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Microsurgical resection of a large cavernous malformation of the medulla oblongata

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:

Open access

Editorial. To embolize or not to embolize: that is the question for arteriovenous malformations

Mustafa K. Baskaya and Angela M. Richardson

Restricted access

Intradural nerve root hematoma in the lumbar spine

Case illustration

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

Full access

Operating microscopes: past, present, and future

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.

Free access

Introduction: surgical management of skull base meningiomas

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.

Open access

Meningioma of posterolateral tentorial incisura: a case demonstration of paramedian supracerebellar transtentorial approach

Abdullah Keles, Burak Ozaydin, and Mustafa K. Baskaya

The paramedian supracerebellar transtentorial approach allows unobstructed exposure to the quadrigeminal cistern, tectal plate, pineal region, tentorial incisura, medial basal temporal lobe, and posterior ambient cistern. The authors present a meningioma of the posterolateral tentorial incisura case in a 62-year-old male who presented with a long history of upper-extremity tremors and walking difficulties. MRI revealed supra- and infratentorial tumor extension and hydrocephalus. This approach enabled us to achieve gross-total resection without causing neurovascular injury or any postoperative neurological deficits. For each pathology, the pros and cons of various approaches should be considered based on the anatomy, vasculature, and any surrounding structures.

The video can be found here:

Free access

Microsurgical clipping of a giant vertebrobasilar junction aneurysm under hypothermic circulatory arrest

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:

Free access

A stepwise illustration of the retrosigmoid approach for resection of a cerebellopontine meningioma

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:

Free access

Clip reconstruction of an 8 cm giant internal carotid artery bifurcation aneurysm: microsurgical technique

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:

Open access

Microsurgical resection of a glioblastoma multiforme of the medulla oblongata with intraoperative subcortical stimulation and mapping

Sima Sayyahmelli, Jian Ruan, Bryan Wheeler, and Mustafa K. Başkaya

Primary glioblastoma multiforme tumors of the medulla oblongata are rare, especially in the adult population. Perhaps due to this rarity, we are not aware of any previous reports addressing the resection of these tumors or their clinical outcomes.

In this surgical video, we present a 43-year-old man with a 1-month history of left-sided paresthesia. The paresthesia initiated in the left hand, along with weakness and reduced fine motor control, and then spread to the entire left side of the body. He had recent weight loss, imbalance, difficulty in swallowing, and hoarseness in his voice. He also had a diminished gag reflex, and significant atrophy of the right side of the tongue with an accompanying deviation of the uvula and fasciculations of the tongue. MRI showed an infiltrative expansile mass within the medulla with peripheral enhancement and central necrosis. In T2/FLAIR sequences, a hyperintense signal extended superiorly into the left inferior aspect of the pons and left inferior cerebellar peduncle and inferiorly into the upper cervical cord.

The decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of this infiltrative expansile intrinsic mass in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials and monitoring of lower cranial nerves IX, X, XI, and XII. A gross-total resection of the enhancing portion of the tumor was performed, along with a subtotal resection of the nonenhancing portion. The surgery and postoperative course were uneventful. Histopathology revealed a grade IV astrocytoma. The patient received radiation therapy.

In this surgical video, we demonstrate important steps for the microsurgical resection of this challenging glioblastoma multiforme of the medulla oblongata.

The video can be found here: