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Objective We evaluated the usefulness of a three-dimensional (3D) interactive atlas to illustrate and teach surgical skull base anatomy in a clinical setting. Study Design A highly detailed atlas of the adult human skull base was created from multiple high-resolution magnetic resonance imaging (MRI) and computed tomography (CT) scans of a healthy Caucasian male. It includes the parcellated and labeled bony skull base, intra- and extracranial vasculature, cranial nerves, cerebrum, cerebellum, and brainstem. We are reporting retrospectively on our experiences with employing the atlas for the simulation and teaching of neurosurgical approaches and concepts in a clinical setting. Setting The study was conducted at the University Hospital Mainz, Germany, and Hirslanden Hospital, Zürich, Switzerland. Participants Medical students and neurosurgical residents participated in this study. Results Handling the layered graphical user interface of the atlas requires some training; however, navigating the detailed 3D content from intraoperative perspectives led to quick comprehension of anatomical relationships that are otherwise difficult to perceive. Students and residents appreciated the collaborative learning effect when working with the atlas on large projected screens and markedly improved their anatomical knowledge after interacting with the software. Conclusion The skull base atlas provides an effective way to study essential surgical anatomy and to teach operative strategies in this complex region. Interactive 3D computer graphical environments are highly suitable for conveying complex anatomy and to train and review surgical concepts. They remain underutilized in clinical practice.
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Papillary meningioma (PM) represents a very rare histological subtype, which may present with massive intracerebral hemorrhage. Gross total tumor resection results in a lower recurrence rate and mortality. A 69-year-old man had been experiencing headache for 6 months. After exacerbating right frontal headache, he was brought to the emergency room. His Glasgow Coma Scale (GCS) was 11/15 and he had a left-sided hemiparesis. A computed tomography brain scan revealed a massive right frontal intracerebral hematoma with transtentorial herniation. During right frontal craniotomy and blood clot evacuation, a fleshy, pigmented tissue was encountered. Histopathological findings were consistent with PM World Health Organization Grade III. Complete tumor resection, Simpson II was achieved with a second operation. The hemiparesis and GCS normalized subsequently. The diagnosis of PM relies largely on histopathology and is not commonly encountered preoperatively in emergency cases. Staged surgery in this case resulted in a good outcome.
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Odontoid fractures constitute the commonest cervical spinal fracture in the elderly. There are varied management approaches with paucity of robust evidence to guide decision-making. We review the case of a 92-years-old man with traumatic Grauer type II B odontoid fracture treated with anterior cannulated screw fixation. Postoperatively, he was noted to have dysphagia due to a zenker's diverticulum. Further history revealed repair of a zenker's diverticulum ~40 years prior. Cervical spine images and video fluoroscopy demonstrated a recurrent zenker's diverticulum. After re-excision of the recurrent zenker's diverticulum his dysphagia resolved. This unique case describes dysphagia due to recurrent zenker's diverticulum presenting after anterior cannulated screw fixation for type II B odontoid fracture. The dysphagia was diagnosed and treated in close collaboration with speech and language therapists and otorhinolaryngologist. This underscores the importance of holistic approach to the elderly patient with odontoid fractures.
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Up-to-date management for metastatic epidural spinal cord compression is based on appropriate scoring systems. In this case, separation surgery and stereotactic radiosurgery achieved an optimized outcome. A 75-year-old man had thoracic band-like pain, left lower limb weakness and difficulty ambulating for 6 weeks. Spinal images showed a T4 metastatic epidural spinal cord compression with a pathological fracture of T4 and T10 and L3 lytic lesions. There was no other neoplastic lesion. The metastasized T4 was decompressed by a posterolateral right costotransversectomy, vertebrectomy and insertion of an expandable titanium cage. The spinal sagittal alignment was restored with T1-T7 pedicle screw fixation. Post-operatively the pain and motor power improved significantly so that the patient was discharged home. Separation surgery and adjuvant stereotactic radiosurgery of the spine successfully improved tumor burden, pain control and overall prognosis.
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BACKGROUND: Meningiomas are associated with the highest postoperative rate of venous thromboembolic events (VTE) among all intracranial tumors. The aim of this study is to compare two entirely different VTE prophylaxis regimens in 724 consecutive patients undergoing meningioma surgery. METHODS: Two cohorts at a single institution treated with different regimens to prevent VTE were reviewed retrospectively. Cohort A (nâ=â482; 314 females, mean age 57 years, range: 11-87 years) received our institutional regimen during the years 1999-2006, consisting of low-molecular-weight heparin (LMWH) and compression stockings. For cohort B (nâ=â242; 163 females, mean age 56.8 years, range: 16-90 years), during the years 2008-2010, the management included intraoperative 10°-20° leg elevation with intermittent pneumatic compression (IPC), heparin and LMWH administration. We compared the incidence of the endpoints pulmonary embolism (PE), deep venous thrombosis (DVT), hemorrhage and death, taking into account several known associated risk factors. RESULTS: For all endpoints, we observed a more favorable outcome with the new regimen. The difference in incidence of PEs (cohort A: 38/482, 8%; cohort B: 6/242, 2.5%) reached statistical significance (pâ=â0.002). In general, patients with skull base meningiomas had a higher risk for PE (OR 2.77). Regarding VTE prophylaxis, an adjusted subgroup analysis suggests that the new regimen is particularly beneficial for patients with skull base meningiomas. CONCLUSIONS: We recommend perioperative prophylaxis using a management composed of intraoperative leg-elevation, IPC, early heparin administration and LMWH to reduce the risk for PE.