Orbitozygomatic approach for large orbital cavernous hemangioma

Background: Cavernous hemangiomas, more accurately defined as cavernous venous malformations, constitute the most common primary intraorbital tumors of adults comprising 4–9% of all tumors,[4] and the second most frequent cause of unilateral proptosis after thyroid-related orbitopathy.[3] Over 80% are located within the intraconal compartment, most commonly in the lateral aspect.[1] Surgical treatment for orbital cavernous hemangioma is generally required in symptomatic cases, optic nerve compression, and cosmetically disfiguring proptosis.[2] Transcranial approaches, the most familiar approaches for neurosurgeons, provide wide access to the entire superior and lateral orbit. They usually offer direct visualization, allowing for a safer dissection, while minimizing significant injury to the native neural and vascular anatomy of the orbit.[5] Although transcranial approaches continue to evolve, in many cases, they have been supplanted by endoscopic skull base approaches and modifications to deep lateral orbitotomy approaches.[5] Case Description: A 62-year-old male patient presented with slowly expanding left proptosis, which he had first noticed 3 years before presentation. He was already blind in his right eye due to a history of traumatic amaurosis in childhood. The left eye examination revealed severe proptosis with restricted eye movement in all directions and significant visual impairment (visual acuity of 20/300, expressed by Snellen test, with no improvement on correction). MRI of the orbit showed a large left superolateral intraconal cavernous hemangioma compressing and displacing the optic nerve, with the typical feature of slow gradual irregular enhancement with delayed washout on contrast-enhanced image. A one-piece modified orbitozygomatic approach was performed and a total en block resection was achieved. The bone flap was fixed with titanium miniplates and screws, the temporal muscle and the skin were closed in a standard fashion. The patient did not present any new deficit in the postoperative period. The patient had good functional and cosmetic outcomes with resolution of proptosis, restoration of eye movements, and improvement of visual acuity in the 3-month follow-up. Postoperative MRI showed total resection. Conclusion: The orbitozygomatic approach for large orbital cavernous hemangioma provides satisfactory orbital decompression and large working space, reduces traction, and increases visualization and freedom to dissect small vessels and nerves that may be tightly attached to the tumor pseudocapsule.

Infundibular hemangioblastoma resection: Video case report

Background: Hemangioblastomas are benign (World Health Organization Grade I), highly vascular neoplasms commonly associated with Von Hippel-Lindau (VHL) disease.[2] The VHL tumor-suppressor gene, located on chromosome 3, is implicated in sporadic cases and cases associated with VHL disease. Hemangioblastomas most commonly arise in the posterior fossa; however, they may also be found supratentorially or within the spinal cord.[3] Surgical intervention is indicated for symptomatic lesions with a goal of complete resection of the enhancing nodule.[1] Case Description: We demonstrate the case of a 69-year-old man with a history of multiple hemangioblastomas who had undergone two previous craniotomies and Gamma-Knife radiosurgery (Video https://drive.google.com/file/d/1lUwsb80NLmIW2Enp-DVdtM9_Oqbid3Ih/view?usp=sharing). He presented with progressive imbalance and diplopia and was found to have a new lesion within the suprasellar cistern. Digital subtraction angiography (DSA) and magnetic resonance imaging (MRI) characteristics were typical of hemangioblastoma. Surgery was determined to be indicated, with a goal of vision preservation. Preoperative embolization was not possible because preoperative DSA demonstrated vascular supply by only small perforators directly from the internal carotid artery. Hypopituitarism was identified preoperatively, although diabetes insipidus was not present. The patient underwent a right orbitozygomatic craniotomy and extradural anterior clinoidectomy for access. The tumor was noted to encapsulate the infundibulum, which necessitated its sacrifice. Postoperatively, the patient remained at his neurologic baseline. He had a positive triphasic diabetes insipidus response and was discharged home on maintenance desmopressin. Postoperative MRI demonstrated complete lesion resection. The patient gave informed consent for treatment and video recording. Institutional review board approval was deemed unnecessary. Conclusion: This video highlights a safe and effective surgical technique for suprasellar lesions as well as the complex anatomy observed through an orbitozygomatic approach.

Minimally Invasive Mini-orbitozygomatic Approach for Clipping an Anterior Communicating Artery Aneurysm: Virtual Reality Surgical Planning

Virtual reality (VR) has increasingly been implemented in neurosurgical practice. A patient with an unruptured anterior communicating artery (AcoA) aneurysm was referred to our institution. Imaging data from computed tomography angiography (CTA) was used to create a patient specific 3D model of vascular and skull base anatomy, and then processed to a VR compatible environment. Minimally invasive approaches (mini-pterional, supraorbital and mini-orbitozygomatic) were simulated and assessed for adequate vascular exposure in VR. Using an eyebrow approach, a mini-orbitozygomatic approach was performed, with clip exclusion of the aneurysm from the circulation. The step-by-step process of VR planning is outlined, and the advantages and disadvantages for the neurosurgeon of this technology are reviewed.

Successful eradication of a large orbital hydatid cyst without rupture using fronto-orbitozygomatic approach, the first case reported from Syria

Hydatid disease is a parasitic infection resulted by Echinococcus granulosus in the larval stage and is most prevalent in the Middle East, India, Africa, South America, New Zealand, Australia, Turkey and Southern Europe. However, orbital hydatid cysts are rare and represent a challenge to the surgeon to eradicate the cyst without rupture. Here, we report a case of a relatively large primary intraconal orbital cyst in a 21-year-old woman. We managed to eradicate the cyst without any complication using fronto-orbitozygomatic approach, and the patient remained disease free after the 3 months of follow-up.