Showing papers by "Juan C. Fernandez-Miranda published in 2023"
TL;DR: The pterygosphenoidal triangle is delineated by the pterygonoidal fissure medially and the vidian nerve laterally as discussed by the authors , which leads to the anterior wall of the foramen lacerum and internal carotid artery.
Abstract: BACKGROUND: Safe exposure of the lacerum segment of the carotid artery remains a challenge in endoscopic endonasal surgery. OBJECTIVE: To introduce the pterygosphenoidal triangle as a novel and reliable landmark for facilitating access to the foramen lacerum. METHODS: Fifteen colored silicone–injected anatomic specimens were dissected using an endoscopic endonasal approach to the foramen lacerum region in a stepwise manner. Twelve dried skulls were studied and 30 high-resolution computed tomography scans were analyzed to measure the borders and angles of the pterygosphenoidal triangle. Surgical cases incorporating the foramen lacerum exposure between July 2018 and December 2021 were reviewed to provide surgical outcomes of the proposed surgical technique. RESULTS: The pterygosphenoidal triangle is delineated by the pterygosphenoidal fissure medially and the vidian nerve laterally. The palatovaginal artery is located at the base of the triangle anteriorly, while the apex is formed by the pterygoid tubercle posteriorly, which leads to the anterior wall of the foramen lacerum and lacerum internal carotid artery. In the reviewed surgical cases, 39 patients underwent 46 foramen lacerum approaches for resection of pituitary adenoma (12 patients), meningioma (6 patients), chondrosarcoma (5 patients), chordoma (5 patients), or other lesions (11 patients). There were no carotid injuries or ischemic events. Near-total resection was achieved in 33 (85%) of 39 patients (gross-total in 20 [51%]). CONCLUSION: This study details the pterygosphenoidal triangle as a novel and practical anatomic surgical landmark for safe and effective exposure of the foramen lacerum in endoscopic endonasal surgery.
1 citations
TL;DR: In this article , a 2D ResNet50V2 convolutional neural network was used as the base architecture for model development, and the average area under (AU) ROC was 78.6% compared to Knosp AU ROC %64.7.
Abstract: INTRODUCTION: Cavernous sinus invasion (CSI) of pituitary adenoma can lead to incomplete resection, failure of endocrinological remission, and a higher tumor recurrence rate. Therefore, precise approaches toward CSI may help guide treatment strategies and patient counseling. METHODS: 135 patients (median age = 50.14±15.56; 1.05:1 male to female ratio) with pathologically confirmed pituitary adenoma were retrospectively identified. High-resolution, coronal T1-contrast enhanced pituitary MR images were used. The study cohort was separated into training (n=101) and testing (n = 34) sets. Bounding box applied over the pituitary gland-cavernous sinus complex served to generate input image data. A 2D ResNet50V2 convolutional neural network was used as the base architecture for model development. Intraoperative inspection of the cavernous sinus and histopathologic analysis of the cavernous sinus medial wall served as ground truths for CSI. RESULTS: 'The receiving operating characteristic (ROC) and precision-recall (PR) curves were used to assess model performance. The model's average area under (AU) ROC was 78.6% compared to Knosp AU ROC %64.7. The model AU PR curve was 82.7% compared to Knosp AU PR curve of 76.7%. The sensitivity and F1 score of the model were 71% and 0.73, respectively, compared to Knosp sensitivity and F1 scores of %35 and 0.50. CONCLUSIONS: Inherent challenges exist regarding the pre-operative evaluation of CSI of pituitary adenoma on MRI by human visual inspection alone. Our study demonstrates the potential for MRI-based machine learning analysis of CSI of pituitary adenomas. A future multi-site study that explores model generalizability could further examine the utility of AI integration in the clinical workflow.
01 Jul 2023
TL;DR: In this paper , the authors present high-quality videos addressing pituitary exploration, cavernous sinus exploration with medial wall removal, and methods of subtotal gland re-section, correlating the novel imaging technique of intraoperative ultrasound with a prior MRI-negative case.
