Haim Ezer

Tuberculum and diaphragma sella meningioma – surgical technique and visual outcome in a series of 20 cases operated over a 2.5-year period

SummaryBackground. A retrospective analysis of 20 cases of tuberculum sella meningioma with emphasis on the surgical technique and visual outcome.Methods. Between 2003 and 2006 twenty patients with tuberculum and diaphragma sella meningioma were treated at the Tel Aviv medical center. There were 17 females and 3 males. The age range was 28–83. Most patients presented with visual deterioration. Surgery was performed using the subfrontal approach. The visual function before and after surgery was evaluated as the main outcome parameter of the surgical treatment of these tumours.Findings. In 16 patients complete tumour resection was achieved and in 4 subtotal removal was performed. Visual acuity improved in 32% of the eyes and deterioration was observed in two eyes (5%). Visual field improved in 28% of the eyes and deteriorated in 14%. There was no complete vision loss as a result of surgery. There was no mortality in our series.Conclusions. Tuberculum and diaphragma sella meningioma can be safely resected using the subfrontal approach with preservation and even improvement of visual function after surgery. Early surgery with better pre-operation visual function and smaller tumour size were associated with a better outcome.

Orbital tumors treated using transcranial approaches: surgical technique and neuroophthalmogical results in 41 patients

OBJECTnOrbital tumors can be divided schematically into primary lesions, originating from the orbit itself, and secondary lesions, extending to the orbit from neighboring structures. These tumors are variable in their biological nature and in their location. The authors evaluate 41 cases of benign and malignant tumors involving the orbit and discuss the surgical challenge, which involves tumor removal, preserving visual function and cosmetic reconstruction.nnnMETHODSnThe authors performed a retrospective analysis of a series of all cases involving patients who underwent surgery for treatment of orbital tumors in their hospital between December 2003 and December 2006. Data were collected from the patients files in the hospitals outpatient clinic, operative notes, and pre- and postoperative imaging studies.nnnRESULTSnThe authors identified 41 patients who met the inclusion criteria (age range 14-82 years, mean 42.2 years, standard deviation 22.4 years). The most common presenting symptoms were proptosis and/or partial ptosis (11 cases [27%]) and headache (7 cases [17%]). In 5 (12%) cases, the tumors were primary intraorbital lesions, and in 34 cases (83%) they were secondary. Two patients had metastases to the orbit. The most common lesion types were meningioma (10 cases [24%]) and osteoma (7 cases [17%]). In 24 cases a midline approach through a frontal craniotomy or a subcranial approach was used; in 13 a lateral approach was used; and in 4 a biopsy procedure was performed. Maxillectomy through a Weber-Ferguson approach or a facial degloving approach was added in 5 cases to complete tumor removal. Duration of follow-up was 1-38 months (mean 20 months). None of the patients died as a result of the procedure, and there were relatively few complications. Excluding the patients who underwent orbital exenteration, none of the patients had visual deterioration following surgery, and most had no change in their visual condition. Two patients had temporary diplopia, 1 had a cerebrospinal fluid leak, and 1 had enophthalmos following removal of an orbital osteosarcoma.nnnCONCLUSIONSnOrbital tumors can be treated safely using transcranial approaches in many cases. Preoperative imaging can accurately define the compartments involved and the surgical approach needed for tumor removal. A multidisciplinary team of surgeons facilitates optimal tumor removal and skull base sealing as well as good cosmetic results.

A non-aggressive, highly efficient, enzymatic method for dissociation of human brain-tumors and brain-tissues to viable single-cells

Background Conducting research on the molecular biology, immunology, and physiology of brain tumors (BTs) and primary brain tissues requires the use of viably dissociated single cells. Inadequate methods for tissue dissociation generate considerable loss in the quantity of single cells produced and in the produced cells’ viability. Improper dissociation may also demote the quality of data attained in functional and molecular assays due to the presence of large quantities cellular debris containing immune-activatory danger associated molecular patterns, and due to the increased quantities of degraded proteins and RNA.ResultsOver 40 resected BTs and non-tumorous brain tissue samples were dissociated into single cells by mechanical dissociation or by mechanical and enzymatic dissociation. The quality of dissociation was compared for all frequently used dissociation enzymes (collagenase, DNase, hyaluronidase, papain, dispase) and for neutral protease (NP) from Clostridium histolyticum. Single-cell-dissociated cell mixtures were evaluated for cellular viability and for the cell-mixture dissociation quality. Dissociation quality was graded by the quantity of subcellular debris, non-dissociated cell clumps, and DNA released from dead cells. Of all enzymes or enzyme combinations examined, NP (an enzyme previously not evaluated on brain tissues) produced dissociated cell mixtures with the highest mean cellular viability: 93xa0% in gliomas, 85xa0% in brain metastases, and 89xa0% in non-tumorous brain tissue. NP also produced cell mixtures with significantly less cellular debris than other enzymes tested. Dissociation using NP was non-aggressive over time—no changes in cell viability or dissociation quality were found when comparing 2-h dissociation at 37xa0°C to overnight dissociation at ambient temperature.ConclusionsThe use of NP allows for the most effective dissociation of viable single cells from human BTs or brain tissue. Its non-aggressive dissociative capacity may enable ambient-temperature shipping of tumor pieces in multi-center clinical trials, meanwhile being dissociated. As clinical grade NP is commercially available it can be easily integrated into cell-therapy clinical trials in neuro-oncology. The high quality viable cells produced may enable investigators to conduct more consistent research by avoiding the experimental artifacts associated with the presence dead cells or cellular debris.

