0000000000016814
AUTHOR
Robert Reisch
Minimally invasive cerebral cavernoma surgery using keyhole approaches - solutions for technique-related limitations.
Cavernomas are often small in size and located in difficultly accessible regions. Preoperative identification of the ideal surgical approach as well as the precise intraoperative implementation of the surgical plan are of critical importance for successful surgery. While aiming for minimally invasive surgical techniques and maximally effective cavernoma resection, we envisaged that employing a combination of precise and technically sophisticated virtual reality surgery planning, modern navigation systems with augmented reality features and endoscope-assisted surgical techniques should contribute to achieve this goal. Between December 2002 and November 2005, 66 patients were operated on for …
Surgical technique of the supraorbital key-hole craniotomy.
BACKGROUND The enormous development of microsurgical techniques and instrumentation together with preoperative planning using the excellent preoperative diagnostic facilities available, enables neurosurgeons to treat more complicated diseases through smaller and more specific approaches. METHODS The technical details of the supraorbital key-hole craniotomy are described in this article as it has been evolving in our experience for more than 10 years. After an eyebrow skin incision with careful soft tissue dissection and single frontobasal burr-hole trephination, a supraorbital craniotomy is carried out with a diameter of about 1.5 x 2.5 cm. As a real frontolateral approach, the supraorbital…
Patients' cosmetic satisfaction, pain, and functional outcomes after supraorbital craniotomy through an eyebrow incision
Object The supraorbital approach through an eyebrow incision offers the opportunity to access a wide variety of lesions of the anterior, middle, and even the posterior fossa. The minimally invasive keyhole craniotomy limits brain exploration and retraction and offers the potential for improved surgical outcomes and reduced approach-related complications. Patient satisfaction, however, has not yet been reported in the literature. Methods From January 2002 through December 2011, the lead author (R.R.) used a supraorbital approach through an eyebrow incision for 418 patients with cerebral aneurysms, brain tumors or cystic lesions, and other miscellaneous pathological conditions. For 408 of th…
Bovine pericardium for duraplasty: clinical results in 32 patients.
Bovine pericardium has been widely used for grafts in cardiac surgery and seems to have suitable properties for use as a dural graft. We report on the use of solvent-preserved, gamma-sterilized Tutoplast bovine pericardium for dural grafts in 32 patients undergoing cranial and spinal operations with the objective of clinically assessing this material and technique by a retrospective analysis. All available records were reviewed and information regarding the indication for grafting, complications, and outcome were collected and analyzed for all patients. Indications for grafting included tethered cord myelolysis, closure of lumbosacral myeloceles, Chiari decompression, posterior fossa cranio…
A case control study of statin and magnesium administration in patients after aneurysmal subarachnoid hemorrhage: incidence of delayed cerebral ischemia and mortality
To analyse the effect of the implementation of statin and magnesium treatment on delayed cerebral ischemia (DCI) and 14 day mortality in patients with subarachnoid hemorrhage (SAH).Retrospective, single-center, observational case control study. One hundred SAH patients received either simvastatin and magnesium, solely statin or no treatment.Eighteen percent (n=5) of patients receiving statin and magnesium treatment developed a DCI whereas 24% (n=5) in the statin group and 16% (n=8) in the control group had DCI. Dead by day 14 was registered in 18% (n=5) of patients in the statin and magnesium group, in 10% (n=2) in the statin group and in 27% (n=14) in the control group. None of the results…
The effects of arterial carbon dioxide partial pressure and sevoflurane on capillary venous cerebral blood flow and oxygen saturation during craniotomy
Intraoperative routine monitoring of cerebral blood flow and oxygenation remains a technological challenge. Using the physiological principle of carbon dioxide reactivity of cerebral vasculature, we investigated a recently developed neuromonitoring device (oxygen-to-see, O2C device) for simultaneous measurements of regional cerebral blood flow (rvCBF), blood flow velocity (rvVelo), oxygen saturation (srvO2), and hemoglobin amount (rvHb) at the capillary venous level in patients subjected to craniotomy. METHODS: Twenty-six neurosurgical patients were randomly assigned to anesthesia with 1.4% or 2.0% sevoflurane end-tidal concentration. After craniotomy, a fiberoptic probe was applied on a ma…
