Pinar Eser Ocak

A Rare Complication of Endovascular Embolization: Extruded Onyx on Trigeminal Nerve

Objectives u2003To demonstrate a rare complication of endovascular tumor embolization with onyx. Design u2003Operative video. Setting u2003Department of neurological surgery in a university hospital. Participants u2003A 39-year-old male who was diagnosed with a right sided hemangioblastoma. Main Outcome Measures u2003Surgical resection of the tumor, preservation of the cranial nerves and extruded embolization material on trigeminal nerve. Results u2003The tumor was embolized with onyx the day before surgery. Patient woke up with no sensation in the right side of his face. Diffusion magnetic resonance imaging (MRI) showed a small restricted diffusion area within the right superior cerebellar vermis. Microsurgical resection of the tumor was uneventful and complete resection was achieved (Fig. 1). After the resection was completed, the trigeminal nerve was identified. Some of the capillaries overlying the nerve as well as the cerebellum and brain stem had extruded onyx-embolic material (Fig. 2). Some of the onyx over the cerebellum was removed; however, the ones on the trigeminal nerve and brain stem were not removed due to the risk of injury to the nerve. Postoperative MRI confirmed total resection. Patient made excellent recovery except he continued to have no sensation in the right side of his face. Conclusion u2003Preoperative embolization is an important adjunct to resection of large hemangioblastomas in selected cases because it may facilitate circumferential dissection and debulking of the tumor. Although extrusion of the embolization material is relatively common, immediate extrusion of onyx and its transfixion on a cranial nerve has not been reported before. Judicial selection of preoperative embolization is required in hemangioblastomas. The link to the Video can be found at: https://youtu.be/s0DjD26Xkas .

Facial nerve outcome and extent of resection in cystic versus solid vestibular schwannomas in radiosurgery era

OBJECTIVE Cystic vestibular schwannomas (CVSs) are a subgroup of vestibular schwannomas (VSs) that are reported to be associated with unpredictable clinical behavior and unfavorable postoperative outcomes. The authors aimed to review their experience with microsurgical treatment of CVSs in terms of extent of resection and postoperative facial nerve (FN) function and compare these outcomes with those of their solid counterparts. METHODS Two hundred-eleven VS patients were treated surgically between 2006 and 2017. Tumors were defined as cystic when preoperative neuroimaging demonstrated cyst formation that was confirmed by intraoperative findings. Solid VS (SVSs) with similar classes were used for comparison. Clinical data of the patients were reviewed retrospectively, including clinical notes and images, as well as operative, pathology, and neuroradiology reports. RESULTS Thirty-two patients (20 males and 12 females) with a mean age of 52.2 years (range 17-77 years) underwent microsurgical resection of 33 CVSs (mean size 3.6 cm, range 1.5-5 cm). Forty-nine patients (26 males and 23 females) with a mean age of 49.9 years (range 21-75 years) underwent microsurgical resection of 49 SVSs (mean size 3 cm, range 2-4.5 cm). All operations were performed via either a retrosigmoid or a translabyrinthine approach. Gross-total resection was achieved in 30 cases in the CVS group (90.9%) and 37 in the SVS group (75.5%). The main reason for subtotal and near-total resection was adherence of the tumor to the brainstem and/or FN in both groups. None of the patients with subtotal or near-total resection in the CVS group demonstrated symptomatic regrowth of the tumor during the mean follow-up period of 41.6 months (range 18-82 months). The FN was anatomically preserved in all patients in both groups. Good FN outcomes were achieved in 15 of CVS (grade I-II; 45.5%) and 35 of SVS (71.4%) surgeries at discharge. Good and fair FN functions were noted in 22 (grade I-II; 81.5%) and 5 (grade III only; 18.5%) of the CVS patients, respectively, at the 1-year follow-up; none of the patients showed poor FN function. CONCLUSIONS Surgery of CVSs does not necessarily result in poor outcomes in terms of the extent of resection and FN function. Special care should be exercised to preserve anatomical continuity of the FN during surgery, since long-term FN function outcomes are much more satisfactory than short-term results. High rates of gross-total resection and good FN outcomes in our study may also suggest that microsurgery stands as the treatment of choice in select cases of large CVSs and SVSs in the era of radiosurgery.

Insights into major facilitator superfamily domain-containing protein-2a (Mfsd2a) in physiology and pathophysiology. What do we know so far?

Major facilitator superfamily domain‐containing protein‐2a (Mfsd2a) which was considered as an orphan transporter has recently gained attention for its regulatory role in the maintenance of proper functioning of the blood–brain barrier. Besides the major role of Mfsd2a in maintaining the barrier function, increasing evidence has emerged with regard to the contributions of Mfsd2a to various biological processes such as transport, cell fusion, cell cycle, inflammation and regeneration, managing tumor growth, functioning of other organs with barrier functions or responses to injury. The purpose of this article is to review the different roles of Mfsd2a and its involvement in the physiological and pathophysiological processes primarily in the central nervous system and throughout the mammalian body under the lights of the current literature.

Resection of complex occipital arteriovenous malformation with giant varix: demonstration of microsurgical technique

The complexity of arteriovenous malformations (AVMs) does not necessarily preclude surgical resection. In this video the authors present a 72-year-old male who was known to have an occipital AVM with a large draining varix for the previous 10 years. The patient had progressively worsening visual and cognitive deficits over several years. Total surgical resection was achieved following single stage preoperative embolization. Although resection of the AVMs is challenging, even in experienced hands, it offers a cure and may improve patient clinical outcome. The video can be found here: https://youtu.be/YI1AwGjJdvo .

Resection of middle petroclival meningioma via combined anterior transpetrosal and retrosigmoid approaches at two separate stages: 3D operative video

Surgical access to the petroclival region poses a challenge to neurosurgeons. A wide range of approaches has been demonstrated in the past. In this video, the authors present a 69-year-old male patient who presented with 3-month history of worsening left-sided numbness. The tumor was totally removed in 2 sessions via anterior transpetrosal and retrosigmoid approaches, respectively. The authors demonstrate 2 separate skull base approaches to resect a petroclival meningioma and discuss pitfalls and problems of management for challenging meningiomas. The authors suggest that surgical approaches to petroclival meningiomas should be selected based on an individual case. A skull base team should be versatile in performing all these approaches. The video can be found here: https://youtu.be/BCVrn3TeNvE .

Intracranial Infectious Aneurysms

development in intracranial arteries and has high mortality and morbidity rates. Infectious aneurysms represent 1% to 6.5% of all intracranial aneurysms. Furthermore, vascular imaging is not used in routine clinical care for screening patients, causing an underestimation of cases. However, diagnosis requires accurate cerebral vascular imaging. Until now, no treatment protocol is widely accepted, as the majority of the existing literature consists of small case series rather than large controlled trials.