Update: Journals of Neurosurgical Interest ordered by Impact factor:

Journals of Neurosurgical Interest ordered by Impact factor:

Neuro-Oncology Impact Factor: 7.371

Journal of Neurology, Neurosurgery and Psychiatry Impact factor: 6.807

Stroke Impact factor 6.008

Pain Impact Factor: 5.557

Fluids and Barriers of the CNS Impact factor 5.30

Journal of Cerebral Blood Flow and Metabolism Impact factor 4.929

Journal of Neurotrauma Impact Factor: 4.377

Neurosurgery Impact Factor: 3.780

Journal of Neurosurgery: 3.443

Journal of Neurosurgical Anesthesiology Impact Factor: 2.828

The Clinical Journal of Pain Impact Factor: 2.703

World Neurosurgery Impact Factor: 2.685

The Spine Journal Impact Factor: 2.660

Progress in neurological surgery Impact factor: 2.56

Neurosurgical Focus Impact Factor: 2.546

Neurosurgery clinics of North America Impact factor: 2.45

Spine Impact Factor: 2.439

Journal of the Peripheral Nervous System Impact Factor: 2.258

European Spine Journal Impact Factor: 2.132

Journal of Neurosurgery Spine Impact Factor: 2.126

Neurosurgical Review Impact Factor: 2.166.

Brain Injury Impact Factor: 1.822

Journal of Neurosurgery Pediatrics Impact Factor: 1.757

Central European Neurosurgery Impact Factor: 1.73

Stereotactic and Functional Neurosurgery Impact Factor: 1.691

Journal of Neurosurgical Sciences Impact Factor 1,651

Acta Neurochirurgica Impact Factor: 1.617

Minimally Invasive Neurosurgery Impact factor: 1.55

Spinal Cord Impact Factor 1.546

Journal of Korean Neurosurgical Society Impact factor: 1.54

Surgical Neurology International Impact factor: 1.41

Clinical Neurology and Neurosurgery Impact Factor: 1.198

Cerebrospinal Fluid Research Impact Factor: 1.12

Child’s Nervous System Impact Factor: 1.080

Journal of Neurological Surgery Impact Factor: 1.079

British Journal of Neurosurgery Impact Factor: 1.063

Brazilian Neurosurgery 0.933

Polish Journal of Neurology and Neurosurgery Impact Factor: 0.747

Journal of Neurological Surgery Reports Impact Factor: 0.723

Pediatric Neurosurgery Impact factor: 0.61

Neurochirurgie Impact Factor: 0.644

Turkish Neurosurgery Impact Factor: 0.508

Global Spine Journal Impact factor: 0.39

Neurocirugia Impact Factor: 0.410

Chinese Journal of Contemporary Neurology and Neurosurgery Impact factor: 0.15

Journal of Spine & Neurosurgery Impact Factor 0.12

Neurosurgery Quarterly Impact Factor: 0.089.

Virtual reality in neurosurgery

Virtual reality (VR), sometimes referred to as immersive multimedia, is a computer-simulated environment that can simulate physical presence in places in the real world or imagined worlds. Virtual reality can recreate sensory experiences, including virtual taste, sight, smell, sound, touch, etc.

Chan et al., highlights a selection of recent developments in research areas related to virtual reality simulation, including anatomic modeling, computer graphics and visualization, haptics, and physics simulation, and discusses their implication for the simulation of neurosurgery 1).


Medicine and surgery are turning towards simulation to improve on limited patient interaction during residency training. Many simulators today utilize virtual reality with augmented haptic feedback with little to no physical elements.

To optimize the learning exercise, it is essential that both visual and haptic simulators are presented to best present a real-world experience. Many systems attempt to achieve this goal through a total virtual interface.

Bova et al., approach has been to create a mixed-reality system consisting of a physical and a virtual component. A physical model of the head or spine is created with a 3-dimensional printer using deidentified patient data. The model is linked to a virtual radiographic system or an image guidance platform. A variety of surgical challenges can be presented in which the trainee must use the same anatomic and radiographic references required during actual surgical procedures.

Using the aforementioned techniques, they have created a ventriculostomy simulators, percutaneous radiofrequency trigeminal rhizotomy, and spinal instrumentation.

The system has provided the residents an opportunity to understand and appreciate the complex 3-dimensional anatomy of the 3 neurosurgical procedures simulated. The systems have also provided an opportunity to break procedures down into critical segments, allowing the user to concentrate on specific areas of deficiency 2).


Shakur et al., developed a real-time augmented reality simulator for percutaneous trigeminal rhizotomy using the ImmersiveTouch platform. Ninety-two neurosurgery residents tested the simulator at American Association of Neurological Surgeons Top Gun 2014. Postgraduate year (PGY), number of fluoroscopy shots, the distance from the ideal entry point, and the distance from the ideal target were recorded by the system during each simulation session. Final performance score was calculated considering the number of fluoroscopy shots and distances from entry and target points (a lower score is better). The impact of PGY level on residents’ performance was analyzed.

Seventy-one residents provided their PGY-level and simulator performance data; 38% were senior residents and 62% were junior residents. The mean distance from the entry point (9.4 mm vs 12.6 mm, P = .01), the distance from the target (12.0 mm vs 15.2 mm, P = .16), and final score (31.1 vs 37.7, P = .02) were lower in senior than in junior residents. The mean number of fluoroscopy shots (9.8 vs 10.0, P = .88) was similar in these 2 groups. Linear regression analysis showed that increasing PGY level is significantly associated with a decreased distance from the ideal entry point (P = .001), a shorter distance from target (P = .05), a better final score (P = .007), but not number of fluoroscopy shots (P = .52).

