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Daniel D. Cavalcanti, Mark C. Preul, M. Yashar S. Kalani and Robert F. Spetzler

, Epstein and McCleary reported that surgery was feasible with reasonable morbidity and mortality. 15 Concurrent with Epstein and McCleary’s report, Raimondi would rationally state that to have the child merely survive (i.e., with severe neurological deficits) is no justification for surgery. 33 The development and improvement of complex skull base surgical approaches and incremental advances in neuroimaging, parallel to image-guided surgery, allowed a few authors to safely and effectively resect lesions in the brainstem. 5 , 23 , 32 Knowledge of different skull base

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Aristotelis S. Filippidis, M. Yashar S. Kalani, Peter Nakaji and Harold L. Rekate

Object

Negative-pressure and low-pressure hydrocephalus are rare clinical entities that are frequently misdiagnosed. They are characterized by recurrent episodes of shunt failure because the intracranial pressure is lower than the opening pressure of the valve. In this report the authors discuss iatrogenic CSF leaks as a cause of low- or negative-pressure hydrocephalus after approaches to the cranial base.

Methods

The authors retrospectively reviewed cases of low-pressure or negative-pressure hydrocephalus presenting after cranial approaches complicated with a CSF leak at their institution.

Results

Three patients were identified. Symptoms of high intracranial pressure and ventriculomegaly were present, although the measured pressures were low or negative. A blocked communication between the ventricles and the subarachnoid space was documented in 2 of the cases and presumed in the third. Shunt revisions failed repeatedly. In all cases, temporary clinical and radiographic improvement resulted from external ventricular drainage at subatmospheric pressures. The CSF leaks were sealed and CSF communication was reestablished operatively. In 1 case, neck wrapping was used with temporary success.

Conclusions

Negative-pressure or low-pressure hydrocephalus associated with CSF leaks, especially after cranial base approaches, is difficult to treat. The solution often requires the utilization of subatmospheric external ventricular drains to establish a lower ventricular drainage pressure than the drainage pressure created in the subarachnoid space, where the pressure is artificially lowered by the CSF leak. Treatment involves correction of the CSF leak, neck wrapping to increase brain turgor and allow the pressure in the ventricles to rise to the level of the opening pressure of the valve, and reestablishing the CSF route.

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Kaan Yagmurlu, Sam Safavi-Abbasi, Evgenii Belykh, M. Yashar S. Kalani, Peter Nakaji, Albert L. Rhoton Jr., Robert F. Spetzler and Mark C. Preul

bifurcation of the contralateral ICA ( Figs. 1 – 8 ). Surgical freedom was defined as the maneuverability of instruments within the surgical approach to a selected point in the brain, such as the bifurcation of the ICA. FIG. 1. The steps of the mini-pterional approach. A: A curvilinear incision is centered on the extension line of the sphenoid groove ( blue dashed line ) 1 cm behind the hairline. B: The subcutaneous tissue, frontal branch of the superficial temporal artery, and superficial fat pad are exposed after the galeal flap is reflected toward the temporal fossa

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Samuel Kalb, Nikolay L. Martirosyan, Luis Perez-Orribo, M. Yashar S. Kalani and Nicholas Theodore

15 32, F systemic hypertension T3–10, T-12 mixed T6–10 laminectomy & fusion * 360° = ACD and corpectomy with posterior laminectomy and fusion. † Type of OPLL as classified by the Japanese Investigation Committee on the Ossification of the Spinal Ligaments. See Tsuyama, 1984. Patients underwent the following surgical approaches ( Table 3 ): ACD and fusion with corpectomy, posterior laminectomy with fusion, posterior open-door laminoplasty, and combined anterior corpectomy with posterior laminectomy and fusion (360° approach). The clinical

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M. Yashar S. Kalani, Kaan Yagmurlu, Nikolay L. Martirosyan, Daniel D. Cavalcanti and Robert F. Spetzler

lesion and places a point at the center (Point A). A second point (Point B) is identified as the point where the lesion is most superficial or where the entry point defines the safest surgical corridor. A line is then drawn from the first point to the second point and onward to the skull. The trajectory of the line dictates the approach. FIG. 3. The two-point method, which is used to guide surgical approach selection for deep-seated lesions. The surgeon places a point at the center of the lesion (Point A). A second point (Point B) is selected where the lesion

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Udaya K. Kakarla, M. Yashar S. Kalani, Giriraj K. Sharma, Volker K. H. Sonntag and Nicholas Theodore

 paresthesias 8  paraplegia 4  paraparesis 1  myelopathy 9  radiculopathy 5 radiological findings  kyphotic deformity 12  epidural abscess 24  discitis on MRI 24  paraspinal abscess common 24 spinal level involved  cervical 11 (26 levels)  thoracic 15 (32 levels)  lumbar 7 (9 levels)  sacral 2 (2 levels) surgical approach  anterior 10  posterior 4  combined anterior-posterior 9  laminectomy 4  instrumentation & fusion 23 pathological diagnosis

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Katalin A. Szabo, Samuel H. Cheshier, M. Yashar S. Kalani, Jonathan W. Kim and Raphael Guzman

sufficient exposure of the injured site and the surrounding area with minimal invasion and visible scar formation. There are 3 main surgical approaches that allow access to the orbital roof: the frontotemporal craniotomy, the subcranial osteotomy, and the anterior orbitotomy. 1 Both methods, frontotemporal craniotomy and anterior subcranial approaches, are accomplished through a bicoronal flap. Craniotomy is indicated if an intracranial injury is suspected, such as a dural tear, CSF leak, or intracranial hematoma. It provides wide exposure, direct visualization of the

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Nam Yoon, Aatman Shah, William T. Couldwell, M. Yashar S. Kalani and Min S. Park

because of their anatomical location and the potential for a vascular pedicle opposite the surgical approach, precluding early devascularization during surgery. Raper et al. 45 demonstrated that resection of skull base meningiomas was associated with higher blood loss and lower chance of gross-total resection than convexity lesions. Thus, skull base meningiomas are an attractive target for preoperative embolization. Nevertheless, the vascular supply to skull base meningiomas is quite complex and variable, with important anastomotic connections to vital neurological

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Kaan Yağmurlu, Hasan A. Zaidi, M. Yashar S. Kalani, Albert L. Rhoton Jr., Mark C. Preul and Robert F. Spetzler

glial tumors), velum interpositum (meningiomas), or fornix . The surgical approaches to pineal region pathology are intimately related to the complex anatomical relationship of the surgical target to surrounding structures, location of feeding blood supply, anatomical variations, and extent of resection goals. Numerous approaches to this region have been described, and they can be tailored to the morphology of the target lesion. These approaches include the supracerebellar infratentorial approach, occipital interhemispheric approach, parietooccipital

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Corey T. Walker, M. Yashar S. Kalani, Mark E. Oppenlander, Jakub Godzik, Nikolay L. Martirosyan, Robert J. Standerfer and Nicholas Theodore

-term sequelae. Although we recognize that the development of this complication in 2 (29%) of the 7 patients represents a substantial percentage, this incidence is within the expected range reported by other groups performing anterior thoracic decompression surgeries. Little is known about the exact rates of CSF–pleural fistulation after transpleural thoracic resection of transdural disc herniations, given the rare nature of this pathology and the diversity of surgical approaches. That said, Hu et al. 12 recently reported on a series of thoracic decompression surgeries in