British Neurosurgical Trainee Course
January 8, 2018 — January 10, 2018
January 8, 2018 — January 10, 2018
With this dehiscence, the fluid in the membranous superior canal (which is located within the tubular cavity of the bony canal) can be displaced by sound and pressure stimuli, creating certain vestibular and/or auditory signs and symptoms.
Since this was first reported in 1998 by Minor and colleagues, there has been much advancement made in terms of diagnosis and treatment 1).
The condition is confirmed on high-resolution computed tomography (CT) imaging.
High-resolution computed tomographic temporal bone images were imported into a freely available segmentation software. Dehiscence lengths and volumes were ascertained by independent authors. Inter-rater observer reliability was assessed using Cronbach’s alpha. Correlation and regression analyses were performed to evaluate for relationships between dehiscence size and symptoms (pre- and post-operative).
Thirty-seven dehiscences were segmented using the novel volumetric assessment. Cronbach’s alpha for dehiscence lengths and volumes were 0.97 and 0.95, respectively. Dehiscence lengths were more variable as compared to dehiscence volumes (σ 2 8.92 vs σ 2 0.55, F = 1.74). The mean dehiscence volume was 2.22 mm 3 (0.74, 0.64-0.53 mm 3 ). Dehiscence volume and headache at presentation were positively correlated ( R pb = 0.67, P = .03). Dehiscence volume and vertigo improvement after surgery were positively correlated, although this did not reach statistical significance ( R pb = 0.46, P = .21).
SSCD volumetry is a novel method of measuring dehiscence size that has excellent inter-rater reliability and is less variable compared to dehiscence length, but its potential as a predictor of symptom outcomes is not substantiated. However, the study is limited by low power 2).
MRI FIESTA scans have recently been used to image SSCD. Additionally, audiometry and vestibular evoked myogenic potential (VEMP) testing are useful screening tools.
Currently, the middle fossa approach is the most common and standard surgical approach to repair SSCD. The transmastoid, endoscopic and transcanal or endaural approaches have also been recently utilized. Presently, there is no consensus as to the best approach, material or technique for repair of SSCD. As we learn more, newer and less invasive approaches and techniques are being used to treat SSCD 3).
Symptoms are often improved by surgical repair. Although a classic middle fossa craniotomy has been used with good results, recent advances in technique have allowed for modification of the traditional approach into a smaller skin incision and a minimally invasive middle fossa keyhole craniectomy roughly 1.7 cm in diameter.
To delineate this novel approach and describe the technique for accurate localization of the dehiscence using preoperative measurements and intraoperative image guidance, thereby minimizing the need for a larger skin incision and craniotomy.
Patients were independently diagnosed with SSCD by the senior authors. Once relevant imaging was acquired, the novel keyhole technique was performed. Patients’ vestibular and auditory symptoms before and after the procedure were assessed. Outcomes from a series of patients treated with this keyhole approach were tabulated and reported.
Twelve cases from 11 patients were included in this series. Auditory symptoms had high rates of resolution with pulsatile tinnitus, internal amplification of sounds, and autophony being resolved in a majority of cases. Only 2 cases reported hearing decline. Sound/pressure induced vertigo and disequilibrium also demonstrated high rates of resolution. No complications were reported.
The minimally invasive middle fossa keyhole craniectomy is a novel approach for the repair of SSCD. This approach may contribute to resolved auditory and vestibular symptoms with low morbidity and quick recovery 4).
A analysis included 24 studies that described 230 patients that underwent either an middle cranial fossa (MCF) (n = 148, 64%) approach or a transmastoid approach (TM) (n = 82, 36%) for primary surgical repair of SSCD. A greater percentage of patients in the MCF group experienced resolution of auditory symptoms (72% vs 59%, p = 0.012), aural fullness (83% vs 55%, p = 0.049), hearing loss (57% vs 31%, p = 0.026), and disequilibrium (75% vs 44%, p = 0.001) when compared to the TM group. The MCF approach was also associated with higher odds of symptom resolution for auditory symptoms (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.14-2.82), aural fullness (OR 4.02, 95% CI 1.04-15.53), hearing loss (OR 2.91, 95% CI 1.14-7.42), and disequilibrium (OR 3.94, 95% CI 1.78-8.73). The mean follow-up was 9 months.
