Jacques J. Morcos

Comparison of transnasal endoscopic and open craniofacial resection for malignant tumors of the anterior skull base

Craniofacial resection (CFR) represents the traditional approach for resection of anterior skull base (ASB) malignancies. However, this past decade has witnessed the emergence of transnasal endoscopic ASB resection (TER) as a feasible alternative. The aim of this study was to compare TER and CFR for ASB malignancy resection.

Detection of microemboli by transcranial Doppler ultrasonography in aneurysmal subarachnoid hemorrhage

OBJECTIVE To determine the frequency and characteristics of microembolic signals (MES) in subarachnoid hemorrhage (SAH). METHODS Twenty-three patients with aneurysmal SAH were monitored with transcranial Doppler ultrasonography for the presence of MES and vasospasm. Each middle cerebral artery was monitored for 30 minutes three times each week. Patients were excluded if they had traumatic SAH or cardiac or arterial sources of emboli. Monitoring was initiated 6.3 days (1–16 d) after SAH and lasted 6.6 days (1–13 d). Eleven individuals without SAH or other cerebrovascular diseases who were treated in the same unit served as control subjects. Each patient underwent monitoring of both middle cerebral arteries a mean of three times; therefore, 46 vessels were studied (a total of 138 observations). Control subjects underwent assessment of each middle cerebral artery once, for a total of 22 control vessels. RESULTS MES were detected for 16 of 23 patients (70%) and 44 of 138 patient vessels (32%) monitored, compared with 2 of 11 control subjects (18%) and 2 of 22 control vessels (9%) (P < 0.05). MES were observed for 83% of patients with clinical vasospasm and 54% of those without clinical vasospasm. Ultrasonographic vasospasm was observed for 71 of 138 vessels monitored; MES were observed for 28% of vessels with vasospasm and 36% of those without vasospasm. Aneurysms proximal to the monitored artery were identified in 38 of 138 vessels, of which 34% exhibited MES, which is similar to the frequency for vessels without proximal aneurysms (31%). Coiled, clipped, and unsecured aneurysms exhibited similar frequencies of MES. CONCLUSION MES were common in SAH, occurring in 70% of cases of SAH and one-third of all vessels monitored. Although MES were more frequent among patients with clinical vasospasm, this difference did not reach statistical significance. We were unable to demonstrate a relationship between ultrasonographic vasospasm and MES, and the presence of a proximal secured or unsecured aneurysm did not alter the chance of detection of MES. Further studies are required to determine the origin and clinical relevance of MES in SAH.

The role of radiosurgery to the tumor bed after resection of brain metastases.

BACKGROUND Optimal postoperative management paradigm for brain metastases remains controversial. OBJECTIVE To conduct a systematic review of the literature to understand the role of postoperative stereotactic radiosurgery after resection of brain metastases. METHODS We performed a MEDLINE search of the literature to identify series of patients with brain metastases treated with stereotactic radiosurgery after surgical resection. Outcomes including overall survival, local control, distant intracranial failure, and salvage therapy use were recorded. Patient, tumor, and treatment factors were correlated with outcomes through the use of the Pearson correlation and 2-way Student t test as appropriate. RESULTS Fourteen studies involving 629 patients were included. Median survival for all studies was 14 months. Local control was correlated with the median volume treated with radiosurgery (r = -0.766, P < .05) and with the rate of gross total resection (r = .728, P < .03). Mean crude local control was 83%; 1-year local control was 85%. Distant intracranial failure occurred in 49% of cases, and salvage whole-brain radiation therapy was required in 29% of cases. Use of a radiosurgical margin did not lead to increased local control or overall survival. CONCLUSION Our systematic review supports the use of radiosurgery as a safe and effective strategy for adjuvant treatment of brain metastases, particularly when gross total resection has been achieved. With all limitations of comparisons between studies, no increase in local recurrence or decrease in overall survival compared with rates with adjuvant whole-brain radiation therapy was found.

Extracranial-intracranial bypass for stroke - Is this the end of the line or a bump in the road?

The results of the recently published Carotid Occlusion Surgery Study, which failed to show a benefit of extracranial-intracranial (EC-IC) bypass over medical therapy in patients with symptomatic hemodynamically significant carotid occlusion, have been interpreted by some as the end of the line for EC-IC bypass in the management of stroke. Despite being carefully conceived and executed, several aspects of the trial design, study population, and underlying assumptions deserve further examination to determine how best to translate these results into clinical practice. Although a general expansion of EC-IC bypass use in this population would not be supported by the trial results, a select subset of patients with medically refractory hemodynamic symptoms may well benefit from surgery performed with sufficiently low perioperative morbidity. The potential for beneficial functional or cognitive impact of revascularization also remains under investigation. Limited application and further study with an eye to future developments, rather than complete abandonment, is warranted.

An alternative extradural exposure to the anterior clinoid process: the superior orbital fissure as a surgical corridor.

