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OBJECTIVE: Brainstem cavernous malformations (BSCMs) account for up to 18% of all intracranial cavernous malformations. Due to their complex anatomic location, they represent a significant challenge for neurosurgeons. As such, the identification of risk factors associated with negative outcomes is of significant importance. We analyze a series of 50 cases of BSCMs treated surgically in order to identify risk factors for unfavorable outcomes. METHODS: Patients who underwent surgical resection of BSCM at our institution between 2000 and 2015 were retrospectively reviewed. Univariate and multivariable logistic regression models were used to identify predictors of unfavorable outcomes, defined as those with a modified Rankin score (mRs) of >2. RESULTS: Fifty Latin American patients, with a mean age of 35.85 ± 13.06 years, consisting of 29 females (58%) and 21 males (42%), underwent surgical resection. Mean modified Rankin Scale (mRs) score at admission was 2.6 ± 1.05, and the mean BCSM size was 18.00 ± 7.19 mm. The rate of gross total resection was 92%. Overall, 80% of patients showed improved or unchanged clinical status at the last follow-up period; however, only 58% of patients had a favorable outcome with a mean mRs of 2.33 ± 1.136. Multivariable logistic binary regression identified hemorrhagic recurrence (P = 0.040), lower cranial nerve deficit (P = 0.019), and BSCMs >15 mm in diameter (P = 0.006) as predictive factors for unfavorable surgical outcomes. CONCLUSION: BSCM size, compromise of lower cranial nerves, and hemorrhagic recurrence before surgery were identified as risk factors associated with unfavorable outcomes of surgically treated BSCMs in this cohort.
Assuntos
Neoplasias do Tronco Encefálico/cirurgia , Hemangioma Cavernoso do Sistema Nervoso Central/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adulto , Neoplasias do Tronco Encefálico/patologia , Feminino , Hemangioma Cavernoso do Sistema Nervoso Central/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
Objective We propose a novel dual-port endonasal and pterional endoscopic approach targeting midline lesions of the anterior cranial fossa with lateral extension beyond the optic nerve. Methods Ten dual-port approaches were performed on five cadaveric heads. All specimens underwent an endoscopic transtuberculum/transplanum approach followed by placement of a pterional port. The endonasal port was combined with an endoscopic extradural pterional keyhole craniectomy. The pterional port was placed at the intersection of the sphenoparietal and coronal sutures. The extradural space was explored using two-dimensional and three-dimensional endoscopes. Results The superolateral access provided by the pterional port may improve the ability to achieve a gross total resection of tumors with lateral extensions. The complete opening of the optic canal achieved through the dual-port approach may enable resection of the intracanalicular portion of a tumor, a crucial step in improvement of visual function and reduction of tumor recurrence. Conclusion The pterional port may enhance control of midline anterior skull base lesions with lateral extension beyond the optic nerve and optic canal. Dual-port endoscopy maintains minimally invasiveness and dramatically increases the working limits and control of anatomical structures well beyond what is attainable through single-port neuroendoscopy.
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Objective We evaluate the feasibility and safety of performing a novel interhemispheric endoscopic fenestration of the lamina terminalis (IEFLT) through a single frontal burr hole immediately lateral to the superior sagittal sinus. Methods Five cadaveric heads underwent IEFLT. Sequential burr holes were made beginning above the glabella and progressed cranially to caudally until the frontal sinus. An endoscope was inserted, and interhemispheric dissection of the arachnoid membranes was completed with endoscopic instruments in a straight direction from the point of entry to the lamina terminalis (LT). Angled optics (0 and 30 degrees) were used to study the neurovascular structures and surgical landmarks. Results The IEFLTs were successfully completed in all specimens and allowed for good visualization of the inferior portion of the LT. The arachnoid dissections were achieved uneventfully. The endoscope provided good surface control of the LT and excellent stereoscopic visualization of the neurovascular complexes. Improved circumferential visualization of the superior part of the anterior portion of the third ventricle was attained. Conclusion IEFLT is a potential alternative to the classic endoscopic third ventriculostomy and a simpler alternative to the subfrontal EFLT, although surgical maneuverability is still limited due to the size of the probe in relation to the narrow surgical corridor.
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Objective To investigate a novel dual-port endonasal and subtemporal endoscopic approach targeting midline lesions with lateral extension beyond the intracavernous carotid artery anteriorly and the Dorello canal posteriorly. Methods Ten dual-port approaches were performed on five cadaveric heads. All specimens underwent an endoscopic endonasal approach from the sella to middle clivus. The endonasal port was combined with an anterior or posterior endoscopic extradural subtemporal approach. The anterior subtemporal port was placed directly above the middle third of the zygomatic arch, and the posterior port was placed at its posterior root. The extradural space was explored using two-dimensional and three-dimensional endoscopes. Results The anterior subtemporal port complemented the endonasal port with direct access to the Meckel cave, lateral sphenoid sinus, superior orbital fissure, and lateral and posterosuperior compartments of the cavernous sinus; the posterior subtemporal port enhanced access to the petrous apex. Endoscopic dissection and instrument maneuverability were feasible and performed without difficulty in both the anterior and posterior subtemporal ports. Conclusion The anterior and posterior subtemporal ports enhanced exposure and control of the region lateral to the carotid artery and Dorello canal. Dual-port neuroendoscopy is still minimally invasive yet dramatically increases surgical maneuverability while enhancing visualization and control of anatomical structures.
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Since the first description of the intradural removal of the anterior clinoid process, numerous refinements and modifications have been proposed to simplify and enhance the safety of the technique. The growing use of endoscopes in endonasal and transcranial approaches has changed the traditional management of many skull base lesions. We describe an endoscopic extradural anterior clinoidectomy and optic nerve decompression through a minimally invasive pterional port. Minimally invasive optic nerve decompression, with endoscopic extradural anterior clinoidectomy, through a pterional keyhole craniotomy was performed on five preserved cadaveric heads. The endoscopic pterional port provided a shorter and more direct route to the anterior clinoid region, and helped avoid unnecessary and extensive bone removal. An extradural approach helped minimize complications associated with infraction of the subdural space and allowed for the maintenance of visibility while drilling with continuous irrigation. Adequate 270° bone decompression of the optic canal was achieved in all specimens. Endoscopic extradural anterior clinoidectomy and optic nerve decompression is feasible through a single minimally invasive pterional port.