Abstract: agnetic resonance imaging (MRI)–negative Cushing disease is one of the most difficult and challenging surgical cases in both pituitary and skull base surgery. Experience is gained by a sequence of success and, unfortunately, failure, which results in a hard-fought experience with these cases. There are a variety of established and novel techniques that would benefit from high-quality video documentation, which could help established surgeons and novices alike improve patient care for this difficult population. In this Neurosurgical Focus: Video edition, we present high-quality videos addressing pituitary exploration, cavernous sinus exploration with medial wall removal, and methods of subtotal gland re-section. In addition, a video correlating the novel imaging technique of intraoperative ultrasound with a prior MRI-negative case is presented. Finally, a very interesting series of cases demonstrating suprasellar/infundibular disease is presented. We believe this collection of videos will be a valuable resource for the neurosurgery and endocrine community in these most difficult cases, MRI-negative Cushing disease.
01 Feb 2023
TL;DR: In this article , two cases of patients with Cushing's disease persisting after previous transsphenoidal surgeries due to residual tumor within the medial wall of the cavernous sinus are presented.
Abstract: Two cases of patients with Cushing's disease persisting after previous transsphenoidal surgeries due to residual tumor within the medial wall of the cavernous sinus are presented. Systematic exposure and exploration of the cavernous sinus enabled complete resection of residual tumors embedded in the medial wall and ligaments, leading to remission of Cushing's disease. Together, these cases illustrate methodical stepwise technique to safely and accurately resect tumors invading the medial wall of the cavernous sinus.
01 Feb 2023
TL;DR: In this article , a comprehensive analysis that combines anatomical, radiological, and surgical considerations of foramen ovale puncture is presented, where the authors present a comprehensive diagnosis of trigeminal rhizotomy.
Abstract: Objective: Percutaneous trigeminal rhizotomy (PTR), including balloon compression, radiofrequency thermoregulation, and glycerol injection, is a widely used procedure for trigeminal neuralgia. However, aberrant anatomy and neurovascular complications still pose significant challenges to neurosurgeons. Injury to the extracranial internal carotid artery or intracranial structures related to cannulation of the foramen ovale can be fatal. Herein, we present a comprehensive analysis that combines anatomical, radiological, and surgical considerations of foramen ovale puncture.
TL;DR: In this paper , a 40-year-old woman presented with homonymous hemianopsia due to a left posterior clinoid meningioma compressing the left optic tract.
Abstract: A 40-year-old woman presented with homonymous hemianopsia due to a left posterior clinoid meningioma compressing the left optic tract. The patient underwent a middle fossa transcavernous approach including extradural anterior clinoidectomy, intradural posterior clinoidectomy, and transection of petroclinoidal ligament to mobilize the oculomotor nerve. Gross total resection was obtained with improvement in visual fields. This case demonstrates methodical stepwise technique for a combined extradural intradural approach to resect tumors in the posterior clinoid region.
TL;DR: In this article , the pterygosphenoidal triangle is proposed to facilitate access in endoscopic endonasal translacerum approach, which is a key landmark in endoscopy.
Abstract: Objective: The foramen lacerum is a key landmark in endoscopic endonasal approaches. Several skull base lesions may involve the foramen lacerum region, most typically chondrosarcomas, but also pathologies affecting the cavernous sinus, Meckel's cave, petrous apex, clivus, nasopharynx, eustachian tube, and jugular foramen. Safe exposure of the lacerum segment of the carotid artery remains a challenge in endoscopic endonasal surgery. In our previous study, the surgical anatomy of the foramen lacerum was investigated; here we continue to propose a novel and reliable landmark, the pterygosphenoidal triangle, to facilitate access in endoscopic endonasal translacerum approach.
