✓ The usefulness of intraoperative monitoring in cerebellopontine angle surgery should be improved by obtaining faster and stronger brainstem auditory evoked potential (BAEP) responses. A new technique of direct recording at the brainstem has been developed, which is applicable to all tumor sizes. By placing a retractor with electrodes attached to its tip at the cerebellomedullary junction, the authors have recorded BAEP amplitudes that are 10 times greater than those recorded using the conventional technique. Only small sampling numbers (64–256 recordings) are required and are obtained in 5 to 15 seconds. The technique has been applied successfully in 34 patients who underwent vestibular schwannoma resections. It has also been tested in patients with intrameatal—extrameatal meningiomas and in those with vascular compressive disorders; there have been no false results. The advantages of this new technique are: 1) identification of BAEP components is easier and faster; 2) reliable BAEP responses are obtained in some cases in which conventional BAEP responses are lost or severely deformed; and 3) BAEP response deterioration and improvement are recognized earlier than would occur using the conventional technique. This last advantage provides the surgeon with a useful warning at a stage of surgery at which BAEP changes are still temporary and can be reversed. This method is different from other trials of intradural BAEP recordings in three respects: its use is not limited to particular tumor sizes; there is no interference with the surgical process; and, most important, the obtained responses correlate well with those of conventional BAEP responses, probably because the recording site is in the vicinity of the anterior cochlear nucleus. In conclusion, the chances of useful monitoring feedback with adequate adaptation of the microsurgical strategy are improved considerably.
Direct brainstem recording of auditory evoked potentials during vestibular schwannoma resection: nuclear BAEP recording
Technical note and preliminary results
Cordula Matthies and Madjid Samii
Frameless free-hand maneuvering of a small-diameter rigid-rod neuroendoscope with a working channel used during high-resolution imaging
Shizuo Oi, Amir Samii, and Madjid Samii
P A newly designed small-diameter rigid-rod neuroendoscope was created to evaluate the applicability of free-hand maneuvering during high-resolution imaging. The neuroendoscope was designed as a light, handheld tool weighing 550 g. A 20-cm-long objective lens, 2 mm in diameter, is placed in the lower two thirds of the single-space lumen of an oval-shaped outer sheath, 16.5 mm long and 3.5 × 2.5 mm at maximum diameter. Included are microinstruments of 1.3-mm diameter for various neuroendoscopic procedures, including microscissors, biopsy forceps, grasping forceps, monopolar coagulator/cutting rod, and bipolar coagulator that can be introduced through the upper one third of the lumen.
Because the endoscope is held steady in the surgeon's left hand, with the handle gripped at the base, quick back-and-forth movements can be made along the long axis, via a peel-away sheath inserted to the ventricle, shifting of the endoscope tip to the side of the objective target will be minimal. Given the instrument's unified configuration, the surgeon will never lose orientation during maneuvering. Using the farthest right of three inlet/outlet orifices, the short and handy semiflexible microinstruments can be guided and controlled by the surgeon's right hand.
After experience in 66 cases in which various neuroendoscopic procedures yielded excellent operative outcomes (morbidity rate in complications related to the endoscopic procedure 0%; mortality rate 0%), the endoscope prototype was finalized in the ideal form for frameless maneuvering that uses a rigid-rod endoscope. The “gun-butt” holder for use with the operator's left hand provides stability and allows the endoscope to be handled with improved control. These new aspects of the neuroendoscope and surgical technique offer substantial improvement over the flexible-steerable fiberoptic endoscopes.
Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients
Madjid Samii, Venelin Gerganov, and Amir Samii
The aim of this study was to evaluate and present the results of current surgical treatment of vestibular schwannomas (VSs) and to report the refinements in the operative technique.
The authors performed a retrospective study of 200 consecutive patients who had undergone VS surgery over a 3-year period. Patient records, operative reports, follow-up data, and neuroradiological findings were analyzed. The main outcome measures were magnetic resonance imaging, neurological status, patient complaints, and surgical complications.
Complete tumor removal was achieved in 98% of patients. Anatomical preservation of the facial nerve was possible in 98.5% of patients. In patients treated for tumors with extension Classes T1, T2, and T3, the rate of facial nerve preservation was 100%. By the last follow-up examination, excellent or good facial nerve function had been achieved in 81% of the cases. By at least 1 year postsurgery, no patients had total facial palsy. In the patients with preserved hearing, the rate of anatomical preservation of the cochlear nerve was 84%. The overall rate of functional hearing preservation was 51%. There was no surgery-related permanent morbidity in this series of patients. Cerebrospinal fluid leakage was diagnosed in 2% of the patients. The mortality rate was 0%.
