Medial Acoustic Tumors: Special Considerations: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Rami O Almefty ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Surgical Resection ◽  
Internal Auditory Canal ◽  
Distinct Type ◽  
Mass Effect ◽  
Hearing Preservation ◽  
Neurological Deficits ◽  
Cystic Tumor ◽  
Brainstem Compression ◽  
Acoustic Tumor ◽  
Giant Size

Abstract Medial acoustic tumors are a rare distinct type of vestibular schwannoma having distinguished clinical and radiological features.1 Originating medially in the cerebellopontine angle without extending into the lateral internal auditory meatus, they are frequently giant in size at presentation in younger patients with a relatively preserved hearing, while they have other neurological deficits from cerebellar or brainstem compression and associated hydrocephalus. Imaging typically shows a cystic tumor with local mass effect and an internal auditory canal filled with cerebrospinal fluid.1,2 Surgical resection of theses schwannoma is particularly challenging not only due to their size and hypervascularity, but also given their particular arachnoidal rearrangement inducing marked adherence to the brainstem and facial nerve.2  The treatment is surgical resection, despite, however, their giant size hearing preservation should be sought and is attainable.1–5 Transmastoid approach with squeletonization and reflection of the transverse sigmoid sinus provides lateral exposure avoiding cerebellar retraction.6 In this report, we demonstrate the specific surgical considerations applied to the resection of a giant medial acoustic tumor in a 40-yr-old patient presenting with ataxia, vertigo, facial paresthesia, and intact hearing. The patient agreed to the surgery and photography.  Image at 1:44 © Ossama Al-Mefty, used with permission; Image at 8:21 from Dunn et al,2 used with permission from JNSPG.

“Save the Nerve”: Technical Nuances for Hearing Preservation and Restoration in Vestibular Schwannoma Surgery: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Rami O Almefty ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Hearing Loss ◽  
Cochlear Implants ◽  
Surgical Resection ◽  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Cochlear Nerve ◽  
Severe Hearing Loss ◽  
Significant Disability ◽  
Microsurgical Resection

Abstract Hearing loss is a significant disability that inflects dysfunction and affects the patient quality of life. Consequently, hearing preservation and the potential of hearing restoration are prized quests in the management of vestibular schwannoma.1 Although small intracanalicular vestibular schwannomas are commonly observed, progressive hearing loss occurs despite the absence of tumor growth; hence, surgical resection can be performed with the sole aim of hearing preservation in well-informed and eager patients. Hearing preservation by surgical resection has proven to be durable.1-4 In this group of patients, we concur with Yamakami et al2 that vascularized meatal flap to reconstruct the canal helps prevent scarring of the cochlear nerve and provides cerebrospinal fluid (CSF) bathing to the cochlear nerve, yielding better long-term hearing preservation.  With larger tumors and more severe hearing loss at presentation, microsurgical resection should aim at preserving the cochlear nerve, a goal frequently achievable, which offers the potential for hearing restoration with cochlear implants.3 The results of cochlear implants in restoration of severe hearing loss have been to say the least most impressive.5 We demonstrate these 2 frequently encountered clinical situations with 2 surgical videos showing specific surgical tenets, including intra-arachnoidal dissection, medial to lateral manipulation of the tumor, preservation of the labyrinthine artery, as well as reconstruction of the internal auditory canal.2,3,6,7 The patients consented to the surgery and to the publication of their picture in a surgical video.  Illustration in video © 1997 O. Al-Mefty. Used with permission. All rights reserved.

scholarly journals Pancreatic Cysts after Endoscopic Ultrasonography-Guided Ethanol and/or Paclitaxel Ablation Therapy: Another Mimic of Pancreatic Pseudocysts

Pathobiology ◽  
2021 ◽  
pp. 1-7
Author(s):  
Soyeon An ◽  
You-Na Sung ◽  
Sung Joo Kim ◽  
Dong-Wan Seo ◽  
Sun-Young Jun ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Cystic Tumor ◽  
Pancreatic Pseudocysts ◽  
Pancreatic Cysts ◽  
Clinical Impression ◽  
Female Ratio ◽  
Ablation Therapy ◽  
Cystic Tumors ◽  
Wide Range ◽  
Egg Shell

