Pablo Miranda-Lloret

Full endoscopic endonasal expanded approach to the petroclival region: optimizing the carotid-clival window

BackgroundThe petroclival junction (PCJ) is a challenging skull base location from neurosurgical point of view, especially if the retrocarotid space has to be reached.MethodIn response to this challenge, this report provides a detailed full description of the endoscopic endonasal expanded approach (EEA) to the petroclival region and retrocarotid space. We present the technique step by step, introducing a critical concept about the optimization of the petroclival drilling, generating the carotid-clival window (CCW). The CCW is delimited by the paraclival segment of the internal carotid artery ICA anterolaterally, the petrous bone posterolaterally, the clival dura medially, the synchondrosis inferiorly, and the cavernous sinus superiorly; therefore, this approach exposes an important nuance to augment the previous approaches for PCJ and retrocarotid space.ConclusionThis technique provides a good surgical window and carries minimal risk.

Indocyanine green videoangiography methodological variations: review

Indocyanine green videoangiography (ICGVA) procedures have become widespread within the spectrum of microsurgical techniques for neurovascular pathologies. We have conducted a review to identify and assess the impact of all of the methodological variations of conventional ICGVA applied in the field of neurovascular pathology that have been published to date in the English literature. A total of 18 studies were included in this review, identifying four primary methodological variants compared to conventional ICGVA: techniques based on the transient occlusion, intra-arterial ICG administration via catheters, use of endoscope system with a filter to collect florescence of ICG, and quantitative fluorescence analysis. These variants offer some possibilities for resolving the limitations of the conventional technique (first, the vascular structure to be analyzed must be exposed and second, vascular filling with ICG follows an additive pattern) and allow qualitatively superior information to be obtained during surgery. Advantages and disadvantages of each procedure are discussed. More case studies with a greater number of patients are needed to compare the different procedures with their gold standard, in order to establish these results consistently.

Microscopic versus endoscopic pituitary surgery

INTRODUCTION AND OBJECTIVE The endoscopic techniques used in pituitary surgery have evolved greatly in recent years. Our objective in this study was to conduct a review of the systematic reviews published in the English language literature, to examine their consistency and conclusions reached following studies comparing microsurgery and endoscopic surgery in hypophyseal surgery. MATERIALS AND METHODS We carried out a bibliographic search on MEDLINE and EMBASE electronic databases, selecting those systematic reviews and meta-analyses published from the year 2000 until January 2013, focusing on comparisons between microsurgical and endoscopic techniques. RESULTS We concluded with type A consistency that hospital stay was shorter and diabetes insipidus and rhinological complications were less frequent in the endoscopy group. We concluded with type B consistency that lower rates of patient blood loss, shorter operative times, higher rate of gross total resection, lesser association to visual impairment and lower rate of hypopituitarism were observed in the endoscopy group. Vascular complications and cerebrospinal fluid fistulas were reduced with microsurgery. It is crucial to perform a combined analysis of all the systematic reviews treating a specific topic, observing and analysing the trends and how these are affected by new contributions. CONCLUSION Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in hypophyseal pathology.

Multitask Box Trainer for Endoscopic Endonasal Skull Base Surgery: ENDOtrainer

A new and low cost multitask training box created to develop some skills needed for endoscopic skull base surgery is presented.

[Transpterygoid expanded endonasal approach in fibrous dysplasia of the skull base: case report and technical note].

