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Daniel Dutra Cavalcanti, Bárbara Albuquerque Morais, Eberval Gadelha Figueiredo, Robert F. Spetzler, and Mark C. Preul

of cavernous malformations and brainstem tumors. 1 , 3 , 4 , 7 , 10 , 11 , 24 , 25 , 29 , 31 , 38 The lateral mesencephalic sulcus (LMS) is the preferred route and is related to major anatomical structures such as the trochlear nerve , superior cerebellar artery (SCA), and distal branches of the posterior cerebral artery (PCA). Different surgical approaches to the midbrain surface have been described, including subtemporal (ST), median supracerebellar infratentorial (SCIT), 22 , 33 paramedian SCIT variant, 37 , 39 and extreme-lateral SCIT variant. 34 , 35

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Leonardo Rangel-Castilla and Robert F. Spetzler

T he thalamus is located in the center of the lateral ventricles rostral to the brainstem. Because it is surrounded by vital neurovascular structures, the surgical approach to it can be challenging. The thalamus is intimately related to the basal ganglia, internal capsule, midbrain, foramen of Monro, stria terminalis, thalamostriate vein, and the internal cerebral veins. 25 Cavernous malformations (CMs) of the thalamus and basal ganglia are relatively rare lesions that can cause devastating neurological deficits. 3 , 14–16 , 21 Because of the rarity of

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Surgical approaches to the orbit

Indications and techniques

Joseph C. Maroon and John S. Kennerdell

mixed lacrimal gland tumors 4 metastatic tumors 75 nonspecific orbital inflammation 110 total cases 308 In this report, we will discuss pertinent surgical anatomy of the orbit, our orbital surgical approaches, the indications for each, and the role of fine-needle aspiration biopsy in orbital tumors. Surgical Anatomy The optic canal lies between the two struts or roots of the lesser sphenoid wing. It is 5 to 10 mm long and 4½ mm wide, and the average height is 5 mm. The roof of the canal is variably 1 to 3 mm thick. The

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Hunt Batjer and Duke Samson

details the clinical characteristics encountered in this population and the alternatives for surgical approaches to these deep lesions. Clinical Material and Methods Between July, 1981, and February, 1986, 15 patients were referred to our institution following the onset of symptoms from AVM's located largely within the ventricular trigone. The majority of these cases were treated quite recently, so the mean follow-up period is now 15 months. In evaluating each patient, referral records including notes from physicians, hospital summaries, and previous radiographic

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Narayan Sundaresan, Jatin Shah, Kathleen M. Foley, and Gerald Rosen

underwent resection of various lesions involving the T1–2 vertebral bodies. The surgical approach described below was used. The clinical features of these patients are summarized in Table 1 . Two patients had primary tumors of the spine; one was a primary osteogenic sarcoma, and the other a post-irradiation sarcoma in a patient who had received external radiation therapy 31 years previously for Hodgkin's disease. Four patients had metastatic cancer from various sites: in two the primary focus was in the breast, one tumor was a Ewing's sarcoma arising in the lower

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Taşkan Akdeniz, Tuncay Kaner, İbrahim Tutkan, and Ali Fahir Ozer

only the latter authors continued to explore the role of the herniated side. We present a series of 5 patients with lumbar disc herniations and contralateral symptoms. In all cases the surgical approach was on the side of the affected disc. To our knowledge, this study is the second reported series of patients surgically treated via only the side of the disc herniation. In a previous series, Sucu and Gelal 14 demonstrated that operations could be performed unilaterally via the side of the herniated disc, but their patients lacked any contralateral symptoms. To our

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Vijayabalan Balasingam, Gregory J. Anderson, Neil D. Gross, Cheng-Mao Cheng, Akio Noguchi, Aclan Dogan, Sean O. McMenomey, Johnny B. Delashaw Jr., and Peter E. Andersen

in calculations for the periclival area, superior exposure, and midline exposure for any of the approaches.) Dissections In each cadaveric head, the four surgical approaches—STO, TOPS, LFO, and MLM—were serially performed and analyzed. Established surgical techniques, an operating microscope, and standard microneurosurgical instruments were used for each surgical approach, and care was taken to avoid anatomical interference between approaches. The salient features of each approach are depicted in Fig. 2 . F ig . 2 Intraoperative photographs showing

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Fredric B. Meyer, Thoralf M. Sundt Jr., and Bruce W. Pearson

follow-up period was 3.5 years (range 1 to 7.5 years). Surgical Technique The current surgical approach used by the neurovascular service emphasizes six fundamental concepts. 1) The preservation of CBF during and after the operation is critical. Therefore, all patients are monitored with intraoperative electroencephalography. 51 Furthermore, patients with large tumors in whom temporary carotid artery occlusion may be required have baseline preocclusion and occlusion xenon-133 ( 133 Xe) CBF studies. 2) Distal exposure of large tumors is obtained by mobilization

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It is not our impression that tumor size should dictate a change in the surgical approach to acoustic neuromas. Rapid reduction in tumor size can be achieved by debulking the lesion with cavitron ultrasonic aspiration. The retraction of cerebellum is minimal when using the suboccipital approach and less harmful than temporal lobe retraction. The high incidence of aphasia reported in the present series underlines the risks of temporal lobe retraction, particularly on the left side. We thank the authors for this careful study, but one must conclude that, because of

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Scott D. Wait, Adib A. Abla, Brendan D. Killory, Peter Nakaji, and Harold L. Rekate

prospective fashion, and portions have been reported in several publications. 1–3 , 5–10 , 15 , 17–21 , 23 , 25 In especially instructive or unusual cases, pre- and postoperative imaging studies, surgical videos, intraoperative photographs, and other appropriate data are also cataloged. We reviewed selective cases treated at different times to evaluate our methods, to share surgical pearls and surgical pitfalls, and to obtain an understanding of how our surgical approaches have evolved over time. Operative Techniques We have used 3 approaches to address HHs