The literature suggests that the MCF approach for the repair of SSCD is associated with greater symptom resolution when compared to the TM approach. This information could help facilitate patient discussions 5).
A total of 72 cases of SSCD in 60 patients were repaired via a middle fossa approach at a single institution. Main Outcome Measures The distance from the proposed reference point to the dehiscence was statistically analyzed using Shapiro-Wilk’s goodness-of-fit test and Student’s t -test. Results Average distance for all patients was 28.84 ± 2.22 mm (range: 22.96-33.43). Average distance for females was 29.08 mm (range: 24.56-33.43) versus 28.26 mm (range: 22.96-32.36) for males. There was no difference in distance by sex ( p = 0.174). The distance measurements followed a normal distribution with 95% of the patients between 24.49 and 33.10 mm.
This study analyzed a potential reference point during a middle fossa approach for SSCD surgery. The distance from this reference point to the SSCD was found to be consistent and may serve as a readily identifiable landmark in localizing the dehiscence 6).
A 35-year-old man with superior semicircular canal dehiscence treated by a joint neurosurgical and otolaryngological team 7).
The treatment for geniculate neuralgia has not been established, although it seems reasonable that the therapeutic approaches used in other more common craniofacial neuralgias, such as trigeminal neuralgia, should be effective.
Conservative medical treatment is always the first-line therapy.
May responde to valproic acid.
Topical antibiotics for secondary infections of herpetic lesions.
Local anesthetic to external auditory canal.
Surgical treatment should be offered if medical treatment fails. The two commonest surgical options are transection of the nervus intermedius, and microvascular decompression of the nerve at the nerve root entry zone of the brainstem. However, extracranial intratemporal division of the cutaneous branches of the facial nerve may offer a safer and similarly effective treatment.
The response to medical treatment for this condition varies between individuals. The long-term outcomes of surgery remain unknown because of limited data 1).
Rupa et al., postulate that geniculate ganglionectomy may be ineffective as the sole treatment for certain cases of geniculate neuralgia, and that nervus intermedius section may also be required to achieve a more complete deafferentation 2).
Excision of the nervus intermedius and/or of the geniculate ganglion by the middle cranial fossa approach without the production of facial paralysis, sometimes in combination with selective section of the Vth cranial nerve, has been successful in relieving the pain of geniculate neuralgia.
Microvascular decompression may be effective as a treatment. Along its cisternal course, the nerve may be difficult to distinguish from the facial nerve. Based on case reports and small series, long-term pain control can be seen after nerve sectioning or microvascular decompression, but no prospective studies exist. Such studies are now necessary to shed light on the efficacy of surgical treatment of nervus intermedius neuralgia 3).
High-frequency hearing loss occurred after MVD for TGN, GPN, or GN, and the greatest incidence occurred on the ipsilateral side. This hearing loss may be a result of drill-induced noise and/or transient loss of cerebrospinal fluid during the course of the procedure. Changes in intraoperative BAEP waveforms were not useful in predicting HFHL after MVD. Repeated postoperative audiological examinations may be useful in assessing the prognosis of HFHL 4).
Surgically excision of the nervus intermedius and geniculate ganglion via the middle cranial fossa approach, Review the long-term outcomes in 64 patients who were treated in this manner. Findings indicate that excision of the nervus intermedius and geniculate ganglion can be routinely performed without causing facial paralysis and that it is an effective definitive treatment for intractable geniculate neuralgia 5).
A total of 31 surgical procedures were performed. Seventeen patients had sequential rhizotomies and one patient had microvascular decompression alone. Based on the clinical diagnosis, the nerves sectioned were singly or in combination: the nervus intermedius (14 patients), geniculate ganglion (10 patients), ninth nerve (14 patients), 10th nerve (11 patients), tympanic nerve (four patients), and chorda tympani nerve (one patient). Microvascular decompression of the involved nerves was undertaken in nine patients, in whom vascular loops were discovered. Adhesions (six patients), thickened arachnoid (three patients), and benign osteoma (one patient) were other intraoperative abnormalities noted. The overall success of these procedures in providing pain relief was 72.2%, and the mean follow-up period was 3.3 years (range 1 month to 14.5 years). There was no surgical mortality. Expected side effects were: decreased lacrimation, salivation, and taste related to nervus intermedius nerve section, and transient hoarseness and diminished gag related to ninth and 10th nerve section. Four patients developed sequelae consisting of sensorineural hearing loss, vertigo, and transient facial nerve paresis. One patient had a cerebrospinal fluid leak and another developed aseptic meningitis as postoperative complications. Except when primary glossopharyngeal neuralgia is the working diagnosis, a combined posterior cranial fossa-middle cranial fossa approach is recommended for adequate exploration and/or section of the fifth, ninth, and 10th cranial nerves as well as the geniculate ganglion and nervus intermedius 6).
