Yeh-Chung Chang, MD

• Assistant Professor of Pediatrics
• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/yeh-chung-chang-md

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In 1981, H�kanson,9 used glycerol as a medium to introduce tantalum mud into the trigeminal cistern as a half of a stereotactic radiosurgical approach for the remedy of trigeminal neuralgia. The improvement of procedural safety was essential for the widespread adoption of percutaneous strategies for treatment of trigeminal neuralgia. Visualization of needle placement to keep away from extratrigeminal injury was first addressed in 1916 by Pollock and Potter15 in cadaveric research, during which the needle site throughout alcohol injection was confirmed utilizing radiography. It was not till 1936 that Putnam and Hampton utilized this procedure to sufferers, with good outcomes. To this finish, in 1955, Silverstone designed an insulated needle with an exposed tip used as a nerve stimulator. An understanding of the relationship among the many foramen, the third division of the nerve (mandibular), and surrounding structures is important to keep away from damage to the neighboring nervous system structures and vasculature. It lies lateral to the foramen lacerum, which is occluded at its base solely by cartilage. Posterolaterally lies the foramen spinosum, which transmits the middle meningeal artery and meningeal branch of the mandibular nerve. Posteroinferiorly lies the jugular foramen, and posterolaterally, the carotid canal. The optic ganglion is located immediately beneath the foramen but can also cross by way of the foramen ovale. It is located on the apex of the petrous portion of the temporal bone and should lengthen to the foramen lacerum, or the posterior lip or flooring of the foramen ovale. The mean distance from the foramen ovale to the gasserian ganglion is 6 mm (range, 5. The size of the sensory root varies from 5 to 15 mm; the size of the mandibular nerve from the anterosuperior margin of the foramen ovale to the gasserian ganglion is 0 to 10 mm. The motor department of the trigeminal nerve runs in front of and medial to the sensory root and passes beneath the ganglion, leaving the skull by way of the foramen ovale and, instantly below this foramen, joining the mandibular nerve. This retrogasserian triangular space has been named the triangular plexus and has been identified as the best place to create a lesion for the remedy of trigeminal neuralgia. It inclines upward as it passes forward close to the medial surface of the dura, forming the decrease part of the lateral wall of the cavernous sinus and reaching the superior orbital fissure. The mandibular nerve occupies most of the gasserian ganglion and takes a caudolateral course from the ganglion and enters the foramen ovale. A report by Gronseth and colleagues details the diagnostic evaluation and treatment of trigeminal neuralgia as an evidence-based evaluation and makes some recommendations. Pain is normally described as spreading outward from the set off level to cover an area that roughly approximates the territory of distribution of 1 (or more) of the trigeminal divisions. Trigeminal neuralgia itself may be as a outcome of a number of causes and pathologic processes, which affect the mode of therapy and end result. To help in diagnosis and treatment of trigeminal neuralgia, a facial pain classification system has been proposed by Burchiel (Table 172-1). That so many percutaneous procedures are available points to the truth that none has proved ideal. That is, nobody percutaneous procedure is applicable in all circumstances with a uniformly excessive price of long-term success and with minimal risk of complication or recurrence. However, there are electrophysiologic and imaging research which might be useful as an adjunct to medical acumen. Some surgeons prefer percutaneous procedures for patients older than 65 years of age. Anticoagulant and antiplatelet medications ought to be stopped earlier than surgery, and sufferers are advised to continue taking any antihypertensive medications throughout the perioperative period. The patient is then positioned with the pinnacle prolonged to about 30 levels to acquire a transparent submental-vertex view of the foramina ovale and spinosum, located on the higher wing of the sphenoid bone, of the affected facet. Magnification (2�) of the fluoroscopic image may be required to visualize the foramen clearly. Some surgeons favor to watch for the vagal response as a guide whereas participating the foramen ovale and should not use preoperative anticholinergics. The needle is directed along a line representing the intersection of a vertical plane passing by way of the medial side of the ipsilateral pupil and a horizontal plane passing via a point 3 cm anterior to the external auditory meatus alongside the inferior border of the zygoma. Lateral fluoroscopy is used thereafter, and the needle is advanced to some extent simply superior to the intersection of the petrous part of the temporal bone and the clivus on a true lateral view. The needle trajectory must be at 45 levels to the planum sphenoidale on this view.

Diseases

• Thyroid carcinoma, papillary (TPC)
• Dyssegmental dysplasia Silverman Handmaker type
• Dentinogenesis imperfecta
• Neuraminidase beta-galactosidase deficiency
• Keratoderma palmoplantaris transgrediens
• Sensory neuropathy
• Gorham syndrome
• Fox Fordyce disease

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The paucity of studies exclusively examining grownup patients with ependymomas and the small sample dimension of current studies together limit our understanding of the impact of age on the survival of grownup sufferers with ependymomas. In studies that embody adults with each supratentorial and infratentorial ependymomas, the impact of age on prognosis is conflicted, with most authors reporting a positive consequence in youthful adults31,76,86 and others reporting that age has no effect on survival of these sufferers. This is as a result of of variability in pattern size, incorrect prognosis, and difficulty in grading anaplastic ependymomas (because of significant intratumoral heterogeneity, and inclusion of subependymomas and ependymoblastomas in some studies). Cross-species genomics matches driver mutations and cell compartments to mannequin ependymoma. Clinical course and progressionfree survival of grownup intracranial and spinal ependymoma patients. The histologic grade is a primary prognostic issue for patients with intracranial ependymomas handled within the microneurosurgical era: an analysis of 258 patients. Incidence patterns for ependymoma: a surveillance, epidemiology, and end outcomes research. Clear cell ependymoma: a clinicopathologic and radiographic evaluation of 10 patients. Intracranial ependymomas: an evaluation of prognostic elements and patterns of failure. Supratentorial ependymomas: prognostic factors and consequence analysis in a retrospective collection of forty six grownup sufferers. Clinical course and progression-free survival of adult intracranial and spinal ependymoma sufferers. Multicentric French study on grownup intracranial ependymomas: prognostic elements analysis and therapeutic issues from a cohort of 152 sufferers. Postoperative radiotherapy of spinal and intracranial ependymomas: evaluation of prognostic elements. Long-term follow-up in 39 patients with an ependymoma after surgical procedure and irradiation. Comparison of the consequences of transcortical and transcallosal removal of intraventricular tumours. Transcortical or transcallosal method to ventricle-associated lesions: a medical study on the prognostic function of surgical method. The transcallosal strategy for lesions affecting the lateral and third ventricles. Initial expertise with endoscopic aspect slicing aspiration system in pure neuroendoscopic excision of large intraventricular tumors. Minimally invasive management of ependymoma of the aqueduct of Sylvius: therapeutic concerns and management. The treatment of ependymoma of the mind or spinal canal by radiotherapy: a report of 79 circumstances. Predicting change in academic talents after conformal radiation remedy for localized ependymoma. Analysis of dose on the site of second tumor formation after radiotherapy to the central nervous system. A multi-center retrospective evaluation of remedy results and quality of life in adult patients with cranial ependymomas. Management of low-grade third ventricular ependymomas in adults by endoscopic biopsy adopted by gamma knife radiosurgery. Intracranial ependymomas treated with radiotherapy: long-term outcomes from a single institution. Predictors of survival amongst pediatric and adult ependymoma instances: a study using Surveillance, Epidemiology, and End Results data from 1973 to 2007. Here, we describe the epidemiology, imaging options, clinical findings, histopathology, pathogenesis, and remedy options of hemangioblastomas. Cerebellar hemangioblastomas frequently happen in the posterior, medial, or both portions (70% to 80% of all cerebellar hemangioblastomas) of the cerebellum. Hemangioblastomas are discovered almost solely in the brainstem, spinal cord, and cerebellum (over 95% of hemangioblastomas are present in these regions). Although indicators and signs can be associated particularly to the mass effect of a hemangioblastoma, neurological dysfunction is most frequently caused by the combined mass effect of the tumor and an related peritumoral cyst. About 70% of symptomatic cerebellar and brainstem hemangioblastomas are related to peritumoral cyst, and more than 90% of symptomatic spinal wire hemangioblastomas are associated with peritumoral cyst (syringomyelia).

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The frame usually limited visualization within the surgical field and offered entry only to bur-hole procedures, such as insertion of electrodes or a biopsy needle. The first frameless stereotactic system was launched by David Roberts and associates20 in 1986. The initial system relied on repeated measurement of transit indicators of ultrasonic sounds between a surgical instrument and a reference frame. Optical digitization technologies utilizing cameras to observe surgical devices with infrared mild were developed in the Nineties and have become extensively well-liked due to their accuracy and ease of use in most surgical environments. Clarke used the time period stereotactic (from the Greek stereo, that means three-dimensional [3D] or solid, and taxis, that means arrangement or order) of their description of a frame apparatus that relied on exterior skull points and was used for his or her animal experiments in 1906. They are essentially the most correct type of cranial marker, however their limitations embrace their invasive utility, which often requires placement after common anesthesia has been administered. Alternative cranial markers embrace the usage of floor anatomic options such because the tragus and canthus, which avoids utility of markers but may be restricted by difficulties in identifying the exact location of the anatomic landmarks comparable to the points selected on imaging. This technique provides a fast, straightforward, and efficient means of registration that avoids floor markers and the need to know exact anatomic landmarks. This approach provides submillimetric accuracy and allows for a big tracking volume. Yet, a disadvantage of this methodology is the want to maintain a free line of sight between the probe markers and cameras. At instances, this can be logistically tough, significantly when an working microscope is used. Common display preparations embody one which portrays the images in anatomic coronal, axial, and sagittal aircraft views that converge at the focal point and another that reveals planes that are steered by the pointing gadget, together with along the axis of the pointer (inline views) and perpendicular to this axis (probe view). This multimodality integration permits for more versatile use of navigation (see later). The pictures are sometimes proven on a large flat panel display positioned a number of toes from the surgeon(s). When surfaces are used, the physical floor is matched or "registered" to the radiographic floor, both by touching multiple random points on the floor ("cloud of factors") or scanning the surface with a laser beam. A number of totally different 3D digitizer applied sciences have been used to allow the navigation laptop to determine the situation of the tracked system in house. Historically, these strategies have included mechanical arms with multiple articulations (both analog and digital), ultrasonography, machine imaginative and prescient, and varied magnetic devices. A, Even massive lesions could additionally be accessed by way of a minimal entry craniotomy when at sufficient depth. B, A lesion of similar dimension close to the cranium, however, requires a bigger, optimal entry craniotomy. Optimal use of navigation requires an understanding of the capabilities and pitfalls in these areas. The minimum dimension of a craniotomy depends partly on the size and depth of the lesion in addition to on the surgical instrumentation. For intraparenchymal lesions on the cortical surface, the craniotomy typically ought to be large sufficient to encompass the extent of presentation of the tumor on the floor. Of course, the opening must be giant sufficient for the surgical instruments to match, in addition to for proper illumination and visualization of the area of labor. Extra-axial lesions corresponding to meningiomas might require larger craniotomies, which must be optimized to account for dural tails, surface and draining veins, and intended extent of resection. Often this data may be gleaned from anatomy alone, and navigation permits for distinctive views of the cortical floor that may resolve ambiguities of surface anatomy as compared with reliance on traditional axial, coronal, and sagittal shows. Further, visualization of important surface or draining veins may be facilitated on these systems. This data could be integrated into preoperative planning and "fused" with a quantity of imaging information units to enable for surgical planning and navigation. This change occurred primarily because earlier procedures have been largely exploratory in nature. Surgical navigation can be utilized to optimize the craniotomy by visualizing the borders of the tumor in relation to the skull and floor anatomic landmarks, thereby resulting in smaller craniotomies. Minimal entry craniotomies have a quantity of advantages, together with reduced size of surgery, decrease incidence of wound infections and hemorrhage, and minimal brain trauma and retraction. Improved postoperative restoration leads to a shorter hospital keep and lowered hospitalization prices.

