André Beer-Furlan

Dural sinus and internal jugular vein thrombosis complicating a blunt head injury in a pediatric patient

IntroductionCerebral venous sinus thrombosis (CVST) following a blunt head trauma is a rare condition, described in the literature along with the lack of consensus regarding diagnosis and management.Case summaryWe present a case of a pediatric patient with a blunt head injury and epidural hematoma, who developed dural sinus and internal jugular vein thrombosis with fatal outcome.DiscussionMost of reports show good outcome and recovery, but CVST might be related to poor recovery and even lead to death. The diagnosis and management of this condition are discussed based on a literature review.ConclusionIt is important to keep a high degree of suspicion of CVST since early diagnosis may prevent potentially treatable catastrophic outcomes.

Microsurgical Approaches to the Ambient Cistern Region: An Anatomic and Qualitative Study.

OBJECTIVEnWe used microscopy to conduct qualitative and quantitative analysis of 4 surgical approaches commonly used in the surgery of the ambient cistern: infratentorial supracerebellar (SC), occipital interhemispheric, subtemporal (ST), and transchoroidal (TC). In addition, we performed a parahippocampal gyrus resection in the ST context.nnnMETHODSnEach approach was performed in 3 cadaveric heads (6 sides). After the microscopic anatomic dissection, the parahippocampal gyrus was resected through an ST approach. The qualitative analysis was based on anatomic observation and the quantitative analysis was based on the linear exposure of vascular structures and the area of exposure of the ambient cistern region.nnnRESULTSnThe ST approach provided good exposure of the inferior portion of the cistern and of the proximal segments of the posterior cerebral artery. After the resection of the parahippocampal gyrus, the area of exposure improved in all components, especially the superior area. A TC approach provided the best exposure of the superior area compared with the other approaches. The posterolateral approaches (SC/occipital interhemispheric) to the ambient cistern region provided similar exposure of anatomic structures. There was a significant difference (P < 0.05) in linear exposure of the posterior cerebral artery when comparing the ST/TC and ST/SC approaches.nnnCONCLUSIONSnThis study has demonstrated that surgical approaches expose dissimilarly the different regions of the ambient cistern and an approach should be selected based on the specific need of anatomic exposure.

Minor blunt cervical spine trauma associated with esophageal perforation and epidural empyema.

Esophageal perforation in the setting of minor blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms.The mechanism of esophageal injury associated with blunt cervical spine trauma is the traction and hyperextension of the neck. Cervical spine fracture and anterolisthesis may also contribute to the mechanism of esophageal perforation. The previous reports have demonstrated its association with high-energy trauma and severe spinal injury [1–3]. Current management of esophageal perforation focuses on early diagnosis and aggressive treatment that may include surgical drainage, attempt of primary repair, and abscess drainage when indicated [1, 2]. Case report

The Role of Endoscopic Assistance in Ambient Cistern Surgery: Analysis of Four Surgical Approaches.

OBJECTIVEnWe used microscopy with endoscopic assistance to conduct an objective analysis of 4 surgical approaches commonly used in the surgery of the ambient cistern: infratentorial supracerebellar (SC), occipital interhemispheric (OI), subtemporal (ST), and transchoroideal (TC). In addition, we performed a parahippocampalis gyrus resection in the ST context.nnnMETHODSnEach approach (SC, OI, ST, TC) was performed on 3 cadaveric heads (6 sides). After the microscopic anatomic dissection, the 30-degree endoscope was used to explore the exposure. The parahippocampalis gyrus was resected through an ST approach and the exposure was evaluated. The quantitative analysis was based on linear exposure of the vascular structures (linear exposure), such as the posterior choroidal artery (PChA), the P2 and P3 segments of the posterior cerebral artery (PCA) with their branches, the basal vein of Rosenthal, and the area of exposure of the ambient cistern region (area of exposure) limited by points on its superior, mesial, and anterior walls. In all cases, a P value of less than 0.05 was considered significant.nnnRESULTSnThere was a significant difference (P < 0.05) in linear exposure of the PCA and medial PChA between microsurgery and endoscopic assistance using the ST approach. This approach also improved the medial, superior, and total exposure of the ambient cistern region.nnnCONCLUSIONSnThis study demonstrates that endoscope assistance improved exposure of the ambient cistern region when using the ST approach. Endoscopic assistance provided similar surgical exposure compared with ST associated with parahippocampalis resection.

