Sorin Aldea

Asymptomatic Spinal Canal Migration of Clavicular K-Wire at the Cervicothoracic Junction

Unstable clavicular fractures can be treated surgically with pins and wires or with plates. The migration of metallic devices such as Kirschner wires (K-wires) from the shoulder to a variety of anatomical proximal and distal locations is well documented. Spinal migration, however, is rare and is normally associated with severe spinal injury. This article presents the case of a man who presented with cervicothoracic migration of a K-wire after treatment of a clavicular fracture sustained during a sports accident. The distinctive feature in this case, when compared to the existing literature, is its fortuitous detection by imaging studies and its surgical removal without neurological sequelae.

Two patients with a solitary fibrous tumor of the thoracic spinal cord

We report two patients with thoracic spinal solitary fibrous tumor (SFT). This report includes a patient with the first secondary SFT arising in the central nervous system from a pleural origin to our knowledge. The diagnosis was confirmed by histological and immunohistochemical analysis. Both patients underwent gross total resection of their tumors and did not show signs of local recurrence. The patient with the secondary lesion later presented with visceral dissemination. We review the reports of spinal SFT and discuss the diagnosis and therapeutic management of this intriguing entity.

Controlateral cavernous syndrome, brainstem congestion and posterior fossa venous thrombosis with cerebellar hematoma related to a ruptured intracavernous carotid artery aneurysm

Intracavernous carotid artery aneurysms (ICCAs) are rarely associated with life-threatening complications. We describe a 55-year-old woman who, after the rupture of an intracavernous carotid artery aneurysm, presented with a contralateral cavernous sinus syndrome and severe posterior fossa and spinal cord symptoms. Following parent artery occlusion, thrombosis of the posterior fossa and spinal cord veins caused a progressive worsening of the neurological status to a “locked-in” state. The patient fully recovered with anticoagulation therapy. Comprehension of the pathophysiological mechanism associated with the rupture of ICCA and early diagnosis of the related symptoms are essential in order to plan a correct treatment that includes the management of the aneurysm rupture and of possible complications related to venous thrombosis.

Bilateral Orbital and Optic Nerve Endoscopic Endonasal Decompression for Nonspecific Inflammatory Orbital Disease: Case Report

BACKGROUND Endoscopic endonasal optic nerve decompression (EEOND) is indicated in traumatic and endocrine orbitopathies as well as in idiopathic intracranial hypertension. CASE We present a patient with bilateral nonspecific inflammatory orbitopathy (NSIO) and optic nerve compression presenting with acute severe visual loss. Bilateral orbital and optic nerve decompression was performed as an emergency procedure with a favorable ophthalmological result. CONCLUSION EEOND is an effective and safe technique in acute orbitopathies and should be taken in consideration in atypical clinical settings causing severe acute visual loss.

Endonasal Endoscopic Odontoidectomy in Ventral Diseases of the Craniocervical Junction: Results of a Multicenter Experience

BACKGROUND Over the past decades, supported by preliminary anatomic and clinical studies exploring its feasibility and safety, experience has increased of the use of the endoscopic endonasal approach (EEA) to ventral diseases at the craniocervical junction (CCJ). METHODS A multicenter study was carried out over a 4-year period of 14 patients managed by EEA odontoidectomy for CCJ diseases causing irreducible atlantoaxial dislocation. The surgical setup included an IGS system based on computed tomography and magnetic resonance images fusion, and 0° and 30° angled endoscopes with dedicated endoscopic tools. RESULTS Nine men and 5 women, with a mean age of 60.7 years, were included. The mean follow-up was 28.5 months; 9 patients had basilar impression, whereas 5 had a degenerative pannus. The quality of anterior decompression was excellent in all cases; nonetheless, a posterior stabilization was deemed necessary in 13 patients, and no external orthosis was used during the postoperative course. No tracheostomy or gastrostomy was required after surgery; no deaths, no new neurologic deficits/complications, and no postoperative cerebrospinal fluid leak were recorded. At follow-up, the neurologic status assessed with Frankel grade did not deteriorate in any of the patients but improved in 13 of them; and no new listhesis was shown on neuroradiologic follow-up. CONCLUSIONS The results show that EEA provides a direct surgical corridor to the CCJ, allowing an adequate decompression as with the more invasive transoral route. Morbidity is less than with a transoral approach, resulting in higher patient comfort and faster recovery.

Anticoagulants et anti-agrégants plaquettaires dans la chirurgie hypophysaire et de la base du crâne

Resume La conduite a tenir concernant les medicaments anticoagulants et anti-agregants dans la pathologie tumorale hypophysaire et de la base du crâne ne fait pas l’objet d’un consensus. Nous presentons l’experience de notre service dans la gestion des anticoagulants et des antiagregants pendant la periode peri-operatoire.

