Alhusain Nagm

Bony surface registration of navigation system in the lateral or prone position: technical note

BackgroundNavigation systems have become essential tools in neurosurgery. Precise registration is indispensable for the accuracy of navigation. The rapid and precise registration by surface matching on the facial skin is possible using the landmarks of the face in the supine position. On the other hand, incomplete registration often occurs in the lateral or prone position due to the direction of the face and displacement of the skin by headpins and obscuring of the skin by the bispectral index monitor and many electrodes on the forehead as well as the eye patch. Surface matching on the occipital scalp is not suitable for registration because the shape of the occipital scalp is flat and it is compressed in the supine position when obtaining preoperative neuroimaging. To overcome this problem, the authors have developed a new method of registration designated as “bony surface registration” in which surface matching is achieved using the bony surface of the skull after exposure.MethodsBetween June and December 2014, this technique was used in 23 patients and its effectiveness was examined.ResultsRegistration time was markedly shortened and useful navigation was achieved due to accurate registration in all patients.ConclusionsThis is the first report of a registration methodology for a navigation system in the lateral or prone position. This bony surface registration method is useful for navigation system image-guided surgery in the lateral or prone position.

Ultrasonography of a bifid median nerve causing carpal tunnel syndrome: MSUS or MRI, which is better?

this neurovascular bundle was 45 mm2. Confirmatory MRI, fat suppressed PD-weighted axial (5) proved the same diagnosis; however, its resolution was inferior to MSUS. A thorough survey of the English literature disclosed that the incidence of bifid median nerve is 3%; however, with the aid of high-resolution MSUS, this incidence might increase up to 19% [1]. The implication of such preoperative diagnosis either by MSUS [2] or MRI [3] can be utilized to preferentially choose the conventional surgery over endoscopic release which might be contraindicated if such anomaly was known [4]. Adequate median nerve exposure minimizes the risk of inadvertent injury to the persistent median artery or smaller nerve branches. Noteworthy, MSUS is a convenient imaging modalities to detect such anomalies and aid their managements [5, 6]. In conclusion, MSUS is an easy, noninvasive, low-cost, fast tool which has novel diagnostic values that might modify the management of CTS by meticulous preoperative evaluation. The patient, a 43-year-old woman, with bilateral carpal tunnel syndrome (CTS). Electrophysiological studies disclosed bilateral severe CTS. High-resolution musculoskeletal ultrasound (MSUS) examination was done, by the first author, using linear probe 18 MHz (TOSHIBA ApIio 400). In (Fig. 1) the median nerve cross-sectional area was 22 mm2 (A) on the right hand (star) (3), normal reported up to 15 mm2. Interestingly, her left wrist transverse volar scan showed a bifid median nerve (asterisk) in grey-scale mode (1) with persistent median artery (straight arrow) in power Doppler mode (2). This morphological anomaly consisted of two unequal median nerve trunks: a large radial trunk (15 mm2) and a small ulnar trunk (4 mm2). The sum of both cross-sectional areas was 19 mm2 (B + C) (4). A small branch can be seen from the radial trunk (curved arrow) with same nerve echogenicity and contained within the hyperechoic epineurium; this was confirmed on dynamic proximal scanning as it was seen originating from main nerve trunk in the forearm. The total cross-sectional area of Rheumatology INTERNATIONAL

Significance of surgical management for cystic prolactinoma

PurposeIt is generally accepted that dopamine agonists (DA) represent the first-line treatment for most patients with prolactinoma, and patients become candidates for surgical intervention when DA is contraindicated. Surgical indication for cystic prolactinoma remains controversial. This study was performed to investigate the significance of surgery for cystic prolactinoma.MethodsA total of 28 patients that underwent transsphenoidal resection of prolactinoma between February 2004 and May 2016 were reviewed. Five consecutive patients with cystic prolactinoma were included in this study. Our surgical strategy for cystic prolactinoma was categorized as follows: first, when the purpose of surgical resection was normalization of the prolactin level, aggressive resection was performed; second, when volume reduction was essential to relieve the visual symptoms and headache, internal decompression was performed followed by DA therapy. The clinical outcomes were analyzed accordingly.ResultsAll cystic prolactinoma were resected via the transsphenoidal approach without any complications, and all symptoms including visual impairment and hypogonadal activity were finally relieved combined with medication.ConclusionsSurgery for cystic prolactinoma could be a better option. Transsphenoidal surgery is relatively safe to remove the cystic prolactinoma, additionally it can normalize the prolactine level and achieve adequate and rapid decompression of optic chiasm. The risk of transsphenoidal surgery is highly dependent on the skill of the surgeon and treatment decision for cystic prolactinoma needs to be individualized for each patient.