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They usually seem as a easily homogeneous, sharply demarcated sclerotic mass extending outward from the bone. Initially described by Jaffe in 1953 and first famous within the skull by Prabhakar and associates in 1972, osteoid osteomas are boneforming neoplasms characterised by the production of osteoid or mature bone by tumor cells. The lesion usually develops slowly and will cause symptoms before being discernible on plain radiographs. Skull hemangiomas are sometimes small and asymptomatic however might evolve into a visible and palpable area of tenderness and swelling. Hemangiomas in less common places such as the bottom of the skull or orbit might trigger cranial neuropathies or proptosis. Capillary hemangiomas are similar however comprise more capillary-sized vessel loops; incessantly, a combination of each histologic forms is current. The bony trabeculae are thought to be brought on by osteoclastic reworking in response to stress from the enlarging vascular malformation. Association of cranium hemangiomas with hemangiomas elsewhere, such as the liver, kidneys, spleen, adrenal gland, and different bones, has been reported. Calvarial hemangiomas are inclined to contain the outer table of the cranium and the diplo�, with relative sparing of the inside table of the cranium. There is usually no surrounding sclerosis, and in reality, there could additionally be a halo of decalcification. A 52-year-old girl had a slowly growing mass in the left frontal region that was excised utterly and a cranioplasty carried out. B, Axial, T2-weighted magnetic resonance image displaying a variegated sample without obvious hemosiderin deposition. C, Excised operative specimen with discoloration but no breach of the outer desk of the skull. D, the inner skull desk of the identical specimen exhibits blistering and reworking by the lesion. Simple curettage might enhance the prospect of leaving residual disease and tumor recurrence. Treatment of a symptomatic cavernous hemangioma of the occipital condyle with methacrylate embolization has also been reported. Isointense Hypointense Aneurysmal bone cyst Lipoma Pools of blood without endothelium. Rare in the cranium Cohort SignsandSymptoms Local ache and swelling Treatment En bloc resection 162 May show enhancement Adolescents and young adults. Avid enhancement If present, related dermal sinus tract increases risk for meningitis. Cranial neuropathies En bloc resection En bloc resection when possible Second via fourth many years of life Headache and cranial neuropathies Possible enhancement of strong component Rare after third decade of life. Homogeneous avid enhancement May be extra prone to be atypical or frankly malignant. Layering of bone in onion peel arrangement- erosion and new bone formation layers. Lytic Mixed section offers (osteoclastic), sclerotic cranium a cotton-wool (osteoblastic), and blended appearance. Langerhans cell histiocytosis (histiocytosis X) Clonal proliferation of S-100�positive histiocytic cells in clusters mixed with inflammatory cells that are predominantly eosinophils. Abducens palsy and diplopia Variable Breast, lung, and prostate are the three commonest primary tumors resulting in skull metastases Plasmacytoma: late fifth decade. Often incidental and located during staging analysis Avid enhancement Homogeneous enhancement Soft tissue part exhibits enhancement No tracer uptake on radionuclide bone scan. Skull base involvement strongly predicts a number of myeloma, which has a much worse prognosis than solitary plasmacytoma and warrants evaluation. Avidly takes up tracer on radionuclide bone scanning Radionuclide bone scanning is very sensitive for these tumors. Headaches, cranial neuropathies, signs of orbital involvement Surgical resection in symptomatic patients.