INTRODUCTION Expanded endonasal approaches (EEA) are becoming a first-level technique for the treatment of skull base pathologies. In some cases, the endoscopic procedures make it possible to dissect structures manipulated with greater difficulty in the classic approaches. We report a full endoscopic transpterygoid EEA for the treatment of a fibrous dysplasia (FD) of the skull base. In addition, we reviewed the English literature available on FD and transpterygoid EEA, establishing an exact surgical technique and showing our intraoperative experience. CASE REPORT A 42-year-old male with right sixth cranial nerve palsy. Cranial MRI and CT showed a central skull base lesion with diagnostic suspicion of FD. Patient underwent a full endoscopic transpterygoid EEA, achieving a wide skull base neurovascular decompression. Neuronavigation and the vidian canal landmark resulted mandatory during intraoperative procedure. DISCUSSION The transpterygoid EEA is a safe technique consistently supported in the literature. It may reduce the morbidity associated to the classic transcranial approaches, since it permits maximum resection with minimum craniofacial distortion. The vidian hole and canal are the landmarks used to locate and avoid injury to the lacerum segment of the carotid injury. The surgical treatment indication in FD cases must be established in symptomatic patients. CONCLUSION Transpterygoid EEA for treatment of FD of the skull base is a safe and effective procedure, thanks to the guide that the vidian canal provides in finding the lacerum segment of the carotid artery.

Xantoastrocitoma pleomórfico espinal: Caso clínico

Resumen Introduccion Presentamos los aspectos clinicopatologicos y radiologicos de uno de los escasos casos de xantoastrocitoma pleomorfico espinal publicado, una entidad neoplasica infrecuente en una realmente rara localizacion. Revisamos la breve literatura inglesa disponible y establecemos un apropiado manejo en funcion de esta. Caso clinico Mujer de 60 anos de edad que consulto por acorchamiento progresivo de su mano izquierda, acompanado de ocasionales parestesias de dos meses de evolucion. La exploracion neurologica mostro debilidad y un leve trastorno de la sensibilidad propioceptiva de la extremidad superior derecha. El diagnostico diferencial tras las pruebas de imagen se establecio entre astrocitoma y ependimoma. La paciente recibio tratamiento quirurgico obteniendose una reseccion completa y el diagnostico de xantoastrocitoma pleomorfico. En los controles de imagen realizados a los 6, 12, 24 y 36 meses no se objetivo recidiva tumoral. Actualmente la paciente ha recuperado su calidad de vida previa. Discusion y conclusion Comparando con los xantoastrocitomas pleomorficos intracraneales, aquellos con localizacion espinal (XAPE) presentan diferentes caracteristicas epidemiologicas, con afectacion predominante de niveles cervical y dorsal alto. La hipotesis de comportamiento mas agresivo de los XAPE podria ser corroborada tras la revision de la literatura. El estudio de extension es fundamental para descartar la descrita diseminacion a traves del neuroeje. El grado de extension de la reseccion quirurgica es crucial en la prevencion de la recurrencia tumoral. La radioterapia adyuvante deberia unicamente considerarse cuando aparece tumor residual y/o anaplasia. Ensayos clinicos randomizados y bases de datos multicentricas son necesarias para conocer todos los aspectos de esta entidad neoplasica.

Incomplete reossification after craniosynostosis surgery—incidence and analysis of risk factors: a clinical-radiological assessment study

OBJECTIVE One of the principles of the surgical treatment of craniosynostosis includes the release of fused bone plates to prevent recurrence. Such bone defects require a reossification process after surgery to prevent a cosmetic problem or brain vulnerability to damage. The objective of this study is to describe and analyze the radiological and clinical evolution of bone defects after craniosynostosis. METHODS From January 2005 to May 2016, 248 infants underwent surgical correction of craniosynostosis at HUiP La Fe Valencia; the authors analyzed data from 216 of these cases that met the inclusion criteria for this study. Various surgical techniques were used according to the age of the patient and severity of the case, including endoscopic-assisted suturectomy, open suturectomy, fronto-orbital advancement, and cranial vault remodeling. Clinical follow-up and radiological quantitative measurements in 2 periods-12-24 months and 2 years after surgery-were analyzed; 94 patients had a postoperative CT scan and were included in the radiological analysis. RESULTS At the end of the follow-up period, 92 of 216 patients (42.59%) showed complete closure of the bone defect, 112 patients (51.85%) had minor bone defects, and 12 patients (5.56%) had significant bone defects that required surgical intervention. In the multivariate analysis, age at first surgery was not significantly associated with incomplete reossification (p = 0.15), nor was surgical site infection (p = 0.75). Multivariate analysis identified area of cranial defect greater than 5 cm2 in the first CT scan as predictive of incomplete reossification (p = 0.04). The mean area of cranial defect in the first CT scan (12-24 months after surgery) was 3.69 cm2 in patients treated with open surgery and 7.13 cm2 in those treated with endoscopic-assisted procedures; in the multivariate analysis, type of procedure was not related to incomplete reossification (p = 0.46). The positive predictive value of palpation as evaluation of bone cranial defects was 50% for significant defects and 71% for minor defects. CONCLUSIONS The incidence of cranial defects due to incomplete reossification requiring cranioplasty was 5.56% in our series. Defects greater than 5 cm2 in the first postoperative CT scan showed a positive association with incomplete reossification. Patients treated with endoscope-assisted procedures had larger defects in the initial follow-up, but the final incidence of cranial defects was not significantly different in the endoscope-assisted surgery group from that in the open surgery group.