Risky Cerebrovascular Anatomic Orientation: Implications for Brain Revascularization

This study documents a risky vascular anatomic orientation that might play an important role in the postoperative hemodynamics following anterior cerebral artery (ACA) revascularization. A 71-year-old woman presented with uncontrollable frequent right lower limb transient ischemic attacks (TIAs) attributed to a left cerebral ischemic lesion due to severe left ACA stenosis. She underwent successful left-sided superficial temporal artery-ACA bypass using interposed vascular graft. The patient awoke satisfactory from anesthesia; however, on postoperative day 1, she developed right-sided hemiparesis. Extensive postoperative investigations disclosed that watershed shift infarction was considered the etiology for this neurologic deterioration.

Relationship Between Successful Extracranial-Intracranial Bypass Surgeries and Ischemic White Matter Hyperintensities

BACKGROUND AND PURPOSE Few studies have described regression of white matter hyperintensities (WMHs); however, no studies have described their recurrence or fluctuation. Thus, we aimed to study the course of WMHs on fluid-attenuated inversion recovery (FLAIR) magnetic resonance image (MRI) after extracranial-intracranial (EC-IC) bypass surgery and its correlation with the clinical outcome. METHODS We enrolled perioperative FLAIR MRIs of 12 patients with WMHs who underwent EC-IC bypass surgeries because of ischemic-vascular stenosis with postoperative improvement of the cerebral blood flow confirmed by (123)I-iodoamphetamine single-photon emission computed tomography. Correlation between WMHs and cerebral blood flow was confirmed by perioperative single-photon emission computed tomography and diffusion-weighted imaging MRI. The WMHs were assessed visually with meticulous volumetric grading. Depending on postoperative changes among different grades, the WMHs course was determined to be improved, fluctuating, worsened, or unchanged. A statistical analysis was performed on the course of WMHs over time. RESULTS Imaging analysis was done with FLAIR MRI in 12 patients. The course of WMHs over time was 41.7% improvement, 33.3% fluctuation, 16.7% unchanged, and 8.3% worsening of the deep WMHs. After unilateral bypass surgery, 80% of the improved WMHs occurred bilaterally. Among patients with improved clinical outcomes, 16.7% showed improvement and 33.3% showed fluctuation, whereas in patients with unchanged clinical outcomes, 25% showed improvement of their WMHs on follow-up FLAIR MRIs. CONCLUSIONS This study might be considered the first step to find a relationship between successful EC-IC bypass surgeries and the course of ischemic WMHs. It could also open the door for further studies to make more solid conclusions.

Relationship Between Muscle Dissection Method and Postoperative Muscle Atrophy in the Lateral Suboccipital Approach to Vestibular Schwannoma Surgery.

BACKGROUND Various techniques are available for occipital skull exposure with muscle dissection, as well as different types of skin incisions in the lateral suboccipital approach to vestibular schwannoma (VS) surgery. The skin incisions are generally classified as S-shaped, J-shaped, or C-shaped. In each method, the technique used for muscle dissection differs in terms of cut, single layer, and multiple layers. This study was performed to identify the relationships among muscle dissection method, skin incision type, and muscle atrophy in the lateral suboccipital approach to surgery for VS. METHODS Between 2002 and 2011, we performed surgical resection in 53 patients with VS at Shinshu University Hospital. Of these 53 patients, 35 with radiographic annual follow-up for >3 years after surgery were evaluated retrospectively. These patients included 14 who underwent an S-shaped incision, 6 with a J-shaped incision, and 15 with a C-shaped incision. Bilateral areas of the skin and occipital muscles were measured, and rates of atrophy were calculated and compared among the 3 methods. RESULTS Postoperative muscle atrophy was significantly advanced in the second postoperative year, but did not tend to develop further after the third year. The postoperative muscle atrophy ratio was significantly lower in the C-shaped incision group (mean ± SD, 4.0% ± 6.9%) compared with the S-shaped (17.1% ± 9.8%) and J-shaped (17.6% ± 10.0%) incision groups within 2 years after surgery (P < 0.05). CONCLUSIONS The C-shaped skin incision with multilayer muscle dissection was associated with significantly reduced postoperative muscle atrophy compared with the other methods.