Brain tissue pO2 related to SjvO2, ICP, and CPP in severe brain injury
The aim of this report is to present first experience in comparing the course of brain tissue oxygen pressure values (PtiO2) to changes in jugular vein oxygen saturation (SjvO2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) after severe brain injury. PtiO2 monitoring was done using a polarographic Clark type microcatheter (LICOX pO2 probe) (GMS, Kiel, Germany) with a diameter of 0.5 mm and a sensitive area 7.9 mm long inserted in a right frontal position. The microcatheter was connected to a LICOX pO2 device. A fiber-optic catheter was used to measure SjvO2 and placed into the right internal jugular vein. The ICP monitoring was performed with a fiber-optic intraparench…
A COLLABORATIVE VIRTUAL REALITY ENVIRONMENT FOR NEUROSURGICAL PLANNING AND TRAINING
OBJECTIVE We have developed a highly interactive virtual environment that enables collaborative examination of stereoscopic three-dimensional (3-D) medical imaging data for planning, discussing, or teaching neurosurgical approaches and strategies. MATERIALS AND METHODS The system consists of an interactive console with which the user manipulates 3-D data using hand-held and tracked devices within a 3-D virtual workspace and a stereoscopic projection system. The projection system displays the 3-D data on a large screen while the user is working with it. This setup allows users to interact intuitively with complex 3-D data while sharing this information with a larger audience. RESULTS We have…
Ten-year Experience with the Supraorbital Subfrontal Approach through an Eyebrow Skin Incision
Abstract OBJECTIVE: More than ever before, the priority in contemporary neurosurgery is to achieve the greatest therapeutic effect while causing the least iatrogenic injury. The evolution of microsurgical techniques with refined instrumentation and illumination and the enormous development of preoperative and intraoperative diagnostic tools enable neurosurgeons to treat different lesions through limited and specific keyhole approaches. METHODS: Based on our surgical experience, the technique of supraorbital subfrontal craniotomy is described in detail in this article. After an eyebrow skin incision is made, a limited supraorbital craniotomy is performed with a width of 15 to 25 mm and a hei…
The minimally invasive supraorbital subfrontal key-hole approach for surgical treatment of temporomesial lesions of the dominant hemisphere
INTRODUCTION: Surgery in the temporomesial region is generally performed using a subtemporal, transtemporal, or pterional-transsylvian approach. However, these approaches may lead to approach-related trauma of the temporal lobe and frontotemporal operculum with subsequent postoperative neurological deficits. Iatrogenic traumatisation is especially significant if surgery is performed in the dominant hemisphere. METHODS: During a five-year period between January 2003 and December 2007, we have approached the temporomesial region in 21 cases via the supraorbital approach. In 15 cases, the lesion was located within the dominant hemisphere, all lesions had space-occupying effects. In all cases, …
Effect of Intra-Arterial Infusion of Papaverine Hydrochloride on Brain Tissue Oxygen Pressure in the Management of Severe Vasospasm Following Aneurysmal Subarachnoid Hemorrhage
Despite considerable advances in diagnostic, surgical and interventional techniques, the overall outcome for patients with aneurysmal subarachnoid hemorrhage remains poor. Concerning perioperative course, cerebral ischaemia is one of the major factors causing secondary brain demage. The aim of all therapeutic interventions is the stabilization and maintance of cerebral blood flow and tissue oxygenation in order to prevent cerebral ischaemia and consecutively brain infarction [1].
The supraorbital endoscopic approach for aneurysms.
Objective To review our surgical experience in minimally invasive transcranial endoscope-assisted microsurgical treatment of intracranial aneurysms, using the supraorbital keyhole craniotomy. Methods The supraorbital keyhole approach was performed through an eyebrow skin incision in 793 cases for treatment of 989 intracranial aneurysms. Of patients, 474 were operated on after subarachnoid hemorrhage, and 319 were operated on under elective conditions. After lateral frontobasal burr hole trephination, a limited subfrontal craniotomy was created. To achieve adequate intraoperative exposure through the limited approach, endoscopes were used routinely. Surgical outcome was assessed using the mo…
Endoscopic aqueductoplasty through a tailored craniocervical approach.