01 Feb 2023
TL;DR: In this article , a 42-year-old man presented with severe left visual loss and right temporal field cut and showed a tuberculum sella meningioma with anterior cerebral artery encasement.
Abstract: A 42-year-old man presented with severe left visual loss and right temporal field cut. Imaging showed a tuberculum sella meningioma with anterior cerebral artery encasement. The patient underwent an endoscopic endonasal approach with accurate tumor dissection from both optic canals and left A1 segment. Gross total resection was obtained with improvement of right visual acuity. This case illustrates technical nuances to deal with severe optic canal invasion and vascular encasement in endonasal endoscopic surgery.
TL;DR: In this paper , the topographical anatomy of the nerve to the zygomaticus major muscle was examined and a median of four (ranges 2-4) branches innervated the muscle.
Abstract: Smile reconstruction using the branches that supply the zygomaticus major muscle as a motor source is an established procedure in facial reanimation surgery for facial paralysis. However, the anatomy of the nerve to the muscle remains unclear. Therefore, we herein examined the topographical anatomy of the nerve to the zygomaticus major muscle to obtain more detailed information on donor nerve anatomy. Preserved cadaver dissection was performed under a microscope on 13 hemifaces of 8 specimens. The branches that innervate the zygomaticus major muscle and their peripheral routes medial to the muscle were traced and examined. A median of four (ranges 2-4) branches innervated the zygomaticus major muscle. The proximal two branches (near the muscle origin) arose from the zygomatic branch, the second of which was the major branch. The distal branches (near the oral commissure) arose from the buccal branch or zygomaticobuccal plexus. The vertical distance from the caudal margin of the zygomatic arch to the major branch intersecting point was 19 ± 4.0 mm, while the horizontal distance parallel to the Frankfort plane was 29 ± 5.2 mm. The proximal two branches innervating the zygomaticus major muscle were detected in the majority of specimens. The anatomical findings obtained herein on the nerve to the zygomaticus major muscle will allow for more reliable donor selection in facial reanimation surgery.
TL;DR: A retrospective chart review of 2 tertiary academic medical centers over 3.5 years was conducted as discussed by the authors to identify factors associated with successful use of free tissue grafting versus vascularized reconstruction after resection of pituitary tumors.
01 Feb 2023
TL;DR: In this article , a multi-institutional study was conducted to delineate the prognosis of recurrence and explore how recurrence subsites associate with overall survival, disease-specific survival, and additional recurrence.
Abstract: Background: With modern treatment paradigms, olfactory neuroblastoma (ONB) has a favorable overall survival (OS); however, the incidence of recurrence remains high. The primary aims of this multi-institutional study were to delineate the prognosis of recurrence and explore how recurrence subsites associate with OS, disease-specific survival (DSS), and additional recurrence.
TL;DR: In this article , the authors used histopathological examination of the cavernous sinus medial wall and intra-operative exploration of the sinus compartments to detect the presence of neuroendocrine-active tumors.
Abstract: INTRODUCTION: Pituitary neuroendocrine tumors (PitNET) continue to offer unique challenges given their proximity to the cavernous sinus, whereby invasive behavior can dictate extent of resection and surgical outcome, especially in neuroendocrine-active tumors. Recent advances in surgical techniques have resulted in the development of transcavernous endonasal surgery for invasive tumors. METHODS: 169 consecutive primary PitNET were analyzed, of which 45% were neuroendocrine-active. There were 64 PIT-1, 62 SF-1, 38 TPIT, and 5 none-staining PitNets. The gold standard for cavernous sinus invasion was based on histopathological examination of the cavernous sinus medial wall and intraoperative exploration of cavernous sinus compartments. RESULTS: Cavernous sinus disease was present in 33% of patients. PIT-1 tumors had a significantly higher predilection for cavernous sinus invasion, 53% versus 24% and 18% for TPIT and SF-1 tumors, respectively (OR 6.13, 95% CI 1.08-2.58; p<0.001). For Knosp 0-2 tumors, 44% of PIT-1 tumors had cavernous sinus invasion compared to 7% and 13% for TPIT and SF-1 tumors, respectively (p < 0.01). Utilizing the transcavernous approach, surgical biochemical remission rates for patients with acromegaly, hyperprolactinemia, and Cushing’s disease were 88%, 87%, and 94%, respectively. Granulation pattern of PIT-1 tumors, corticotroph functional status, and Crooke’s cell corticotroph morphology did not influence cavernous sinus invasion. CONCLUSIONS: Likelihood of cavernous sinus invasion differed by transcription factor expression; PIT-1 expressing somatotroph and lactotroph tumors had a higher predilection for invading the cavernous sinus compared to other tumor subtypes. This elucidates a unique cavernoinvasive behavior absent in cells from other lineages. Innovative surgical techniques, however, can mitigate tumor behavior and achieve robust, reproducible biochemical remission and gross total resection rates. These findings can have considerable implications on the surgical management and study of PitNET biology and behavior.
