Archivos de la categoría Base de Cráneo

Journal of Neurosurgery Junio 2014

Suprasellar meningioma

FEATURED ARTICLE

Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients

With the goal of gross-total tumor resection and visual improvement, endoscopic endonasal surgery (EES) can achieve very good results, (comparable to microscopic approaches) for the treatment of suprasellar meningiomas. Avoidance of brain and optic nerve retraction, preservation of the vascularization of the optic apparatus, and wide decompression of the optic canals are the main advantages of EES for the treatment of suprasellar meningiomas, while cerebrospinal fluid leakage remain a disadvantage 1).

1) Koutourousiou M, Fernandez-Miranda JC, Stefko ST, Wang EW, Snyderman CH, Gardner PA. Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg. 2014 Jun;120(6):1326-39. doi: 10.3171/2014.2.JNS13767. Epub 2014 Mar 28. PubMed PMID: 24678782.

Mary Koutourousiou, MD, joined the University of Pittsburgh Department of Neurological Surgery in May 2012 to complete a clinical fellowship in open and endoscopic endonasal skull base surgery with Drs. P.A. Gardner and J.C. Fernandez-Miranda. Prior to this appointment, since April 2010, she was a research fellow at the University of Pittsburgh Department of Neurological Surgery. Dr. Koutourousiou, a native from Thessaloniki, Greece, received her medical degree from the Aristotle University of Thessaloniki, Greece and completed her neurosurgical residency at the General Hospital of Athens “G. Gennimatas”, Athens, Greece. She has completed a clinical fellowship in minimally invasive and endoscopic neurosurgery with Prof. J.A. Grotenhuis at the Department of Neurosurgery, UMC St Radboud, Nijmegen, The Netherlands. Dr. Koutourousiou is accomplishing her Ph.D. on the Endocrinology and Pathophysiology of pituitary adenomas at the University of Athens, School of Medicine, Greece.

Clinical Fellowship – Head and Neck Oncology/Skull Base Surgery

Aurora-St. Lukes’s Hospital Fellowship in Head and Neck Oncologic Surgery and Skull Base Surgery is a one year fellowship intended for Otolaryngologists-Head and Neck Surgeons who are Board Eligible (American Board of Otolaryngology) or a Fellow of the Royal College of Surgeons of Canada.

During the one year fellowship, Fellows will gain experience in both Head and Neck Oncologic Surgery and Skull Base Surgery.   The Head and Neck Oncology component will be supervised by Dr. Martin Corsten, and will consist of clinical and operative exposure to mucosal Head and Neck Cancer, salivary gland malignancies, head and neck melanoma, and thyroid pathology.   The Skull Base Surgery component will be supervised by Dr. Martin Corsten and Dr. Amin Kassam, and will consist of exposure to both Endoscopic Endonasal Approaches to the skull base as well as conventional open skull base approaches.   The Fellow will have an opportunity to learn the intricacies of skull base anatomy from both the dorsal and ventral perspectives.  The 360o Cranial Base Laboratory is equipped with state-of the-art microscopic and endoscopic cadaveric dissection stations that are augmented with powerful imaging and navigation platforms.  Fellows will master both conventional and endoscopic endonasal skull base approaches by observing them in the operating rooms and then performing them on cadaveric specimens in the laboratory.  Subsequently, Fellows will be immersed in the high-volume clinical Head and Neck Oncology and Skull Base service where they will function as junior staff members.

The fellowship program is academically oriented. Research projects with focus on Head and Neck Oncology and Skull Base Surgery are encouraged and supported. Fellows are expected to submit at least two manuscripts for publication annually. Fellows are also encouraged to submit abstracts for major national and international meetings.

Unique Features

1) Exposure to full range of Head and Neck Oncology.

2) Comprehensive approach to minimally invasive skull base surgery: the goal is not to promote one approach over the other; instead, the Fellow will gain excellent experience in both conventional and endoscopic approaches.

3) Easy and encouraged access to the 360 Cranial Base Laboratory

4) The spirit of collegiality nurtured by our team. We “listen” to and “learn” from our fellows as much (if not more) than they “listen” and ” learn” from us.

5) Innovation is welcomed and encouraged by each of our team members.

Fellowship Objectives

Objectives of Fellowship

•                     To gain sufficient clinical experience in Head and Neck Oncology, including exposure to multi-disciplinary clinical conferences on Head and Neck Cancer lesions.

•                     To gain sufficient clinical experience in complex Skull Base surgery; both conventional and endoscopic.

•         To actively participate in Head and Neck Oncology and Skull Base research.

•         To have the opportunity to publish and establish expertise in the areas above, to prepare for an academic career and consultative service in this subspecialty.

Eligibility and Qualifications

The candidate should be a Board Eligible Otolaryngologist – Head and Neck Surgeon  (American Board of Otolaryngology) or a Fellow of the Royal College of Surgeons of Canada) who is eligible for a Wisconsin medical license. Non US citizens must be eligible for an H1-B visa.

Stipends and Benefits

The ANI offers a highly competitive compensation package. Details will be discussed during the interview.

Selection Process

Eligible applicants should direct their CVs and letter of intent to the fellowship program director. The letter of intent should specify the desired start date. Competitive  applicants will be invited for an interview. Applicants are evaluated on the basis of their academic standing, research productivity, letters of references, future goals and objectives.

