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Sima Sayyahmelli and Mustafa K. Başkaya

In this surgical video, we present a 57-year-old man with neck pain, dizziness, and imbalance. MRI showed a heterogeneously enhancing mass lesion within the posterior medulla at the level of the foramen magnum. Because the patient was symptomatic from this cavernous malformation, the decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of the cavernous malformation in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials.

The surgery and postoperative course were uneventful. The postoperative MRI showed gross-total resection of the mass with histopathology indicating a cavernous malformation. The patient continues to do well without recurrence at 7 years of follow-up. In this video, we demonstrate important microsurgical steps for the resection of this challenging and rare vascular malformation.

The video can be found here: https://youtu.be/gbGleLowzxo.

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Kutluay Uluç, Gregory C. Kujoth and Mustafa K. Başkaya

The operating microscope is a fixture of modern surgical facilities, and it is a critically important factor in the success of many of the most complex and difficult surgical interventions used in medicine today. The rise of this key surgical tool reflects advances in understanding the principles of optics and vision that have occurred over centuries. The development of reading spectacles in the late 13th century led to the construction of early compound microscopes in the 16th and 17th centuries by Lippershey, Janssen, Galileo, Hooke, and others. Perhaps surprisingly, Leeuwenhoek's simple microscopes of this era offered improved performance over his contemporaries' designs. The intervening years saw improvements that reduced the spherical and chromatic aberrations present in compound microscopes. By the late 19th century, Carl Zeiss and Ernst Abbe ushered the compound microscope into the beginnings of the modern era of commercial design and production. The introduction of the microscope into the operating room by Nylén in 1921 initiated a revolution in surgical practice that gained momentum throughout the 1950s with multiple refinements, the introduction of the Zeiss OPMI series, and Kurze's application of the microscope to neurosurgery in 1957. Many of the refinements of the last 50 years have greatly improved the handling and practical operation of the surgical microscope, considerations which are equally important to its optical performance. Today's sophisticated operating microscopes allow for advanced real-time angiographic and tumor imaging. In this paper the authors discuss what might be found in the operating rooms of tomorrow.

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Ulas Cikla, Kutluay Uluc and Mustafa K. Baskaya

Thrombosed giant intracranial aneurysms usually present with symptoms and signs from their mass effect. Although multiple treatment options are available, direct clip reconstruction with thromboendarterectomy remains the gold standard. Here we present a 66-year-old man with seizure, aphasia and hemiparesis. Work-up revealed a giant partially thrombosed aneurysm of the internal carotid artery bifurcation with surrounding vasogenic edema. He underwent clip reconstruction of the aneurysm via a cranio-orbital approach. Although we prepared for bypass with the radial artery and/or the superficial temporal artery, we were able to clip-reconstruct the aneurysm without bypass. The patient improved upon his pre-morbid state after surgery and made an excellent recovery.

The video can be found here: http://youtu.be/P_10hRQFuPo.

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Mustafa K. Başkaya, Richard Roberts and Richard S. Polin

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Ulaş Cıkla, Gregory C. Kujoth and Mustafa K. Başkaya

The retrosigmoid approach is a work-horse approach to the cerebellopontine angle (CPA), providing access from the foremen magnum to the tentorium. Indications for this approach are variable such as resection of meningiomas, acoustic neuromas and epidermoid tumors, treatment of vascular lesions of vertebrobasilar system, vascular decompression of cranial nerves (V, VII, IX, X), cranial nerve neurectomies, and intrinsic lesions of the cerebellum and brainstem. In this video, we demonstrate the use of retrosigmoid craniotomy for resection of a large CPA meningioma, delineating all steps including positioning, mapping.

The video can be found here: http://youtu.be/kISkYS16Brk.

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Kyle I. Swanson, Ulas Cikla, Kutluay Uluc and Mustafa K. Baskaya

The supracerebellar transtentorial approach via a suboccipital craniotomy provides a corridor to reach lesions of the tentorial incisura and supratentorial lesions of the posterior medial basal temporal lobe, such as lesions of the posterior parahippocampal and fusiform gyri. The supracerebellar transtentorial approach obviates the need for either retraction of eloquent cortex or a transcortical route to reach lesions in this region. We present three cases that demonstrate the utility of this approach: a left-sided tentorial meningioma with superior projection, a left-sided posterior parahippocampal cavernous malformation, and a left-sided posterior parahippocampal grade 2 oligodendroglioma.

The video can be found here: https://youtu.be/OLnzUGZfUqk.