TL;DR: In this article , a 26-year-old man was found comatose due to a giant calcified craniopharyngioma extending into the third ventricle and leading to obstructive hydrocephalus.
Abstract: A 26-year-old man was found comatose due to a giant calcified craniopharyngioma extending into the third ventricle and leading to obstructive hydrocephalus. Endoscopic endonasal approach was performed with precise resection of tumor from hypothalamus by meticulously dissecting along the pial interface between tumor and brain. Gross total resection was obtained with neurological recovery. This case illustrates the subpial hypothalamic dissection technique necessary to preserve hypothalamus and prevent injury when resecting adherent craniopharyngiomas in this region.
01 Feb 2023
TL;DR: In this paper , the efficacy and safety of the transcavernous approach in patients who had previously undergone pituitary surgery with subsequent recurrent and/or residual disease were examined in a clinical trial.
Abstract: Objective: Endoscopic endonasal transcavernous surgery has evolved out of necessity to address cavernous sinus disease, increasing the extent of resection and rates of biochemical remission for functional pituitary tumors. The purpose of this study is to examine the efficacy and safety of the transcavernous approach in patients who had previously undergone pituitary surgery with subsequent recurrent and/or residual disease.
01 Feb 2023
TL;DR: In this article , a 63-year-old man presented with severe left visual loss secondary to large tuberculum sella meningioma extending into clinoidal region and planum sphenoidale.
Abstract: A 63-year-old man presented with severe left visual loss secondary to large tuberculum sella meningioma extending into clinoidal region and planum sphenoidale. Given the tumor complexity, a two-stage procedure was planned: left fronto-orbital approach with extradural anterior clinoidectomy, followed 3 days after endoscopic endonasal approach. This video illustrates the advantages and limitations of transcranial and endonasal approaches for complex tuberculum sella meningiomas, and the potential benefit of combining approaches to improve surgical outcomes.
TL;DR: In this article , a series of three cases of awake craniotomies for glioma resections was used to demonstrate a technique that allows the first and most direct evidence of fiber tract stimulation and assignment of function or deficit in vivo through the intraoperative, real-time fusion of electrical cortical stimulation, augmented reality, and fiber tractography.
01 Jul 2023
TL;DR: In this article , the authors present two cases of Cushing's disease that underscore the power of this surgical technique in achieving remission in microadenomas that ectopically present in the cavernous sinus or have invaded the medial wall of the sinus.
Abstract: Emerging evidence from multiple highly specialized groups continues to support a role for resection of the medial wall of the cavernous sinus when it is invaded by functional pituitary adenomas, to offer durable biochemical remission. The authors present two cases of Cushing’s disease that underscore the power of this surgical technique in achieving remission in microadenomas that ectopically present in the cavernous sinus or have invaded the medial wall of the sinus. This video demonstrates key steps in the safe removal of the medial wall of the cavernous sinus and successful resection of tumor burden in the cavernous sinus for sustained postoperative remission. The video can be found here: https://stream.cadmore.media/r10.3171/2023.4.FOCVID2323
01 Feb 2023
TL;DR: The authors divided the cavernous sinus into four partitions, the inferior, superior, posterior, and lateral compartments, and the lateral compartment is considered the most difficult and least forgiving due to its intimate relationship with the inferolateral trunk, tentorial artery, dorsal meningeal artery, as well as cranial nerves III-VI.