<b><i>Background:</i></b> Endoscopic ultrasound-guided ablation (EUS-A) therapy is a minimally invasive procedure for pancreatic-cystic tumors in patients with preoperative comorbidities or in patients who are not indicated for surgical resection. However, histopathologic characteristics of pancreatic cysts after ablation have not been well-elucidated. <b><i>Methods:</i></b> Here, we analyzed pathological findings of 12 surgically resected pancreatic cysts after EUS-A with ethanol and/or paclitaxel injection. <b><i>Results:</i></b> Mean patient age was 49.8 ± 13.6 years with a 0.3 male/female ratio. Clinical impression before EUS-A was predominantly mucinous cystic neoplasms. Mean cyst size before and after ablation therapy was similar (3.7 ± 1.0 cm vs. 3.4 ± 1.6 cm; <i>p</i> = 0.139). Median duration from EUS-A to surgical resection was 18 (range, 1–59) months. Mean percentage of the residual neoplastic lining epithelial cells were 23.1 ± 37.0%. Of the resected cysts, 8 cases (67%) showed no/minimal (&#x3c;5%) residual lining epithelia, while the remaining 4 cases (33%) showed a wide range of residual mucinous epithelia (20–90%). Ovarian-type stroma was noted in 5 cases (42%). Other histologic features included histiocytic aggregation (67%), stromal hyalinization (67%), diffuse egg shell-like calcification along the cystic wall (58%), and fat necrosis (8%). <b><i>Conclusion:</i></b> Above all, diffuse egg shell-like calcification along the pancreatic cystic walls with residual lining epithelia and/or ovarian-type stroma were characteristics of pancreatic cysts after EUS-A. Therefore, understanding these histologic features will be helpful for precise pathological diagnosis of pancreatic cystic tumor after EUS-A, even without knowing the patient’s history of EUS-A.

Interhemispheric Subdural Electrodes: Technique, Utility, and Safety

2013 ◽  
Vol 73 (2) ◽  
pp. ons253-ons260 ◽  
Author(s):  
Tarek Abuelem ◽  
David Elliot Friedman ◽  
Satish Agadi ◽  
Angus A. Wilfong ◽  
Daniel Yoshor
Keyword(s):  
Patient Monitoring ◽  
Intractable Epilepsy ◽  
Mass Effect ◽  
Neurological Deficits ◽  
Epileptic Focus ◽  
Epileptogenic Zone ◽  
Invasive Monitoring ◽  
Cortical Function ◽  
Subdural Electrodes ◽  
Dorsolateral Cortex

Abstract BACKGROUND: Invasive monitoring using subdural electrodes is often valuable for characterizing the anatomic source of seizures in intractable epilepsy. Covering the interhemispheric surface with subdural electrodes represents a particular challenge, with a potentially higher risk of complications than covering the dorsolateral cortex. OBJECTIVE: To better understand the safety and utility of interhemispheric subdural electrodes (IHSE). METHODS: We retrospectively reviewed the charts of 24 patients who underwent implantation of IHSE by a single neurosurgeon from 2003 to 2010. Generous midline exposure, meticulous preservation of veins, and sharp microdissection were used to facilitate safe interhemispheric grid placement under direct visualization. RESULTS: The number of IHSE contacts implanted ranged from 10 to 106 (mean = 39.8) per patient. Monitoring lasted for 5.5 days on average (range, 2-24 days), with an adequate sample of seizures captured in all patients before explantation, and with a low complication rate similar to that reported for grid implantation of the dorsolateral cortex. One patient (of 24) experienced symptomatic mass effect. No other complications clearly related to grid implantation and monitoring, such as clinically evident neurological deficits, infection, hematoma, or infarction, were noted. Among patients implanted with IHSE, monitoring led to a paramedian cortical resection in 67%, a resection in a region not covered by IHSE in 17%, and explantation without resection in 17%. CONCLUSION: When clinical factors suggest the possibility of an epileptic focus at or near the midline, invasive monitoring of the paramedian cortex with interhemispheric grids can be safely used to define the epileptogenic zone and map local cortical function.

