the effect of clipping versus coiling on recovery from OMNP in PCOM aneurysms. A retrospective review and meta-analysis was conducted to assess the relationship between PCOM aneurysm treatment and OMNP. Materials and Methods: Medical records of all patients presenting between January 2000 and February 2013 with intracranial aneurysm were searched. All patients with OMNP secondary to PCOM aneurysm were included for analysis. Patients undergoing surgical clipping or endovascular coiling were compared with respect to complete resolution of OMNP after aneurysm surgery (i.e., primary outcome). A meta-analysis of published studies of OMNP associated with PCOM aneurysm was performed after a MEDLINE search. Results: Seventeen patients with OMNP secondary to PCOM aneurysms met the inclusion criteria. Surgical clipping (seven of eight patients, or 87.5%) resulted in greater complete resolution of OMNP compared with endovascular coiling (four of nine patients, or 44.4%), P = 0.13. A meta-analysis of similar studies revealed that complete resolution of OMNP was more commonly associated with surgical clipping (36 of 43 patients, or 83.7%) than with endovascular coiling (29 of 55 patients, or 52.7%), yielding an adjusted odds ratio (OR) of 6.04 [confidence interval (CI) =1.88-19.45, P = 0.003]. Multivariate analysis found that the degree of pre-operative OMNP (OR = 0.07, CI = 0.02-0.28, P = 0.001) and surgical clipping (OR = 6.37, CI = 1.73-23.42, P = 0.005) were significant factors that affected the complete recovery of OMNP. Conclusion: Complete recovery of OMNP with PCOM aneurysms is more commonly associated with surgical clipping than with endovascular coiling. Also, the degree of pre-operative OMNP and the treatment modality are significant factors that affect the complete recovery of OMNP.

Sudden intraoperative hemorrhage during intracranial aneurysm surgery from vascular injury or aneurysmal rupture has been known to dramatically increase the associated morbidity and mortality. We describe the first reported use of rapid ventricular pacing (RVP) assisted hypotension to control sudden intraoperative hemorrhage during intracranial aneurysm surgery where temporary arterial occlusion was not achievable.

We present a case of tongue necrosis due to intraoperative pressure injury. A laryngeal mask airway with adhesive electrodes was inserted into the oropharynx, over an endotracheal tube, to facilitate glossopharyngeal nerve monitoring during craniotomy for a cerebellopontine angle tumor. The case, mechanisms of injury, and modifications to our current practice are discussed.

Introduction: Carotid-cavernous fistulas (CCFs) are arteriovenous fistulas (AVFs) between the carotid artery or its branches and the adjacent cavernous sinus. The purpose of this report is to present a case of recurrent indirect CCF presenting 47 years after previous operative trapping of the ICA for traumatic direct CCF, the longest reported recurrence to date. Methods: A spontaneous recurrence of indirect carotid-cavernous fistula presented 47 years following initial surgical trapping of the internal carotid artery for traumatic direct carotid-cavernous fistula. Results: The patient was successfully treated with an orbitozygomatic extended middle cranial fossa approach for direct petrous internal carotid artery clip ligation after failure of percutaneous embolization techniques. Conclusions: CCFs can be difficult entities to treat, requiring extensive knowledge and experience with both potential endovascular and surgical options. In addition, recurrences are not uncommon and may present remotely from initial treatment and with different anatomical configurations. This also represents, to our knowledge, the first case reported that required direct petrous carotid ligation to treat the fistula after all endovascular and standard approaches were attempted or not plausible. Clinicians must be aware of these possibilities and ensure close follow-up to guarantee long-term occlusion.