Brain retraction injury

OBJECT The highest incidence of olfactory dysfunction following a pterional approach and its modifications for an intracranial aneurysm has been reported in cases of anterior communicating artery (ACoA) aneurysms. The radiological characteristics of unruptured ACoA aneurysms affecting the extent of retraction of the frontal lobe and olfactory nerve were investigated as risk factors for postoperative olfactory dysfunction. METHODS A total of 102 patients who underwent a pterional or superciliary keyhole approach to clip an unruptured ACoA aneurysm from 2006 to 2013 were included in this study. Those patients who complained of permanent olfactory dysfunction after their aneurysm surgery, during a postoperative office visit or a telephone interview, were invited to undergo an olfactory test, the Korean version of the Sniffin’ Sticks test. In addition, the angiographic characteristics of ACoA aneurysms, including the maximum diameter, the projecting direction of the aneurysm, and the height of the neck of the aneurysm, were all recorded based on digital subtraction angiography and sagittal brain images reconstructed using CT angiography. Furthermore, the extent of the brain retraction was estimated based on the height of the ACoA aneurysm neck. RESULTS Eleven patients (10.8%) exhibited objective olfactory dysfunction in the Sniffin’ Sticks test, among whom 9 were anosmic and 2 were hyposmic. Univariate and multivariate analyses revealed that the direction of the ACoA aneurysm, ACoA aneurysm neck height, and estimated extent of brain retraction were statistically significant risk factors for postoperative olfactory dysfunction. Based on a receiver operating characteristic (ROC) analysis, an ACoA aneurysm neck height > 9 mm and estimated brain retraction > 12 mm were chosen as the optimal cutoff values for differentiating anosmic/hyposmic from normosmic patients. The values for the area under the ROC curves were 0.939 and 0.961, respectively. CONCLUSIONS In cases of unruptured ACoA aneurysm surgery, the height of the aneurysm neck and the estimated extent of brain retraction were both found to be powerful predictors of the occurrence of postoperative olfactory dysfunction.

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Contralateral Supracerebellar-Infratentorial Approach for Resection of Thalamic Cavernous Malformations

Operative Neurosurgery ◽

10.1093/ons/opy004 ◽

2018 ◽

Vol 15 (4) ◽

pp. 404-411 ◽

Cited By ~ 5

Author(s):

Justin Mascitelli ◽

Jan-Karl Burkhardt ◽

Sirin Gandhi ◽

Michael T Lawton

Keyword(s):

Intraoperative Complications ◽

Occipital Lobe ◽

Senior Author ◽

Pineal Region ◽

Neurological Deficits ◽

Cavernous Malformations ◽

Posterior Thalamus ◽

Neurological Outcomes ◽

The Right ◽

Brain Retraction

Abstract BACKGROUND Surgical resection of cavernous malformations (CM) in the posterior thalamus, pineal region, and midbrain tectum is technically challenging owing to the presence of adjacent eloquent cortex and critical neurovascular structures. Various supracerebellar infratentorial (SCIT) approaches have been used in the surgical armamentarium targeting lesions in this region, including the median, paramedian, and extreme lateral variants. Surgical view of a posterior thalamic CM from the traditional ipsilateral vantage point may be obscured by occipital lobe and tentorium. OBJECTIVE To describe a novel surgical approach via a contralateral SCIT (cSCIT) trajectory for resecting posterior thalamic CMs. METHODS From 1997 to 2017, 75 patients underwent the SCIT approach for cerebrovascular/oncologic pathology by the senior author. Of these, 30 patients underwent the SCIT approach for CM resection, and 3 patients underwent the cSCIT approach. Historical patient data, radiographic features, surgical technique, and postoperative neurological outcomes were evaluated in each patient. RESULTS All 3 patients presented with symptomatic CMs within the right posterior thalamus with radiographic evidence of hemorrhage. All surgeries were performed in the sitting position. There were no intraoperative complications. Neuroimaging demonstrated complete CM resection in all cases. There were no new or worsening neurological deficits or evidence of rebleeding/recurrence noted postoperatively. CONCLUSION This study establishes the surgical feasibility of a contralateral SCIT approach in resection of symptomatic thalamic CMs It demonstrates the application for this procedure in extending the surgical trajectory superiorly and laterally and maximizing safe resectability of these deep CMs with gravity-assisted brain retraction.