Hearing Preservation After Translabyrinthine Vestibular Schwannoma Excision: Audiometry and Electrocochleography Results

2018 ◽  
Vol 127 (8) ◽  
pp. 563-567 ◽  
Author(s):  
Kenneth Akakpo ◽  
William J. Riggs ◽  
Michael S. Harris ◽  
Edward E Dodson
Keyword(s):  
Hair Cell ◽  
Vestibular Schwannoma ◽  
Cranial Nerve ◽  
Cell Activity ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Healthy Patient ◽  
Cochlear Hair Cell ◽  
Translabyrinthine Approach ◽  
Cranial Nerve Viii

Objectives: To describe a case of inadvertent hearing preservation following a classical translabyrinthine resection of a vestibular schwannoma of the internal auditory canal in an otherwise healthy patient. Methods: Herein, we describe the case of an otherwise healthy patient who underwent resection of an intracanalicular vestibular schwannoma via a translabyrinthine approach. Furthermore, as part of an ongoing study aimed at characterizing hearing changes due to intraoperative events, cochlear hair cell and nerve activity were monitored using electrocochleography throughout surgery. Unexpectedly, the patient maintained serviceable hearing following surgery. As a result, we are able to provide electrophysiologic evidence of cochlear hair cell activity at various stages of this surgery. Results: Hair cell responses across tested frequencies were detectable prior to and following completion of the translabyrinthine procedure. Neural integrity of the auditory division of cranial nerve VIII was maintained throughout. Lastly, postoperative audiometric testing supported the patient’s subjective assertion of serviceable hearing in the surgical ear. Conclusion: Our results suggest that some degree of hair cell and neural integrity can be maintained throughout the course of the translabyrinthine approach, and if preservation of the auditory division of cranial nerve VIII is feasible, a functional amount of hearing preservation is attainable.

scholarly journals Metastatic Extrapulmonary Small Cell Carcinoma to the Cerebellopontine Angle: A Case Report and Review of the Literature

2015 ◽  
Vol 2015 ◽  
pp. 1-6
Author(s):  
Debebe Theodros ◽  
C. Rory Goodwin ◽  
Genevieve M. Crane ◽  
Jason Liauw ◽  
Lawrence Kleinberg ◽  
...  
Keyword(s):  
Cell Carcinoma ◽  
Surgical Resection ◽  
Small Cell Carcinoma ◽  
Vestibular Schwannoma ◽  
Primary Tumor ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Small Cell ◽  
Poorly Differentiated ◽  
Small Intestinal

Extrapulmonary small cell carcinomas (EPSCC) are rare malignancies with poor patient prognoses. We present the case of a 63-year-old male who underwent surgical resection of a poorly differentiated small cell carcinoma, likely from a small intestinal primary tumor that metastasized to the cerebellopontine angle (CPA). A 63-year-old male presented with mild left facial paralysis, hearing loss, and balance instability. MRI revealed a 15 mm mass in the left CPA involving the internal auditory canal consistent with a vestibular schwannoma. Preoperative MRI eight weeks later demonstrated marked enlargement to 35 mm. The patient underwent a suboccipital craniectomy and the mass was grossly different visually and in consistency from a standard vestibular schwannoma. The final pathology revealed a poorly differentiated small cell carcinoma. Postoperative PET scan identified avid uptake in the small intestine suggestive of either a small intestinal primary tumor or additional metastatic disease. The patient underwent whole brain radiation therapy and chemotherapy and at last follow-up demonstrated improvement in his symptoms. Surgical resection and radiotherapy are potential treatment options to improve survival in patients diagnosed with NET brain metastases. We present the first documented case of skull base metastasis of a poorly differentiated small cell carcinoma involving the CPA.

scholarly journals Ovarian fibrothecoma: An uncommon cause of a large pelvic mass

2016 ◽  
Author(s):  
Nikita Kumari ◽  
Reenu Kanwar ◽  
Bindu Bajaj ◽  
Garima Kapoor
Keyword(s):  
Ovarian Tumor ◽  
Histopathological Examination ◽  
Wide Spectrum ◽  
Pelvic Mass ◽  
Mass Effect ◽  
Left Ovary ◽  
Cystic Tumor ◽  
Normal Limits ◽  
Malignant Ovarian Tumor ◽  
Cystic Changes

