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Paul A. Gardner and A. Leland Albright

✓Anterior sacral meningocele (ASM) is a relatively rare, congenital disorder. Usually it presents sporadically, but there are case reports of hereditary ASMs and evidence of a dominant mode of inheritance. In this article the authors describe a case illustrating the hereditary nature of ASM and present available literature on the disease.

The authors present the case of a 19-month-old boy in whom an ASM was diagnosed during a workup for constipation. The child's 31-year-old mother had been treated for the same condition 20 years earlier, when she had presented with back pain. These cases are discussed in the context of previous reports of similar cases.

There are several case reports in the literature in which an ASM occurred as a familial, isolated disorder (in the absence of other caudal abnormalities or syndromes). The condition is reported more commonly in women, but it is unclear whether this is a true difference in prevalence or a diagnosis or reporting bias. A review of the literature indicates an autosomal-dominant inheritance with variable penetrance and presentation.

Anterior sacral meningoceles can be hereditary. Given the potential complications of the disease if left untreated and the simplicity of screening—obtaining an abdominal radiograph and the patient's clinical history—we recommend screening of immediate family members of affected individuals. Surgical treatment is recommended if an ASM is discovered.

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Amin B. Kassam, Paul A. Gardner, Arlan Mintz, Carl H. Snyderman, Ricardo L. Carrau and Michael Horowitz

✓Paraclinoidal aneurysms, especially superior hypophyseal artery (SHA) aneurysms (with medial projection), can be challenging to access via a pterional craniotomy and damage to the optic nerve can occur during surgery. The authors have previously reported on endonasal clipping and aneurysmorrhaphy of a vertebral artery aneurysm following proximal and distal protection of the aneurysm using partial coil embolization. To the best of the authors' knowledge no unprotected aneurysm has been clipped using an endonasal approach.

The 56-year-old woman in this report was found to have two unruptured aneurysms: an anterior communicating artery (ACoA) aneurysm and an SHA aneurysm. An endoscopic endonasal, transplanar–transsellar approach was used to successfully clip the SHA aneurysm. Proximal and distal control was obtained endonasally prior to successful clip occlusion of the aneurysm. The ACoA aneurysm was clipped via a pterional craniotomy during the same anesthetic session. This report shows that it is possible to successfully clip a medially projecting, paraclinoidal aneurysm using an endonasal approach. Such cases must be chosen with extreme caution and only performed by surgeons with significant experience with both endoscopic endonasal approaches and neurovascular surgery.

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Amin B. Kassam, Paul A. Gardner, Carl H. Snyderman, Ricardo L. Carrau, Arlan H. Mintz and Daniel M. Prevedello

Object

Craniopharyngiomas are notoriously difficult to treat. Surgeons must weigh the risks of aggressive resection against the long-term challenges of recurrence. Because of their parasellar location, often extending well beyond the sella, these tumors challenge vision and pituitary and hypothalamic function. New techniques are needed to improve outcomes in patients with these tumors while decreasing treatment morbidity. An endoscopic expanded endonasal approach (EEA) is one such technique that warrants understanding and evaluation. The authors explain the techniques and approach used for the endoscopic endonasal resection of suprasellar craniopharyngiomas and introduce a tumor classification scheme.

Methods

The techniques and approach used for the endoscopic, endonasal resection of suprasellar craniopharyngiomas is explained, including the introduction of a tumor classification scheme. This scheme is helpful for understanding both the appropriate expanded approach as well as relevant involved anatomy.

Results

The classification scheme divides tumors according to their suprasellar extension: Type I is preinfundibular; Type II is transinfundibular (extending into the stalk); Type III is retroinfundibular, extending behind the gland and stalk, and has 2 subdivisions (IIIa, extending into the third ventricle; and IIIb, extending into the interpeduncular cistern); and Type IV is isolated to the third ventricle and/or optic recess and is not accessible via an endonasal approach.

Conclusions

The endoscopic EEA requires a thorough understanding of both sinus and skull base anatomy. Moreover, in its application for craniopharyngiomas, an understanding of tumor growth and extension with respect to the optic chiasm and infundibulum is critical to safely approach the lesion via an endonasal route.

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Paul A. Gardner, Daniel M. Prevedello, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau and Arlan H. Mintz

✓Craniopharyngiomas have always been an extremely challenging type of tumor to treat. The transsphenoidal route has been used for resection of these lesions since its introduction. The authors present a historical review of the literature from the introduction of the endonasal route for resection of craniopharyngiomas until the present. Abandoned early due to technological limitations, this approach has been expanded both in its application and in its anatomical boundaries with subsequent progressive improvements in outcomes. This expansion has coincided with advances in visualization devices, imaging guidance techniques, and anatomical understanding. The progression from the use of headlights, to microscopy, to endoscopy and fluoroscopy, and finally to modern intraoperative magnetic resonance–guided techniques, combined with collaboration between otolaryngologists and neurosurgeons, has provided the framework for the development of current techniques for the resection of sellar and suprasellar craniopharyngiomas.

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Paolo Cappabianca, Luigi M. Cavallo, Felice Esposito and Enrico De Divitiis

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Paul A. Gardner, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau, Arlan H. Mintz, Steven Grahovac and Susan Stefko

Object

Craniopharyngiomas are challenging tumors that most frequently occur in the sellar or suprasellar regions. Microscopic transsphenoidal resections with various extensions and variations have been performed with good results. The addition of the endoscope as well as the further expansion of the standard and extended transsphenoidal approaches has not been well evaluated for the treatment of this pathological entity.

Methods

The authors performed a retrospective review of all patients who underwent a purely endoscopic, expanded endonasal approach (EEA) for the resection of craniopharyngiomas at their institution between June 1999 and February 2006. Endocrine and ophthalmological outcomes, extent of resection, and complications were evaluated.