Because technical performance of percutaneous rhizotomy increases with training, they proposed that the skills in performing the procedure in there virtual reality model would also increase with PGY level, if this simulator models the actual procedure. The results confirm this hypothesis and demonstrate construct validity 3).


Alaraj et al., developed a real-time sensory haptic feedback virtual reality aneurysm clipping simulator using the ImmersiveTouch platform. A prototype middle cerebral artery aneurysm simulation was created from a computed tomographic angiogram. Aneurysm and vessel volume deformation and haptic feedback are provided in a 3-dimensional immersive virtual reality environment. Intraoperative aneurysm rupture was also simulated. Seventeen neurosurgery residents from 3 residency programs tested the simulator and provided feedback on its usefulness and resemblance to real aneurysm clipping surgery.

Residents thought that the simulation would be useful in preparing for real-life surgery. About two-thirds of the residents thought that the 3-dimensional immersive anatomic details provided a close resemblance to real operative anatomy and accurate guidance for deciding surgical approaches. They thought the simulation was useful for preoperative surgical rehearsal and neurosurgical training. A third of the residents thought that the technology in its current form provided realistic haptic feedback for aneurysm surgery.

Neurosurgical residents thought that the novel immersive VR simulator is helpful in their training, especially because they do not get a chance to perform aneurysm clippings until late in their residency programs 4).


Lemole et al., use the ImmersiveTouch (ImmersiveTouch, Inc., Chicago, IL) virtual reality platform, developed at the University of Illinois at Chicago, to simulate the task of ventriculostomy catheter placement as a proof-of-concept. Computed tomographic data are used to create a virtual anatomic volume.

Haptic feedback offers simulated resistance and relaxation with passage of a virtual three-dimensional ventriculostomy catheter through the brain parenchyma into the ventricle. A dynamic three-dimensional graphical interface renders changing visual perspective as the user’s head moves. The simulation platform was found to have realistic visual, tactile, and handling characteristics, as assessed by neurosurgical faculty, residents, and medical students.

They developed a realistic, haptics-based virtual reality simulator for neurosurgical education. The first module recreates a critical component of the ventriculostomy placement task. This approach to task simulation can be assembled in a modular manner to reproduce entire neurosurgical procedures 5).


1) Chan S, Conti F, Salisbury K, Blevins NH. Virtual reality simulation in neurosurgery: technologies and evolution. Neurosurgery. 2013 Jan;72 Suppl 1:154-64. doi: 10.1227/NEU.0b013e3182750d26. PubMed PMID: 23254804.
2) Bova FJ, Rajon DA, Friedman WA, Murad GJ, Hoh DJ, Jacob RP, Lampotang S, Lizdas DE, Lombard G, Lister JR. Mixed-reality simulation for neurosurgical procedures. Neurosurgery. 2013 Oct;73 Suppl 1:138-45. doi: 10.1227/NEU.0000000000000113. PubMed PMID: 24051877.
3) Shakur SF, Luciano CJ, Kania P, Roitberg BZ, Banerjee PP, Slavin KV, Sorenson J, Charbel FT, Alaraj A. Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training. Neurosurgery. 2015 Sep;11 Suppl 3:420-5; discussion 425. doi: 10.1227/NEU.0000000000000853. PubMed PMID: 26103444.
4) Alaraj A, Luciano CJ, Bailey DP, Elsenousi A, Roitberg BZ, Bernardo A, Banerjee PP, Charbel FT. Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback. Neurosurgery. 2015 Mar;11 Suppl 2:52-8. doi: 10.1227/NEU.0000000000000583. PubMed PMID: 25599200; PubMed Central PMCID: PMC4340784.
5) Lemole GM Jr, Banerjee PP, Luciano C, Neckrysh S, Charbel FT. Virtual reality in neurosurgical education: part-task ventriculostomy simulation with dynamic visual and haptic feedback. Neurosurgery. 2007 Jul;61(1):142-8; discussion 148-9. Review. PubMed PMID: 17621029.

Curso de Entrenamiento sobre cirugía en paciente despierto

Curso de Entrenamiento sobre cirugía en paciente despierto

Costa Rica, Enero 2017

Estimados colegas,

Hemos recibido invitación del Dr. Gabriel Rodriguez de Costa Rica, sobre la visita del Profesor Dr. Huges Duffau, en el curso de entrenamiento sobre el manejo de paciente despierto durante cirugía cerebral.

Este evento se realizará en San Jose, Costa Rica, el día 20 de Enero de 2017.

Update: Cerebellopontine angle lipoma

Characteristically lipomas of the CPA have the facial nerve and vestibulocochlear nerve coursing through it on their way to the IAM. They are associated with intravestibular lipomas and sensorineural hearing loss.

Epidemiology

They account for ~10% of all intracranial lipomas.

Diagnosis

Radiographic features

MRI brain Signal characteristics are those of a lipoma

T1: high signal

images.radiopaedia.org_images_2107232_e3e8537790364cc8a2404efc00cdd4_gallery.jpg

https://images.radiopaedia.org/images/2107232/e3e8537790364cc8a2404efc00cdd4_gallery.jpg

T2: high signal

true FISP/FIESTA: low signal margin due to chemical shift artefact fat saturated sequences: shows signal dropout.

http://www.otosurgery.org/DJL_NEWSITE%20images/MRI_cpa-lipoma.gif

Differential diagnosis

Cerebellopontine angle tumors (CPA) are frequent; vestibular schwannomas and cerebellopontine angle meningiomas represent the great majority of such tumors. However, a large variety of unusual lesions can also be encountered in the CPA. The site of origin is the main factor in making a preoperative diagnosis for an unusual lesion of the CPA. In addition, it is essential to analyze attenuation at computed tomography (CT), signal intensity at magnetic resonance (MR) imaging, enhancement, shape and margins, extent, mass effect, and adjacent bone reaction. CPA masses can primarily arise from the cerebellopontine cistern and other CPA structures (arachnoid cyst, nonacoustic schwannoma, aneurysm, melanoma, miscellaneous meningeal lesions) or from embryologic remnants (epidermoid cyst, dermoid cyst, lipoma). Tumors can also invade the CPA by extension from the petrous bone or skull base (cholesterol granuloma, paraganglioma, chondromatous tumors, chordoma, endolymphatic sac tumor, pituitary adenoma, apex petrositis). Finally, CPA lesions can be secondary to an exophytic brainstem or ventricular tumor (glioma, choroid plexus papilloma, lymphoma, hemangioblastoma, ependymoma, medulloblastoma, dysembryoplastic neuroepithelial tumor). A close association between CT and MR imaging findings is very helpful in establishing the preoperative diagnosis for unusual lesions of the CPA 1).


The differential for lesions with high T1 signal includes:

haemorrhagic vestibular schwannoma

neurenteric cyst

thrombosed berry aneurysm

white epidermoid

ruptured intracranial dermoid

Treatment

They are not associated with malformations and can become symptomatic in a slowly progressive way by affecting the more susceptible of the cranial nerves in this region. As a result of the rare occurrence, the experience in treating and managing these tumors is limited. Consequently, the recommendations for treatment and for the role of surgery are very variable 2).

Free article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1656654/pdf/skullbasesurg00018-0039.pdf

Resections are considered in symptomatic patients who are refractory to targeted medical therapies, but at those stages the lipomas have often reached considerable sizes and encompass critical neurovascular structures.

Scoring system

The objective of a study is to develop and to evaluate the utility of a scoring system for CPA lipomas. The hypothesis is that CPA lipomas with lower scores are probably best managed with early surgery.

The PubMed database was searched using relevant terms. Data on patient and lipoma characteristics were extracted and used to design a scoring system. CPA lipomas were stratified by scores with corresponding managements and outcomes analyzed.

One hundred and seventeen patients with CPA lipomas were identified and 40 CPA lipomas were scored. The remaining CPA lipomas were deficient in data and not scored. No lipomas were scored as 1. Score 2 lipomas (n = 12; 30%) most often underwent serial surveillances (n = 5; 41.6%), with the majority of symptoms remaining unimproved (n = 2; 40%). Patients with score 2 CPA lipomas treated with medical therapies (n = 3; 25%) often experienced symptom resolution (n = 2; 66.6%) (p = 0.0499). Patients with score 2 CPA lipomas undergoing surgical resections (n = 3; 25%) all experienced symptom resolution (n = 3; 100%) (p = 0.0499). Score 3 was most common (n = 16; 40%) and these lipomas were often surgically resected (n = 10; 62.5%). The majority of patients with score 3 CPA lipomas having undergone surgical resections (n = 10; 62.5%) experienced symptom improvement (n = 1; 10%) or resolution (n = 4; 40%).

Score 2 CPA lipomas are smaller and would be deemed non-surgical in general practice. However, the data of Lagman et al., suggest that these lipomas may benefit from either medical therapies or early surgical resections. The advantages of early surgery are maximal resection, decreased surgical morbidity, and improved symptom relief 3).

Case series

2014

Of 15 patients with CPA lipomas, six were female and nine were male, with an average age at presentation of 50.2 years (range, 31.7-76.4 yr) and an average follow-up time of 51.7 months (range, 6-216 mo). The lipomas were unilateral in all cases, nine on the right (60%) and six on the left (40%) side. None of the lipomas increased in size. All patients were treated conservatively. Sensorineural hearing loss was the main presenting symptom (80%) followed by tinnitus (46.7%) and vertigo (20%). None of the patients suffered from facial nerve dysfunction. There was no correlation between weight gain and tumor growth.

CPA lipomas can be diagnosed accurately with appropriate magnetic resonance imaging techniques and be managed conservatively with safety. Cochleovestibular are the most common presenting symptoms, whereas facial nerve involvement is rare. CPA lipomas do not tend to grow and can be monitored on a less regular basis 4).

2013

Between 1996 and 2012, 15 patients were diagnosed with a CPA or IAC lipoma at the authors’ institution and were included in the analysis. The mean duration of radiological and clinical follow-up was 3.4 years and 5.1 years, respectively. Eight lesions were confined to the IAC, while seven involved the CPA. The median tumor size at diagnosis was 7.2 mm; one patient demonstrated tumor growth on serial MRI while the remaining subjects did not have radiological progression. The most common presenting symptoms were sensorineural hearing loss (40%) and tinnitus (33%); five patients were diagnosed after incidental discovery on MRI. Fourteen patients were managed with observation, while one subject underwent subtotal resection. None of the observed patients reported worsening symptoms at last follow-up.

While rare, lipomas should be included in the differential diagnosis of CPA and IAC lesions. Owing to a generally benign clinical course and high morbidity associated with resection, microsurgery should only be considered in cases of definite tumor enlargement with intractable symptoms from mass effect. Careful radiological evaluation is critical for establishing an accurate diagnosis in order to prevent unnecessary morbidity associated with resection 5).