Introduction: Ovarian fibrothecomas represent an ovarian stromal neoplasm developing in a wide spectrum of clinical settings. These tumors have been described as rare ovarian neoplasm, accounting for about 4% of all ovarian tumors. We report a case whose clinical presentation was highly deceptive and was clinically and radiologically diagnosed as malignant ovarian tumor. Ascitic fluid cytology revealed absence of malignant cells. On histopathological examination, it was diagnosed as benign fibrothecoma with cystic changes. Postoperative follow-up for about six months was uneventful. Case: A 45 year old female presented to the gynae emergency with large abdominal lump of 20 weeks size with acute pain abdomen. She was admitted for initial management and thorough evaluation. Hematological and biochemical parameters were within normal limits. USG revealed a large multilocular, predominantly cystic lesion 20.9x9.6x11.4 cm in pelvis. CECT revealed ovarian cystadencarcinoma left ovary with locoregional mass effect, mild ascites and suspicious metastasis to internal iliac lymph nodes. Radiological and preoperative clinical diagnosis was malignant ovarian tumor. Panhysterectomy and omentectomy was performed. On gross examination, a well encapsulated, multinodular cystic tumor of left ovary about 17x14x7 cm was identified. Cut surface was mostly solid with few cystic areas. Uterus, cervix, right ovary and both tubes were unremarkable. On microscopic examination, multiple sections showed spindle shaped cells in storiform and palisading pattern. No mitotic activity was identified. On special staining, it was positive for vimentin, which is a characteristic feature of ovarian fibrothecoma. Conclusion: The accurate preoperative diagnosis of ovarian fibrothecoma with cystic changes could have prevented the extensive surgical intervention such as bilateral salpingo- oopherectomy with hysterectomy.

scholarly journals Hearing Preservation Surgery via Retrosigmoid Approach with Retrolabyrinthine Meatotomy in Small Vestibular Schwannoma

2019 ◽  
Vol 80 (S 03) ◽  
pp. S281-S283 ◽  
Author(s):  
Diego Cazzador ◽  
Daniele Borsetto ◽  
Enrico Alexandre ◽  
Chiara Pavone ◽  
Domenico d'Avella ◽  
...  
Keyword(s):  
Care Center ◽  
Tertiary Care ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Anatomical Landmarks ◽  
Main Function ◽  
Hearing Function ◽  
Brainstem Response ◽  
Unfavorable Condition ◽  
Hearing Preservation Surgery

Objectives Vestibular schwannomas (VS) extending into the internal auditory canal (IAC) are currently considered as an unfavorable condition for hearing preservation surgery (HPS) via retrosigmoid (RS) approach due to the poor direct visualization of the facial and cochlear nerves course through the IAC and the fundus during microsurgery. Design The operative steps are described in a surgical instructional video. Setting The surgery took place at a tertiary-care center. Participants Patient is a 45-year-old man who was incidentally diagnosed with an extrameatal VS extending for 9 mm into the left cerebellopontine angle (CPA). Hearing function at diagnoses was excellent, with pure tone average (PTA) = 15 dB and speech discrimination score (SDS) = 100% (class A according to the Tokyo classification) and minimal impairments on auditory brainstem response (ABR). Given these preoperative features in small VS, hearing was the main function to look into in the treatment planning. Initial observation or HPS were proposed. Results The patient underwent surgical excision for HPS via RS approach combined with retrolabyrinthine meatotomy (RLM). RLM enables the complete exposure of the IAC to the fundus, after drilling the bony surface of the posterior IAC wall, under guidance of the anatomical landmarks, namely, the endolymphatic duct, the blue lines of the posterior, and superior semicircular canals, and common crus. Nor intra-, neither postoperative complications occurred. Histologic examination confirmed the diagnosis of VS. A 3-month short-term follow-up revealed a class B hearing function with PTA = 30 dB, SDS = 100%, and normal facial nerve status. Conclusions RLM via RS approach proved to be effective for HPS, enabling the full course of the facial and cochlear nerves through the IAC to be directly exposed.The link to the video can be found at: https://youtu.be/KC1S4pxpLCk.

scholarly journals Large mesenteric lymphangioma in an adult patient: an unusual presentation of a rare disease

2018 ◽  
pp. bcr-2018-226319 ◽  
Author(s):  
Kevin C Wall ◽  
Robin Schmitz ◽  
John M Carney ◽  
Dan G Blazer III
Keyword(s):  
Surgical Resection ◽  
Gastrointestinal Symptoms ◽  
Mass Effect ◽  
Cross Sectional ◽  
Mesenteric Lymphangioma ◽  
Abdominal Symptoms ◽  
Vesicular Rash ◽  
Operative Planning ◽  
Cross Sectional Imaging ◽  
Painless Mass

