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Jeroen R. Coppens, John D. Cantando, and Saleem I. Abdulrauf

The authors describe their minimally invasive technique for performing a superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, which relies on an enlarged bur hole (2–2.5 cm) rather than the standard craniotomy. They perform this procedure in a minimally invasive fashion, using CT angiography for intraoperative neuronavigation as well as for preoperative identification of the donor and recipient vessels and planning of bur hole location. They present 2 cases in which this procedure was used, including one involving a patient with multivessel occlusive disease and significant cerebrovascular hemodynamic compromise in whom they performed the procedure using only local anesthetic and propofol sedation in order to minimize the risk of hypotension associated with the use of general anesthetic agents. A comprehensive literature search revealed no previously published case of an extracranial–intracranial arterial bypass procedure performed in an awake patient.

The authors have adopted the described minimally invasive method for all STA–MCA bypass procedures. The awake setting, however, is reserved for specific indications, primarily patients with severe moyamoya disease, in whom ventilator-related hypocarbia can result in intraoperative ischemia, or patients with multivessel occlusive disease and significant cerebral hemodynamic compromise, in whom general anesthesia–related hypotension can lead to intraoperative ischemia.

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Jeroen R. Coppens, Kelly B. Mahaney, and Saleem I. Abdulrauf

Object

The aim of this study was to define an anteromedial approach to the temporal horn via a transsylvian approach to avoid injury to the optic radiation fibers as well as the uncinate fasciculus. This route was compared with standard surgical approaches to the temporal horn, and their relationship to the optic radiation and uncinate fasciculus was reviewed.

Methods

Three cadaveric brain specimens were prepared with freezing and thawing cycles according to the Klingler technique. Dissection was performed in a lateral-to-medial fashion with the help of wooden spatulas. Photographs were taken through the operating microscope at every level of the dissection. The dissection was continued until the optic radiation was encountered. Particular attention was paid to the relationship of the uncinate fasciculus with the optic radiation. An anteromedial transsylvian approach was defined to enter the temporal horn without injuring the optic radiation or the uncinate fasciculus.

Conclusions

A transsylvian anteromedial approach through the pyriform cortex at the level of the anterior and superior surface of the uncus enables a safe entry into the temporal horn without injury to the optic radiation fibers or the main part of the uncinate fasciculus.

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Todd McCall, Jeroen Coppens, William Couldwell, and Andrew Dailey

A paracondylar process is a bony exostosis that arises from the skull base lateral to the occipital condyle and extends inferiorly toward the transverse process of the atlas. This congenital anomaly can vary in size from a small protuberance to an elongated process articulating with an epitransverse process arising from C-1. Typically, a paracondylar process is an incidental finding described in anatomical studies. The authors report on a patient with a symptomatic paracondylar process articulating with an epitransverse process that caused occipitocervical pain. Resection of the paracondylar and epitransverse processes completely relieved the patient's pain.

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Philipp Taussky, Ricky Kalra, Jeroen Coppens, Jahan Mohebali, Randy Jensen, and William T. Couldwell

Object

Stereotactic radiosurgery and fractionated stereotactic radiotherapy are commonly used in the treatment of residual or recurrent benign tumors of the skull base and cavernous sinus. A major risk associated with radiosurgical or radiotherapy treatment of residual or recurrent tumors adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors have used a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual tumor within the cavernous sinus. Here, the authors analyze the long-term endocrinological outcomes in patients with residual and recurrent tumors who undergo hypophysopexy and adjuvant radiosurgical or conformal fractionated radiotherapy treatment.

Methods

Pituitary transposition involves placement of a fat graft between the normal pituitary gland and residual tumor in the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and the graft is interposed between the pituitary gland and the residual tumor. The residual tumor may then be treated with stereotactic radiosurgery or conformal fractionated radiation therapy. The authors evaluated endocrinological outcome, safety of the procedure, and postoperative complications in patients who underwent this procedure during a 7-year period.

Results

Hypophysopexy has been used in 34 patients with nonfunctioning pituitary adenomas (19), functional pituitary adenomas (8), chordomas (2), meningiomas (2), chondrosarcoma (1), hemangiopericytoma (1), or hemangioma (1) involving the sella and cavernous sinus. Follow-up (radiographic and endocrinological) has been performed yearly in all patients. Two patients experienced postoperative endocrine deficits before radiosurgery (1 transient), but none of the patients developed new hypopituitarism during the median 4-year follow-up (range 1–8 years) after radiosurgery or fractionated stereotactic radiotherapy.

Conclusions

The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery or radiotherapy and effectively reduces the incidence of radiation injury to the normal pituitary gland when compared with historical controls.

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Georgios Alexopoulos, Nabiha Quadri, Maheen Khan, Henna Bazai, Carla Formoso Pico, Connor Fraser, Neha Kulkarni, Joanna Kemp, Jeroen Coppens, Richard Bucholz, and Philippe Mercier

OBJECTIVE

Penetrating brain injury (PBI) is the most lethal of all firearm injuries, with reported survival rates of less than 20%. The projectile trajectory (PT) has been shown to impact mortality, but the significant lobar tracks have not been defined. The aim of this retrospective case-control study was to test for associations between distinct ballistic trajectories, missile types, and patient outcomes.

METHODS

A total of 243 patients who presented with a PBI to the Saint Louis University emergency department from 2008 through 2019 were identified from the hospital registry. Conventional CT scans combined with 3D CT reconstructions and medical records were reviewed for each patient to identify distinct PTs.

RESULTS

A total of 65 ballistic lobar trajectories were identified. Multivariable regression models were used, and the results were compared with those in the literature. Penetrating and perforating types of PBI associated with bitemporal (t-statistic = −2.283, p = 0.023) or frontal-to-contralateral parietal (t-statistic = −2.311, p = 0.025) projectile paths were universally found to be fatal. In the group in which the Glasgow Coma Scale (GCS) score at presentation was lower than 8, a favorable penetrating missile trajectory was one that involved a single frontal lobe (adjusted OR 0.02 [95% CI 0.00–0.38], p = 0.022) or parietal lobe (adjusted OR 0.15 [95% CI 0.02–0.97], p = 0.048). Expanding or fragmenting types of projectiles carry higher mortality rates (OR 2.53 [95% CI 1.32–4.83], p < 0.001) than do nondeformable missiles. Patient age was not associated with worse outcomes when controlled by other significant predictive factors.

CONCLUSIONS

Patients with penetrating or perforating types of PBI associated with bitemporal or frontal-to-contralateral parietal PTs should be considered as potential donor candidates. Trauma patients with penetrating missile trajectories involving a single frontal or parietal lobe should be considered for early neurosurgical intervention, especially in the circumstances of a low GCS score (< 8). Surgeons should not base their decision-making solely on advanced patient age to defer further treatment. Patients with PBIs caused by nondeformable types of projectiles can survive multiple simultaneous intracranial missile trajectories.