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Lana D. Christiano, Rachid Assina and Ira M. Goldstein

Ossification of the ligamentum flavum (OLF) is a disease of ectopic bone formation within the ligamentum flavum, which may result in mass effect and neurological compromise. The low thoracic region is the most common region of occurrence, and this is followed by the cervical, then lumbar, spine. The prevalence of OLF is significantly higher in the Japanese population compared with other nationalities and has a male preponderance. Ossification of the ligamentum flavum has been reported in association with the more common ligamentous pathological entities—ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. These latter two conditions have been linked to several metabolic processes, and a possible genetic basis has been hypothesized. Here, the authors present a unique case of OLF of the cervical spine in a patient with idiopathic hypercalcemia.

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Chirag D. Gandhi, Lana D. Christiano and Charles J. Prestigiacomo

The management of stroke has progressed significantly over the past 2 decades due to successful treatment protocols including intravenous and intraarterial options. The intravenous administration of tissue plasminogen activator within an established treatment window has been proven in large, well-designed studies. The evolution of endovascular strategies for acute stroke has been prompted by the limits of the intravenous treatment, as well as by the desire to demonstrate improved recanalization rates and improved long-term outcomes. The interventional treatment options available today are the intraarterial administration of tissue plasminogen activator and newer antiplatelet agents, mechanical thrombectomy with the MERCI device and the Penumbra system, and intracranial angioplasty and stent placement. In this review the authors outline the major studies that have defined the current field of acute stroke management and discuss the basic treatment paradigms that are commonly used today.

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James K. Liu, Lana D. Christiano, Gaurav Gupta and Peter W. Carmel

Giant craniopharyngiomas in the retrochiasmatic space are challenging tumors, given the location and surrounding vital structures. Surgical removal remains the first line of therapy and offers the best chance of cure. For tumors with extension into the retrochiasmatic space, the authors use the translamina terminalis corridor via the transbasal subfrontal approach. Although the lamina terminalis can be accessed via anterolateral approaches (pterional or orbitozygomatic), the surgical view of the optic chiasm is oblique and prevents adequate visualization of the ipsilateral wall of the third ventricle. The transbasal subfrontal approach, on the other hand, offers the major advantage of direct midline orientation and access to the third ventricle through the lamina terminalis. This provides the significant advantage of visualization of both walls of the third ventricle and hypothalamus as well as inferior midline access to the interpeduncular cistern to permit safe neurovascular dissection and total tumor removal. In this report, the authors describe the transbasal subfrontal translamina terminalis approach, with specific emphasis on technical surgical nuances in removing retrochiasmatic craniopharyngiomas. An illustrative video demonstrating the technique is also presented.

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Osamah J. Choudhry, Lana D. Christiano, Rahul Singh, Barbara M. Golden and James K. Liu

Bone morphogenetic protein (BMP) has been reported to cause early inflammatory changes, ectopic bony formation, adjacent level fusion, radiculitis, and osteolysis. The authors describe the case of a patient who developed inflammatory fibroblastic cyst formation around the BMP sponge after a lumbar fusion, resulting in compressive lumbar radiculopathy. A 70-year-old woman presented with left L-4 and L-5 radiculopathy caused by a Grade I spondylolisthesis with a left herniated disc at L4–5. She underwent a minimally invasive transforaminal lumbar interbody fusion with BMP packed into the interbody cage at L4–5. Her neurological symptoms resolved immediately postoperatively. Six weeks later, the patient developed recurrence of radiculopathy. Radiological imaging demonstrated an intraspinal cyst with a fluid-fluid level causing compression of the left L-4 and L-5 nerve roots. Reexpoloration of the fusion was performed, and a cyst arising from the posterior aspect of the cage was found to compress the axilla of the left L-4 nerve root and the shoulder of the L-5 nerve root. The cyst was decompressed, and the wall was partially excised. A collagen BMP sponge was found within the cyst and was removed. Postoperatively, the patient's radiculopathy resolved and she went on to achieve interbody fusion. Bone morphogenetic protein can be associated with inflammatory cyst formation resulting in neural compression. Spine surgeons should be aware of this complication in addition to the other reported BMP-related complications.

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James K. Liu, Lana D. Christiano, Smruti K. Patel and Jean Anderson Eloy

Retrochiasmatic craniopharyngiomas are challenging tumors to remove given their deep location and proximity to critical neurovascular structures. Complete surgical removal offers the best chance of cure and prevention of recurrence. The endoscopic endonasal extended transsphenoidal approach offers direct midline access to the retrochiasmatic space through a transplanum transtuberculum corridor. Excellent visualization of the undersurface of the optic chiasm and hypothalamus can be obtained to facilitate bimanual extracapsular dissection to permit complete removal of these formidable tumors. In this report the authors review the endoscopic endonasal extended transsphenoidal approach, with specific emphasis on technical operative nuances in removing retrochiasmatic craniopharyngiomas. An illustrative intraoperative video demonstrating the technique is also presented.