2006

A healthy 42-year-old woman who presented with left-sided hearing loss and facial synkinesis. T1-weighted magnetic resonance imaging revealed an enhancing lesion of the left CPA with no signal on fat suppression sequences. Despite conservative therapy, the patient developed progressive hemifacial spasm, and a suboccipital craniotomy approach was used to debulk the tumor, which encased cranial nerves V, VII, VIII, IX, X, and XI. Surgical histopathology demonstrated mature adipocytes, consistent with lipoma. Two years after surgery, the patient remains free of facial nerve symptoms. Cerebellopontine angle lipomas are rare lesions of the skull base and are reliably diagnosed with T1-weighted and fat suppression magnetic resonance sequences, which we recommend in the routine radiologic workup of CPA tumors. Accurate preoperative diagnosis is crucial because most CPA lipomas should be managed conservatively. Partial surgical resection is indicated only to alleviate intractable cranial neuropathies or relieve brainstem compression 6).

2002

Tankéré et al., report four new cases of CPA lipomas diagnosed in the Department of Otorhinolaryngology-Head and Neck Surgery of Hôpital Pitié-Salpêtrière and review 94 cases reported previously in the literature.

Lipomas represented 0.14% of CPA and internal acoustic meatus tumors. Localization was on the left side in 59.9%, on the right side in 37%, and bilateral in 3.1% of the patients. The diagnosis was confirmed radiologically in 33 of 98 patients, surgically in 60 patients, and by autopsy in 5 patients. The most frequent associated symptoms were of cochleovestibular origin, such as hearing loss (62.2%), dizziness (43.3%), and unilateral tinnitus (42.2%). Other associated symptoms involved the facial nerve (9%) or the trigeminal nerve (14.4%). Complete resection was performed in only 32.8% of the patients with frequent cranial nerve involvement. Frequent cranial nerve involvement was seen in 95.4% of all patients. After surgery, patient symptomatology was unchanged in 9.2% of the patients, and 50% were improved; however, new postoperative deficits occurred in two-thirds of the patients. Overall, 72.2% of the patients experienced new postoperative deficits such as hearing loss (64.8%). Preservation of hearing was possible in only 26% of the patients. Only 18% of patients were improved after surgery without any new postoperative deficits.

Preoperative diagnosis of internal acoustic meatus/CPA lipomas is based on magnetic resonance imaging. The aim of surgery in these cases is not tumor removal but cranial nerve decompression or vestibular transection, and surgery is performed only in patients with disabling and uncontrolled symptoms 7).

1998

17 IAC/CPA lipomas, bringing the total number of documented cases to 84 in 1998. There appears to be a nearly 2:1 male to female predominance. Sixty percent were left-sided lesions, and three were bilateral. Hearing loss, dizziness, and tinnitus were the most common presenting symptoms. Surgical resection was performed in 52 (62%) of these lesions; however, total tumor removal was accomplished in only 17 (33%), which is most likely because of the fact that these tumors tend to have a poorly defined matrix and a dense adherence to neurovascular structures. Sixty-eight percent of patients experienced a new deficit postoperatively, 11% were unchanged, and only 19% improved with no new deficit. Only one documented case of tumor growth was identified; however, the reported follow-up was short (average, less than 3 years).

With the magnetic resonance imaging techniques now available, lipomas can be reliably differentiated from other masses within the CPA and IAC, so histopathologic diagnosis is rarely necessary. Because of the potential for significant morbidity with resection of these lesions, we believe that conservative follow-up is the best treatment option for patients with these rare lesions. Surgery is indicated only when significant progressive or disabling symptoms are present 8).

Case reports

2012

A 5-year-old boy was evaluated for recurrent primary generalized seizures of 20 days duration. He had preceding headache, vomiting for which he was subjected to a Magnetic resonance imaging (MRI) scan of the brain. Imaging studies revealed a hyperintense mass in the right CPA suggestive of lipoma/epidermoid. He was referred to us for further management.

Basic routine blood investigations were essentially normal. His vital parameters were stable. He was conscious, oriented, and obeying commands. Child was active and had no motor/sensory/cranial nerve deficits. Plantars were bilaterally flexor with normal deep tendon reflexes. MR imaging has now achieved a very high sensitivity and specificity for detecting lipomas. On T1-weighted MR images, lipomas typically appear hyperintense compared with brain tissue and hyperintense on T2-weighted MR images. MRI scan of the brain was done and the findings is given below.

Multiplanar, multisequences, MR imaging, including SE T1 axial, flair axial, FSE T2 axial were done. Postcontrast T1-weighted multiplanar sequences were also performed.

A 17mm (trans) ×15mm (AP) × 15mm (CC) well-encapsulated mass lesion noted in the right CP angle which was hyperintense on T1, T2, and FLAIR with inversion on fat suppression sequence. The lesion was situated inferior to the right Vth nerve and indenting upon right lower pons and medulla. The right VIIth and VIIIth nerves and superior cerebellar artery were encased by the lesion. No evidence of tumor extension into IAC was noted. There was neither significant shift nor hydrocephalus. Right cerebello pontine angle tumor–lipoma/epidermoid.

A right retro sigmoid suboccipital approach was chosen to expose the tumor. The lesion was extra-axial, yellowish and surrounding the seventh and eighth nerve complex. Branches of the AICA were embedded in the tumor. The lesion was partially decompressed. Neurovascular structures were preserved. There were no postoperative deficits.

Histopathological evaluation revealed it to be lipoma-right CP angle

These tumors can cause symptoms related to the VIII nerve involvement, such as hearing loss, tinnitus, and vertigo. However, trigeminal symptoms such as neuralgia, paresthesia or headache, can also occur with CPA lipomas extending to the trigeminal cisterns.

This patient presented with headache, and seizures. Neuroimaging revealed a hypodense mass in the right CPA suggestive of lipoma/epidermoid. He underwent surgical exploration and decompression of the tumor. Histopathology confirmed it as lipoma 9).