Traumatic carotid-cavernous fistula at the anterior ascending segment of the internal carotid artery in a pediatric patient

IntroductionTraumatic carotid-cavernous fistula (CCF) in children is a rare condition. Early diagnosis and treatment is still a challenge, and it is associated with good neurological recovery.Case summaryWe present a rare case of a 10-year-old boy with mild head trauma, who developed a CCF at the anterior segment of the ascending internal carotid artery. The patient was treated with endovascular coil embolization and evolved with a favorable outcome.DiscussionMost of reports in the literature address the traumatic CCF in adult patients, in which early treatment may prevent poor recovery or fatal outcomes. The diagnosis and management of this condition are discussed based on a literature review.ConclusionIt is important to keep a high degree of suspicion for CCF, especially in traumatic head injury associated with skull base fracture, since the early diagnosis and treatment may prevent potentially permanent neurological deficits.

The Evolution of Endoscopic Approaches to the Lateral Cavernous Sinus

Lateral Transorbital Neuroendoscopic Approach to the Lateral Cavernous Sinus n nThe endonasal endoscopic approaches undoubtedly pushed the envelope in the treatment of skull base lesions. However, large midline tumors with lateral extension beyond the cavernous sinus and ICA are still a challenge despite the improvement of surgical techniques and instrumentation. Surgeons are faced with a situation of decision making between an endonasal and a transcranial approach when treating these tumors, and frequently more than one approach is required if the goal is a gross total resection. n nIn this context, we read with great interest the recent paper by Bly et al.1 In this anatomical study the authors evaluated the feasibility of performing a transorbital endoscopic approach to the lateral cavernous sinus. The authors used a navigation system to evaluate approach trajectories with preservation of the orbital rim and defined the area of the greater wing of the sphenoid bone that required removal. Anatomical dissections were performed in three preserved latex-injected cadaver heads. A lateral retrocanthal endoscopic approach provided access to the orbit and enabled the bone removal with an ultrasonic bone aspirator. Once the approach was complete, the navigation system was used again to evaluate anatomical exposure. n nBly et al achieved an adequate working corridor with medial orbital retractionu2009<u20099u2009mm and obtained access to the orbital apex in addition to the cavernous sinus, middle fossa floor, Meckel cave region, and their associated neurovascular structures. They highlighted the strengths and limitations of the lateral transorbital endoscopic approach. n nWe have also studied multiport endoscopic approaches and agree with the authors about the potential benefits of minimally invasive routes used solely or in adjunct to the endonasal approach.2 3 The lateral reach limitation of the endoscopic endonasal surgery may be overcome by the use of a supplemental transcranial endoscopic approach that provides view and working space directly to the parasellar and paraclival regions (“beyond” the nerves). n nDifferent transcranial endoscopic routes (supraorbital, transorbital, pterional, or subtemporal) have been described to access the lateral cavernous sinus and Meckel cave regions.1 2 3 4 Although they are all directed to the parasellar and paraclival regions, each approach has an advantageous working corridor. The knowledge of the anatomical limitations of each approach is essential to obtain the desired exposure. The supraorbital endoscopic approach provides an anterior superior route to the lateral cavernous sinus region, but it requires the use of angled endoscopes if a more inferior exposure is needed.4 The lateral transorbital endoscopic approach offers access to the anterior inferior lateral cavernous sinus region, but the superior orbital fissure (SOF) limits the exposure superiorly.1 The pterional endoscopic approach provides a lateral route to the same region exposed by the supraorbital approach and permits better inferior working corridor of the lateral cavernous sinus (unpublished data). The subtemporal endoscopic approaches provide good inferior posterior access to the lateral cavernous sinus. It also provides access superiorly above the SOF, but it has the disadvantage of the temporal lobe retraction.2 n nThe concept of approaching skull base lesions exclusively with dual-port or multiport endoscopy (the combination of the endonasal and a transcranial approaches) is still in its infancy. It may ease mobilization and removal of mass lesions, assist anatomical orientation, and provide circumferential visualization of neurovascular structures, especially when displaced by the tumor. It has the potential to enhance safety and decrease time when dissecting the associated neurovascular structures in midline skull base lesions with lateral extension. n nNonetheless, some aspects of these transcranial endoscopic approaches need to be pointed out. Our experience demonstrates that these narrow corridors may limit the surgical maneuverability and application of microsurgical techniques. This is of particular importance when working in and around the neurovascular structures of the cavernous sinus. However, the use of an endoscope significantly improves illumination and provides a wide view of the surgical field if enough working space is achieved. n nThe limitation of surgical maneuverability can be minimized when the port or keyhole craniotomy (supraorbital, transorbital, pterional, or subtemporal) is placed based on the target area of interest. In addition, the development of multifunction endoscopic instrumentation, as stated by Bly et al, might minimize the crowding through the surgical port. It might even allow work in smaller surgical windows. n nLimited brain retraction due to the small bone openings is also a concern. Although it has the obvious benefit of less brain manipulation, sometimes it may hinder adequate exposure of the area of interest. In this article, we had difficulty understanding how the authors maintained temporal lobe retraction to perform bimanual dissection of the lateral cavernous sinus. n nAt last, we should always keep in mind the risk-to-benefit profile these minimally invasive approaches where the aesthetic result should never be a priority in relation to the patients safety. In that sense, we still have some doubts of the real benefits by not removing the orbital rim in the lateral transorbital approach. n nWe are enthusiasts of the subject and believe that these single-port and multiport endoscopic approaches will likely become increasingly popular with the improvement of endoscopic instrumentation and the refinement of robotic neurosurgery. Therefore, we applaud Bly et al for their valuable contribution to the literature and stimulating work in the field of endoscopic surgery.