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E, Intraoperative image showing full resection with the anterior cerebral artery seen via its intact cistern. F-H, Postoperative magnetic resonance pictures displaying complete removal of the tumor. A medium-sized cerebellopontine angle meningioma in a 45-year-old lady evaluated for progressive headaches and imbalance. The tumor was utterly resected via a retrosigmoid strategy undertaken with the affected person in the semisitting place. C-E, Intraoperative pictures displaying the tumor being eliminated (C), the resection cavity after tumor removal (D), and the decrease cranial nerves properly seen after resection (E). A hypoglossal meningioma seen in a 54-year-old girl presenting with recurrent headaches, gait difficulties, and dysphagia. The tumor was utterly resected by way of a retrosigmoid approach with the patient in the semisitting place. A-C, Preoperative magnetic resonance pictures exhibiting the extra-axial tumor with brainstem compression. F-H, Postoperative magnetic resonance pictures showing full resection of the tumor. Prolactin-secreting tumors are the most typical pituitary adenomas and characterize about 50% of them. Surgery may be supplied as a first option when visual deterioration has occurred rapidly. Although the standard suggestion advises medical treatment as first-line remedy for small prolactinomas and surgical remedy as reserved for nonresponders or patients intolerant to medications, surgical removing could additionally be an upfront possibility for youthful, wholesome sufferers. Cure is outlined as normalization of the prolactin serum level to less than 25 ng/mL in females and less than 20 ng/mL in males, even though some authors use a level of lower than 10 ng/mL on the primary postoperative day. Dopamine agonists are successful in normalizing prolactin levels in more than 90% of patients. A recurrent C1-C2 synovial cyst inflicting marked cervical wire compression in a 75-year-old man who previously underwent drainage at another hospital. The patient suffered headache, neck pain, loss of stability, and episodic dysphagia. The cyst was successfully resected via a navigationguided, endoscope-assisted posterior method with the patient in the semisitting place. There was no recurrence for greater than 30 months after surgical procedure, symptomatically or radiologically. A-B, Preoperative magnetic resonance photographs exhibiting the synovial cyst on the atlantoaxial junction. The microscope used is a Muller microscope, which permits picture-inpicture visibility. H-J, Another example of the technique of endoscopic-assisted microsurgery, this time in a 51-year-old girl discovered to have a small clival lesion. J, Intraoperative endoscopic view of the tumor mattress after the tumor was resected utilizing normal microneurosurgical technique. Cure is defined as a postoperative cortisol level of less than 1 �g/dL, and these patients generally require glucocorticoid alternative for up to 1 yr. Bilateral adrenalectomy is often carried out when surgical procedure or radiosurgery fails. Nonfunctioning pituitary adenomas are the second most common pituitary adenoma after prolactinoma and symbolize about 20% of all pituitary adenomas; 80% of them are of gonadotroph cell origin. In a current study, full surgical removal was attainable in 64% of 491 sufferers with nonfunctioning pituitary adenomas (all, aside from one, have been macroadenomas). If one performs surgical maneuvers exterior this layer, complications such as leakage of cerebrospinal fluid and neurovascular injury are minimized. Second, transsphenoidal pituitary microsurgery have to be performed as shut as possible to the sagittal airplane; straying from the sagittal aircraft places lateral structures, such because the intracavernous carotid arteries, at jeopardy. Third, the anterior pituitary is all the time anterior to the tumor, despite being stretched thin by a macroadenoma.

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Should such deficits be thought-about expected (although undesirable) outcomes of surgery or neurological complications This rate consists of all adverse occasions (expected and unexpected), regardless of severity. In basic, larger complication rates are reported by investigators at tertiary neurosurgical centers, who prospectively analyze complications and embrace all antagonistic events (expected and unexpected). Other series have discovered higher overall outcomes for centers and surgeons that perform greater volumes of tumor surgery. Minimizing complications is achieved by thorough understanding of all potential opposed occasions related to the procedure, a complete plan to stop their prevalence, and optimized affected person choice. Some present tendencies associated to poor patient prognosis and increasing complication fee embody age greater than 60 years, decreased Karnofsky Performance Scale score, tumors in eloquent or near-eloquent areas, and tumors of the posterior fossa. In-depth understanding of the operative anatomy, including the structural and functional anatomy of the normal mind as properly as any variations introduced by the tumor, is essential. Finally, an skilled neurosurgeon also mentally rehearses the entire operation and postoperative period to determine potential hazards and develop appropriate contingency plans. Some investigators view all problems as potentially avoidable and attributable to one of three main causes: (1) lack of information. The risk for a model new neurological deficit (minor or major) after craniotomy for intrinsic tumor ranges from 2% to 25% in trendy surgical series. In a big sequence by Sawaya and associates, the estimated risks for neurological, regional, or systemic problems have been eight. Avoidance of this drawback begins by precisely figuring out the conventional structural and functional anatomy of the operative field and the tumor borders with adjoining critical brain structures. This preoperative information, mixed with cortical and subcortical mapping methods, is helpful in preserving motor pathways, particularly throughout resection of tumors of the posterior frontal lobe. Frameless stereotactic strategies have revolutionized neurosurgery by offering an easy, intuitive, and accurate technique for intracranial navigation. Monitoring the extent of tumor resection throughout the operation can help to forestall inadvertent resection of normal brain tissue. Therefore, integrating intraoperative feedback supplied by frameless stereotaxis with standard methods (including visual inspection) is finest to assess the extent of resection, measurement of the tumor cavity, and identification of regular adjoining structures. A, In this 40-year-old man with generalized seizure and normal neurological examination, craniotomy and resection of the left frontal tumor was the procedure of alternative, with a predicted complication price of 5%. B, In this 65-year-old man with progressive right-sided weak point over 6 weeks, enhancing tumor was seen throughout the left motor cortex. With a predicted 25% complication price for open resection, stereotactic biopsy was recommended. B and C, Diffusion tensor imaging displaying that the tumor was abutting the arcuate fasciculus (green). Given that it additionally significantly will increase the size and price of surgical procedure,16 more high-quality studies are needed to outline the real advantages of these rising technologies. A B BrainEdema Another common complication associated with neurological morbidity is mind edema, which in its extreme kind may end up in herniation and death. Factors that contribute to postoperative edema embrace extreme mind retraction and subtotal resection of malignant tumors, particularly glioblastomas. Edema brought on by extreme brain retraction may be minimized by proper patient positioning, hyperventilation, high-dose corticosteroids, diuretics, and intermittent retractor release. Although frameless stereotaxis can help determine the optimal surgical trajectory and cut back the necessity for prolonged retraction, hyperventilation and diuretics are often omitted during frameless procedures to decrease brain shift, presumably resulting in extreme retraction and postoperative edema. Importantly, craniotomy and resection of malignant glioma ought to be undertaken with the goal of either gross total or radical subtotal resection. Several research have established that patients with malignant glioma and low-grade glioma who undergo partial resection expertise larger neurological morbidity and decreased survival versus patients who undergo gross total resection. A, Preoperative contrast-enhanced magnetic resonance picture exhibiting that the tumor was quite vascular and only a subtotal resection could probably be achieved. Four hours after surgery, the patient exhibited a sudden decline in degree of consciousness with a left hemiplegia.

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The neurosurgeon must attempt to fully remove a vascular tumor to keep away from this complication. After resection, all bleeding factors have to be precisely coagulated; considered one of a quantity of hemostatic brokers. A 75-year-old woman with a left parietal glioblastoma with a large draining vein overlying the tumor. Postoperatively, the patient was neurologically intact for forty eight hours after which developed a progressive proper hemiparesis. B, Noncontrast computed tomography scan revealing patchy hemorrhage and edema deep to the resection cavity in keeping with venous infarction. A 32-year-old woman with a recurrent left temporal glioblastoma abutting the sylvian fissure. During resection using the ultrasonic aspirator, the pia-arachnoid of the sylvian fissure was traversed, inflicting harm to the middle cerebral artery. Postoperatively, the affected person had a profound expressive aphasia and right hemiplegia. B, Noncontrast magnetic resonance image performed 2 months after surgery demonstrating infarction within the territory of the center cerebral artery. The affected person had a residual expressive dysphasia and proper arm weak spot, however was able to ambulate. To keep away from this catastrophic complication, the neurosurgeon must clearly define the anatomic relationship between the tumor and close by arteries on preoperative imaging, often distinction magnetic resonance angiography or computed tomographic angiography. A common strategy during tumor resection is to preserve a subpial dissection airplane to keep away from main arterial vessels. A 43-year-old lady with a history of breast cancer who presented with a generalized seizure. A, Contrast-enhanced magnetic resonance picture exhibiting a left frontal metastatic tumor. Immediately after resection the affected person was neurologically intact, however she became lethargic the following morning with expressive dysphasia and delicate left hemiparesis. B, Noncontrast computed tomography scan displaying a big hemorrhage filling the resection cavity and increasing into parenchyma. Provocative testing using the Valsalva maneuver and blood strain elevation additional confirms the patency of hemostasis. Subdural hematomas are usually the outcomes of torn bridging veins which have been stretched by mind shift. Factors that contribute to brain shift embody mind atrophy, use of diuretics, resection of enormous parenchymal tumors, and ventricular entry. When excessive mind shift is recognized throughout surgical procedure, the anesthesiologist can lower the head of bed, progressively normalize the partial pressure of carbon dioxide, and gently rehydrate the patient to facilitate mind reexpansion. Epidural hematomas rarely happen with use of dural retention sutures (along bone edges and centrally) and liberal waxing of bone edges. The anesthesiologist ought to be reminded to keep away from arterial hypertension or Valsalva maneuvers. Regional Complications Regional issues are related to the surgical website. Regional problems have an effect on 1% to 5% of patients who bear craniotomy for removing of intrinsic mind tumors,20,26 and are especially common in elderly sufferers in poor neurological situation. As anticipated, resection of parenchymal tumors located within the posterior fossa is associated with the next threat for regional problems, including pseudomeningocele, cerebrospinal fluid fistula, and hydrocephalus. Reoperation is mostly associated with an elevated danger for wound issues. Our statement is that nearly all experienced neurosurgeons acknowledge the elevated dangers inherent in a reoperation and modify their surgical technique to cut back these issues to a degree similar to that of a primary craniotomy. Without antiepileptic medication, 30% to 40% of glioma patients will probably have some medical seizure exercise at some time throughout their disease course. The incidence of instant seizures after supratentorial craniotomy ranges from 0. In general, the extent of cortical damage correlates with epileptogenic potential and will increase when operations contain extended retraction.