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Combined supra/infratentorial approach to tentorial meningiomas

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2005000100010 ◽

2005 ◽

Vol 63 (1) ◽

pp. 50-54 ◽

Cited By ~ 4

Author(s):

Igor de Castro ◽

Daniel de Holanda Christoph ◽

José Alberto Landeiro

Keyword(s):

Surgical Treatment ◽

Surgical Technique ◽

Occipital Lobe ◽

Transverse Sinus ◽

Surgical Removal ◽

Tentorial Meningioma ◽

Operative Evaluation ◽

Unique Approach ◽

Microsurgical Techniques ◽

Brain Retraction

In spite of significant advancements in imaging technology, monitoring, and microsurgical techniques, complete and safe removal of tentorial meningiomas remains a challenge for most neurosurgeons. Classifications of tentorial meningiomas are revised. The combined supra/infratentorial approach to resects tentorial meningioma is discussed. This approach provides a wider exposure of the supra/infratentorial region with less brain retraction. With this approach the occipital lobe and the cerebellum are exposed along the tentorium. Two illustrative cases are presented. The patients were studied with computerized tomography, magnetic resonance and angiography. The anatomy of the transverse sinus and the confluence of the sinus could be appreciated with these studies. The operative technique is described stepwise. Emphasis is placed on pre-operative evaluation and surgical technique, leading to a total surgical removal of the lesion with margins of safety. The goal of surgical treatment of tentorial meningiomas is their complete and safe removal. With this unique approach we sought to confirm that it offers a safe means of resection not only the neoplasm but also the infiltrated dura.

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A Side Door to Meckel's Cave: Anatomic Feasibility Study for the Lateral Transorbital Approach

Operative Neurosurgery ◽

10.1093/ons/opx042 ◽

2017 ◽

Vol 13 (5) ◽

pp. 614-621 ◽

Cited By ~ 17

Author(s):

Blake Harrison Priddy ◽

Cristian Ferrareze Nunes ◽

Andre Beer-Furlan ◽

Ricardo Carrau ◽

Iacopo Dallan ◽

...

Keyword(s):

Skull Base ◽

Surgical Navigation ◽

Cranial Nerves ◽

Anatomical Study ◽

Middle Cranial Fossa ◽

Middle Fossa ◽

Meckel’S Cave ◽

Side Door ◽

Meckel's Cave ◽

Brain Retraction

Abstract BACKGROUND: In the last decade, endoscopic skull base surgery has significantly developed and generated a plethora of techniques and approaches for access to the cranial ventral floor. However, the exploration for the least-aggressive, maximally efficient approach continues. OBJECTIVE: To describe in detail an anatomical study, along with the technical nuances of a novel endoscopic approach to Meckel's Cave (MC) using a lateral transorbital (LTO) route. METHODS: Eighteen orbits of injected cadaveric specimens were operated on, using an endoscopic LTO approach to MC, middle cranial fossa, and paramedian skull base preserving the orbital rim. Surgical navigation and an after-the-fact infratemporal craniectomy were utilized to identify the limits of the approach. RESULTS: Following a transorbital approach opening a trapezoid window at the superolateral aspect (average 166.7 mm2), a middle fossa “peeling” and full visualization of MC was accomplished with no difficulties in all specimens. The entire approach was performed extradurally without the need to expose the temporal lobe. CONCLUSION: In a cadaveric model, the endoscopic LTO approach affords a direct route to access MC. Its main advantage is that it is minimally disruptive in nature, less brain retraction is required, and it reaches the middle fossa in an anterolateral perspective. It also requires no manipulation of the temporalis muscle, limited cosmetic incision, and rapid recovery. It seems a viable alternative to traditional approaches for lesions lateral to the cranial nerves at the cavernous sinus and MC, that is, schwannomas. Clinical utilization of this approach will challenge its efficacy and identify limitations.