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Gabriel Zada, Mustafa K Başkaya and Mitesh V. Shah

Meningiomas represent the most common primary intracranial neoplasm treated by neurosurgeons. Although multimodal treatment of meningiomas includes surgery, radiation-based treatments, and occasionally medical therapy, surgery remains the mainstay of treatment for most symptomatic meningiomas. Because of the intricate relationship of the dura mater and arachnoid mater with the central nervous system and cranial nerves, meningiomas can arise anywhere along the skull base or convexities, and occasionally even within the ventricular system, thereby mandating a catalog of surgical approaches that neurosurgeons may employ to individualize treatment for patients. Skull base meningiomas represent some of the most challenging pathology encountered by neurosurgeons, on account of their depth, invasion, vascularity, texture/consistency, and their relationship to bony anatomy, cranial nerves, and blood vessels. Resection of complex skull base meningiomas often mandates adequate bony removal to achieve sufficient exposure of the tumor and surrounding region, in order to minimize brain retraction and optimally identify, protect, control, and manipulate sensitive neurovascular structures. A variety of traditional skull base approaches has evolved to address complex skull base tumors, of which meningiomas are considered the paragon in terms of both complexity and frequency.

In this supplemental video issue of Neurosurgical Focus, contributing authors from around the world provide instructional narratives demonstrating resection of a variety of skull base meningiomas arising from traditionally challenging origins, including the clinoid processes, tuberculum sellae, dorsum sellae, petroclival region, falco-tentorial region, cerebellopontine angle, and foramen magnum. In addition, two cases of extended endoscopic endonasal approaches for tuberculum sellae and dorsum sellae meningiomas are presented, representing the latest evolution in accessing the skull base for selected tumors. Along with key pearls for safe tumor resection, an equally important component of open and endoscopic skull base operations for meningiomas addressed by the contributing authors is the reconstruction aspect, which must be performed meticulously to prevent delayed cerebrospinal fluid leakage and/or infections. This curated assortment of instructional videos represents the authors’ optimal treatment paradigms pertaining to the selection of approach, setup, exposure, and principles to guide tumor resection for a wide spectrum of complex meningiomas.

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Pinar Eser Ocak, Cem Dinc, Ulaş Cikla and Mustafa K. Başkaya

The complexity of arteriovenous malformations (AVMs) does not necessarily preclude surgical resection. In this video the authors present a 72-year-old male who was known to have an occipital AVM with a large draining varix for the previous 10 years. The patient had progressively worsening visual and cognitive deficits over several years. Total surgical resection was achieved following single stage preoperative embolization. Although resection of the AVMs is challenging, even in experienced hands, it offers a cure and may improve patient clinical outcome.

The video can be found here: https://youtu.be/YI1AwGjJdvo.

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Ulas Cıkla, Kutluay Uluç and Mustafa K. Baskaya

Giant posterior circulation aneurysms pose a significant challenge to neurovascular surgeons. Among various treatment methods that have been applied individually or in combination, clipping under hypothermic circulatory arrest (HCA) is rarely used. We present a 62-year-old man who initially underwent coil occlusion of the right vertebral artery (VA) for a 2.5 cm giant vertebrobasilar junction (VBJ) aneurysm. His neurological condition had declined gradually and the aneurysm grew to 4 cm in size. The patient underwent clip reconstruction of giant VBJ aneurysm under HCA. His postoperative course was prolonged due to his preexisting neurological deficits. His preoperative Modified Rankin Score was 5, and improved postoperatively to 3 at three and six months, and to 2 at one year.

The video can be found here: http://youtu.be/L53SiLV8eJY.

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Sima Sayyahmelli, Ilhan Aydin, Bryan Wheeler and Mustafa K. Baskaya

Although the surgical treatment of thalamic tumors remains challenging due to the proximity to the internal capsule, safe resection of gliomas or metastatic tumors of the thalamus are possible in some selected cases due to a better understanding of microsurgical anatomy and due to advances in neurophysiological mapping and monitoring.

In this video, the authors demonstrate the use of mapping of the internal capsule with direct subcortical stimulation for the resection of a metastatic tumor. The patient is a 58-year-old man with a history of renal cell carcinoma and metastasis in the left thalamus and parieto-occipital region. He underwent stereotactic radiation of both tumors at an outside hospital. Due to the increased size of both tumors and surrounding vasogenic edema, he was referred to the authors for resection. He underwent gross-total resection via an interhemispheric transcallosal approach. His postoperative course was uneventful and did not have any focal neurological deficits, including motor, sensory, or visual functions.

The authors’ surgical approach to this metastatic thalamic tumor and the intraoperative real-time direct subcortical stimulation of the internal capsule during surgery are demonstrated in this video.

The video can be found here: https://youtu.be/DmDxjJUSZWU.