2009

A 13-year-old female patient was evaluated due to a 1-year history of headache and hearing loss. The physical examination was unremarkable. The audiometric evaluation demonstrated a discrete sensorineural hearing loss on the right side. The CT scan revealed a markedly hypodense non-enhancing mass in the right CPA. The MR imaging showed a lesion measuring 2.1 × 2.0 × 1.7 cm in the right CPA cistern. The mass was hyperintense on T1-weighted images and isointense with hypointense halo (chemical-shift) on T2-weighted images, with very low signal on T1-weighted images with fat suppression (Figs 1 and 2). The VII and VIII cranial nerves were seen as linear images with low signal inside the CPA mass. The diagnosis of CPA lipoma was suggested and the surgical treatment was chosen once the patient was young and the chance of lesion growing and future complications was considerable. A craniotomy with posterior fossa approach was performed, the lesion was partially removed, and the histological examination confirmed the diagnosis of lipoma. Six months after the surgery the patient remains asymptomatic. The parent signed the informed consent agreeing with the study.

Case 2

A 35-year-old woman presented with a six-month history of vertigo, without significant abnormalities on physical examination. A CT scan revealed a left-sided hypodense non-enhancing CPA mass. The MR imaging showed a left CPA cistern hyperintense lesion on T1-wheighted images and isointense with hypointense halo (chemical-shift) on T2-weighted images, measuring 1.4 × 1.3 cm and showing no enhancement after contrast administration (Fig 3). The diagnosis of CPA lipoma was suggested and the patient was managed conservatively. The symptoms were controlled with medical therapy. The follow-up MR imaging performed one year later showed no significant modifications 10).

1997

The case of an extensive lipoma of the cerebellopontine angle (CPA) represents 0.05% of all CPA tumors operated on in a department from 1978 to 1996. The lipoma constitutes an important differential diagnosis because the clinical management differs significantly from other CPA lesions. The clinical presentation and management of the presented case are analyzed in comparison to all previously described cases of CPA lipomas. The etiology and the radiological features of CPA lipomas are reviewed and discussed. CPA lipomas are maldevelopmental lesions that may cause slowly progressive symptoms. Neuroradiology enables a reliable preoperative diagnosis. Attempts of complete lipoma resection usually result in severe neurological deficits. Therefore, we recommend a conservative approach in managing these patients. Limited surgery is indicated if the patient has an associated vascular compression syndrome or suffers from disabling vertigo 11).

1994

Two patients with cerebellopontine angle (CPA) lipoma were studied. They were submitted to surgical treatment. Available literature was reviewed and 29 cases with same lesion were identified which had been treated by surgery. Clinical manifestations, possibility of diagnostic methods, surgical indications and treatment strategies are discussed. Attention is called to the peculiarities of CPA lipomas and the doubtful validity of attempting complete excision in all cases12).


1) Bonneville F, Sarrazin JL, Marsot-Dupuch K, Iffenecker C, Cordoliani YS, Doyon D, Bonneville JF. Unusual lesions of the cerebellopontine angle: a segmental approach. Radiographics. 2001 Mar-Apr;21(2):419-38. PubMed PMID: 11259705.
2) , 11) Schuhmann MU, Lüdemann WO, Schreiber H, Samii M. Cerebellopontine angle lipoma: a rare differential diagnosis. Skull Base Surg. 1997;7(4):199-205. PubMed PMID: 17171031; PubMed Central PMCID: PMC1656654.
3) Lagman C, Voth BL, Chung LK, Bui TT, Lee SJ, Barnette NE, Gopen Q, Yang I. Evaluating the utility of a scoring system for lipomas of the cerebellopontine angle. Acta Neurochir (Wien). 2017 Jan 21. doi: 10.1007/s00701-017-3076-5. [Epub ahead of print] PubMed PMID: 28110401.
4) Kontorinis G, Freeman SR, Potter G, Rutherford SA, Siripurapu R, King AT, Lloyd SK. Management of cerebellopontine angle lipomas: need for long-term radiologic surveillance? Otol Neurotol. 2014 Jun;35(5):e163-8. doi: 10.1097/MAO.0000000000000395. PubMed PMID: 24691513.
5) White JR, Carlson ML, Van Gompel JJ, Neff BA, Driscoll CL, Lane JI, Link MJ. Lipomas of the cerebellopontine angle and internal auditory canal: Primum Non Nocere. Laryngoscope. 2013 Jun;123(6):1531-6. doi: 10.1002/lary.23882. PubMed PMID: 23401141.
6) Brodsky JR, Smith TW, Litofsky S, Lee DJ. Lipoma of the cerebellopontine angle. Am J Otolaryngol. 2006 Jul-Aug;27(4):271-4. PubMed PMID: 16798407.
7) Tankéré F, Vitte E, Martin-Duverneuil N, Soudant J. Cerebellopontine angle lipomas: report of four cases and review of the literature. Neurosurgery. 2002 Mar;50(3):626-31; discussion 631-2. Review. PubMed PMID: 11841733.
8) Bigelow DC, Eisen MD, Smith PG, Yousem DM, Levine RS, Jackler RK, Kennedy DW, Kotapka MJ. Lipomas of the internal auditory canal and cerebellopontine angle. Laryngoscope. 1998 Oct;108(10):1459-69. Review. PubMed PMID: 9778284.
9) Venkataramana N, Rao SA, Naik AL, Chaitanya K, Murthy P. Cerebello pontine angle lipoma in a child. J Pediatr Neurosci. 2012 Jan;7(1):75-7. doi: 10.4103/1817-1745.97635. PubMed PMID: 22837790; PubMed Central PMCID: PMC3401666.
10) Borges RS, Brito CC, Carvalho GA, Domingues RC, Gasparetto EL. Cerebellopontine angle lipomas: magnetic resonance imaging findings in two cases. Arq Neuropsiquiatr. 2009 Jun;67(2B):496-8. PubMed PMID: 19623450.
12) Ferreira MP, Ferreira NP, Lenhardt R. Lipoma of the cerebellopontine angle. Case reports and literature review. Arq Neuropsiquiatr. 1994 Mar;52(1):58-63. Review. PubMed PMID: 8002809.