Transtubular versus microsurgical approach for single lumbar disc herniation: a prospective study

Earlier studies have compared transtubular discectomy with microsurgical discectomy in the treatment of lumbar disc herniations, but a few prospective studies with homogeneous groups of patients have been conducted. The aim of this study was to compare intraoperative and immediate postoperative results in a group of patients submitted to discectomy with the use of a tubular retractor (TTD) to the one operated with standard microdiscectomy as described by Caspar (MSD). A total of 83 patients were prospectively observed and reviewed. Two homogeneous groups of patients were compared. All patients were preoperatively examined by the operating surgeon and the anaesthesiologist. All surgical data and constatations were collected on the operative summary. Several parameters like operative time, morphinic consumption in recovery room, length of hospital stay and peri- and post-operative complications were compared. Results show that both procedures lead to excellent recovery and that TTD is a viable alternative to MSD. There was no statistically significant difference in most of the examined parameters between the two techniques.

Contralateral Eyebrow Approach for Unilateral Suprasellar Meningioma

Unilateral suprasellar meningiomas have distinct features compared to other midline tumors, as they may produce severe visual symptoms even if small due to an early involvement of the optic canal. Surgical treatment of these tumors from an ipsilateral approach is challenging, as the tumor is covered by the optic nerve that needs to be mobilized to access the optic canal extension. A contralateral approach allows a direct line of sight to the tumor despite a longer working distance. We report the case of a 49-year-old patient presenting with unilateral visual loss related to a left suprasellar meningioma extending to the left optic canal and displacing the optic nerve laterally. Through a right eyebrow approach, a 2.5/2 cm supraorbital bone flap was raised and the orbital floor was thoroughly flattened. After dural opening, the carotid cistern was opened and CSF evacuated allowing a surgery without fixed retractors. The intracranial part of the tumor was removed, but the optic nerve seemed to be still displaced by the intracanalicular part. Under copious irrigation, the medial part of the optic canal was drilled, the dura incised, and the tumor removed. Postoperative course was favorable and the patient made a complete visual recovery. Postoperative MRI showed complete removal of the tumor. We present different surgical steps and discuss the nuances of the procedure. The contralateral eyebrow approach is an interesting addition to the surgical armamentarium and should be discussed for unilateral suprasellar tumors. The link to the video can be found at: https://youtu.be/2LTEOaGoKzo .

Multiple Aneurysms Clipping Through the Eyebrow Approach: 2-Dimensional Operative Video

The eyebrow approach is a versatile technique that may apply to various vascular and tumoral pathologies of the anterior skull base. We present a case of multiple aneurysms clipping through the eyebrow approach and we discuss the nuances of this technique. A 44-yr-old patient presented with incidentally found aneurysms. Angiography showed 2 4.5-mm aneurysms on the left middle cerebral artery (MCA) and internal carotid artery (ICA) bifurcations. At surgery, the patient is positioned supine with the head elevated, slightly rotated, and extended in order to obtain good access and gravity retraction of the brain. A 3-cm incision is placed in the eyebrow and a small supraorbital bone flap is raised. The floor of the orbit and the edges of the craniotomy are thoroughly drilled in order to maximize the working space. After dural opening, the sylvian fissure was widely dissected and the MCA aneurysm was identified. A large opening of the sylvian and carotid cistern allows retractor free surgery. The ICA bifurcation aneurysm is then dissected and clipped. The MCA aneurysm is treated last in order to avoid a conflict between instruments especially during clipping. Aneurysms occlusion and vessel permeability is verified by Doppler ultrasonography and indocyanine green (ICG) angiography. After achieving hemostasis, the dura is closed and a subcuticular continuous suture is used at the skin. The postoperative course was uneventful. The eyebrow approach allows simultaneous treatment of multiple aneurysms of the anterior circle of Willis in selected cases. Proper positioning, drilling of the orbital floor and extensive arachnoid dissection are the key steps of this procedure.

How I do it: Endoscopic endonasal approach for odontoid resection

BACKGROUND Since it was first described in 2005 by Kassam et al., the technique of endoscopic resection of the odontoid by the transnasal route has gained broad acceptance. Its advantages over the transoral approach are currently well-demonstrated. METHOD The authors present the surgical technique developed by the senior author in a series of 12 patients, specifying the planning, complications avoidance and showing a film of the operating technique. CONCLUSION Endoscopic endonasal odontoidectomy is an effective procedure with low morbidity. This technique has a place in the treatment of complex pathologies of the craniovertebral junction and has many advantages over the transoral route.