The goal of VS treatment should be total removal in one stage and preservation of neurological function, as they determine a patient’s quality of life. This goal can be safely and successfully achieved using the retrosigmoid approach.
Microsurgical management of vestibular schwannoma after failed previous surgery
Madjid Samii, Hussam Metwali, and Venelin Gerganov
Microsurgical treatment of recurrent vestibular schwannoma (VS) is difficult and poses specific challenges. The authors report their experience with 53 cases of surgically treated recurrent VS. Outcome of these tumors was compared to that of primarily operated on VS. Special attention was given to the facial nerve functional outcome.
A retrospective analysis was performed of the patients who underwent surgery for recurrent VS at one institution from 2000 to 2013. The preoperative data, intraoperative findings, and outcome in terms of facial nerve function and improvement of the preoperative symptoms were analyzed and compared with those in a control group of 30 randomly selected patients with primarily operated on VS. A multivariate regression analysis was performed to test the factors that could affect the facial nerve outcome in each group.
Fifty-three consecutive patients underwent surgery for recurrent VS. Seventeen patients were previously operated on and received postoperative radiosurgery (Group A). Thirty-six patients were previously operated on but did not receive postoperative radiosurgery (Group B). The overall postoperative facial nerve function was significantly worse in Groups A and B in comparison with the control group (Group C). Interestingly, there was no significant difference in the facial nerve outcome among the 3 groups in patients who had good preoperative facial nerve function. The tumor size and the preoperative facial nerve function are variables that significantly affect the facial nerve outcome. Most of the patients showed improvement of the preoperative symptoms, such as trigeminal hypesthesia, gait disturbance, and headache.
Complete microsurgical tumor removal is the optimal management for patients with recurrent or regrowing VS. The procedure is safe, associated with favorable facial nerve outcome, and may also improve existing neurological symptoms.
Syringomyelia associated with foramen magnum arachnoiditis
Jörg Klekamp, Giorgio Iaconetta, Ulrich Batzdorf, and Madjid Samii
Object. Syringomyelia is often linked to pathological lesions of the foramen magnum. The most common cause is hindbrain herniation, usually referred to as Chiari I or II malformation. Foramen magnum arachnoiditis without either Chiari I or II malformation is a rare cause of syringomyelia. The authors undertook a retrospective analysis of 21 patients with foramen magnum arachnoiditis (FMA) and syringomyelia treated between 1978 and 2000 to determine clinical course and optimum management.
Methods. In the review of records, 21 patients with FMA and syringomyelia were documented. A stable clinical course was demonstrated in three patients in whom surgery was not performed, and one patient refused surgical intervention. Seventeen patients underwent 23 operations to treat progressive neurological disease. Of these 23 operations, 18 involved opening of the foramen magnum, arachnoid dissection, and placement of a large dural graft. One patient underwent insertion of a ventriculoperitoneal shunt for treatment of accompanying hydrocephalus, one patient received a cystoperitoneal shunt for an accompanying arachnoid cyst; two syringoperitoneal and one syringosubarachnoid shunts were also inserted. Hospital and outpatient files, neuroimaging studies, and intraoperative photographic and video material were analyzed. Additional follow-up information was obtained by telephone interview and questionnaires.
Standard and cardiac-gated magnetic resonance imaging studies are the diagnostic procedures of choice in these patients. Sensory disturbances, dysesthesias, and pain were the only symptoms likely to improve after foramen magnum surgery. Motor weakness and gait disturbances, which were severe in a considerable number of patients, and swallowing disorders tended to remain unchanged. As a consequence of the rather severe arachnoid lesions in most patients, clinical recurrences were observed in 57% over a 5-year period.
Conclusions. Surgery for FMA and syringomyelia has to provide clear cerebrospinal fluid pathways between the cerebellopontine cisterns, spinal canal, and fourth ventricle. If this can be achieved successfully, the syrinx decreases in size and the clinical course of the patient may even improve. In patients with severe and widespread areas of arachnoiditis, however, multiple operations may be required at least to stabilize the clinical course.
Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome
Madjid Samii, Marcos Tatagiba, and Gustavo A. Carvalho
The goal of this study was to determine whether some petroclival tumors can be safely and efficiently treated using a modified retrosigmoid petrosal approach that is called the retrosigmoid intradural suprameatal approach (RISA).
The RISA was introduced in 1983, and since that time 12 patients harboring petroclival meningiomas have been treated using this technique. The RISA includes a retrosigmoid craniotomy and drilling of the suprameatus petrous bone, which is located above and anterior to the internal auditory meatus, thus providing access to Meckel's cave and the middle fossa.
Radical tumor resection (Simpson Grade I or II) was achieved in nine (75%) of the 12 patients. Two patients underwent subtotal resection (Simpson Grade III), and one patient underwent complete resection of tumor at the posterior fossa with subtotal resection at the middle fossa. There were no deaths or severe complications in this series; all patients did well postoperatively, being independent at the time of their last follow-up examinations (mean 5.6 years). Neurological deficits included facial paresis in one patient and worsening of hearing in two patients.
The approach described here is a useful modification of the retrosigmoid approach, which allows resection of large petroclival tumors without the need for supratentorial craniotomies. Although technically meticulous, this approach is not time consuming; it is safe and can produce good results. This is the first report on the use of this approach for petroclival meningiomas.
Introduction. Update on the treatment of acoustic tumors
Michael J. Link, Douglas Kondziolka, and Madjid Samii
Efficacy of microsurgical tumor removal for treatment of patients with intracanalicular vestibular schwannoma presenting with disabling vestibular symptoms
Madjid Samii, Hussam Metwali, and Venelin Gerganov
The aim of this study was to analyze the efficacy and risks of microsurgery via the hearing-preserving retrosigmoid approach in patients with intracanalicular vestibular schwannoma (VS) suffering from disabling vestibular symptoms, with special attention to vertigo.
This is a retrospective analysis of 19 patients with intracanalicular VS and disabling vestibular dysfunction as the main or only symptom (Group A). All of the patients reported having had disabling vertigo attacks. Subjective evaluation of the impairment of patients was performed before surgery, 3 weeks after surgery, 3 months after surgery, and 1 year after surgery, using the Dizziness Handicap Inventory (DHI). The main outcome measures were improvement in quality of life as measured using the DHI, and general and functional outcomes, in particular facial function and hearing. Patient age, preoperative tumor size, preoperative DHI score, and preservation of the nontumorous vestibular nerve were tested using a multivariate regression analysis to determine factors affecting the postoperative DHI score. The Mann-Whitney U-test was used to compare the postoperative DHI score at 3 weeks, 3 months, and 1 year after surgery with a control group of 19 randomly selected patients with intracanalicular VSs, who presented without vestibular symptoms (Group B). The occurrence of early postoperative discrete vertigo attacks was also compared between groups.
The preoperative DHI score was ≥ 54 in all patients. All patients reported having had disabling rotational vertigo before surgery. The only significant factor to affect the DHI outcome 3 weeks and 3 months after surgery was the preoperative DHI score. The DHI outcome after 1 year was not affected by the preoperative DHI score. Compared with the control group, the DHI score at 3 weeks and 3 months after surgery was significantly worse. There was no significant difference between the groups after 1 year. Vertigo was improved in all patients and completely resolved after 1 year in 17 patients.
Disabling vestibular dysfunction that affects quality of life should be considered an indication for surgery, even in otherwise asymptomatic patients with intracanalicular VS. Surgical removal of the tumor is safe and very effective in regard to symptom relief. All patients had excellent facial nerve function within 1 year after surgery, with a very good chance of hearing preservation.
Endoscope-assisted retrosigmoid infralabyrinthine approach to jugular foramen tumors
Madjid Samii, Maysam Alimohamadi, and Venelin Gerganov
Removal of jugular foramen (JF) tumors usually requires extensive skull base approaches and is frequently associated with postoperative morbidities such as lower cranial nerve injury. The endoscope-assisted retrosigmoid infralabyrinthine approach is a relatively new approach to tumors extending into the bony canal of the JF. The authors present their experience with this approach.
The endoscope-assisted retrosigmoid infralabyrinthine approach was used in 7 patients, including 5 with schwannomas and 2 with paragangliomas. The access to the tumor, extent of its removal, postoperative neurological outcome, and approach-related morbidities were evaluated.
Two patients had a history of previous partial tumor removal, and 1 was treated by embolization followed by two courses of Gamma Knife radiosurgery. In this latter patient near-total resection was achieved. Gross-total resection was possible in the remaining 6 patients. Five patients benefited from endoscopic assistance: in 2 patients it showed a tumor remnant after microscopic tumor removal, while in 3 patients it allowed safe removal of the intraforaminal tumor by visualizing the surrounding structures. No permanent neurological deficit was observed after the operation. Two patients presenting with swallowing disturbance had temporary postoperative worsening that improved later. One patient developed CSF leakage that was managed with a lumbar drain.
This study shows that the judicious application of the endoscope-assisted retrosigmoid infralabyrinthine approach is safe and effective for removal of the schwannomas extending into the JF and selected paragangliomas without significant luminal invasion of the sigmoid-jugular system.