- Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Posterior Petrosal Approach. [Journal Article]
- JNJ Neurol Surg B Skull Base 2019; 80(4):338-351
- Introduction Although numerous anatomical and operative atlases have been published, those that have focused on the skull base either have provided views that are quite difficult to achieve in the op…
Introduction Although numerous anatomical and operative atlases have been published, those that have focused on the skull base either have provided views that are quite difficult to achieve in the operating room to better depict surgical anatomy or are written at the level of an audience with considerable knowledge and experience. Methods Five sides of three formalin-fixed latex-injected specimens were dissected under microscopic magnification. A posterior petrosectomy approach was performed by three neurosurgical residents at different training levels with limited previous experience in anatomical dissection mentored by the senior authors (C. L. W. D. and M. J. L.) and a clinical skull base fellow with additional anatomical dissection experience (M. P. C.). Anatomical dissections were performed until the expected level of dissection quality was achieved to demonstrate each important step of the surgical approach that would be understandable to all trainees of all levels. Following dissection education, representative case applications were reviewed. Results The posterior petrosectomy (also known as presigmoid retrolabyrinthine approach) affords excellent access to cranial nerves III to XI and a diverse array of pathologies. Key steps include positioning and skin incision, scalp and muscle flaps, burr holes, craniotomy flap elevation, superficial mastoidectomy, otic capsule exposure and presigmoid dura decompression, primary presigmoid durotomy, inferior temporal durotomy, superior petrosal sinus ligation, tentorium sectioning, and final exposure. Conclusion The posterior petrosectomy is a challenging approach; thorough operative-style laboratory dissection is essential to provide trainees with a suitable guide. We describe a comprehensive approach to learning this technique, intended to be understandable and usable by a resident audience.
- A Successful Outcome Despite Delayed Intervention for Cauda Equina Syndrome in a Young Patient with a Posterior Epidural Disc Extrusion. [Case Reports]
- CCureus 2019 May 11; 11(5):e4645
- Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation,…
Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation, this is an unusual presentation with epidural disc extrusion. We present a very rare case of Cauda Equina syndrome, resulting from an epidural disc extrusion at L3-L4 level. Patient care and progress notes were reviewed along with pre-, post-, and intra-operative radiological imaging. Here, a 19-year-old male with a past medical history of type I diabetes mellitus, fell asleep on a chair at home in an unusual position and was unable to walk on awakening. The patient developed progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction. In addition, he experienced paresthesia and severe lower back pain unresponsive to steroids. Pre-operative magnetic resonance imaging (MRI) demonstrated a herniated disk epidurally with disc extrusion and mass effect and compression at the L3-L4 level, wrapping around the posterior aspect of the dura. A diagnosis of cauda equina syndrome was made and surgical decompression was performed. Using microsurgical technique and fluoroscopic guidance, a bilateral laminectomy of L3 was achieved with bilateral partial laminectomy of L4, with bilateral foraminotomy of L4. After removal of the lamina, a mass was immediately visualized in the posterior epidural space. Further dissection of the substance and following it posteriorly, identified the mass as a portion of the extruded disc. Post-operatively, the patient experienced rapid recovery. In conclusion, this case demonstrates that a disc extrusion can occur within the epidural space and can cause cauda equina syndrome. As this presentation is unusual, surgeons must be aware that they may encounter disc mass in unexpected locations, in a clinically delayed setting, long after the initial onset of symptoms.
- Extraneural Metastasis of Primary Glioma Occurring in a Setting of Occupational Ionizing Radiation Exposure. [Case Reports]
- CRCase Rep Neurol Med 2019; 2019:1748739
- Malignant gliomas account for 60% of all primary brain tumors in adults. Glioblastoma Multiforme (GBM) is the most common primary glial tumor with a dismal prognosis and a median survival of approxim…
Malignant gliomas account for 60% of all primary brain tumors in adults. Glioblastoma Multiforme (GBM) is the most common primary glial tumor with a dismal prognosis and a median survival of approximately 14 months. Extra-neural metastases from primary brain tumors are unusual with an incidence rate of less than 2%. This has been attributed to factors such as short survival, lack of true lymphatics in the CNS, and physical barriers provided by the dura, extracellular matrix, and basement membrane. Although most GBMs occur sporadically, there is a known association with therapeutic radiation exposure and with work in nuclear disaster cleanup. To our knowledge, no case of GBM with metastasis occurring in a patient with occupational radiation exposure currently exists in the literature. In this article, we present a case of GBM with lung metastasis occurring in a 51-year-old Caucasian male, whose history is significant for occupational exposure to ionizing radiation, and review the literature on GBM risk factors and potential mechanisms of metastasis.
- Erratum: A sewing needle in contact with the cervical dura mater and vertebral artery: A case report: Erratum. [Published Erratum]
- MMedicine (Baltimore) 2017; 96(16):e6797
- [This corrects the article DOI: 10.1097/MD.0000000000005764.].
[This corrects the article DOI: 10.1097/MD.0000000000005764.].
- Vascular involvement in anterior clinoidal meningiomas : Biting the 'artery' that feeds. [Journal Article]
- CNClin Neurol Neurosurg 2019 Jul 06; 184:105413
- CONCLUSIONS: These tumours are often fed by supraclinoid ICA. It is possible to resect the tumor from vessel wall despite complete encasement/ narrowing on preoperative angiograms. The tumor often lethally embraces the ICA bifurcation making it the most dangerous zone for resection. This is possibly due to an arterial twig that arises close to the bifurcation to irrigate the clinoidal dura and the tumor infiltrates the adventitia at its origin.
