Joham Choque-Velasquez

Supracerebellar Infratentorial Paramedian Approach in Helsinki Neurosurgery: Cornerstones of a Safe and Effective Route to the Pineal Region

OBJECTIVE The supracerebellar infratentorial (SCIT) paramedian approach in sitting position represents one of the most used surgical routes for dealing with pineal region lesions. The purpose of this study is to determine the cornerstones to perform this approach in a simple, safe, and effective way, so that it could be easily reproduced in other neurosurgical centers, particularly in those with modest resources. METHODS We reviewed and analyzed the surgical videos of 24 pineal region lesions that were operated on through an SCIT approach between June 2012 and October 2015. The SCIT approach may be divided into 3 main steps: 1) skin-muscle incision; 2) craniotomy; and 3) dura opening and access to the pineal region. RESULTS Complete lesion removal was accomplished in 23 cases, and subtotal removal was accomplished in 1 case. The pineal region was effectively and safely reached through the SCIT approach in the sitting position with a mean time of 14 minutes, using a basic set of microsurgical instruments. Cornerstones and potential delaying events were carefully recorded for each of the 3 main steps of the approach. Moreover, we present in a short video a step-by-step guide to perform the SCIT approach in a fast and safe way. CONCLUSIONS A correct application of microsurgical principles may allow to safely and rapidly perform the SCIT approach, therefore offering an effective and relatively atraumatic route for dealing with pineal region lesions.

Seven Cerebral Aneurysms: A Challenging Case from the Andean Slopes Managed with 1-Stage Surgery

BACKGROUND Treatment of multiple intracranial aneurysms is particularly demanding and even more so in a developing country where access to specialized centers may be prevented by different factors. METHODS Single-stage surgical treatment of 7 cerebral aneurysms was performed in a 58-year-old woman from the northern Peruvian Andes. RESULTS All 7 aneurysms were successfully and safely clipped through 2 lateral supraorbital craniotomies. The double clip technique was used in 3 aneurysms to prevent any residual aneurysmal neck. CONCLUSIONS Good teamwork and correct application of microsurgical principles may allow effective treatment in complex neurosurgical cases even in resource-challenged environments.

The open access video collection project “Hernesniemi's 1001 and more microsurgical videos of Neurosurgery”: A legacy for educational purposes

Background: Neurosurgical educational programs and courses are helpful to improve the quality of training. Moreover, nowadays, online activities may represent a very useful tool to globally enhance neurosurgical education. The “Hernesniemis 1001 and more microneurosurgical videos” project aims to show the microsurgical style developed by the senior author and his TEAMs in more than 40 years of experience. Methods: More than 1100 high-definition videos of microneurosurgical operations performed by the senior author were carefully edited. These videos illustrate the philosophy of “simple, clean, fast and preserving the normal anatomy” while offering a step by step guide of different neurosurgical procedures. Results: All the aforementioned material is well organized in an electronic videobook, freely available in Surgical Neurology International. The book also includes comments of great current neurosurgeons and writings of the authors and editors. Conclusion: We are sure that our project will be able to instill in and spread across the neurosurgical community the microneurosurgical style of the senior author, thus representing an efficient educational tool for surgeons all around the world.

Virtual Reality Glasses and “Eye-Hands Blind Technique” for Microsurgical Training in Neurosurgery

OBJECTIVE Microsurgical skills and eye-hand coordination need continuous training to be developed and refined. However, well-equipped microsurgical laboratories are not so widespread as their setup is expensive. Herein, we present a novel microsurgical training system that requires a high-resolution personal computer screen, smartphones, and virtual reality glasses. METHODS A smartphone placed on a holder at a height of about 15-20 cm from the surgical target field is used as the webcam of the computer. A specific software is used to duplicate the video camera image. The video may be transferred from the computer to another smartphone, which may be connected to virtual reality glasses. RESULTS Using the previously described training model, we progressively performed more and more complex microsurgical exercises. It did not take long to set up our system, thus saving time for the training sessions. CONCLUSION Our proposed training model may represent an affordable and efficient system to improve eye-hand coordination and dexterity in using not only the operating microscope but also endoscopes and exoscopes.

Papillary Tumor of the Pineal Region in Children: Presentation of a Case and Comprehensive Literature Review

BACKGROUND Papillary tumor of the pineal region (PTPR) is a rare grade II-III pineal lesion with peculiar histological and immunohistochemical features. These tumors mostly occur in adults, only rarely in children, with 19 cases reported up to now. CASE DESCRIPTION We present a 3-year-old boy who underwent reoperation for a recurrent PTPR (grade II). Gross total resection of the lesion through an occipital interhemispheric approach with the patient in a sitting position was followed by adjuvant radiotherapy and chemotherapy. Histological examination revealed tumor progression (grade III) and an MIB-1 proliferation index >25%. The patient continues to do well with no evidence of recurrence more than 3 years following surgery. A comprehensive literature review regarding the PTPR, including the current management in children, is reported. CONCLUSIONS PTPRs are extremely rare in children, and immunohistochemistry is needed to differentiate them from other pineal tumors. These tumors show a high rate of recurrence, and a multidisciplinary management approach (microsurgical resection followed by radiotherapy and/or chemotherapy) can help achieve a favorable outcome.

Moyamoya Disease in an 8-Year-Old Boy: Direct Bypass Surgery in a Province of Peru

BACKGROUND Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors. CASE DESCRIPTION Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patients motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru. CONCLUSIONS The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.