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

The scope and purpose of the Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use.

The intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient.

Carney et al. think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neurointensive care have been early pioneers and supporters of evidence based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines 1).

4th edition

Free article of Neurosurgery


1) Carney N, Totten AM, OʼReilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2016 Sep 20. [Epub ahead of print] PubMed PMID: 27654000.

NOVOCART® Disk plus

Chondrocytes are the only cells found in healthy cartilage. They produce and maintain the cartilaginous matrix, which consists mainly of collagen and proteoglycans. Although the word chondroblast is commonly used to describe an immature chondrocyte, the term is imprecise, since the progenitor of chondrocytes (which are mesenchymal stem cells) can differentiate into various cell types, including osteoblasts.

From least- to terminally-differentiated, the chondrocytic lineage is:

Colony-forming unit-fibroblast (CFU-F)

Mesenchymal stem cell / marrow stromal cell (MSC)

Chondrocyte

Hypertrophic chondrocyte

When referring to bone, or in this case cartilage, the originally undifferentiated mesenchymal stem cells lose their pluripotency, proliferate and crowd together in a dense aggregate of chondrogenic cells (cartilage) at the location of chondrification. These chondrogenic cells differentiate into so-called chondroblasts, which then synthesize the cartilage extra cellular matrix (ECM), consisting of a ground substance (proteoglycans, glycosaminoglycans for low osmotic potential) and fibers. The chondroblast is now a mature chondrocyte that is usually inactive but can still secrete and degrade the matrix, depending on conditions.

BMP4 and FGF2 have been experimentally shown to increase chondrocyte differentiation.

Chondrocytes undergo terminal differentiation when they become hypertrophic, which happens during endochondral ossification. This last stage is characterized by major phenotypic changes in the cell.


Autologous chondrocyte implantation (ACI, ATC code M09AX02 (WHO)) is a biomedical treatment that repairs damages in articular cartilage. ACI provides pain relief while at the same time slowing down the progression or considerably delaying partial or total joint replacement (knee replacement) surgery. The goal of ACI is to allow people suffering from articular cartilage damage to return to their old lifestyle; regaining mobility, going back to work and even practicing sports again.

ACI procedures aim to provide complete hyaline repair tissues for articular cartilage repair. Over the last 20 years, the procedure has become more widespread and it is currently probably the most developed articular cartilage repair technique.

The surgical technique was first performed in Sweden in 1987; the results of the 9 year follow up are available in Lars Peterson et al. 2000. Brittberg published the first description of the technique on humans in 1994. He reported good and promising results with 23 patients for defects on the femoral condyles .The technique also seems promising with regard to long-term results.


NOVOCART® Disk plus, an autologous cell compound for autologous disk chondrocyte transplantation, was developed to reduce the degenerative sequel after lumbar discectomy or to prophylactically avoid adjacent segment disease, if present.

The NDisc trial is an ongoing multi-center, randomized study with a sequential phase I study within the combined phase I/II trial with close monitoring of tolerability and safety. Twenty-four adult patients were randomized and treated with the investigational medicinal product NDisc plus or the carrier material only. Rates of adverse events in Phase I of this trial were comparable with those expected in the early time course after elective disk surgery. There was one reherniation 7 months after transplantation, which corresponds to an expected reherniation rate. Immunological markers like C reactive protein and IL6 were not significantly elevated and there were no imaging abnormalities. No indications of harmful material extrusion or immunological consequences due to the investigational medicinal product NDplus were observed. Therefore, the study appears to be safe and feasible. Safety analyses of Phase I of this trial indicate a relatively low risk considering the benefits that patients with debilitating degenerative disk disease may gain 1).


1) Tschugg A, Diepers M, Simone S, Michnacs F, Quirbach S, Strowitzki M, Meisel HJ, Thomé C. A prospective randomized multicenter phase I/II clinical trial to evaluate safety and efficacy of NOVOCART disk plus autologous disk chondrocyte transplantation in the treatment of nucleotomized and degenerative lumbar disks to avoid secondary disease: safety results of Phase I-a short report. Neurosurg Rev. 2017 Jan;40(1):155-162. doi: 10.1007/s10143-016-0781-0. Erratum in: Neurosurg Rev. 2017 Jan;40(1):177. PubMed PMID: 27567635.

Venous sinus stenting for idiopathic intracranial hypertension


Trials suggest that venous sinus stenting offers both comparable rates of efficacy – with improved papilledema in 97% of patients, resolved headache in 83%, and improved visual acuity in 78% .

Patients whose sight is threatened by medically refractory IIH must often consider invasive procedures to control their disease. Venous sinus stenting may offer equal efficacy and lower failure and complication rates than traditional surgical approaches such as optic nerve sheath fenestration and cerebrospinal fluid diversion 3).

Videos

Reviews

2017

A systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews.

Forty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost.

No surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality 4).

2015

Kanagalingam et al., review the role of cerebral venous sinus stenting in the management of patients with medically refractory pseudotumor cerebri. Although long- term studies are needed in this field, the current reports indicate a favorable outcome for preventing vision loss and symptom control 5).