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The history of brain retractors throughout the development of neurological surgery

Neurosurgical FOCUS ◽

10.3171/2014.2.focus13564 ◽

2014 ◽

Vol 36 (4) ◽

pp. E8 ◽

Cited By ~ 10

Author(s):

Rachid Assina ◽

Sebastian Rubino ◽

Christina E. Sarris ◽

Chirag D. Gandhi ◽

Charles J. Prestigiacomo

Keyword(s):

Degrees Of Freedom ◽

Brain Parenchyma ◽

Neurosurgical Procedures ◽

Intracranial Surgery ◽

Different Types ◽

History Of ◽

Brain Retraction ◽

Neurological Surgery ◽

The 19Th Century ◽

The Brain

Early neurosurgical procedures dealt mainly with treatment of head trauma, especially skull fractures. Since the early medical writings by Hippocrates, a great deal of respect was given to the dura mater, and many other surgeons warned against violating the dura. It was not until the 19th century that neurosurgeons started venturing beneath the dura, deep into the brain parenchyma. With this advancement, brain retraction became an essential component of intracranial surgery. Over the years brain retractors have been created pragmatically to provide better visualization, increased articulations and degrees of freedom, greater stability, less brain retraction injury, and less user effort. Brain retractors have evolved from simple handheld retractors to intricate brain-retraction systems with hand-rest stabilizers. This paper will focus on the history of brain retractors, the different types of retractors, and the progression from one form to another.

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Anatomical study of the superior orbital fissure as seen during a pterional approach

Journal of Neurosurgery ◽

10.3171/jns.2007.106.1.151 ◽

2007 ◽

Vol 106 (1) ◽

pp. 151-156 ◽

Cited By ~ 13

Author(s):

Mario Ammirati ◽

Antonio Bernardo

Keyword(s):

Anatomical Study ◽

Pterional Approach ◽

Superior Orbital Fissure ◽

Specific Sequence ◽

Anterior Portion ◽

Important Landmark ◽

Controlled Exposure ◽

Surrounding Areas ◽

Brain Retraction ◽

Good Exposure

Object The superior orbital fissure (SOF) is an important landmark in the neurosurgical pterional approach, but the anatomical features of the SOF and the procedures necessary to fully expose it and its contents have not been detailed. Although the pterional approach is commonly used during skull base or vascular surgery by neurosurgeons who may already be familiar with its nuances and anatomical relationships to the SOF, this knowledge may also be useful to the wider neurosurgical community. The authors describe the spatial relationships of the contents of the SOF and suggest a specific sequence of steps for exposing the SOF region in a pterional approach. Methods Using standard microsurgical equipment and instruments, the authors performed 20 pterional approaches in 10 embalmed cadaver heads in which the vascular systems had been injected with colored material. Five sequential steps were delineated for approaching and dissecting the SOF and its contents: 1) drilling the sphenoidal ridge, anterior clinoidal process, and part of the greater and lesser wings of the sphenoid; 2) resecting the dural bridge; 3) detaching the hemispheric dura mater, thereby exposing the anterior portion of the cavernous sinus and the neural component entering the SOF; 4) identifying and dissecting the extraanular structures; and 5) opening the anulus of Zinn and identifying its neural constituents. Conclusions Knowing the 3D relationships of the contents of the SOF encountered in the pterional approach enables safe neurosurgical access to the area. The proposed sequence of steps allows a controlled exposure of the SOF and surrounding areas. Untethering the frontotemporal lobe by transecting the dural bridge connecting the dura to the perior-bita allows good exposure of the basal frontotemporal lobes, both intra- and extradurally, and reduces brain retraction.

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