OBJECTIVEDolenc has pioneered the extradural approach to the anterior clinoid process (ACP) in approaching the cavernous sinus, clinoidal space, and orbital apex. A key step is the division of the frontotemporal dural fold (FTDF). Less experienced surgeons may not be as versatile in their three-dimensional understanding of the superior orbital fissure and thus may risk injury to its contents. Through our cadaveric and subsequent clinical experience, we have devised a modification of the approach that permits safer handling of the contents of the superior orbital fissure. METHODSIn five consecutive injected cadaveric heads (10 sides), we performed on one side a traditional extradural exposure of the ACP. On the other side, we performed our alternative dissection. Instead of exposing the ACP from medial to lateral and dividing the frontotemporal dural fold along the assumed path of safety, we followed the edge of the lesser wing from lateral to medial, uncovered the superior orbital fissure, and peeled the outer layer of the cavernous sinus medial to the foramen rotundum along the greater wing, thus uncovering the inferolateral surface of the ACP. This allowed dural division under full visualization. RESULTSThe alternative method proved easier and more reliable in every case. We applied this technical modification in seven patients with no complications. Specifically, there was no injury to the oculomotor, lacrimal, frontal, or trigeminal nerves or branches. We present detailed anatomic expositions of the injected specimens. CONCLUSIONThis technical modification of the extradural approach of Dolenc is a simple, safe, and valuable adjunct to the exposure of the ACP. We recommend its use particularly by relatively inexperienced surgeons.

Penetration of the optic nerve by an internal carotid artery-ophthalmic artery aneurysm: case report and literature review.

OBJECTIVE AND IMPORTANCEAlthough it is well known that large or giant internal carotid artery-ophthalmic artery aneurysms can cause visual deficits, penetration and schism of the optic nerve by an aneurysm are very rare. CLINICAL PRESENTATIONA 48-year-old man presented with an acute onset of right visual deterioration after an episode of severe headache. Magnetic resonance imaging demonstrated penetration of the right optic nerve by an intracranial aneurysm. Cerebral angiography revealed an internal carotid artery-ophthalmic artery aneurysm of 12 × 7 mm. The aneurysm was directed superomedially and appeared to have a “waist” within the penetration. INTERVENTIONIntraoperatively, we observed that part of the aneurysm wall was visible through the optic nerve fibers at the junction with the optic chiasm. CONCLUSIONAlthough there was no direct evidence of subarachnoid hemorrhage on imaging scans or with operative exploration, we think that the patient must have experienced sentinel hemorrhaging, leading to visual deterioration. We describe the case in detail and review the world literature.

Preliminary results of the ARUBA study.

1. Martino J, da Silva-Feritas R, Caballero H, Marco de Lucas E, García-Porrero JA, Vázquez-Barquero A. Fiber dissection and DTI tractography study of the temporo-parietal fiber intersection area. Neurosurgery. 2013;72(3):87-98. 2. Makris N, Kennedy DN, McInerney S, et al. Segmentation of subcomponents within the superior longitudinal fascicle in humans: a quantitative, in vivo, DT-MRI study. Cereb Cortex. 2005;15(6):854-869. 3. Wernicke C. Verhandlungen der Physiologischen Gesellschaft zu Berlin Jahrgang I und II (XX Sitzung am 12 Januar 1877).Deutsche Medizinische Wochenschrift. 1877; 12:2-4. 4. Ross J. Reviews and notices of books Lehrbuch der Gehirnkrankheiten für Aerzte und Studierende. Von Dr. C. Wernicke. 3 vols. Fischer, Kassel, 1881-1883. (see vol. 1, p. 23). Brain. 1883;6(3):398-403. 5. Quain J. Quains Elements of anatomy. Vol. III. Part I., The Spinal Cord And Brain; Sharpey-Schäfer EA, Sir, Thane GD, eds. London, United Kingdom: Longmans, Green and Co. 1891;pp.165-166. 6. Dejerine J, Dejerine-Klumpke AM. Anatomie des centres nerveux. Paris, France: Rueff & Cie; 1895;pp.757-758,778-783. 7. Noback CR, Demarest RJ. The Human Nervous System: Basic Principles of Neurobiology. New York, NY: McGraw-Hill; 1975;p.451. 8. Sachs H.Das Hemisphärenmark des menschlichen Grosshirns. 1. Der Hinterhauptslappen. Leipzig, Germany: Thieme; 1892;pp.6,8-9,15-19,23-24,26-27,29, Phot.1-6. 9. Bartsch AJ, Biller A, Homola G. Tractography for surgical targeting. In: Johansen-Berg H, Behrens TEJ, eds. Diffusion MRI: From Quantitaive Measurement to in Vivo Neuroanatomy. Amsterdam: Elsevier; 2009;pp.415-444. 10. Greenblatt SH. Alexia without agraphia or hemianopsia. Anatomical analysis of an autopsied case. Brain. 1973;96(2):307-316. 11. Greenblatt SH. Left occipital lobectomy and the preangular anatomy of reading. Brain Lang. 1990;38(4):576-595. 12. Epelbaum S, Pinel P, Gaillard R, et al. Pure alexia as a disconnection syndrome: new diffusion imaging evidence for an old concept. Cortex. 2008;44(8): 962-974. 13. Molko N, Cohen L, Mangin JF, et al. Visualizing the neural bases of a disconnection syndrome with diffusion tensor imaging. J Cogn Neurosci. 2002;14(4):629-636. 14. Vuilleumier P,Mohr C, ValenzaN,Wetzel C, Landis T.Hyperfamiliarity for unknown faces after left lateral temporo-occipital venous infarction: a double dissociation with prosopagnosia. Brain. 2003;126(pt 4):889-907. 15. Damasio AR, Damasio H. The anatomic basis of pure alexia. Neurology. 1983;33 (12):1573-1583. 16. Homola GA, Jbabdi S, Beckmann CF, Bartsch AJ. A brain network processing the age of faces. PLoS One. 2012;7(11):e49451. doi: 10.1371/journal.pone.0049451.

