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Scott D. Wait, Adib A. Abla, Brendan D. Killory, Peter Nakaji and Harold L. Rekate

prospective fashion, and portions have been reported in several publications. 1–3 , 5–10 , 15 , 17–21 , 23 , 25 In especially instructive or unusual cases, pre- and postoperative imaging studies, surgical videos, intraoperative photographs, and other appropriate data are also cataloged. We reviewed selective cases treated at different times to evaluate our methods, to share surgical pearls and surgical pitfalls, and to obtain an understanding of how our surgical approaches have evolved over time. Operative Techniques We have used 3 approaches to address HHs

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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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Timothy Uschold, Adib A. Abla, David Fusco, Ruth E. Bristol and Peter Nakaji

Object

The heterogeneous clinical manifestations and operative characteristics of pathological entities in the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options have included endoscopic transventricular resection; open supratentorial microsurgical approaches through the midline, choroidal fissure, lateral ventricle, and tentorium; and supracerebellar infratentorial (SCIT) approaches through the posterior fossa. The object of the current study was to review the preoperative characteristics and outcomes for a cohort of patients treated purely via the novel endoscopically controlled SCIT approach.

Methods

A single-institution series of 9 consecutive patients (4 male and 5 female patients [10 total cases]; mean age 21 years, range 6–37 years) treated via the endoscopically controlled SCIT approach for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 13.2 months.

Results

The endoscopically controlled SCIT approach was successfully used to approach a variety of pineal lesions, including pineal cysts (6 patients), epidermoid tumor, WHO Grade II astrocytoma (initial biopsy and recurrence), and malignant mixed germ cell tumor (1 patient each). Gross-total resection and/or adequate cyst fenestration was achieved in 8 cases. Biopsy with conservative debulking was performed for the single case of low-grade astrocytoma and again at the time of recurrence.

The mean preoperative tumor and cyst volumes were 9.9 ± 4.4 and 3.7 ± 3.2 cm3, respectively. The mean operating times were 212 ± 71 minutes for tumor cases and 177 ± 72 minutes for cysts. Estimated blood loss was less than 150 ml for all cases. A single case (pineal cyst) was converted to an open microsurgical approach to enhance visualization. There were no operative complications, as well as no documented CSF leaks, additional CSF diversion procedures, or air emboli. Seven patients underwent concomitant third ventriculostomy into the quadrigeminal cistern. At the time of the last follow-up evaluation, all patients had a stable or improved modified Rankin Scale score.

Conclusions

The endoscopically controlled SCIT approach may be used for the biopsy and resection of appropriately selected solid tumors of the pineal region, in addition to the fenestration and/or resection of pineal cysts. Preoperative considerations include patient presentation, anticipated disease and vascularity, degree of local venous anatomical distortion, and selection of optimal paramedian trajectory.

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Pakrit Jittapiromsak, Pushpa Deshmukh, Peter Nakaji, Robert F. Spetzler and Mark C. Preul

, 49 Due to the approach-related dissection and high mobility of the orbital tissue, meticulous measurements of deep structures may have little significance. Anatomical relationships are our main concern when performing approach-related dissection. Medial Approach to the Orbit Surgical approaches to the orbit must provide maximum surgical safety and optimum exposure. The specific approach to an orbital lesion depends on the type of pathology, its location within the orbit, and its involvement with adjacent structures. 3 , 33 Basically, surgical approaches to

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Harjot Thind, Douglas A. Hardesty, Joseph M. Zabramski, Robert F. Spetzler and Peter Nakaji

the treatment of choice in many cases. Surgical treatment of dAVFs has evolved from disconnection of the fistula and resection of the involved segment of dura and venous sinus to surgical disconnection of the venous drainage alone. The latter procedure has proved to be as efficacious as resection with less risk of venous stroke. 3 , 6 Preoperative imaging, such as MRI, CT angiography, and digital subtraction angiography (DSA), is essential for determining the location of, and the surgical approach to, dAVFs. Intraoperatively, the point at which the fistula

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Leonardo Rangel-Castilla, Fangxiang Chen, Lawrence Choi, Justin C. Clark and Peter Nakaji

-tailed). Lower: Correlation is not significant at either the 0.05 or 0.01 level (2-tailed). DTCS = distance to coronal suture; DTSS = distance to sagittal suture. Discussion Surgical approaches to colloid cysts include trans-callosal-transventricular, transcortical-transventricular, stereotactic cyst aspiration, and endoscopic excision with and without Stealth image guidance. 5 , 6 , 9 , 13 , 14 , 16 , 17 , 20 , 27 , 28 , 34 Although each treatment modality has shown fairly good clinical outcome, there has been discussion about which approach is the

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Peyton L. Nisson, Robert T. Wicks, Xiaochun Zhao, Whitney S. James, David Xu and Peter Nakaji

Cavernous malformations of the brain are low-flow vascular lesions that have a propensity to hemorrhage. Extensive surgical approaches are often required for operative cure of deep-seated lesions. A 23-year-old female presented with a cavernous malformation of the left posterior insula with surrounding hematoma measuring up to 3 cm. A minimally invasive (mini-)pterional craniotomy with a transsylvian approach was selected. Endoscopic assistance was utilized to confirm complete resection of the lesion. The minipterional craniotomy is a minimally invasive approach that provides optimal exposure for sylvian fissure dissection and resection of many temporal and insular lesions.

The video can be found here: https://youtu.be/9z6_EhU6lxs.

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Francisco A. Ponce, Robert F. Spetzler, Patrick P. Han, Scott D. Wait, Brendan D. Killory, Peter Nakaji and Joseph M. Zabramski

. Preoperative Planning The need for cardiac standstill was made on a case-by-case basis, factoring in the size (large or giant), location (posterior circulation), complexity (multilobed, calcified, thrombosed, or dolichoectatic), and projection (posterior) of the aneurysm and considering the aneurysm neck anatomy (wide, dysmorphic, or other anatomical characteristics rendering a patient a poor candidate for endovascular therapy) or previous treatment. A member of the endovascular team was present during the decision-making process. Surgical Approaches and Operative Data

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Carl H. Snyderman, Paul A. Gardner and Juan C. Fernandez-Miranda

can be performed for small lesions, open approaches remain the standard of care for large JNAs.” The authors are to be commended for providing a detailed and honest description of their experience. We disagree, however, with their selection of the optimal surgical approach and their overall treatment strategy. Current staging systems for JNA categorize intracranial extension as the highest stage. The amount of intracranial extension is not the most important prognostic factor for surgery; rather, it is the remaining tumor vascularity following embolization. This