Unique double recurrence of cerebral arteriovenous malformation.

Surgically treated patients with arteriovenous malformations (AVMs) are considered cured when the postoperative angiogram proves complete resection. However, despite no residual nidus or early draining vein on postoperative angiogram, rare instances of AVM recurrence have been reported in adults. In this paper, the authors present a case of a 24-year-old woman with asymptomatic double recurrence of her cerebral AVM after angiographically proven complete resection. To the authors’ knowledge, this patient represents the first case with double de novo asymptomatic recurrence of Spetzler–Martin grade I AVM. Also, she represents the first case with unique AVM criteria in each recurrence.

Petroclival tension pneumocephalus: an unrivalled life threatening complication linked to molecular-targeted therapy

A 73-year-old man with a petroclival tumor (metastatic renal cell carcinoma) presented with a progressive consciousness disturbance attributed to tension pneumocephalus during molecular-targeted therapy following low-dose fractionated radiotherapy for a petroclival tumor. The skull base defect was successfully reconstructed vi an endoscopic endonasal approach.

Endoscopic transpalpebral transorbital anterior petrosectomy: does “safer surgical freedoms” necessitates modifications?

Dear Editor: We have read with great consideration the paper BEndoscopic transorbital route to the petrous apex: a feasibility anatomic study,^ by Professor Paolo Cappabianca and colleagues [3]. The authors [3] presented an excellent qualitative stepwise endoscopic transpalpebral transorbital route to the petrous apex with adequate petrous apicectomy. Additionally, they were able to delineate three anatomic spaces (cerebellopontine angle, middle tentorial incisura, and ventral brainstem) and they analyzed the limitations of their technique [3]. As our lead author (A.N.) is involved in the endoscopic transorbital anatomical studies and collecting novel data [4], he would like to ask the authors [3] about specific surgical nuances that might allow surgeons to create an ideal surgical space with safer exposure and good maneuverability that evolved from combinations of pearls from multiple approaches [1–5] while avoiding major drawbacks. Based on our lead author’s (A.N.) experience with anatomic transorbital anterior petrosectomy (Fig. 1), such techniques are not without disadvantages. The exceptionally deep-narrow surgical corridor and the crowding of surgical instruments forces the surgeon to become accustomed to uncomfortable maneuverability and place the orbit and the lacrimal gland at a great risk. Therefore, our lead author (A.N.) now opt, instead, for adding endoscopic endonasal medial orbital apex decompression (might extend to the nasolacrimal duct) before starting the transorbital approaches to the regions beyond the orbital cone to avoid several drawbacks (Fig. 1). By carefully studying the degree of safe surgical freedom at the area of exposure at entry site in the presented technique [3], we would like to ask about:

Neuroendoscopy Via an Extremely Narrow Foramen of Monro: A Case Report

Herein, safe and reliable neuroendoscopic biopsy via an extremely narrow foramen of Monro (ENFM) for a non-hydrocephalic patient with hypothalamic and pineal region tumors was successfully applied. A 17-year-old boy presented with hypothalamic manifestations attributed to hypothalamic and pineal region tumors. Small ventricles were seen. Intraoperatively, to advance different diameter steerable fiberscopes via ENFM, the third ventricle was flushed to induce a moment increase in the intraventricular pressure with subsequent dilatation of FM. Postoperative course was uneventful. Histopathological studies revealed a yolk sac tumor. Adjuvant therapy was applied. Follow-up neuroimaging disclosed marvellous improvement of the condition. His symptoms gradually improved.