Object. Neuroendoscopy has an essential role in the management of occlusive hydrocephalus due to a membranous obstruction of the sylvian aqueduct. Well-known endoscopic methods include endoscopic third ventriculostomy (ETV) and endoscopic aqueductoplasty through a frontal burr hole. Building on their experience in the endoscopic management of hydrocephalus, the authors realized that not all of their patients with aqueductal obstruction were eligible for the aforementioned lines of treatment. Certain anatomical situations made it impossible to perform ETV or endoscopic aqueductoplasty through a frontal burr hole. Long-term complications of the shunt system led the authors to seek an alternat…
Virtual reality system for planning minimally invasive neurosurgery
Object The authors report on their experience with a 3D virtual reality system for planning minimally invasive neurosurgical procedures. Methods Between October 2002 and April 2006, the authors used the Dextroscope (Volume Interactions, Ltd.) to plan neurosurgical procedures in 106 patients, including 100 with intracranial and 6 with spinal lesions. The planning was performed 1 to 3 days preoperatively, and in 12 cases, 3D prints of the planning procedure were taken into the operating room. A questionnaire was completed by the neurosurgeon after the planning procedure. Results After a short period of acclimatization, the system proved easy to operate and is currently used routinely for pre…
The keyhole concept in aneurysm surgery: results of the past 20 years.
Item does not contain fulltext BACKGROUND: Improvements in preoperative imaging and intraoperative visualization have led to a refinement in surgical techniques. OBJECTIVE: Report of a 20-year experience with application of the keyhole technique as a contribution to the ongoing debate on the impact of limited craniotomies in aneurysm surgery. METHODS: Over a 20-year period, 1000 consecutive patients with 1297 aneurysms were surgically treated in 1062 operations: 651 in the acute stage after SAH and 411 with unruptured aneurysms. The outcome was assessed with the modified Rankin scale and approach-related complications. RESULTS: The majority of the cases were treated by 4 different keyhole a…
Intraoperative monitoring of cerebral microcirculation and oxygenation--a feasibility study using a novel photo-spectrometric laser-Doppler flowmetry.
The present study assesses the utility of a novel invasive device (O2C-, oxygen-to-see-device) for intraoperative measurement of the cerebral microcirculation. CO2 vasoreactivity during 2 different propofol concentrations was used to investigate changes of capillary venous cerebral blood flow (rvCBF), oxygen saturation (srvO2), and hemoglobin concentration (rvHb) during craniotomy.Thirty-four patients were randomly assigned to a low propofol (4 mg/kg/h) versus a high propofol (6 mg/kg/h) group. A fiberoptic probe was applied on the cortex next to the surgical site. Measurements were performed during lower (35 mm Hg) and higher (45 mm Hg) levels of partial pressure of carbon dioxide (paCO2).…
Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem.
BACKGROUND The natural history of brain stem cavernous malformations is unfavorable because of their high hemorrhage rate and resulting neurological deterioration among patients. However, direct surgery of intrinsic and anteriorly situated cavernomas is hazardous and leads to a bad postoperative outcome because of trauma to lateral and dorsally situated eloquent areas of the brain stem. METHODS We review the cases of two patients with symptomatic cavernous malformations of the anterior brain stem and describe the usefulness of a transoral-transclival approach. A 23-year-old man developed progressive hemihypaesthesia and paraesthesia, hemiparesis with gait ataxia, dysarthria, dysphonia, and …
Image-guided endonasal transsphenoidal microsurgical treatment of recurrent microadenomas of the pituitary gland.
BACKGROUND Neuronavigation is a commonly used technology that provides continuous, three-dimensional information for the precise localization of and surgical trajectory to brain lesions. This study was performed to evaluate the role that navigation can play in assisting microsurgical transsphenoidal surgery for precise localization and removal of recurrent pituitary tumours while simultaneously preserving pituitary gland function. METHOD During a 6-month period -- July 2004 until December 2004 -- 9 patients with recurrent pituitary tumours (5 female and 4-male) were treated with navigation-guided transsphenoidal microsurgical resection. Surgery was performed via a paraseptal or endonasal tr…
Endoscopic endonasal pituitary surgery: Surgical and outcome analysis of 50 cases
Abstract Objective Microsurgical transsphenoidal surgery for pituitary tumors has been standard therapy for decades and was established by Harvey Cushing in the early twentieth century. Today, endoscopy is increasingly accepted in the therapy of pituitary lesions. In this retrospective study, we analysed the surgical technique and outcome of 50 patients with pituitary lesions treated with an endoscopic endonasal trans-sphenoidal approach. Methods Between January 2004 and July 2005, 50 patients (30 female and 20 male) with pituitary tumors were operated upon using an endoscopic endonasal trans-sphenoidal procedure without nasal speculum or postoperative nasal packing. The follow-up period ra…