Contralateral interhemispheric transfalcine approach to precuneal glioblastoma: fluorescein guided microsurgical resection and endoscopic microinspection tool

Maximum safe resection remains a primary goal in the treatment of glioblastoma, with gross-total resection conveying additional survival benefit. Multiple intraoperative visualization techniques have been developed to improve the extent of resection. Herein, the authors describe the use of fluorescein and endoscopic assistance with a novel microinspection device in achieving a gross-total resection of a deep seated precuneal glioblastoma. An interhemispheric transfalcine approach was utilized and microsurgical resection was completed with fluorescein guidance. A 45° endoscope was then used to inspect the resection bed, and remaining areas of concern were then resected under endoscopic visualization. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21195

Simultaneous Endoscopic and Microscopic Visualization in Microvascular Decompression for Hemifacial Spasm

BACKGROUND Hemifacial spasm (HFS) is a socially limiting condition leading to decreased quality of life that can be treated with microvascular decompression (MVD). Endoscopy has been described as an adjunct to traditional microscopy for MVD, although the best visualization technique is debated. OBJECTIVE To review the current literature on use of endoscopy in MVD for HFS and to describe the simultaneous microscopic and endoscopic visualization technique along with a video illustration. METHODS Patients who underwent MVD for HFS were retrospectively reviewed from January 2011 to December 2019. The first set of patients in the series were done using traditional endoscopic assisted visualization, followed by a change in technique in the subsequent patients using the simultaneous endoscopic technique. The surgical technique is described as well as illustrated with a video. RESULTS In total, 21 patients underwent 24 MVDs to treat HFS. The simultaneous endoscopic/microscopic technique was used in 48% of cases for visualization. All but one patient had resolution of their symptoms immediately after the procedure. In total, 7 patients had recurrence of HFS, with 4 (17%) resolving spontaneously and 3 (13%) ultimately undergoing redo MVD. Postoperatively 7 patients (29%) had transient complications that all resolved completely. There was no significant difference between the traditional alternating microscopic and endoscopic technique with the simultaneous endoscopic microscopic technique. CONCLUSION Endoscopic assistance during MVD for HFS is beneficial and may be streamlined by using the simultaneous microscope and endoscope visualization technique.

Surgery of hypertensive intracranial hematomas using one-portal mini-access and video endoscopic assistance

Background. Hypertensive intracranial hemorrhage is an extremely serious complication of hypertension, which accounts for 10 % to 20 % of all cerebral strokes. About 50 % patients die within the next year, and their 5-year survival rate does not exceed 30 %. Objective. To study the effectiveness of surgical treatment of hypertensive intracranial hematomas using one-portal mini-access and video endoscopic assistance. Design and methods. The study included 23 patients with supratentorial intracerebral hypertensive hematomas aged 26 to 70 years (median age 55 (50; 61) years). All patients underwent one-portal endoscopic surgery. The median volume of intracerebral hematoma, calculated according to the Tada formula, was 50 (40; 60) ml. The comparison group included 28 patients who received conservative treatment. The dynamics of the severity was assessed using the Glasgow Coma Scale (GCS), NIHSS, Rankin, Rivermead scales upon admission to the hospital, on days 3 and 7 of treatment, at discharge for outpatient treatment, and after 6 months.Results. There were no lethal outcomes in either the main group or the comparison group. The hematoma was removed totally in all patients, which was accompanied by a rapid improvement of general cerebral symptoms and, as a consequence, an increase in GCS values from 13 (12; 14) to 13 (12; 15) points by 3rd day after the disease onset. By the 7th day, there was a slow positive dynamic in both groups, however, all patients still had a pronounced or severe disability according to the Rankin scale. After 6 months, patients who underwent surgical treatment showed faster and more complete recovery. Conclusions. The results of the study are consistent with current worldwide data on the effectiveness of modern endoscopic technologies in patients with hypertensive intracerebral hemorrhage in relation to the rate and degree of regression of neurological loss.

Transoral Excision of a Large Accessory Parotid Gland Tumor

Accessory parotid gland (APG) tumors account for 1% to 7% of all parotid gland neoplasms but are more likely to be malignant than main parotid gland tumors. Management of APG neoplasms entails surgical excision. Four primary approaches to resection have been described in the literature with varying facial nerve outcomes. We report a case of a 4-cm APG pleomorphic adenoma utilizing a transoral approach for excision without postoperative facial nerve injury. A transoral approach is known to mitigate patients’ cosmetic concerns; however, prior reports utilized endoscopic assistance on patients with smaller tumors. We conclude that large APG tumors can be excised through a transoral approach without undue risk to the distal facial nerves, though this transoral approach ultimately may not be appropriate for malignant neoplasms or difficult dissections.

Endoscopic Assistance in the Deep and Narrow Spaces of the Brain—Microscopic Tumor Surgery Supported by the New Micro-Inspection Tool QEVO® (Technical Note)

Introduction: To evaluate the feasibility and efficacy of the innovative micro-inspection tool QEVO® (Carl Zeiss Meditec, Oberkochen, Germany) as an endoscopic adjunct to microscopes for better visualization of the surgical field in complex deep-seated intracranial tumors in infants and adults.Materials and Methods: We retrospectively assessed the surgical videos of 25 consecutive patients with 26 complex intracranial lesions (time frame 2018–2020). Lesions were classified according to their anatomical area: 1 = sellar region (n = 6), 2 = intra-ventricular (except IV.ventricle, n = 9), 3 = IV.ventricle and rhomboid fossa (n = 4), and 4 = cerebellopontine angle (CPA) and foramen magnum (n = 7). Indications to use the QEVO® tool were divided into five “QEVO® categories”: A = target localization, B = tailoring of the approach, C = looking beyond the lesion, D = resection control, and E = inspection of remote areas.Results: Overall, the most frequent indications for using the QEVO® tool were categories D (n = 19), C (n = 17), and E (n = 16). QEVO® categories B (n = 8) and A (n = 5) were mainly applied to intra-ventricular procedures (anatomical area 2).Discussion: The new micro-inspection tool QEVO® is a powerful endoscopic device to support the comprehensive visualization of complex intracranial lesions and thus instantly increases intraoperative morphological understanding. However, its use is restricted to the specific properties of the respective anatomical area.