Endoscopic fenestration of the lamina terminalis: alternatives to the classic third ventriculostomy.

We readwith great interest the recent paper byVulcu et al.1 In this radiologic and cadaveric study, the authors evaluated the feasibility of performing a transventricular lamina terminalis (LT) fenestration using rigid and flexible endoscopes and two approaches, anterior and posterior to the coronal suture. The authors verified that when inserted 2 cm behind the coronal suture in the posterior approach (the ideal trajectory to the LT), both the rigid and flexible endoscopes caused moderate to severe damage to the foramen and fornix. Additionally, the posterior approach posed a risk of injury to the primary sensory and motor cortices. They also found that using the standard approach (Kocher point) with a flexible endoscope reduced the risk of damage to these structures. After completion of the anatomical investigation, the authors performed a transventricular fenestration of the LT using a flexible endoscope on one clinical case. Over the past several decades, endoscopic third ventriculostomy (ETV) performed at the floor of the third ventricle through a precoronal burr hole has become a well-established surgical technique. It is the treatment of choice for many forms of obstructive hydrocephalus. However, anatomical variations of the basilar artery, clivus, and their relationships to the floor of the third ventricle may hinder the standard EVT in a small subpopulation of patients. Despite the description of different techniques (microscopic and endoscopic) and locations for ventriculostomy, each strategy has its limitations or disadvantages in the search for an alternative procedure that is as simple, safe, and minimally invasive as the classic ETV.2–8 Several advantages are gained when using a flexible endoscope in a transventricular approach, particularly the ability to use the same burr hole to change surgical strategy upon the location of fenestration of the third ventricle. However, we believe its disadvantages outweigh this benefit and that a good alternative to the classic ETV has yet to be found. Vulcu et al highlighted the strengths and limitations of the flexible endoscope compared with the rigid endoscope. We agree that the handling of thin and long instruments is more difficult because instruments are seen in the periphery of the field of view and the optical image is poor. This would thus necessitate switching endoscopes when performing this procedure clinically. We have studied in cadavers an interhemispheric endoscopic approach to the LT through a single frontal burr hole immediately lateral to the superior sagittal sinus (unpublished data). In our study, the fenestration of the LT was demonstrated to be feasible through a 15-mm burr hole and easier to perform when closest to the anterior cranial base without violating the frontal sinus. It is important to point out that transcranial endoscopic approaches to the LT do not necessitate crossing of the brain parenchyma. This is of particular importance considering that the ideal entry point in the transventricular LT fenestration is located in close proximity to the premotor area. Moreover, the transcranial approach also avoids maneuvering close to the important functional structures (fornix, hypothalamus, and thalamus). The LTventriculostomy through a transcranial route has the advantage of providing optimal control of the vessels around the stoma site, which is not attainable in a transventricular approach. Furthermore, the arachnoidmembranes and adhesions that are dissected to reach the LT in the transcranial approach have the potential to reduce the failure of cerebrospinal fluid outflow from the third ventricle.