Outcomes and Management Strategies after Nondiagnostic Stereotactic Biopsies of Brain Lesions

Background/Aims: A significant minority of stereotactic biopsies (SBs) of brain lesions is nondiagnostic, yet there are no optimal strategies for preventing nondiagnostic SB (NDSB) and for managing patients after NDSB. We performed this study in order to identify risk factors for NDSB, to determine how diagnoses are eventually reached in these patients, and to ascertain whether NDSB affects clinical outcomes. Methods: Retrospective chart review of patients at our institution who underwent SB of brain lesions. Results: Twenty-four out of 100 SBs were nondiagnostic. NDSB was less likely in contrast-enhancing brain lesions in immunocompetent patients, with larger lesions and in the setting of diagnostic findings on intraoperative frozen section analysis. Of 16 patients with adequate postoperative follow-up, a diagnosis was eventually reached in 11, via further review of the pathology, retrieval of additional tissue specimens or additional noninvasive testing. Survival times for patients with NDSB and eventual tumor diagnoses were within expected ranges for patients with similar tumors. Three of the 5 patients who never received a final diagnosis enjoyed prolonged survival without progressive symptoms. Conclusions: Surgeons should consider taking additional specimens in the case of nondiagnostic intraoperative frozen section during SB. If a tumor is suspected and final pathology is nondiagnostic, outside review of the slides may be helpful, and sampling further tissue should be considered. For diseases other than tumors, the diagnosis will generally be made without a repeat biopsy. The delays in diagnosis resulting from NDSB do not appear to affect survival, at least in patients eventually found to have brain tumors.

Isolated unilateral hypoglossal nerve palsy secondary to an atlantooccipital joint juxtafacet synovial cyst: Case report and review of the literature

Juxtafacet cysts of the atlantooccipital joint that present with isolated hypoglossal nerve palsy are rare and may mimic more common pathological entities. The authors report on the third such case in the literature and discuss the differential diagnosis, imaging hallmarks, preoperative recognition, and surgical management of this lesion, and provide a review of the literature. The authors discuss their experience with the treatment of a 67-year-old woman who presented with an isolated hypoglossal nerve palsy caused by a nonenhancing cystic septated lesion abutting the lateral medulla just medial to the left hypoglossal canal. The lesion was presumed to be a necrotic hypoglossal schwannoma or epidermoid tumor. Intradural surgical exploration failed to demonstrate an intradural lesion, but confirmed the presence of an extradural mass caudal to the hypoglossal nerve. Extradural exploration revealed a synovial cyst of the atlantooccipital joint, which was then resected. Postoperatively, the patient developed worsening dysphagia and hoarseness. Failure to recognize this rare entity preoperatively resulted in unnecessary intradural exploration and cranial nerve morbidity. In retrospect, the preoperative diagnosis of this lesion was suggested by lack of central enhancement, absence of dumbbell formation and the presence of erosive synovial changes. Regardless, the extreme rarity of this lesion at this location will always make its recognition challenging.

Operative Approach Via the Superior Ophthalmic Vein for the Endovascular Treatment of Carotid Cavernous Fistulas That Fail Traditional Endovascular Access

BACKGROUND Endovascular embolization is the preferred treatment for carotid-cavernous fistulas (CCFs), but failure to catheterize the cavernous sinus may occur as a result of tortuosity, hypoplasia, or stenosis of the normal venous routes. In these cases, direct operative cannulation of the arterialized superior ophthalmic vein (SOV) offers an excellent alternative approach. METHODS We reviewed the records of patients who underwent surgical cannulation of the SOV in preparation for embolization and identified 10 patients with indirect CCF, all of whom presented with ocular signs and symptoms. All had previously undergone unsuccessful endovenous attempts at treatment at our institution. In the operating room, the SOV was catheterized under microscopic magnification through an eyelid or eyebrow incision, and the patients were taken directly to the angiographic suite for embolization. RESULTS In 9 of 10 patients, embolization of the CCF was complete with clinical improvement. In 1 case, navigation of the catheter into the SOV proved difficult, and the procedure was aborted because of contrast extravasation after partial embolization. One patient required a small orbital osteotomy to localize the SOV. There were no clinical complications and no known recurrences. Cosmetic results were excellent in all patients. CONCLUSION Surgical access to the superior ophthalmic vein for embolization of a CCF is an excellent and definitive alternative treatment when traditional endovenous routes are inaccessible. The operative approach to the SOV is straightforward and can be performed safely and expeditiously by the neurovascular team.