Intraoperative FNMEP monitoring can be useful for predicting facial nerve function after skull base surgery. This new method is a valuable adjunct to conventional facial nerve monitoring.
S urgical removal of tumors located in the skull base or deep intracranial regions requires a high order of anatomical knowledge that can be obtained only through a large number of surgical experiences and has therefore been recognized as a challenging category in the neurosurgical field. Object. In this paper, the authors' goal was to report their novel presurgical simulation method applying interactive virtual simulation (IVS) using 3D computer graphics (CG) data and microscopic observation of color-printed plaster models based on these CG data in surgery for skull base and deep tumors.Methods. For 25 operations in 23 patients with skull base or deep intracranial tumors (meningiomas, schwannomas, epidermoid tumors, chordomas, and others), the authors carried out presurgical simulation based on 3D CG data created by image analysis for radiological data. Interactive virtual simulation was performed by modifying the 3D CG data to imitate various surgical procedures, such as bone drilling, brain retraction, and tumor removal, with manipulation of a haptic device. The authors also produced color-printed plaster models of modified 3D CG data by a selective laser sintering method and observed them under the operative microscope.Results. In all patients, IVS provided detailed and realistic surgical perspectives of sufficient quality, thereby allowing surgeons to determine an appropriate and feasible surgical approach. Surgeons agreed that in 44% of the 25 operations IVS showed high utility (as indicated by a rating of "prominent") in comprehending 3D microsurgical anatomies for which reconstruction using only 2D images was complicated. Microscopic observation of color-printed plaster models in 12 patients provided further utility in confirming realistic surgical anatomies.Conclusions. The authors' presurgical simulation method applying advanced 3D imaging and modeling techniques provided a realistic environment for practicing microsurgical procedures virtually and enabled the authors to ascertain complex microsurgical anatomy, to determine the optimal surgical strategies, and also to efficiently educate neurosurgical trainees, especially during surgery for skull base and deep tumors. (http://thejns.org/doi/abs/10.3171/2013.3.JNS121109) keY WorDs • neurosurgery • presurgical simulation • skull base tumor • surgical anatomy • 3D imaging • oncology Abbreviations used in this paper: CAD = computer-aided designing; CG = computer graphics; CN = cranial nerve; CPA = cerebellopontine angle; CTA = CT angiography; DSA = digital subtraction angiography; IAC = internal auditory canal; IVS = interactive virtual simulation; MRA = MR angiography.
A-63-year-old woman underwent gamma knife surgery (GKS) for acoustic neuroma. Six years later, she suffered sudden onset of severe headache followed by a disturbance of consciousness and subarachnoid haemorrhage due to a ruptured aneurysm originating from the distal anterior inferior cerebellar artery. The aneurysm was not located at a branching site and was included within the radiation field. The aneurysm was treated by endovascular embolization, and now, 15 months later, the patient has recovered satisfactorily. This is the first report of aneurysm formation following GKS for acoustic neuroma.
A high CSF protein concentration in fluid from the cerebellomedullary cistern is one of the most important factors contributing to hydrocephalus associated with vestibular schwannoma. It is important to judge whether or not any further treatment is required for hydrocephalus, in addition to tumor resection, especially in patients with communicating hydrocephalus.
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