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Omar A. AlMasri, Emma E. Brown, Alan Forster, and Mahmoud H. Kamel

Object

The aim in this paper was to localize and detect incipient damage to the ophthalmic and maxillary branches of the trigeminal nerve during tumor surgery.

Methods

This was an observational study of patients with skull base, retroorbital, or cavernous sinus tumors warranting dissection toward the cavernous sinus at a university hospital. Stimuli were applied as normal during approach to the cavernous sinus to localize cranial nerves (CNs) III, IV, and VI. Recordings were also obtained from the facial muscles to localize CN VII. The trigeminofacial reflex was sought simply by observing a longer time base routinely.

Results

Clear facial electromyography responses were reproduced when stimuli were applied to the region of V1, V2, and V3. Response latency was increased compared with direct CN VII stimuli seen in some cases. Responses gave early warning of approach to these sensory trigeminal branches.

Conclusions

The authors submit this as a new technique, which may improve the chances of preserving trigeminal sensory branches during surgery in this region.

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Skull base tumor model

Laboratory investigation

Cristian Gragnaniello, Remi Nader, Tristan van Doormaal, Mahmoud Kamel, Eduard H. J. Voormolen, Giovanni Lasio, Emad Aboud, Luca Regli, Cornelius A. F. Tulleken, and Ossama Al-Mefty

Object

Resident duty-hours restrictions have now been instituted in many countries worldwide. Shortened training times and increased public scrutiny of surgical competency have led to a move away from the traditional apprenticeship model of training. The development of educational models for brain anatomy is a fascinating innovation allowing neurosurgeons to train without the need to practice on real patients and it may be a solution to achieve competency within a shortened training period. The authors describe the use of Stratathane resin ST-504 polymer (SRSP), which is inserted at different intracranial locations to closely mimic meningiomas and other pathological entities of the skull base, in a cadaveric model, for use in neurosurgical training.

Methods

Silicone-injected and pressurized cadaveric heads were used for studying the SRSP model. The SRSP presents unique intrinsic metamorphic characteristics: liquid at first, it expands and foams when injected into the desired area of the brain, forming a solid tumorlike structure. The authors injected SRSP via different passages that did not influence routes used for the surgical approach for resection of the simulated lesion. For example, SRSP injection routes included endonasal transsphenoidal or transoral approaches if lesions were to be removed through standard skull base approach, or, alternatively, SRSP was injected via a cranial approach if the removal was planned to be via the transsphenoidal or transoral route. The model was set in place in 3 countries (US, Italy, and The Netherlands), and a pool of 13 physicians from 4 different institutions (all surgeons and surgeons in training) participated in evaluating it and provided feedback.

Results

All 13 evaluating physicians had overall positive impressions of the model. The overall score on 9 components evaluated—including comparison between the tumor model and real tumor cases, perioperative requirements, general impression, and applicability—was 88% (100% being the best possible achievable score where the evaluator strongly agreed with the proposed factor). Individual components had scores at or above 80% (except for 1). The only score that was below 80% was related to radiographic visibility of the model for adequate surgical planning (score of 74%). The highest score was given to usefulness in neurosurgical training (98%).

Conclusions

The skull base tumor model is an effective tool to provide more practice in preoperative planning and technical skills.

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Michael O. Kelleher, Dylan J. Murray, Anne McGillivary, Mahmoud H. Kamel, David Allcutt, and Michael J. Earley

Object

The neurobehavioral morbidity of nonsyndromic trigonocephaly is incompletely understood. The purpose of this study was twofold: first, to assess the degree of developmental, educational, and behavioral problems in patients with nonsyndromic trigonocephaly and second, to establish whether patients with mild degrees of trigonocephaly had a lower frequency of such problems.

Methods

The authors performed an observational study of the frequency of developmental, educational, and behavioral problems in 63 children with trigonocephaly at the National Craniofacial Centre in the Republic of Ireland between 1989 and 2004. The parents of the children completed a follow-up questionnaire. Thirty percent of patients had a mild form of trigonocephaly and were treated conservatively. The remainder underwent surgical correction. Speech and/or language delay was reported in 34% of the children. Thirty-three percent of the children needed to be assessed by a school psychologist, and 47% were receiving remedial or resource hours within the school system. Twenty percent of children required a special needs classroom assistant because of behavioral issues, and 37% of parents expressed concerns about their child’s behavior. There were no statistically significant differences between children treated with surgery and those who had a mild deformity and were treated conservatively.

Conclusions

Nonsyndromic trigonocephaly is associated with a high frequency of developmental, educational, and behavioral problems. The frequency of these problems is not related to the severity of the trigonocephaly.