Radiological Study of the Carotid-Clival Window and Its Application in Endoscopic Endonasal Expanded Approaches

BACKGROUND The surgical approach to the petrous apex (PA) and petroclival junction (PCJ) remains a challenge. The carotid-clival window (CCW) represents the widest window available to approach the PCJ from a mediolateral endoscopic route. Here we define the CCW radiologically in nonpathological conditions, to establish the anatomic variability of the PCJ, relate this variability to pneumatization patterns, and evaluate some technical concerns conditioned by the CCW. METHODS This was an analytical study of 10 multislice computed tomography scans from patients without SB pathology. Bilateral measures were taken at the roof and floor levels of the lacerum canal (LC) and its posterior projection over the PCJ (segments DE and QR). All measures were compared across different pneumatization patterns. RESULTS The DE and QR lengths were found to be the most important measures affecting the width of the CCW. Wide variability was observed, with a mean DE length of 8.52 mm (range, 2.4-12.8 mm) at the LC floor level and a mean QR length of 9.11 mm (range, 4.3-13.1 mm) at the LC roof level. The presence of retrocarotid pneumatization was statistically significantly associated with longer DE and QR segments. No differences were found among other pneumatization patterns. CONCLUSIONS The CCW varies widely among individuals. The presence of pneumatization behind the paraclival carotid represents an advantageous characteristic when planning an endoscopic approach to the PCJ.

Transantral endoscopic approach for the treatment of lesions affecting the maxillary nerve

BackgroundSurgical approaches to skull base lesions that affect the maxillary nerve are complex, due to deep location and presence of relevant neurovascular structures surrounding this area.MethodWe propose the transantral endoscopic approach (TEA) for the treatment of lesions affecting the maxillary nerve or its vicinity. More specifically, the ones that are located anterior to the foramen rotundum.ConclusionsThis technique represents a minimally invasive treatment option for these kind of cranial base lesions. It offers optimal visualisation similar to the endonasal approach, whereas less dissection is required.

Endoscopia endonasal de base de cráneo

INTRODUCTION AND OBJECTIVE The endoscopic endonasal techniques used in skull base surgery have evolved greatly in recent years. Our study objective was to perform a qualitative systematic review of the likewise systematic reviews in published English language literature, to examine the evidence and conclusions reached in these studies comparing transcranial and endoscopic approaches in skull base surgery. MATERIAL AND METHODS We searched the references on the MEDLINE and EMBASE electronic databases selecting the systematic reviews, meta-analyses and evidence based medicine reviews on skull based pathologies published from January 2000 until January 2013. We focused on endoscopic impact and on microsurgical and endoscopic technique comparisons. RESULTS Full endoscopic endonasal approaches achieved gross total removal rates of craniopharyngiomas and chordomas higher than those for transcranial approaches. In anterior skull base meningiomas, complete resections were more frequently achieved after transcranial approaches, with a trend in favour of endoscopy with respect to visual prognosis. Endoscopic endonasal approaches minimised the postoperative complications after the treatment of cerebrospinal fluid (CSF) leaks, encephaloceles, meningoceles, craniopharyngiomas and chordomas, with the exception of postoperative CSF leaks. CONCLUSIONS Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in skull base surgery.