Far-Lateral Transcondylar Approach to a Right Cervicomedullary Dural Arteriovenous Fistula of the Posterior Fossa

Abstract Objectives Dural arteriovenous fistulas (DAVFs) at the cervicomedullary junction are uncommon and often accompanied by subarachnoid hemorrhage (SAH). We aim to illustrate in detail the microsurgical procedure for treating a DAVF located at the cervicomedullary junction. Design We present a two-dimensional operative video that includes clinical history, preoperative imaging, surgical strategy, still images with labels, clinical course, and postoperative imaging. Setting The microsurgery was performed at an academic medical center. Participant The patient is a 55-year-old female who presented with SAH, acute onset headache, nausea, and vomiting. Angiography demonstrated right vertebral artery vasospasm and a persistent arteriovenous shunt at the cervicomedullary junction supplied by small perforating arteries of the right vertebrobasilar junction (Fig. 1). Main Outcome Measures The patient was placed in the park-bench position with the head turned to the contralateral side. A hockey stick incision was made, followed by a right-side far-lateral transcondylar approach. Indocynanine green videoangiography was performed to help identify the areas of arteriovenous shunting. Multiple clips were placed to interrupt vessels that corresponded to arterial feeders at the level of the C1 and C2 nerve root sleeves (Fig. 2). The dura was closed in a water tight fashion and the posterior fossa was reconstructed with a titanium mesh. Results Postoperative imaging showed no evidence of continued arteriovenous shunting. The patient was discharged in good clinical condition with an uneventful postoperative course. Conclusion A deep understanding of the microsurgical vascular anatomy is necessary for successful occlusion of a cervicomedullary DAVF.The link to the video can be found at: https://youtu.be/-LfOcNB05BY.

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Far-lateral transcondylar approach: surgical technique and its application in neurenteric cysts of the cervicomedullary junction

Neurosurgical FOCUS ◽

10.3171/foc.2005.19.2.10 ◽

2005 ◽

Vol 19 (2) ◽

pp. 1-7 ◽

Cited By ~ 17

Author(s):

James K. Liu ◽

William T. Couldwell

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Clinical Presentation ◽

Benign Lesions ◽

Endodermal Cell ◽

Transcondylar Approach ◽

Cervicomedullary Junction ◽

Skull Base Approach ◽

The Central Nervous System ◽

Far Lateral

Neurenteric cysts are rare benign lesions of the central nervous system that are lined by endodermal cell–derived epithelium. Although they occur mostly in the spine, they can occur intracranially, most often in the posterior fossa. Neurenteric cysts that are located in the anterior cervicomedullary junction are even rarer and often require a skull base approach for adequate resection. The authors describe two cases of neurenteric cysts arising from the cervicomedullary junction that were resected via a far-lateral transcondylar approach. They discuss the surgical approach and operative nuances involved in removing these lesions, and review the clinical presentation of neurenteric cysts in this region as well as the neuroimaging characteristics, histopathological findings, and surgical management. Intraoperative videos are presented.

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Disorders Involving a Persistent Craniopharyngeal Canal: A Case Series

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1692638 ◽

2019 ◽

Vol 81 (05) ◽

pp. 562-566

Author(s):

Seerat K. Poonia ◽

Diego Cazzador ◽

Adam C. Kaufman ◽

Michael A. Kohanski ◽

Edward C. Kuan ◽

...

Keyword(s):

Congenital Anomaly ◽

Surgical Repair ◽

Medical Center ◽

Academic Medical Center ◽

Case Series ◽

Cerebrospinal Fluid Leak ◽

Preoperative Imaging ◽

Academic Medical ◽

Craniopharyngeal Canal ◽

Transnasal Endoscopic Repair

Objectives A persistent craniopharyngeal canal (CPC) is a rare embryologic remnant that presents as a well-corticated defect of the midline sphenoid body extending from the sellar floor to the nasopharynx. Our case series aims to describe three unique presentations of this congenital anomaly and their subsequent management.Design Retrospective review.Setting Tertiary academic medical center.Participants Patients who underwent endoscopic transnasal surgical repair of a CPC lesion.Main Outcome Measures Resolution of symptoms and surgical outcomes.Results A total of three patients were identified. The clinical presentation varied, however, all cases prompted further imaging which demonstrated a persistent CPC and associated pathologic lesion. The presentation of a persistent CPC with nasal obstruction and subsequent iatrogenic cerebrospinal fluid leak as in Case 1 demonstrates the importance of imaging in this work-up. Cases 2 and 3 in the series were representative of the larger subset of patients in the literature who present with the defect incidentally but still warrant surgical management. Nonetheless, a standard approach to diagnosis with preoperative imaging and subsequent transnasal endoscopic repair of the skull base defect was undertaken.Conclusion The persistent CPC is a rare congenital anomaly associated with diverse pathology and careful review of preoperative radiology is critical to the management. When warranted, subsequent surgical repair and reconstruction is associated with excellent postoperative outcomes.

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The Influence of Household Income on Survival following Posterior Fossa Tumor Resection at a Large Academic Medical Center

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1715590 ◽

2020 ◽

Author(s):

Rachel Blue ◽

Donald K. Detchou ◽

Ryan Dimentberg ◽

Kaitlyn Shultz ◽

Michael Spadola ◽

...

Keyword(s):

Socioeconomic Status ◽

Brain Tumor ◽

Posterior Fossa ◽

Household Income ◽

Medical Center ◽

Academic Medical Center ◽

Tumor Resection ◽

Academic Medical ◽

Significant Difference

Abstract Objectives The present study examines the effect of median household income on mid- and long-term outcomes in a posterior fossa brain tumor resection population. Design This is a retrospective regression analysis. Setting The study conducted at a single, multihospital, urban academic medical center. Participants A total of 283 consecutive posterior fossa brain tumor cases, excluding cerebellar pontine angle tumors, over a 6-year period (June 09, 2013–April 26, 2019) was included in this analysis. Main Outcome Measures Outcomes studied included 90-day readmission, 90-day emergency department evaluation, 90-day return to surgery, reoperation within 90 days after index admission, reoperation throughout the entire follow-up period, mortality within 90 days, and mortality throughout the entire follow-up period. Univariate analysis was conducted for the whole population and between the lowest (Q1) and highest (Q4) socioeconomic quartiles. Stepwise regression was conducted to identify confounding variables. Results Lower socioeconomic status was found to be correlated with increased mortality within 90 postoperative days and throughout the entire follow-up period. Similarly, analysis between the lowest and highest household income quartiles (Q1 vs. Q4) demonstrated Q4 to have significantly decreased mortality during total follow-up and a decreasing but not significant difference in 90-day mortality. No significant difference in morbidity was observed. Conclusion This study suggests that lower household income is associated with increased mortality in both the 90-day window and total follow-up period. It is possible that there is an opportunity for health care providers to use socioeconomic status to proactively identify high-risk patients and provide additional resources in the postoperative setting.

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Variations in the Anterolateral Thigh Flap's Vascular Anatomy in African Americans

Journal of Reconstructive Microsurgery ◽

10.1055/s-0037-1604087 ◽

2017 ◽

Vol 34 (04) ◽

pp. 300-306 ◽

Cited By ~ 1

Author(s):

Soobin Lim ◽

Noah Atwi ◽

Sarah Long ◽

Aran Toshav ◽

Frank Lau

Keyword(s):

Multinomial Logistic Regression ◽

Medical Center ◽

Academic Medical Center ◽

Vascular Anatomy ◽

Preoperative Imaging ◽

Chi Square ◽

Circumflex Femoral Artery ◽

Organ Systems ◽

Anterolateral Thigh ◽

Arterial Anatomy

Background Variations in anterolateral thigh (ALT) arterial anatomy are well documented. Ethnicity is a known risk factor for vascular variation in several organ systems, but its impact on ALT anatomy has not been studied. Anecdotally, we observed frequent ALT arterial variation in African American (AA) patients. We thus hypothesized that AA patients have higher rates of anomalous branching. Materials and Methods A total of 277 computed tomography angiograms (513 lower extremities) captured between May 1, 2013 and May 31, 2015 at a tertiary academic medical center were retrospectively analyzed to determine ALT arterial branching. Patient records were examined to ascertain demographics. Data were analyzed using descriptive statistics and multinomial logistic regression. Results Males comprised 84.5%. Ethnic distribution was 55.2% AA and 36.5% Caucasian. The descending branch of the lateral circumflex femoral artery (dLCFA) originated from non-LCFA arteries (deep femoral, common femoral, or superficial femoral arteries) in 18.9% of Caucasian versus 9.1% of AA (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.33–3.93, p < 0.01). An oblique branch was identified in 41.1% of Caucasian versus 51.9% of AA (OR: 1.56; 95% CI: 1.08–2.24, p = 0.02). Ethnicity was the only driving factor of dLCFA and oblique branch of the LCFA (oLCFA) anatomy (Wald chi-square: 14 and 11, p = 0.03 and 0.02, respectively). Conclusions Ethnicity significantly affects ALT arterial anatomy. AA are more likely to have classical dLCFA branching with a fourth oLCFA branch. A flap with an unrecognized oLCFA-dominant supply places patients at a higher risk for flap failure and loss. We recommend preoperative imaging before undertaking an ALT flap reconstruction.

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