2013

In 2013, a review of the literature was performed which identified patients with IIH treated with venous sinus stenting. The procedural data and outcomes are presented. A total of 143 patients with IIH (87% women, mean age 41.4 years, mean body mass index 31.6 kg/m(2)) treated with venous sinus stenting were included in the analysis. Symptoms at initial presentation included headache (90%), papilledema (89%), visual changes (62%) and pulsatile tinnitus (48%). There was a technical success rate of 99% for the stent placement procedure with a total of nine complications (6%). At follow-up (mean 22.3 months), 88% of patients experienced improvement in headache, 97% demonstrated improvement or resolution of papilledema, 87% experienced improvement or resolution of visual symptoms and 93% had resolution of pulsatile tinnitus. In patients with IIH with focal venous sinus stenosis, endovascular stent placement across the stenotic sinus region represents an effective treatment strategy with a high technical success rate and decreased rate of complications compared with treatment modalities currently used 6).


Teleb et al., aimed to review all published cases and case series of dural sinus stenting for IIH, with analysis of patient presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications.

A Medline search was performed to identify studies meeting pre-specified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The manuscripts were reviewed and data was extracted.

A total of 22 studies were identified, of which 19 studies representing 207 patients met criteria and were included in the analysis. Only 3 major complications related to procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved the (172/189) 90%. Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 (n=185) to 3.2 mm Hg (n=172). Stenting had an overall symptom improvement rate of 87%.

Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted 7).

Case series

2017

Seventeen patients underwent dural venous sinus stenting (DVSS). Average pre- and post-intervention pressure gradients were 23.06 and 1.18 mmHg, respectively (p < 0.0001). Sixteen (94%) noted improvement in headache, fourteen (82%) had visual improvement and all (100%) patients had improved main symptom. Of 11 patients with optical coherence tomography, 8 showed decreased RNFL thickness and 3 remained stable; furthermore, these 11 patients had improved vision with improved papilledema in 8, lack of pre-existing papilledema in 2 and stable, mild edema in 1 patient.

This series of patients with dural sinus stenosis demonstrated improvement in vision and reduction in RNFL thickness. DVSS appears to be a useful treatment for IIH patients with dural sinus stenosis 8).

2016

Ten patients for whom medical therapy had failed were prospectively followed. Ophthalmological examinations were assessed, and patients with venous sinus stenosis on MR angiography proceeded to catheter angiography, venography with assessment of pressure gradient, and ICP monitoring. Patients with elevated ICP measurements and an elevated pressure gradient across the stenosis were treated with stent placement. RESULTS All patients had elevated venous pressure (mean 39.5 ± 14.9 mm Hg), an elevated gradient across the venous sinus stenosis (30.0 ± 13.2 mm Hg), and elevated ICP (42.2 ± 15.9 mm Hg). Following stent placement, all patients had resolution of the stenosis and gradient (1 ± 1 mm Hg). The ICP values showed an immediate decrease (to a mean of 17.0 ± 8.3 mm Hg), and further decreased overnight (to a mean of 8 ± 4.2 mm Hg). All patients had subjective and objective improvement, and all but one improved during follow-up (median 23.4 months; range 15.7-31.6 months). Two patients developed stent-adjacent stenosis; retreatment abolished the stenosis and gradient in both cases. Patients presenting with papilledema had resolution on follow-up funduscopic imaging and optical coherence tomography (OCT) and improvement on visual field testing. Patients presenting with optic atrophy had optic nerve thinning on follow-up OCT, but improved visual fields. CONCLUSIONS For selected patients with IIH and venous sinus stenosis with an elevated pressure gradient and elevated ICP, venous sinus stenting results in resolution of the venous pressure gradient, reduction in ICP, and functional, neurological, and ophthalmological improvement. As patients are at risk for stent-adjacent stenosis, further follow-up is necessary to determine long-term outcomes and gain an understanding of venous sinus stenosis as a primary or secondary pathological process behind elevated ICP 9).


El Mekabaty et al., retrospectively reviewed a prospectively maintained database spanning December 2011 to May 2015 of all patients with idiopathic intracranial hypertension who were screened for possible venous sinus stenting, including only patients who received a stent, noting symptomatic improvements, changes in opening lumbar puncture pressure, demographic characteristics, and any subsequent intervention after stent placement. Fisher’s exact test and logistic regression were used to test each of seven potential predictors for retreatment. RESULTS: There were eight revisions in 31 patients (25.8%). Among Caucasians, 8.0% required a revision compared with 100% of African-Americans (p<0.001). The c-index for race was 0.857. Body mass index (BMI) was also a significant predictor of revision (p=0.031): among class III obese patients the revision rate was 46.2% compared with 16.7% among class I and II obese patients and 0% among overweight to normal weight patients.

BMI was a significant predictor of revision, suggesting that higher BMI may have a higher risk of revision. The small number of African-Americans in the study makes interpretation of the practical significance of the revision rate in these patients uncertain. None of the other studied factors was statistically significant. 10).


A written informed consent approved by the Weill Cornell institutional review board was signed and obtained from the study participants. Thirty-seven consecutive patients with IIH and venous sinus stenosis who were treated with venous sinus stenting between Jan.2012-Jan.2016 were prospectively evaluated. Patients without pulsatile tinnitus were excluded. Tinnitus severity was categorized based on “Tinnitus Handicap Inventory” (THI) at pre-stent, day-0, 1-month, 3-month, 6-month, 12-month, 18-month and 2-year follow-up. Demographics, body-mass index (BMI), pre and post VSS trans-stenotic pressure gradient were documented. Statistical analysis performed using Pearson’s correlation, Chi-square analysis and Fischer’s exact test.