Abstract: Background: Recent anatomical advances have divided the cavernous sinus into four partitions, the inferior, superior, posterior, and lateral compartments. The lateral compartment is considered the most difficult and least forgiving due to its intimate relationship with the inferolateral trunk, tentorial artery, dorsal meningeal artery, as well as cranial nerves III–VI.
01 Feb 2023
TL;DR: In this article , a 74-year-old male presented with a history of odontoid fracture and progressive myelopathy from compression of the cervicomedullary junction.
Abstract: A 74-year-old male presented with a history of odontoid fracture and progressive myelopathy from compression of the cervicomedullary junction. Through an endonasal approach, resection of the fractured odontoid achieved successful decompression. We demonstrate how to obtain a wide posterior corridor while preserving potential reconstructive flap pedicles via “reverse-rescue flaps,” designing the nasopharyngeal incisions to allow for excellent access and reconstruction, and technical pointers in the dissection and resection of C1/C2 anatomy.
TL;DR: In this paper , a simple technique for obtaining right and left 2D endoscopic images with manual angulation of the optic was described, and the results of taking a photograph with an endoscope and its assembly to a 3D image has been divided into two parts: photo acquisition and image processing.
Abstract: Background: Most neurosurgical photographs are limited to two-dimensional (2D), in this sense, most teaching and learning of neuroanatomical structures occur without an appreciation of depth. The objective of this article is to describe a simple technique for obtaining right and left 2D endoscopic images with manual angulation of the optic. Methods: The implementation of a three-dimensional (3D) endoscopic image technique is reported. We first describe the background and core principles related to the methods employed. Photographs are taken demonstrating the principles and also during an endoscopic endonasal approach, illustrating the technique. Later, we divide our process into two sections containing explanations, illustrations, and descriptions. Results: The results of taking a photograph with an endoscope and its assembly to a 3D image has been divided into two parts: Photo acquisition and image processing. Conclusion: We conclude that the proposed method is successful in producing 3D endoscopic images.
TL;DR: In this article , the endonasal transtuberculum approach was used to access the suprasellar and retrochiasmatic lesions with hypothalamic involvement.
Abstract: INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE
The endoscopic endonasal transtuberculum approach grants access to suprasellar and retrochiasmatic lesions with hypothalamic involvement. Here, we present a case of a 13-year-old boy with a history of stunted growth, decreased vision, headaches, and low energy with a tuberoinfundibular craniopharyngioma. The patient consented to the procedure.
ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT
Evaluation of the sphenoid sinus pneumatization, internal carotid artery disposition, presence of clinoidal rings, variations of the infrachiasmatic corridor (optic chiasm location, height of dorsum sella), and location of the pituitary stalk are crucial for surgical strategy.
ESSENTIALS STEPS OF THE PROCEDURE
Harvesting of nasoseptal flap and access to the sphenoid sinus; drilling the sella, tuberculum, and chiasmatic sulcus up to the limbus sphenoidalis and laterally exposing the clinoidal carotid artery segment; wide dural opening to the level of distal rings inferolaterally and falciform ligaments superolaterally; identification and coagulation of superior hypophyseal branches providing tumor supply; intracapsular dissection and debulking and subpial sharp dissection at the hypothalamic tumor interface to achieve complete removal; and reconstruction with inlay collagen, fascia lata, and nasoseptal flap.