Management of trigeminal neuralgia in sclerosteosis

Background: Sclerosteosis is a rare bone disorder characterized by a progressive craniotubular hyperostosis. The diagnosis of sclerosteosis is based on characteristic clinical and radiographic features and a family history consistent with autosomal recessive inheritance. The skull overgrowth may lead to lethal elevation of intracranial pressure, distortion of the face, and entrapment of cranial nerves, resulting in recurrent facial palsy or secondary trigeminal neuralgia. Cases Description: The authors reported cases of two siblings who were diagnosed with familial sclerosteosis and presented with secondary trigeminal neuralgia. The patients were 28 and 40-year-old and presented with pain in the right V2-V3 and V3 distributions, respectively. The facial pain was resistant to medications and was treated with percutaneous techniques. The foramen ovale puncture was complicated initially and the difficulty increased over the years due to stenosis of the foramen. Conclusion: The treatment of the trigeminal neuralgia secondary to hyperostosis and resistant to medications presents a dilemma. The narrowing of the foramen oval and difficulty in the identifying and approaching of the foramen makes the percutaneous technique a challenge for the neurosurgeon in patients harboring sclerosteosis. Microvascular decompression should not be considered since the primary cause of the trigeminal neuralgia is the nerve entrapment by the narrowing of neurovascular foramina and not the neurovascular conflict related to essential trigeminal neuralgia. Stereotactic radiosurgery may be a good treatment option, but there is a lack of published data supporting the use of this method in cranial hyperostosis.

Endoscopic endonasal approach in invasive aspergillosis of the clivus in an immunocompetent patient.

Dear Editor, Invasive aspergillosis is a morbid and rare condition, usually associatedwith immunocompromised patients. Central nervous system (CNS) aspergillosis does not have a specific imaging pattern and hence poses a difficult diagnostic challenge, especially when treating an immunocompetent patient [1]. A 38-year-old man had suffered from persistent headache for 3 months. The patient had no morbidities, unremarkable past medical history and physical examination. Investigation with a head computed tomography scan showed a hypodense lesion in the sphenoid sinus with a small bone erosion of the clivus. The magnetic resonance imaging (MRI) showed a small portion of the lesion invading the posterior fossa with hypointesity in T2-weighted images, isointensity in T1weighted (T1W) images and intense and homogeneous gadolinium enhancement on the postcontrast T1W study (Fig. 1a). An endoscopic endonasal excisional biopsy of the sphenoid sinus lesion was performed and pathology confirmed Aspergillus sp. The patient had a negative screening for immunodeficiencies and other fungal infection in the body. He was started on intravenous amphotericin B for 21 days with worsening of the headache. The new brain MRI showed significant enlargement (Fig. 1b) of the posterior fossa component of lesion associated with edema of the pons. An endoscopic endonasal transclival approach was performed [2] and maximal removal of the lesion was attempted. Small residual lesions that were adherent to the brainstem and basilar artery were left in place (Fig. 1c). The patient was started on intravenous voriconazole for 1 week and continued oral treatment for 90 days. Pathology and polymerase chain reaction detection of the surgical specimen confirmed Aspergillus fumigatus (Fig. 1d). The patient was asymptomatic with stable radiological findings until 14 months after surgery, when he developed right-side trigeminal neuralgia. The MRI confirmed lesion infiltrating the right trigeminal root and ganglion. Antifungal therapy with voriconazole and medical treatment for the pain were started. The patient’s pain symptoms improved with dexamethasone and, despite medical advice, he started an abusive use of corticosteroids on the following months. As a consequence, the patient developed a right-side third nerve palsy due to lesion growth and died of fungal sepsis 18 months after the surgery. Aspergillosis should always be considered on the differential diagnosis of unusual intracranial and skull base lesions, even in immunocompetent patients. This case highlights the aggressiveness and morbidity associated with invasive CNS fungal infection. The treatment should be based on maximal lesion removal associated with long-term antifungal therapy. * André Beer-Furlan beerfurlan@uol.com.br

Delayed unilateral traumatic brain swelling in a child

Traumatic brain injury is a leading cause of morbidity and death in the pediatric population. In this study, we report a delayed unilateral traumatic brain swelling in a child with initial favorable evolution and sudden neurological deterioration after 4 days; highlighting clinical, physiopathological and radiological aspects of delayed unilateral brain swelling.