The “Agnes Fast” Craniotomy: The Modified Pterional (Osteoplastic) Craniotomy

The Agnes Fast craniotomy is a fast and simple way of performing the pterional craniotomy while preserving the temporalis muscle, together with its fascia and bony attachment. Using this technique, the surgeon need not divide the temporalis muscle, separate it from its bony attachment, or perform an interfacial dissection. With a little practice, this craniotomy can be performed in less than 5 minutes and is highly recommended in emergent settings. The modified pterional craniotomy was performed in 10 cadaveric specimens, preserving the temporalis muscle with its attachment. An interfascial dissection was not performed while exposing the frontozygomatic process. The exposure gained, the length of the procedure, and the ease of application were recorded for all heads studied. In all heads studied, the Agnes Fast craniotomy was performed, with complete preservation of the temporalis muscle and its attachments. This procedure was performed quickly, with complete preservation of the fascial nerve and its branches. The muscle was put back in its natural place following the craniotomy. The Agnes Fast craniotomy offers a fast way of performing a pterional craniotomy while preserving the temporalis muscle, with its blood supply, neural innervation, bony attachment, and fascia intact. Replacing the muscle is also fast and simple and involves placement of two CranioFix (Aesculap, Inc., Center Valley, PA) holders to the bone, with no suture material. This approach does not limit the exposure gained and offers the same exposure as the usual pterional craniotomy.

Petrous Carotid Exposure with Eustachian Tube Preservation: A Morphometric Elucidation

Inadvertent injury to eustachian tube leading to cerebrospinal fluid rhinorrhea is a known complication associated with drilling of Glasscocks triangle to expose the horizontal petrous internal carotid artery (ICA) for management of difficult tumors (especially malignant) or aneurysms at the cranial base. Contrary to the usual approach, we hypothesize that a medial-to-lateral approach to Glasscocks triangle drilling will minimize eustachian tube injury. Four formalin-fixed human cadaveric heads were dissected, and underwent appropriate morphometric analysis; yielding a total of eight datasets. The diameter of the horizontal petrous ICA exposed was 4.7u2009±u20090.9 mm (range, 3.8 to 5.6 mm).The mean distance from the medial carotid wall midpoint to the medial-most point on the eustachian tube was 6.35u2009±u20090.58 mm (range, 5.4 to 7.1 mm), yielding a safety zone for eustachian tube, ranging 0.2 to 1.9 mm lateral to the lateral carotid wall. With the medial-to-lateral approach, the eustachian tube remained preserved in all the specimens. The results of our study provide a practical, consistent, and safe method of maximizing horizontal petrous carotid artery exposure while minimizing the eustachian tube injury.

Intracranial and Orbital Complications of Bony Lesions Involving the Anterior Skull Base and Paranasal Sinuses

Purpose: A spectrum of conditions may be encountered in the sinonasal region and skull base composed of varying proportions of new bone and fibrous tissue such as osteomas, ossifying fibroma, fibrous dysplasia, and osteosarcoma. We present a series of 41 patients with anterior skull base bony tumors, and we focus on the cases with intracranial or orbital complications. Clinically manifested intraorbital and/or intracranial involvements are indications for surgical treatment. The purpose of this study is to describe our experience with the surgical treatment of these rare and serious manifestations of these lesions. Methods: Our cases involved the frontal sinus, orbit, and cribriform area. A retrospective analysis was done using patients files from the hospital and the outpatient clinic, operative notes, and pre- and postoperative imaging studies. The surgical technique included an anterior frontal sinus wall door, a type A or a type B subcranial approach, and reconstruction with fascia lata, titanium mesh coated with pericranium and plates, calvarial bone grafts, and fascia sling. Results: The age of the patients was 14 to 41 (mean, 25 yrs). Fifteen of the 41 patients presented with serious intracranial or orbital complications (headaches, CSF leak, pneumocephalus, seizures or proptosis, partial ptosis, and rapid visual deterioration). Twenty were males and 21 were females. Fifteen cases were operated using a subcranial approach and in 26 cases, only the anterior wall of the frontal sinus was removed. Complete removal of the tumor was achieved in all cases and all patients are alive. Surgical complications were mostly of short duration. Conclusions: Bony lesions of the anterior skull base can have serious local clinical effects including orbital and intracranial symptomatology. Our experience shows that these lesions are resectable with generally few complications. The subcranial approach provides a wide anatomical exposure and allows the complete resection of these tumors.