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Open access

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.

Open access

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: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2138.

Full access

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

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.

Open access

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: https://youtu.be/QHbOVxdxbeU.

Free access

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.

Free access

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.

Free access

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.

Restricted access

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