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Historically, it has been suggested that roughly 20% to 30% of patients with breast cancer have a brain metastasis. It has been estimated to vary from 21,000 to greater than one hundred,000 new instances per year,2 and its incidence is thought to be rising with improved most cancers survival, an getting older population, higher consciousness of the disease, and better diagnostic exams. In the national survey for intracranial neoplasms reported by Walker and colleagues,4 only 20% of the instances of mind metastases identified during 1973 and 1974 were verified by tissue examination. The estimates of incidence from earlier epidemiologic research of large populations in the United States, Iceland, and Central Finland range from 2. A larger incidence of lung cancer and melanoma, longer survival times of patients with most cancers, and an getting older affected person population may have resulted in a true enhance. The incidence of brain metastases and the spectrum of metastasizing major cancers differ with patient age. In kids, the commonest reason for mind metastases is leukemia, followed by lymphoma. Table 146-1 summarizes the revealed class I studies evaluating the remedy of mind metastasis. Radiation Therapy For the past 60 years, radiation remedy has performed a significant position within the palliation of metastatic brain disease. Cranial nerve deficits have additionally been reported to improve in additional than 40% of patients. Patients with all 4 favorable characteristics had a predicted 200-day survival rate of 52%. Patients with none of the favorable components had a predicted 200-day survival rate of 8%. Patients 233 217 233 227 447 228 227 26 33 130 125 30 53 forty four 36 213 216 193 200 196 one hundred ninety 36 34 167 164 Scheme 30Gy/10fx/2wks 30Gy/15fx/3wks 40Gy/15fx/3wks 40Gy/20fx/4wks 20Gy/5fx/1wk 30Gy/10fx/2wks 40Gy/15fx/3wks 10Gy/1fx/1day 12Gy/2fx/2days 30Gy/10fx/2wks 50Gy/20fx/4wks 48Gy/1. Neurological operate response of patients receiving "ultrarapid" treatment was comparable with that of sufferers receiving more protracted schedules. However, length of enchancment, time of development to improved neurological standing, and fee of complete disappearance of neurological symptoms have been usually much less for patients receiving 10 to 12 Gy, leading the researchers to conclude that ultrarapid schedules may not be as effective as higher-dose schedules in palliation of brain metastases. Gelber and associates69 categorized ambulatory patients with breast cancer who had no soft tissue metastases, ambulatory patients with lung most cancers in whom the first was not found or who had no extracerebral metastases, and ambulatory sufferers with different primaries and no extracerebral metastases as "favorable" subgroups who had a median survival time of 28 weeks, in contrast to 11 weeks for the remaining patients. Further investigation of radiosensitizers has continued, with the analysis of gadolinium texaphyrins. Overall survival occasions and responses have been related within the two trial arms, however in the subset of patients with lung most cancers, Mgd administration appeared to produce better cognitive outcomes. Larger doses of irradiation led to greater decreases in the threat of mind metastasis, in accordance with an evaluation of four whole doses (8 Gy, 24 to 25 Gy, 30 Gy, and 36 to forty Gy) (P for development =. Yet not one of the 15 patients who had been handled with extra trendy fractionation schemes (less than three Gy per fraction) had dementia at one 12 months. The Prophylactic Cranial Surgical Resection Surgical resection is an important part within the therapeutic arsenal for cerebral metastases. These effects may be larger for metastases than for major intraparenchymal tumors, as a end result of metastases grow by expansion and compression rather than by infiltration and since metastases usually produce a considerable amount of edema. This concern is important as a end result of as many as 10% 15% of sufferers with a medical prognosis of metastasis could, actually, have nonmetastatic lesions similar to abscesses and first tumors. These benefits must be weighed in opposition to the requisite "invasiveness" of surgical procedure, which topics patients to potential untoward intraoperative and postoperative problems, together with bleeding, wound infection, pulmonary emboli, myocardial infarction, and sepsis. Retrospective research have identified several prognostic components inside every of those classes that help in identifying optimum surgical candidates. Although each must be evaluated individually, these components must be fastidiously built-in in the strategy of affected person choice. Patients with single mind metastases are the most acceptable surgical candidates. Oldberg92 was the primary to acknowledge that surgical procedure for single mind metastases might result in longer survival occasions for patients than other remedies. Multiple retrospective surgical sequence consistently verified this discovering, nevertheless it was not till Patchell and colleagues88 and Vecht associates89 reported the outcomes of unbiased randomized potential trials that surgical resection turned the usual remedy for single brain metastases. Thus, the worth of surgery for remedy of single mind metastases could also be realized only in patients with a possible for long-term survival (see later). The historic bias in opposition to resecting a quantity of mind metastases was questioned by Bindal and colleagues,ninety who retrospectively reviewed 56 sufferers who underwent resection of two or three brain metastases.

