Hydrocephalus represents one of the most frequent pathologic entities requiring neurosurgical intervention. Even in present times the treatment of hydrocephalus is a highly debated subject. Neuroendoscopy is one of the technique posibility. The present study includes patients with different types of hydrocephalus classified according to imagistic criteria (MRI). Neuroendoscopic therapeutic options are presented for different types of hydrocephalus and the postoperative results of these procedures are revealed by imaging. In conclusion, we consider neuroendoscopy useful in each type of hydrocephalus.
Introduction: The fronto-temporal approach represent the shortest distance to the ipsilateral optic nerve and carotid artery, and allow the direct verification of the optical nerves, the carotid arteries, the pituitary stalk, the tumor and its relationship with the suprasellar structures. Objective: The purpose of this study is to advocate an available cranial base technique for removing these tumors and to delineate the technique’s advantages that aid in achieving an improved extent of tumor resection and enhancing the patients’ overall outcome. Materials and methods: We present a retrospective study of a single surgeon experience on 355 consecutive cases with sellar and parasellar tumors admitted and operated by transcranial approaches in our department between January 2000 and December 2012. Results: Tumors in the sellar region represent 11, 8% of all tumors operated in our department. The most common type of tumor was pituitary adenomas, 165 of cases, followed by sellar and parasellar meningiomas, 128 of cases. Craniopharyngioma represent 12% of cases encountered in this region. All our cases underwent surgery by transcranial approach, unilateral frontotemporal in 252 of cases (71%). In pituitary adenomas total and near total resection was achieved in 100% of patients operated by transcranial approaches. For resection of craniopharyngiomas we have frequently chosen the extended fronto-temporal approach. The most common surgical related complications were: postoperative hematomas 9 of cases; wound infections, 6 of cases and CSF leakage, 12 of cases; transient visual alteration in 12 cases, transient third cranial nerve palsy in 6 of cases, transient motor deficit in 7 cases, hydrocephalus, 6 cases; transient diabetes insipidus in the large majority of pituitary adenomas and craniopharingiomas. Only 4 cases of pituitary adenomas and 6 of craniopharingiomas recurred after subtotal resection, requiring re-intervention. The mortality rate in our study was 2%. Conclusions: Our experience demonstrated that the management of the large suprasellar tumors via fronto-temporal approach remains the main route for these tumors with significant extrasellar extension, fibrous tumors, cases with unrelated pathology that might complicate a transsphenoidal approach and recurrent tumors after previous transsphenoidal surgery. In our opinion there is no need for larger osteotomies or extensive drilling of cranial base. “Instead of bone, remove the tumor; it's easier even for the patient”.
Craniopharyngiomas are rare, highly complex tumors with bimodal incidence in the pediatric and adult age groups. In our opinion, depending on the means possible, total microscopic ablation offers the best chance of healing, or at least prolongs the time interval of recurrences.Objective : The purpose of this paper is to add our surgical experience to in the last 11 years, in the context of the large debate from literature regarding the best therapeutically option concerning craniopharyngioma treatments.Materials and Methods : We performed a retrospective analysis of 42 consecutive patients with craniopharyngioma who underwent surgical resection by one surgeon at the Neurosurgical Department of Cluj-Napoca County Emergency Hospital between January 2002 and December 2012. We perform a systematic review of the published review on goals and techniques associated with selected surgical strategies for the treatment of CPH.Results : During this period a total of 42 patients with craniopharyngioma were treated in our institution by a single neurosurgeon, representing 12% from all cases of sellar and parasellar tumors respectively operated in last 11 years. There is a significant male preponderance. Nine patients were less than 18 years of age at admission. The patient age distribution showed a peak incidence between 10 and 15 years and another between 45 and 50 years. Considering the pediatric and adult populations together, the most common presenting symptom was visual disturbances with 60% of patients presenting in this manner, followed by severe headache in more than 50% of cases. Obstructive hydrocephalus occurred in 31% of cases. Calcifications were seen in 45% of cases, more frequently in children. All our cases underwent surgery by transcranial approach; extended frontotemporal, as the first choice, in 57% of cases. Gross total removal was achieved in over half of cases and near total resection was achieved in 40% of cases. The most frequent postoperative complications: diabetes insipidus and syndrome of inappropriate antidiuretic hormone secretion. No visual impairment was observed after surgery in the patients with normal visions at presentation. Only 3 of cases primarily operated by us recurred, in an interval of one to five years. The mortality rate in our cases treated by transcranial surgery was 2% in primary cases and 7% in cases of tumor recurrence.Conclusions : Radical surgery offers the best chance for cure. Radical surgery is also associated with a higher risk of postoperative morbidity, being the reason for why many neurosurgeons recommend a subtotal resection followed by radiotherapy. In our opinion radical surgery is possible in large majority of the cases, fronto-temporal approach offering the most appropriate way to reach this objective. Every case must be judged with maximal attention based on preoperative neuroimagistic data but decisively, on intraoperative findings.