29 patients with a mean age of 29.5±8.5 years M:F = 1:28. Median (mean) THI pre and post stenting were: 4 (3.7) and 1 (1) respectively. Median time of tinnitus resolution post VSS was 0-days. There was significant improvement of THI (Δ Mean: 2.7 THI [95% CI: 2.3-3.1 THI], p<0.001) and transverse-distal sigmoid sinus gradient (Δ Mean: -15.3 mm Hg [95% CI: 12.7-18 mm Hg], p<0.001) post-stenting. Mean follow-up duration of 26.4±9.8 months (3-44 months). VSS was feasible in 100% patients with no procedural complications. Three-patients (10%) had recurrent sinus stenosis and tinnitus at mean follow-up of 12 months (6-30 months).

Venous sinus stenting is an effective treatment for pulsatile tinnitus in patients with IIH and venous sinus stenosis 11).

2013

Fields et al reviewed all cases of dural stents for IIH. Eligibility criteria included medically refractory IIH with documented papilledema and dural venous sinus stenosis of the dominant venous outflow system (gradient ≥10 mm Hg).

Fifteen cases (all women) of mean age 34 years were identified. All had failed medical therapy and six had failed surgical intervention. Technical success was achieved in all patients without major periprocedural complications. The mean preprocedural gradient across the venous stenosis was reduced from 24 mm Hg before the procedure to 4 mm Hg after the procedure. Headache resolved or improved in 10 patients. Papilledema resolved in all patients and visual acuity stabilized or improved in 14 patients. There were no instances of restenosis among the 14 patients with follow-up imaging.

In this small case series, dural sinus stenting for IIH was performed safely with a high degree of technical success and with excellent clinical outcomes. These results suggest that angioplasty and stenting for the treatment of medically refractory IIH in patients with dural sinus stenosis warrants further investigation as an alternative to LPS, VPS and ONSF 12).


1) , 4) Kalyvas AV, Hughes M, Koutsarnakis C, Moris D, Liakos F, Sakas DE, Stranjalis G, Fouyas I. Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature. Acta Neurochir (Wien). 2017 Jan;159(1):33-49. doi: 10.1007/s00701-016-3010-2. Review. PubMed PMID: 27830325.
2) Dinkin MJ, Patsalides A. Venous Sinus Stenting for Idiopathic Intracranial Hypertension: Where Are We Now? Neurol Clin. 2017 Feb;35(1):59-81. doi: 10.1016/j.ncl.2016.08.006. Review. PubMed PMID: 27886896.
3) Chaudhry S, Bryant TK, Peeler CE. Venous sinus stenting in idiopathic intracranial hypertension: a safer surgical approach? Curr Opin Ophthalmol. 2016 Nov;27(6):481-485. Review. PubMed PMID: 27585210.
5) Kanagalingam S, Subramanian PS. Cerebral venous sinus stenting for pseudotumor cerebri: A review. Saudi J Ophthalmol. 2015 Jan-Mar;29(1):3-8. doi: 10.1016/j.sjopt.2014.09.007. Review. PubMed PMID: 25859134; PubMed Central PMCID: PMC4314570.
6) Puffer RC, Mustafa W, Lanzino G. Venous sinus stenting for idiopathic intracranial hypertension: a review of the literature. J Neurointerv Surg. 2013 Sep 1;5(5):483-6. doi: 10.1136/neurintsurg-2012-010468. Review. PubMed PMID: 22863980.
7) Teleb MS, Cziep ME, Lazzaro MA, Gheith A, Asif K, Remler B, Zaidat OO. Idiopathic Intracranial Hypertension. A Systematic Analysis of Transverse Sinus Stenting. Interv Neurol. 2013;2(3):132-143. PubMed PMID: 24999351; PubMed Central PMCID: PMC4080637.
8) Smith KA, Peterson JC, Arnold PM, Camarata PJ, Whittaker TJ, Abraham MG. A case series of dural venous sinus stenting in idiopathic intracranial hypertension: association of outcomes with optical coherence tomography. Int J Neurosci. 2017 Feb;127(2):145-153. PubMed PMID: 26863329.
9) Liu KC, Starke RM, Durst CR, Wang TR, Ding D, Crowley RW, Newman SA. Venous sinus stenting for reduction of intracranial pressure in IIH: a prospective pilot study. J Neurosurg. 2016 Dec 23:1-8. doi: 10.3171/2016.8.JNS16879. [Epub ahead of print] PubMed PMID: 28009240.
10) El Mekabaty A, Obuchowski NA, Luciano MG, John S, Chung CY, Moghekar A, Jones S, Hui FK. Predictors for venous sinus stent retreatment in patients with idiopathic intracranial hypertension. J Neurointerv Surg. 2016 Dec 13. pii: neurintsurg-2016-012803. doi: 10.1136/neurintsurg-2016-012803. [Epub ahead of print] PubMed PMID: 27965382.
11) Boddu S, Dinkin M, Suurna M, Hannsgen K, Bui X, Patsalides A. Resolution of Pulsatile Tinnitus after Venous Sinus Stenting in Patients with Idiopathic Intracranial Hypertension. PLoS One. 2016 Oct 21;11(10):e0164466. doi: 10.1371/journal.pone.0164466. PubMed PMID: 27768690; PubMed Central PMCID: PMC5074492.
12) Fields JD, Javedani PP, Falardeau J, Nesbit GM, Dogan A, Helseth EK, Liu KC, Barnwell SL, Petersen BD. Dural venous sinus angioplasty and stenting for the treatment of idiopathic intracranial hypertension. J Neurointerv Surg. 2013 Jan 1;5(1):62-8. doi: 10.1136/neurintsurg-2011-010156. PubMed PMID: 22146571.