Suboccipital osteoblastoma: Microsurgical resection of a rare entity

Background: Osteoblastomas are rare lesions comprising 1% of all bone tumors. The occipital bone is one of the rarest affected bone, with only 11 cases reported during the last 40 years. Case Description: Here, we describe the clinical presentation and the radiological features of a suboccipital osteoblastoma that was successfully resected in a 30-year-old man. A short video shows the microsurgical removal of the lesion. There was no recurrence during a 12-month follow-up. Conclusions: Even if osteoblastomas are benign tumors, a complete removal has to be achieved to reduce the risk of recurrences. This makes necessary an appropriate monitoring of the patient.

Venous air embolisms and sitting position in Helsinki pineal region surgery

Background: Nowadays, the sitting position has lost favor among neurosurgeons partly due to assumptions of increased complications, such as venous air embolisms (VAEs) and hemodynamic disturbances. The aim of our study is to describe the importance of some anesthetic considerations and the utility of antigravity trousers as well, together with a skillful neurosurgery and an imperative proper teamwork, in order to prevent the risk of severe VAE during pineal region surgery. We routinely use them for the variant of the sitting position we developed, the “praying position.” Methods: A retrospective review of 51 pineal lesions operated on in the “praying position” using antigravity trousers was carried out. In the “praying position” the legs of the patient are kept parallel to the floor. Hence, antigravity trousers are used to generate an adequate cardiac preload. Results: VAE associated to persistent hemodinamic changes was nonexistent in our series. The rate of VAE was 35.3%. VAEs were diagnosed mainly by monitoring of the end-tidal CO2 (83.33%). A venous system lesion was the cause in most of the cases. When VAE was suspected, an inmediate reaction based on a good teamwork was imperative. No cervical spine cord injury nor peripheral nerve damage were reported. The average microsurgical time was 48 ± 33 min. Conclusions: The risks of severe VAE during pineal region surgery in the “praying-sitting position” may be effectively prevented by some essential anesthetic considerations and the use of antigravity trousers together with a skillful neurosurgery, and an imperative proper teamwork.

One burr-hole craniotomy: Subtemporal approach in helsinki neurosurgery

Background: In this video-abstract, we present the Helsinki Neurosurgery one burr-hole craniotomy standard subtemporal approach to the floor of the middle fossa and the interpeduncular space. This procedure facilitates access to the multiple structures; the basilar artery bifurcation, the superior cerebellar artery, or the P1-P2 segments of the posterior cerebral artery, and lesions located around the posterior clinoid process/less than 10 mm above it. Even though the specific location and size of the lesion may vary, this approach accesses all mentioned structures with very minimal variation. Case Description: The patient with a basilar artery bifurcation aneurysm is placed in park bench position. A spinal drain is inserted to release 50–100 ml of cerebrospinal fluid. Next, the skin incision starts in front of the tragus above the earlobe, crossing the zygomatic line. Inferior retraction for the craniotomy is provided by hooks and hemostatic Raney clips placed at the superior border of the skin flap. The zygomatic line represents the anatomical landmark of the floor of the middle fossa. A burr-hole is made at the most cranial border of the bone flap. After the detachment of the dura with long flexible blunt dissectors, a craniotomy is performed to expose the dura of the inferior temporal lobe. A few drill holes are made for tacking-up sutures. The dural opening is then performed based on the zygomatic line. Cutting and opening of the tentorium runs posterior to the tentorial insertion of the fourth nerve. Conclusion: The described one burr-hole craniotomy offers a more efficient subtemporal approach. Videolink: http://surgicalneurologyint.com/videogallery/subtemporal-approach-unedited/

One burr-hole craniotomy: Suboccipital midline approach to the fourth ventricle in Helsinki neurosurgery

Background: In this video-abstract, we present one burr-hole craniotomy for the standard suboccipital midline approach developed in Helsinki neurosurgery for the microsurgical management of forth ventricle lesions, distal posterior inferior cerebellar artery aneurysms, and tumoral and vascular lesions of the vermis, cisterna magna region, and posterior brainstem as well. Case Description: We prefer to position the patient in sitting praying position. A midline straight single-layer incision starts on the inion and extends caudally toward the level of C2. The muscles are divided with diathermia along the occipital bone. Three curved retractors, two upward and one downward, provide a wide clean space for the craniotomy. Finger palpation and blunt dissection with cottonoids balls provide identification of the foramen magnum and the spinous process of C1. A burr-hole is made 1 cm lateral and below the level of the transverse sinus. After the detachment of the dura with a curved angled dissector, two cuts from both sites of the burr-hole are made with the craniotome. In case of an adherent dura particularly present in elderly patients, a long blunt flexible dissector (yasargil dissector) is used for the detachment of the bone from the dura. A craniotomy around the midline overlying the occipital sinus and the falx cerebelli is performed to expose medial aspects of cerebellar tonsils, the medulla oblongata, and the occipital sinus. Special care should be taken to avoid damaging the vertebral artery and the epidural sinuses running at the foramen magnum. A few drill holes are made for tack-up sutures. After a craniocervical-based opening of the dura, the fourth ventricle is accessed directly by telovelar route. Conclusion: The described one burr-hole craniotomy may represent the more efficient manner for performing the suboccipital midline approach to the fourth ventricle. Videolink: http://surgicalneurologyint.com/videogallery/suboccipital-midline-approach/