Objective: The ultimate anatomy of the Meyer's loop continues to elude us. Diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) may be able to demonstrate, in vivo, the anatomy of the complex network of white matter fibers surrounding the Meyer's loop and the optic radiations. This study aims at exploring the anatomy of the Meyer's loop by using DTI and fiber tractography. Methods: Ten healthy subjects underwent magnetic resonance imaging (MRI) with DTI at 3 T. Using a region-of-interest (ROI) based diffusion tensor imaging and fiber tracking software (Release 2.6, Achieva, Philips), sequential ROI were placed to reconstruct visual fibers and neighboring projection fibers involved in the formation of Meyer's loop. The 3-dimensional (3D) reconstructed fibers were visualized by superimposition on 3-planar MRI brain images to enhance their precise anatomical localization and relationship with other anatomical structures. Results: Several projection fiber including the optic radiation, occipitopontine/parietopontine fibers and posterior thalamic peduncle participated in the formation of Meyer's loop. Two patterns of angulation of the Meyer's loop were found. Conclusions: DTI with DTT provides a complimentary, in vivo, method to study the details of the anatomy of the Meyer's loop. Meyer's loop is commonly known as the temporal loop of the anterior fibers of the optic radiation that originate in the lateral geniculate body and course anteriorly, into the temporal lobe, before turning posteriorly to reach the occipital visual cortex. Adolf Meyer applied histological, brain lesion studies to describe this peculiar course into the temporal lobe of the visual projection fibers, in 1907 [1]. Histological staining techniques that are applicable in humans provide an ambiguous visualization of the myelinstained white matter fibers and are limited by an inability to precisely trace and reconstruct the course of these fibers. Therefore, the composition and course of the Meyer's loop, or the fact that this temporal loop is composed exclusively by the optic radiation fibers remains unclear.A unique 3D perspective on the white matter architecture can be achieved by applying the fiber dissection technique, but with this technique it is difficult to differentiate individual visual projection fibers, because of the intrinsic limitations of this technique to distinguish and trace individual fibers among the complex network of many neighboring fibers [2,3]. Furthermore, the delineation of the Meyer's loop using the fiber dissection technique is challenging and its exact fiber composition and location are a point of controversy. Knowledge of the anatomy of the Meyer's loop is essential for minimizing the risk of damaging this structure during surgery for temporal lobe lesions and epilepsy. However, the ultimate anatomical details of the Meyer's loop remain even today obscure, because both histological and fiber dissection techniques are less suitable to accurately demonstrate its precise fiber composition and exact lo...
The fiber dissection technique involves peeling away white matter fiber tracts of the brain to display its three-dimensional anatomic arrangement. The intricate three-dimensional configuration and structure of the internal capsule (IC) is not well defined. By using the fiber dissection technique, our aim was to expose and study the IC to achieve a clearer conception of its configuration and relationships with neighboring white matter fibers and central nuclei. The lateral and medial aspects of the temporal lobes of twenty, previously frozen, formalin-fixed human brains were dissected under the operating microscope using the fiber dissection technique. The details of the three-dimensional arrangement of the fibers within the IC were studied and a comprehensive understanding of their relations was achieved. The white matter fiber dissection provides an enhanced perspective of the intricate architecture of the internal structure of brain. This enhanced understanding of intrinsic brain anatomy, particularly of functional highly relevant fiber systems such as the internal capsule, is essential for performing modern neurosurgical procedures.
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