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Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature.

Nayak NR, Thawani JP, Sanborn MR, Storm PB, Lee JY - Surg Neurol Int (2015)

Bottom Line: Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII.The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not.It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104.

ABSTRACT

Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas.

Case descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility.

Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

No MeSH data available.


Related in: MedlinePlus

The endoscope, stabilized by the Mitaka pneumatic holding arm, allowing the surgeon to operating using with both hands
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Figure 13: The endoscope, stabilized by the Mitaka pneumatic holding arm, allowing the surgeon to operating using with both hands

Mentions: For endoscopic endonasal procedures at our institution, the ear, nose, and throat (ENT) surgeon performs the approach and then moves to the patient's left side and works through the left nostril, while the neurosurgeon simultaneously stands on the patient's right side and works through the right nostril. Both surgeons operate with 2 hands. The ENT surgeon generally controls the endoscope, allowing the neurosurgeon to use both hands for dissection. In the retrosigmoid and supracerebellar/infratentorial approaches, the neurosurgeon operates alone using 2 hands for dissection. The endoscope is stabilized by the Mitaka pneumatic holder [Figure 13], which is anchored to the side of the operating table facing the anesthesiologist.


Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature.

Nayak NR, Thawani JP, Sanborn MR, Storm PB, Lee JY - Surg Neurol Int (2015)

The endoscope, stabilized by the Mitaka pneumatic holding arm, allowing the surgeon to operating using with both hands
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4418103&req=5

Figure 13: The endoscope, stabilized by the Mitaka pneumatic holding arm, allowing the surgeon to operating using with both hands
Mentions: For endoscopic endonasal procedures at our institution, the ear, nose, and throat (ENT) surgeon performs the approach and then moves to the patient's left side and works through the left nostril, while the neurosurgeon simultaneously stands on the patient's right side and works through the right nostril. Both surgeons operate with 2 hands. The ENT surgeon generally controls the endoscope, allowing the neurosurgeon to use both hands for dissection. In the retrosigmoid and supracerebellar/infratentorial approaches, the neurosurgeon operates alone using 2 hands for dissection. The endoscope is stabilized by the Mitaka pneumatic holder [Figure 13], which is anchored to the side of the operating table facing the anesthesiologist.

Bottom Line: Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII.The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not.It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104.

ABSTRACT

Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas.

Case descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility.

Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

No MeSH data available.


Related in: MedlinePlus