PITFALLS/AVOIDANCE OF COMPLICATIONS
Preservation of the superior hypophyseal arteries and stalk is essential for preventing pituitary dysfunction. Preoperative reckoning of hypothalamic invasion and identification of adequate interface aids in avoiding complications. To reduce CSF leak risk, multilayer reconstruction was performed and lumbar drain placed postoperatively.
VARIANTS AND INDICATIONS FOR THEIR USE
For retroclival extension, intradural pituitary transposition should be considered to expand the corridor; in patients with preoperative hypopituitarism, pituitary sacrifice is most effective to increase retroclival access.
TL;DR: The ventral part of the petroclival fissure is composed by the sphenoid, temporal and occipital bones and it is intimately related to the ICA as discussed by the authors .
Abstract: Objective: The endoscopic endonasal approach (EEA) has emerged as an excellent option for the treatment of lesions involving the petroclival fissure, typically chordomas and chondrosarcomas. The ventral part of the petroclival fissure is composed by the sphenoid, temporal and occipital bones and it is intimately related the ICA. Here we investigated the surgical anatomy of ventral PCF and its surgical application in endoscopic endonasal surgery.
TL;DR: In this paper , a simplified and more comprehensive classification system was developed to predict surgical outcomes of other primary benign orbital tumors (PBOTs) in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs).
Abstract: INTRODUCTION
The CHEER staging system has become the gold standard for outcomes reporting in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs). A recent systematic review demonstrated similar outcomes between OCHs and other primary benign orbital tumors (PBOTs). Therefore, we hypothesized that a simplified and more comprehensive classification system could be developed to predict surgical outcomes of other PBOTs.
METHODS
Patient and tumor characteristics as well as surgical outcomes from 11 international centers were recorded. All tumors were retrospectively assigned an Orbital Resection by Intranasal Technique (ORBIT) class and stratified based on surgical approach as either exclusively endoscopic or combined (endoscopic and open). Outcomes based on approach were compared using chi-squared or Fisher's exact tests. The Cochrane-Armitage test for trend was used to analyze outcomes by class.
RESULTS
Findings from 110 PBOTs from 110 patients (age 49.0 ± 15.0 years, 51.9% female) were included in the analysis. Higher ORBIT class was associated with a lower likelihood of gross total resection (GTR). GTR was more likely to be achieved when an exclusively endoscopic approach was utilized (p<0.05). Tumors resected using a combined approach tended to be larger, to present with diplopia, and to have an immediate post-operative cranial nerve palsy (p<0.05).
CONCLUSION
Endoscopic treatment of PBOTs is an effective approach, with favorable short- and long-term post-operative outcomes as well as low rate of adverse events. The ORBIT classification system is an anatomic-based framework that effectively facilitates high-quality outcomes reporting for all PBOTs. This article is protected by copyright. All rights reserved.
TL;DR: In this article , the authors propose a new paradigm in the surgical anatomy laboratory regarding the latest photography equipment and skills, which is essential for improving the quality of anatomic research and education.
Abstract: Objective: Two (2D) and three-dimensional (3D) photography is the most critical cornerstone in neurosurgical teaching, broadcasting, and research. Staying updated on emerging digital technologies is essential for improving the quality of anatomic research and education. Therefore, in the current study, the authors propose a new paradigm in the surgical anatomy laboratory regarding the latest photography equipment and skills.
TL;DR: Vigo, Vera MD; Asmaro, Karam P. MD; Nunez, Maximiliano A. MD, PhD; Desai, Atman MD; Fernandez-Miranda, Juan C. MD Author Information as discussed by the authors
Abstract: Vigo, Vera MD; Asmaro, Karam P. MD; Nunez, Maximiliano A. MD; Bobrow, Aidan BS; Dodd, Robert L. MD, PhD; Desai, Atman MD; Fernandez-Miranda, Juan C. MD Author Information
01 Feb 2023
TL;DR: In this paper , the authors investigated the dorsal perspective of petroclival fissure and its implication in selecting transcranial approaches for skull base neurosurgery, including anterior transpetrosal (Kawase), presigmoidal, far lateral and combined approaches.