For more information visit us at:

Www.aurora.org/ANII or

http://www.aurorahealthcare.org/services/neurology-neurosurgery/neuroscience-innovation-institute

Journal of Neurosurgery March 2014

Featured Article

Nonfunctioning pituitary adenoma

Nonfunctioning pituitary adenomas (NFAs) are the most common type of pituitary adenoma and, when symptomatic, typically require surgical removal as an initial means of management.
Treatment

Gamma Knife radiosurgery (GKRS) is an alternative therapeutic strategy for patients whose comorbidities substantially increase the risks of resection. In

Lee et al, evaluated the efficacy and safety of initial GKRS for NFAs.

An international group of three academic Gamma Knife centers retrospectively reviewed outcome data in 569 patients with NFAs.

Forty-one patients (7.2%) underwent GKRS as primary management for their NFAs because of an advanced age, multiple comorbidities, or patient preference. The median age at the time of radiosurgery was 69 years. Thirty-seven percent of the patients had hypopituitarism before GKRS. Patients received a median tumor margin dose of 12 Gy (range 6.2-25.0 Gy) at a median isodose of 50%. The overall tumor control rate was 92.7%, and the actuarial tumor control rate was 94% and 85% at 5 and 10 years postradiosurgery, respectively. Three patients with tumor growth or symptom progression underwent resection at 3, 3, and 96 months after GKRS, respectively. New or worsened hypopituitarism developed in 10 patients (24%) at a median interval of 37 months after GKRS. One patient suffered new-onset cranial nerve palsy. No other radiosurgical complications were noted. Delayed hypopituitarism was observed more often in patients who had received a tumor margin dose > 18 Gy (p = 0.038) and a maximum dose > 36 Gy (p = 0.025).

GKRS resulted in long-term control of NFAs in 85% of patients at 10 years. This experience suggests that GKRS provides long-term tumor control with an acceptable risk profile. This approach may be especially valuable in older patients, those with multiple comorbidities, and those who have endocrine-inactive tumors without visual compromise due to mass effect of the adenoma1.

Spine

Three-dimensional motion analysis of the cervical spine for comparison of anterior cervical decompression and fusion versus artificial disc replacement in 17 patients.

Cervical arthroplasty

Cervical arthroplasty with an artificial disc (AD) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF) for the management of cervical spondylosis.

It is an effective, reliable, and safe procedure for the treatment of cervical degenerative disc disease. However, there is no definitive evidence that DCI arthroplasty has better intermediate-term results than anterior cervical discectomy and fusion (ACDF).

3D motion analysis data comparing patients after ACDF and AD replacement in ten patients who underwent C5-6 ACDF and 7 who underwent C5-6 AD replacement were enrolled. Using biplanar fluoroscopy and a model-based track technique (accurate up to 0.6 mm and 0.6°), motion analysis of axial rotation and flexion-extension of the neck was performed. Three nonoperative segments (C3-4, C4-5, and C6-7) were assessed for both intervertebral rotation (coronal, sagittal, and axial planes) and facet shear (anteroposterior and mediolateral). Results There was no difference in total neck motion comparing ACDF and AD replacement for neck extension (43.3° ± 10.2° vs 44.3° ± 12.6°, p = 0.866) and rotation (36.0° ± 6.5° vs 38.2° ± 9.3°, p = 0.576). For extension, when measured as a percentage of total neck motion, there was a greater amount of rotation at the nonoperated segments in the ACDF group than in the AD group (p = 0.003). When comparing specific motion segments, greater normalized rotation was seen in the ACDF group at C3-4 (33.2% ± 4.9% vs 26.8% ± 6.6%, p = 0.036) and C6-7 (28.5% ± 6.7% vs 20.5% ± 5.5%, p = 0.009) but not at C4-5 (33.5% ± 6.4% vs 31.8% ± 4.0%, p = 0.562). For neck rotation, greater rotation was observed at the nonoperative segments in the ACDF group than in the AD group (p = 0.024), but the differences between individual segments did not reach significance (p ≥ 0.146). Increased mediolateral facet shear was seen on neck extension with ACDF versus AD replacement (p = 0.008). Comparing each segment, C3-4 (0.9 ± 0.5 mm vs 0.4 ± 0.1 mm, p = 0.039) and C4-5 (1.0 ± 0.4 mm vs 0.5 ± 0.2 mm, p = 0.022) showed increased shear while C6-7 (1.0 ± 0.4 mm vs 1.0 ± 0.5 mm, p = 0.767) did not.

This study illustrates increased motion at nonoperative segments in patients who have undergone ACDF compared with those who have undergone AD replacement. Further studies will be required to examine whether these changes contribute to adjacent-segment disease 2.

Pediatrics

The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants.

In infants with hydrocephalus, a greater 1-year CSF diversion failure rate may occur after ETV compared with shunt placement. This risk is most significant for procedures performed within the first 90 days of life. Further investigation of the need for multiple reoperations, cost, and impact of surgeon and hospital experience is necessary to distinguish which treatment is more effective in the long term3

  1. Lee CC, Kano H, Yang HC, Xu Z, Yen CP, Chung WY, Pan DH, Lunsford LD, Sheehan JP. Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas. J Neurosurg. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24405068. []
  2. McDonald CP, Chang V, McDonald M, Ramo N, Bey MJ, Bartol S. Three-dimensional motion analysis of the cervical spine for comparison of anterior cervical decompression and fusion versus artificial disc replacement in 17 patients. J Neurosurg Spine. 2013 Dec 20. [Epub ahead of print] PubMed PMID: 24359000. []
  3. Jernigan SC, Berry JG, Graham DA, Goumnerova L. The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants. J Neurosurg Pediatr. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24404970. []