Lymphangiomas are most commonly described as a small painless mass in the neck or a vesicular rash in an infant patient. Ninety per cent of cases are diagnosed before the age of 2. Treatment usually involves surgical resection. Intra-abdominal lymphangiomas and mesenteric lymphangiomas, as described in our case report, represent a rare pathology. The exact prevalence of this condition is unclear but it has been suggested in the literature that there have been as few as 820 cases since the 16th century. The clinical presentation is usually subacute and diagnosis made incidentally during a workup of chronic gastrointestinal symptoms. Acute abdominal symptoms, as in our case presentation, are unusual but may be explained by the mass effect of a large intra-abdominal lesion. Cross-sectional imaging is key in preoperative workup and operative planning. Complete surgical resection is recommended and curative in the majority of cases with a low risk of local recurrence.

Preservation of hearing in patients undergoing excision of acoustic neuromas and other cerebellopontine angle tumors

1985 ◽  
Vol 63 (2) ◽  
pp. 168-174 ◽  
Author(s):  
Charles H. Tator ◽  
Julian M. Nedzelski
Keyword(s):  
Tumor Size ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Cochlear Nerve ◽  
Consecutive Series ◽  
Speech Discrimination ◽  
Content Type ◽  
Acoustic Neuromas ◽  
Fine Print

✓ Microsurgical techniques have made it possible to identify and preserve the cochlear nerve from its origin at the brain stem and along its course through the internal auditory canal in patients undergoing removal of small or medium-sized acoustic neuromas or other cerebellopontine angle (CPA) tumors. In a consecutive series of 100 patients with such tumors operated on between 1975 and 1981, an attempt was made to preserve the cochlear nerve in 23. The decision to attempt to preserve hearing was based on tumor size and the degree of associated hearing loss. In cases of unilateral acoustic neuroma, the criteria for attempted preservation of hearing were tumor size (2.5 cm or less), speech reception threshold (50 dB or less), and speech discrimination score (60% or greater). In patients with bilateral acoustic neuromas or tumors of other types, the size and hearing criteria were significantly broadened. All patients were operated on through a suboccipital approach. Hearing was preserved postoperatively in six (31.6%) of the 19 patients with unilateral acoustic neuromas, although the cochlear nerve was preserved in 16. Of the six patients with postoperative hearing, three retained excellent hearing, and the other three had only sound awareness and poor discrimination. Hearing was preserved in three cases with other CPA tumors, including an epidermoid cyst and small petrous meningiomas in the internal auditory canal. Of the two cases with bilateral tumors, hearing was preserved in one. Of the 23 patients in whom hearing preservation was attempted, nine (39.1%) had some postoperative hearing, which in six was equal to or better than the preoperative level. Thus, it is worthwhile to attempt hearing preservation in selected patients with CPA tumors.

Endovascular Treatment of an Aneurysm of a Persistent Primitive Hypoglossal Artery With Complete Resolution of Brainstem Compressive Symptoms: Case Report

Neurosurgery ◽  
2011 ◽  
Vol 68 (3) ◽  
pp. E854-E857 ◽  
Author(s):  
Ferdinand K. Hui ◽  
Albert J. Schuette ◽  
Charles M. Cawley
Keyword(s):  
Lower Extremity ◽  
Complete Resolution ◽  
Mass Effect ◽  
Neurological Deficits ◽  
Lower Extremity Weakness ◽  
Computed Tomographic ◽  
Hypoglossal Artery ◽  
Patient Reported ◽  
Persistent Primitive Hypoglossal Artery ◽  
The Right

Abstract BACKGROUND AND IMPORTANCE: Aneurysms of the posterior circulation may manifest with neurological deficits related to mass effect on the brainstem. We present an unusual case of an aneurysm resulting in selective lower-extremity weakness and gait instability. CLINICAL PRESENTATION: A 61-year-old man presents with progressively worsening gait instability over the course of several months. A magnetic resonance image and computed tomographic angiogram demonstrate a persistent hypoglossal artery associated with an aneurysm invaginating into the pontomedullary junction. The patient manifested only lower-extremity symptoms. An endovascular approach through the right internal carotid artery and persistent primitive hypoglossal artery was assayed, coiling off the aneurysm with complete angiographic occlusion. One month after the procedure, the patient reported marked improvement in symptoms with residual difficulty walking. At the 1-year postprocedure interval, he reported nearly complete resolution of symptoms. CONCLUSION: Endovascular therapy of an aneurysm invaginating into the brainstem is safe and efficacious.

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