Results

Sixteen patients underwent endoscopic EEA for the resection of craniopharyngiomas. Five patients (31%) presented with recurrent disease. Complete resection was planned in 11 of the 16 patients. Three elderly patients with vision loss underwent planned debulking, 1 patient with vision loss and a moderate-sized tumor had express wishes for debulking, and 1 patient had a separate, third ventricular nodule that was not resected. Of those in whom complete resection was planned, 91% underwent near-total (2/11) or gross-total (8/11) resection. No patient who underwent gross-total resection suffered a recurrence. The mean follow-up period was 34 months. Of the 14 patients who presented with vision loss, 93% had improvement or complete recovery and 1 patient's condition remained stable. No patient experienced visual worsening. Eighteen percent of patients (without preexisting hypopituitarism) developed panhypopituitarism and 8% developed permanent diabetes insipidus. There were no cases of new obesity. The postoperative cere-brospinal fluid leak rate was 58%. All leaks were resolved, and there were no cases of bacterial meningitis. There was 1 vascular injury (posterior cerebral artery perforator branch) resulting in the only new neurological deficit. No patient died.

Conclusions

Endoscopic EEA for the resection of craniopharyngiomas provides acceptable results and holds the potential to improve outcomes.

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Paul A. Gardner, Pawel G. Ochalski and John J. Moossy

Palmar hyperhidrosis is a disorder of the autonomic nervous system characterized by excessive perspiration of the palms, but may involve other body parts as well. Traditional posterior approaches have been performed less often in favor of less invasive thoracoscopic sympathectomies, which have a high success rate with low associated morbidity. However, some patients are not candidates for a transthoracic surgery and may need an alternative treatment strategy.

In situations in which a posterior approach may be necessary, the authors have developed a minimal access endoscopic-assisted dorsal sympathectomy procedure, applying minimally invasive spine muscle splitting techniques. The authors believe that the development of this technique may help to minimize surgical morbidity associated with the traditional posterior approach by reducing pain, tissue damage, and length of postoperative recovery. This paper is a report on the successful treatment of palmar hyperhidrosis using a minimally invasive posterior technique and describes the surgical approach and outcomes in 2 patients who have been treated in this manner.

Two patients underwent minimally invasive endoscopic-assisted posterior thoracic sympathectomy for hyperhidrosis. Both patients experienced relief of their symptoms after surgery with follow-up durations of 32 and 9 months and length of stays of 0.9 and 2.8 days, respectively. One patient suffered a unilateral Horner syndrome and underwent an eyelid lift. The other patient was readmitted to the hospital 2 days after discharge with atelectasis. She was obese and suffered from chronic obstructive pulmonary disease at baseline, which were reasons she opted for a posterior approach. Neither patient suffered a pneumo- or hemothorax.

Minimally invasive endoscopic-assisted posterior thoracic sympathectomy can be safely performed for relief of hyperhidrosis. The procedure has risks for the usual complications of sympathectomy. This technique may provide an alternative to thoracoscopic approaches, especially in those patients with pulmonary disease or obesity.

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Hilal A. Kanaan, Paul A. Gardner, Gabrielle Yeaney, Daniel M. Prevedello, Edward A. Monaco III, Geoffrey Murdoch, Ian F. Pollack and Amin B. Kassam

Olfactory schwannomas are rare tumors of the anterior skull base that are possibly derived from ectopic Schwann cells, perivascular neural tissue, or sensory nerves of the meninges. The authors report the case of a 14-year-old boy with an olfactory schwannoma that extended inferiorly through the cranial base and superiorly into the frontal lobe. Because of the growth characteristics of the tumor and the significant overlying frontal lobe edema, the lesion was approached via an endonasal endoscopic route, as a strategy to minimize brain retraction. This tumor was characterized radiographically as contrast-enhancing with cystic areas and erosion into bone. The tumor showed immunoreactivity for S100 protein and leukocyte antigen 7 (CD57) but not epithelial membrane antigen, supporting the diagnosis of olfactory schwannoma. A gross-total resection was achieved. This approach represents a novel application of endoscopic endonasal surgery to the pediatric neurosurgical context, as well as a favorable outcome in an extremely unusual tumor type, that should be applicable to other appropriately selected pediatric brain tumors.

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Jose M. Pascual

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Paul A. Gardner, Johnathan Engh, Dave Atteberry and John J. Moossy

Object

External ventricular drain (EVD) placement is one of the most common neurosurgical procedures performed. Rates and significance of hemorrhage associated with this procedure have not been well quantified.

Methods

All adults who underwent EVD placement at the University of Pittsburgh Medical Center between July 2002 and June 2003 were evaluated for catheter-associated hemorrhage. Patients without postprocedural imaging were excluded.

Results

Seventy-seven (41%) of 188 EVDs were associated with imaging evidence of hemorrhage after either placement or removal. Most of these were insignificant, punctate intraparenchymal, or trace subarachnoid hemorrhages (51.9%). Thirty-seven (19.7%) were associated with larger hemorrhages, which were divided into 3 groups according to volume of hemorrhage: 16 patients (8.5%) had < 15 ml of hemorrhage, 20 (10.6%) had hemorrhages of > 15 ml or associated intraventricular hemorrhage, and in 1 case there was a subdural hematoma that required surgical evacuation. No hemorrhages larger than punctate or trace were seen after EVD removal. Hemorrhage was associated with 44.3% of EVDs placed in an intensive care unit compared with 34.8% in EVDs placed in the operating room (p > 0.10).

Conclusions

External ventricular drain placement has a significant risk of associated hemorrhage. However, the hemorrhages are rarely large and almost never require surgical intervention. There is a favorable trend, but no significant risk reduction when EVDs are placed in the operating room rather than the intensive care unit.