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The corpus callosum is incised medial to the pericallosal artery, and the best lateral ventricle is opened. In lesions which have already enlarged the foramen of Monro, no further motion may be necessary. Dissection begins lateral to the right fornix at the posterior margin of the foramen of Monro, and the tela choroidea is progressively incised. Dissection is carried out between the 2 inner cerebral veins, with care taken to avoid the medial posterior choroidal artery. After incising the inferior membrane of the tela choroidea and mobilizing the choroid plexus of the third ventricle, the right fornix is gently mobilized towards the alternative aspect, and the best thalamus (including the thalamostriate vein) may be visualized posteriorly up to the posterior commissure and superiorly to the splenium of the corpus callosum (Video 153-4). Axial (A and B), sagittal (C), and coronal (D) contrast-enhanced T1-weighted magnetic resonance photographs of a 34-year-old man with extreme headache. E, Exposure of the tumor was achieved by a right-sided mixed pterionalorbitozygomatic craniotomy via a curved skin incision. H and I, Total tumor removing was achieved, as seen on postoperative magnetic resonance pictures, without producing further neurological deficits. A-C, Preoperative magnetic resonance photographs of a 34-year-old lady demonstrating two separate cavernous malformations: one located in the proper frontal periventricular space (arrow) and the opposite within the third ventricle on the level of the foramen of Monro. D, Both lesions were eliminated via a right frontal transsulcal, transcortical access route with the patient within the supine place; a coronal skin incision behind the hairline was used. Both vascular malformations have been utterly resected, as seen on the postoperative computed tomography scan (E) and magnetic resonance pictures (F-H). The transfrontal access route could be seen on postoperative T2-weighted sagittal (G) and coronal magnetic resonance images (H). Preoperative axial (A), coronal (B), and sagittal (C) T1-weighted magnetic resonance photographs demonstrating a contrast-enhancing irregular tumor confined to the third ventricle. Initially, endoscopic ventriculocisternostomy was performed at another establishment. D, Subsequently, the tumor was removed via the interhemispheric transcallosal paraforniceal strategy with the affected person placed in the supine place. E-H, Complete tumor excision was confirmed on postoperative magnetic resonance pictures. The distinction between our approach and the usual method (see earlier) lies in the reality that we favor to mix the supratentorial craniotomy with an infratentorial craniotomy extending bilaterally to the midline. Surgery is begun by opening the cerebellar dura beneath the transverse sinus on either side. This allows inspection of the supracerebellar bridging veins before exposing the supratentorial area (Video 153-5). Incision of the tentorium just lateral to the straight sinus could be done extra safely with precise data of the infratentorial venous sample. Moreover, dissection of the agency arachnoid surrounding the tectal plate and the vein of Galen can easily be performed earlier than incising the tentorium from the infratentorial direction firstly of the process. This facilitates orientation and subsequent dissection from the supratentorial direction. In all circumstances, the arachnoid that surrounds the tectal plate and the veins that drain into the vein of Galen are dissected meticulously to clearly establish all anatomic structures within the region. Common Tumors of the Third Ventricle ColloidCysts Colloid cysts are benign tumors with an incidence of zero. This pathology was first described by Wallmann in 1858 as an post-mortem discovering, and Walter Dandy was the primary to efficiently take away this sort of tumor in 1921. The tumor can remain clinically silent for a very long time and is subsequently typically detected only at post-mortem. Colloid cysts can attain a large quantity that probably occludes the foramen of Monro and results in acute, obstructive hydrocephalus. The episodic look of symptoms with irregular symptom-free intervals makes the analysis somewhat challenging based mostly purely on clinical examination. Other symptoms arising from elevated intracranial stress include nausea, vomiting, dizziness, and fatigue.

Anog, 49 years: Although this strategy defers treatment-related risk and treatment-related prices, it might enhance the risk of tumor development and the subsequent growth of recent neurologic deficits or intractable seizures in addition to the danger of malignant dedifferentiation of the lesion. Thus these time tendencies may be defined at least in part by enhancements in detection and diagnostic precision. Inhibition of Akt inhibits growth of glioblastoma and glioblastoma stem-like cells.

Hurit, 37 years: These osteotomies must be prolonged as posterior as attainable to prevent lack of orbital bone, which would require reconstruction to forestall enophthalmos. Cancer cells frequently activate telomerase to keep telomere size and escape apoptosis. They are useful in the remedy of diabetic neuropathy, postherpetic neuralgia, different peripheral neuropathies, and continual low back pain.

Redge, 41 years: Management of the facial nerve in lateral skull base surgery analytic retrospective examine. Complications of transsphenoidal surgery: outcomes of a nationwide survey, evaluate of the literature, and personal expertise. Postoperative deficits and useful recovery following elimination of tumors involving the dominant hemisphere supplementary motor space.

Zakosh, 25 years: The bridging veins are inspected, and an method is chosen that will minimize the variety of veins sacrificed. In addition, total administration of cranium base tumors has considerably modified prior to now decade as a outcome of the unequivocal understanding that radiosurgery, either in single or multiple fractions, is ready to control most meningiomas and vestibular schwannomas. Surgical outcomes in 31 sufferers with craniopharyngiomas extending exterior the suprasellar cistern: an evaluation of the frontobasal interhemispheric strategy.

Samuel, 42 years: On microscopic tissue examination, a tangle of nonmuscular venous vessels is seen. Various stories have shown a low risk of growing spinal metastatic illness following whole-brain irradiation or whole-ventricular irradiation. Among sinonasal malignancies, squamous cell carcinoma and adenoid cystic carcinoma might involve the skull base (and from there the dura and the brain) by direct invasion or by perineurial or foraminal unfold.

Bogir, 22 years: A craniotome is used to connect the slots, which permits the bone flap to be elevated. Treatment of idiopathic intracranial hypertension: topiramate vs acetazolamide, an open-label examine. Clear cell ependymoma: a clinicopathologic and radiographic analysis of 10 sufferers.

Sancho, 56 years: Visual outcomes evaluating surgical techniques for administration of severe idiopathic intracranial hypertension. Traditional transcranial approaches require transection of the falciform ligament and retraction of or blind dissection behind an typically already tenuous ipsilateral optic nerve; this carries a well-documented threat of vision loss. They could be differentiated from meningiomas on immunohistochemical and ultrastructural grounds.

Rune, 21 years: Initially, many had been skeptical in regards to the outcomes that could be achieved and anxious in regards to the radioresistance of such tumors. The epidemiology, scientific features, diagnostic strategy, radiographic findings, pure history, and treatment of every illness is discussed (Table 165-1). The affected person had intact tactile sensibility in his left limbs, however pain sensation was abolished.

Ramon, 33 years: Once hemostasis is obtained and the retractors are removed, the dura is closed in as watertight a way as potential. Antiangiogenesis remedy for glioblastoma multiforme: challenges and opportunities. It is critical that the same microsurgical strategies used for open approaches be followed strictly when operating endonasally.

Irmak, 58 years: Convection-enhanced delivery can be utilized to safely ship therapeutic agents to the central nervous system. Anatomic dissection of the inferior fronto-occipital fasciculus revisited within the lights of brain stimulation information. Hemangioblastomas share protein expression with embryonal hemangioblast progenitor cell.

Bufford, 62 years: For larger tumors, central enucleation permits subsequent microsurgical separation of the tumor capsule from surrounding arachnoidal areas. Inferior and medial to the higher petrosal nerve lies the petrous inner carotid artery. The recurrence charges of meningiomas differ from one series to one other; the best recurrence charges (>20%) are found in patients with sphenoid wing meningiomas, adopted by these with parasagittal meningiomas (8% to 24%).

Sanford, 60 years: Incidence of cranial nerve palsy after preoperative embolization of glomus jugulare tumors utilizing Onyx. The main constructions limiting lateral intracranial extension below the optic nerve are the inner carotid and ophthalmic arteries. Interestingly, in the study by Mack and colleagues, chromosome 22 loss was frequently seen in group B however not in group A posterior fossa ependymomas.

Jack, 29 years: In sure positions the head is considerably elevated over the extent of the center, which carries an increased danger of venous air embolism and postoperative symptomatic pneumocephalus. Intra-axial metastases almost always exhibit peritumoral edema, the extent of which is often considerably greater than the actual tumor size. If a complete maxillectomy is required, a lateral rhinotomy and a lipsplit incision could also be needed.

Ayitos, 54 years: Primary vitreoretinal lymphoma: a report from an International Primary Central Nervous System Lymphoma Collaborative Group symposium. Interstitial chemotherapy with drug polymer implants for the treatment of recurrent gliomas. Long-term impact of optic sheath decompression on intracranial stress in pseudotumor cerebri.

Abbas, 26 years: Anti-amphiphysin related limbic encephalitis: a paraneoplastic presentation of smallcell lung carcinoma. After the verification of hypercortisolemia, subsequent research are aimed at identifying the supply of hormonal excess. B, Axial, T1-weighted, contrast-enhanced magnetic resonance image exhibiting the tumor indenting the temporo-occipital cortex and nestling in opposition to the sagittal sinus.

Bengerd, 35 years: Grading of pineal parenchymal tumors relies on histologic and immunohistochemical features and forms the premise for various classification schemes with prognostic value. On the primary meningeal tumors with special concern to the hemangiopericytoma pathology and biology. Investigators found that 33% of patients who died had necrosis at presentation or recurrence, in contrast with only 2% of residing sufferers.

Osko, 34 years: There have been stories of craniotomy during pregnancy for resection of meningioma when indicated. Similarly, indications for endonasal approaches will increase with more versatile instruments and improved methods in repairing the skull base. Stereotactic radiosurgery as an alternative to fractionated radiotherapy for patients with recurrent or one hundred fifty 1182.

Kalan, 44 years: Patients with obstructive hydrocephalus want both a temporary ventriculostomy before a planned resection or a ventriculoperitoneal shunt. Though necrotic tumors like glioblastoma can also have nonenhancing cores, their rims can most frequently be distinguished from abscess by their variable thickness and irregular form. Endoscopic versus traditional approaches for excision of juvenile nasopharyngeal angiofibroma.

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