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Lana D. Christiano, Gaurav Gupta, Charles J. Prestigiacomo and Chirag D. Gandhi

Segal and McLaurin first described giant serpentine aneurysms, based on their distinct angiographic features, in 1977. These lesions are ≥ 25 mm, partially thrombosed aneurysms with a patent, serpiginous vascular channel that courses through the aneurysm. There is a separate inflow and outflow of the aneurysm, of which the outflow channel supplies brain parenchyma in the territory of the parent vessel. Given the large size, unique neck, and dependent distal vessels, these aneurysms pose a technical challenge in treatment. Initial management has included surgical obliteration, but as endovascular techniques have evolved, treatment options too have expanded. In this review the authors attempt to summarize the existing body of literature on this rare entity and describe some of their institutional management strategies.

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Chirag D. Gandhi, Lana D. Christiano, Jean Anderson Eloy, Charles J. Prestigiacomo and Kalmon D. Post

Over the past century, pituitary surgery has undergone multiple evolutions in surgical technique and technological advancements that have resulted in what practitioners now recognize as modern transsphenoidal surgery (TSS). Although the procedure is now well established in current neurosurgical literature, the historical maze that led to its development continues to be of interest because it allows a better appreciation of the unique contributions by the pioneers of the technique, and of the innovative spirit that continues to fuel neurosurgery. The early events in the history of TSS have already been well documented. This paper therefore summarizes the major early transitions along the timeline, and then further concentrates on some of the more recent advancements in TSS, such as the surgical microscope, fluoroscopy, endoscopy, intraoperative imaging, and frameless guidance. The account of each of these innovations is unique because they were each developed as a response to certain historical needs by the surgeon. An understanding of these more recent contributions, coupled with the early history, provides a more complete perspective on modern TSS.

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James K. Liu, Lana D. Christiano, Smruti K. Patel, R. Shane Tubbs and Jean Anderson Eloy

Tuberculum sellae meningiomas frequently extend into the optic canals. Radical tumor resection including the involved dural attachment, underlying hyperostotic bone, and intracanalicular tumor in the optic canal offers the best chance of a Simpson Grade I resection to minimize recurrence. Decompression of the optic canal with removal of the intracanalicular tumor also improves visual outcome since this portion of the tumor is usually the cause of asymmetrical visual loss.

The purely endoscopic endonasal extended transsphenoidal approach offers a direct midline trajectory and immediate access to tuberculum sellae meningiomas without brain retraction and manipulation of neurovascular structures. Although the endoscopic approach has been previously criticized for its inability to remove tumor within the optic canals, complete Simpson Grade I tumor removal including intracanalicular tumor, dural attachment, and involved hyperostotic bone can be achieved in properly selected patients. Excellent visualization of the suprasellar region and the inferomedial aspects of both optic canals allows for extracapsular, extraarachnoid dissection of the tumor from the critical structures using bimanual microsurgical dissection.

In this report, the authors describe the operative nuances for removal of tuberculum sellae meningiomas with optic canal involvement using a purely endoscopic endonasal extended transsphenoidal (transplanum transtuberculum) approach. They specifically highlight the technique for endonasal bilateral optic nerve decompression and removal of intracanalicular tumor to improve postoperative visual function, as demonstrated in 2 illustrative cases. Special attention is also given to cranial base reconstruction to prevent CSF leakage using the vascularized pedicled nasoseptal flap.

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James K. Liu, Lana D. Christiano, Smruti K. Patel, R. Shane Tubbs and Jean Anderson Eloy

Olfactory groove meningiomas represent 10% of intracranial meningiomas and arise in the midline of the anterior cranial fossa along the dura of the cribriform plate and planum sphenoidale. Hyperostosis of the adjacent underlying bone is common, and further extension into ethmoid sinuses and nasal cavity can occur in 15%–25% of cases. Radical tumor resection including the involved dural attachment and underlying hyperostotic bone offers the best chance of a Simpson Grade I resection to minimize recurrence. Incomplete removal of involved hyperostotic bone can result in tumor recurrence at the cribriform plate with extension into the paranasal sinuses. Resection has traditionally been performed using a bifrontal or pterional approach, both of which require some degree of brain retraction or manipulation to expose the tumor.

The endoscopic endonasal transcribriform approach offers the most direct and immediate exposure to the tumor without brain retraction and manipulation of neurovascular structures. An endonasal “keyhole craniectomy” is performed in the ventral skull base directly over the basal dural attachment, extending from the posterior wall of the frontal sinus to the planum sphenoidale and tuberculum sellae in the anteroposterior plane, and from one medial orbit to the other in the coronal plane. Excellent panoramic visualization of the keyhole skull base defect can be obtained with a 30° endoscope after performing a modified Lothrop procedure. Because the dural attachment is adjacent to the paranasal sinuses, early devascularization and total Simpson Grade I removal of the tumor including the dural attachment and underlying hyperostotic bone can be achieved in properly selected patients. This approach is also very suitable for meningiomas that have recurred or extended into the paranasal sinuses. Extracapsular, extraarachnoid dissection of the tumor from the frontal lobes and neurovascular structures can be performed using conventional bimanual microsurgical techniques.

In this report, we review the surgical technique and describe our operative nuances for removal of olfactory groove meningiomas, including recurrent tumors with extension into the nasal cavity, using a purely endoscopic endonasal transcribriform approach. In addition, we discuss the advantages, limitations, patient selection, and complications of this approach. We specifically highlight our technique for multilayer reconstruction of large anterior skull base dural defects using fascia lata and acellular dermal allograft supplemented by bilateral vascularized pedicled nasoseptal flaps. Three new cases of endoscopically resected olfactory groove meningiomas are also presented.