Abstract: Objective: Tumors involving the petroclival fissure (PCF) are generally regarded as one of the most formidable challenges for skull base neurosurgeons where surgical corridors are primarily hindered by critical nerves and arteries. Endonasal approaches have emerged as key alternatives but transcranial approaches remain relevant for selected cases. Transcranial skull base approaches to the PCF include anterior transpetrosal (Kawase), presigmoidal, far lateral and combined approaches. Here, we investigated dorsal perspective of petroclival fissure and its implication in selecting transcranial approaches
TL;DR: In this article , six silicon-injected postmortem heads underwent trigeminal rhizotomy (PTR) and the surgical corridors were dissected, and the neurovascular relationships were studied.
Abstract: BACKGROUND: Percutaneous trigeminal rhizotomy (PTR) is a widely used procedure for trigeminal neuralgia. However, comprehensive analyses that combine anatomic, radiological, and surgical considerations are rare. OBJECTIVE: To present high-quality anatomic dissections and radiological studies that highlight the technical nuances of this procedure. METHODS: Six silicon-injected postmortem heads underwent PTR. The surgical corridors were dissected, and the neurovascular relationships were studied. In addition, 20 dried human skulls and 50 computed tomography angiography and MRI scans were collected to study the anatomic relationships for a customized puncture corridor. RESULTS: The PTR corridor was divided into 3 segments: the buccal segment (length, 34.76 ± 7.20 mm), the inferior temporal fossa segment (length, 42.06 ± 6.92 mm), and the Meckel cave segment (length, 24.75 ± 3.34 mm). The puncture sagittal (α) and axial (β) angles measured in this study were 38.32° ± 4.62° and 19.13° ± 2.82°, respectively. The precondylar reference line coincided with the foramen ovale in 75% of the computed tomography angiography scans, and the postcondylar line coincided with the carotid canal in 70% of the computed tomography angiography scans; these lines serve as the intraoperative landmarks for PTR. The ovale-carotid-pterygoid triangle, delineated by drawing a line from the foramen ovale to the carotid canal and the lateral pterygoid plate, is a distinguished landmark to use for avoiding neurovascular injury during fluoroscopy. CONCLUSION: Knowledge of the anatomic and radiological features of PTR is essential for a successful surgery, and a customized technical flow is a safe and effective way to access the foramen ovale.
TL;DR: In this article , the transcaruncular approach is proposed as a powerful working corridor that provides access through the medial orbit to the frontal sinus with excellent postoperative cosmesis.
Abstract: Introduction: Frontal sinus meningoceles and encephaloceles encompass a rare spectrum of pathologies that pose a significant surgical challenge. To manage them, traditional open approaches such as osteoplastic flaps and frontal sinus cranialization through trephination have given way to less invasive, incisionless endoscopic techniques. As surgeons become increasingly facile operating in this area, advancements in instrumentation continue to further support this paradigm shift in management. Despite this, the variable pattern of pneumatization and anatomy of the frontal sinus makes instrumenting and reconstructing all of its various zones in a purely endoscopic manner challenging, nonetheless. To overcome this, surgeons augment endoscopic techniques with minor external incisions that provide critical access to challenging treatment zones of the frontal sinus. Recent anatomical feasibility studies have proposed the transcaruncular approach as a powerful working corridor that provides access through the medial orbit to the frontal sinus with excellent postoperative cosmesis.
TL;DR: In this article , an endoscopic supraorbital keyhole approach for small to medium-sized tuberculum sellae meningiomas (TSMs) was performed and performed radical tumor removal similar to conventional transcranial procedure.
TL;DR: In this paper , the effect of cervical sagittal balance on the direction and type of atlantoaxial dislocation was analyzed for 55 patients seen at a hospital for atlataxial instability/dislocation caused by os odontoideum.