- Case report of primary dural lymphoma mimicking a cerebellar meningioma and brief review of literature. [Journal Article]
- ANActa Neurol Belg 2019 Jul 12
- Primary dural lymphoma (PDL) is an extremely rare subtype of primary central nervous system lymphoma arising from the dura mater in absence of systemic disease. The most common histological type is t…
Primary dural lymphoma (PDL) is an extremely rare subtype of primary central nervous system lymphoma arising from the dura mater in absence of systemic disease. The most common histological type is the low-grade marginal zone lymphoma, whereas high-grade lymphomas are unusual. We present a case of primary diffuse large B-cell lymphoma, presenting as PDL in the posterior fossa, originating from the dura mater of the petrous bone covering the surface of the left cerebellum, a location not previously described. A 65-year-old woman presented with sudden onset of severe dizziness was admitted in otolaryngology department then transferred to neurosurgery ward. CT scan revealed a large lesion involving left cerebellum, subsequent MRI of the brain demonstrated an enhancing mass suggestive for petrous bone meningioma. The tumor was excised, and the histopathological examination unexpectedly revealed a diffuse large B-cell lymphoma. The patient received postoperative chemoradiotherapy. 20 months after surgery a good outcome was registered. Due to the rarity of primary dural lymphomas no standard treatment is available, however, gross total or subtotal resection followed by adjuvant therapy seems to be a good choice to manage the pathology.
- Anatomy of the human spinal cord arachnoid cisterns: applications for spinal cord surgery. [Journal Article]
- JNJ Neurosurg Spine 2019 Jul 12; :1-8
- CONCLUSIONS: Arachnoid cisterns are organized on each side of a median dorsal septum and compartmentalized in relation with the attachments of denticulate ligament and exit/entrance of rootlets.
- Evaluation of the Structure of Myodural Bridges in an Equine Model of Ehlers-Danlos Syndromes. [Journal Article]
- SRSci Rep 2019 Jul 10; 9(1):9978
- Myodural bridges have been described in various species as connective tissue structures "bridging" small cranio-cervical muscles to the dura. Myodural bridges are thought to stabilize the dural sac d…
Myodural bridges have been described in various species as connective tissue structures "bridging" small cranio-cervical muscles to the dura. Myodural bridges are thought to stabilize the dural sac during head and neck movements and promote cerebrospinal fluid motion; however, their role in neurological diseases has not yet been established. We report ultrasonographic visualization, necropsy, histopathologic and ultrastructural findings of myodural bridges in horses with hereditary equine regional dermal asthenia (HERDA), an equine model of Ehlers-Danlos syndromes. Five HERDA and 5 control horses were studied. Post-mortem examination and ultrasonographic studies (3 HERDA and 4 controls) demonstrated that the atlanto-occipital and atlanto-axial myodural bridges are dynamic structures "moving" the dura. En block resection of the myodural bridges (4 HERDA and 5 controls) was accomplished and histopathology showed myofiber degeneration in 3 HERDA horses and 1 control. Ultrastructural examination revealed loosely packed collagen fibrils with abnormal orientation in all HERDA horses compared to mild abnormalities in 2 controls. Our study provides necropsy and ultrasonographic evidence of the dynamic aspect of the myodural bridges as dural sac stabilizers. Myodural bridges may be pathologically altered in connective tissue disease as evidenced by the ultrastructural morphology in the HERDA myodural bridge.
- A 34-year-old Female with Hirayama Disease Complicated with Severe Spinal Cord Injury. [Journal Article]
- WNWorld Neurosurg 2019 Jul 05
- CONCLUSIONS: The present case clarified the potential involvement of cervical kyphosis and cervical loading-related exercise to the onset and progression of HD. ACCF could serve as a promising way for the treatment of HD with severe spinal cord injury.
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- Use of a Wireless Video-EEG System to Monitor Epileptiform Discharges Following Lateral Fluid-Percussion Induced Traumatic Brain Injury. [Journal Article]
- JVJ Vis Exp 2019 Jun 21; (148)
- The lateral fluid percussion injury (FPI) model is well established and has been used to study TBI and post-traumatic epilepsy (PTE). However, considerable variability has been reported for the speci…
The lateral fluid percussion injury (FPI) model is well established and has been used to study TBI and post-traumatic epilepsy (PTE). However, considerable variability has been reported for the specific parameters used in different studies that have employed this model, making it difficult to harmonize and interpret the results between laboratories. For example, variability has been reported regarding the size and location of the craniectomy, how the Luer lock hub is placed relative to the craniectomy, the atmospheric pressure applied to the dura and the duration of the pressure pulse. Each of these parameters can impact injury severity, which directly correlates with the incidence of PTE. This has been manifested as a wide range of mortality rates, righting reflex times and incidence of convulsive seizures reported. Here we provide a detailed protocol for the method we have used to help facilitate harmonization between studies. We used FPI in combination with a wireless EEG telemetry system to continuously monitor for electrographic changes and detect seizure activity. FPI is induced by creating a 5 mm craniectomy over the left hemisphere, between the Bregma and Lambda and adjacent to the lateral ridge. A Luer lock hub is secured onto the skull over the craniectomy. This hub is connected to the FPI device, and a 20-millisecond pressure pulse is delivered directly to the intact dura through pressure tubing connected to the hub via a twist lock connector. Following recovery, rats are re-anesthetized to remove the hub. Five 0.5 mm, stainless steel EEG electrode screws are placed in contact with the dura through the skull and serve as four recording electrodes and one reference electrode. The electrode wires are collected into a pedestal connector which is secured into place with bone cement. Continuous video/EEG recordings are collected for up to 4 weeks post TBI.