Excision of the nervus intermedius and/or of the geniculate ganglion by the middle cranial fossa approach without the production of facial paralysis, in any of 15 cases with geniculate neuralgia is reported. Use of these new techniques, sometimes in combination with selective section of the Vth cranial nerve, has been successful in relieving the pain of geniculate neuralgia 7).
A 39-year-old man presented with a history of left “deep” ear pain within his ear canal. He noted occasional pain on the left side of his face around the ear. He had been treated with neuropathic pain medications without relief. His wife described suicidal ideations discussed by her husband because of the intense pain.
The patient’s neurologic examination was normal, and otolaryngologic consultation revealed no underlying structural disorder. Anatomic imaging revealed a tortuous vertebral artery-posterior inferior cerebellar artery complex with the posterior inferior cerebellar artery loop impinging on the root entry zone of the nervus intermedius-vestibulocochlear nerve complex and just inferior to the root entry zone of the facial nerve and a small anterior inferior cerebellar artery loop interposed between the cranial nerve VII-VIII complex and the hypoglossal and glossopharyngeal nerves. A left-sided retromastoid craniotomy was performed, and the nervus intermedius was transected. An arterial loop in contact with the lower cranial nerves at the level of the brainstem was mobilized with a polytetrafluoroethylene implant.
The patient indicated complete relief of his preoperative pain after surgery. He has remained pain-free with intact hearing and balance 8).
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January 8, 2018 — January 10, 2018
January 8, 2018 — January 12, 2018
January 17, 2018 — January 19, 2018
January 18, 2018 — January 19, 2018
January 26, 2018 — January 27, 2018
January 29, 2018
February 1, 2018 — February 2, 2018
February 26, 2018 — March 1, 2018
St Louise, Missouri, USA
March 2, 2018 — March 3, 2018
March 5, 2018 — March 8, 2018
|SBNS (Society of British Neurological Surgeons) Spring Meeting – TORQUAY|
|11 – 13 April 2018|
| Call for Abstract
March 15, 2018 — March 17, 2018
March 19, 2018 — March 21, 2018
|The Third WFNS Foundation Rabat Live Surgery Seminar for Young African Neurosurgeons|
|23 – 25 March 2018|
April 11, 2018 — April 13, 2018
April 12, 2018 — April 14, 2018
St Louis, Missouri, USA
|12th Annual Meeting of the Saudi Association of Neurological Surgery & 8th Neurosurgery Update Conference (SANS 2018)|
|15 – 16 April 2018|
|WFNS education course in conjunction with 4th ISMINS-Congress|
|19 – 21 April 2018|
April 26, 2018 — April 28, 2018
Please see the website for further details.
April 28, 2018 — May 2, 2018
New Orleans, LA, USA
May 1, 2018
May 2, 2018 — May 5, 2018
May 6, 2018 — May 9, 2018
May 9, 2018 — May 11, 2018
May 14, 2018 — May 18, 2018
Annual meeting of The International Society for the Study of the Lumbar Spine.
May 16, 2018 — May 18, 2018
May 16, 2018 — May 18, 2018
22nd Congress of the SENEC.
May 16, 2018 — May 18, 2018
May 23, 2018 — May 24, 2018
May 24, 2018 — May 25, 2018
San Giovanni Rotondo, Italy
May 25, 2018 — May 25, 2018
|69th Annual Meeting of the German Society of Neurosurgery (DGNC)|
|3 – 6 June 2018|
June 6, 2018 — June 8, 2018
6 – 7 June 2018
June 7, 2018
June 20, 2018 — June 22, 2018
June 22, 2018 — June 23, 2018
June 25, 2018 — June 29, 2018
July 12, 2018 — July 15, 2018
24 – 27 July 2018
August 11, 2018 — August 16, 2018
August 29, 2018 — September 3, 2018
September 19, 2018 — September 21, 2018
For more information please visit http://www.eurospinemeeting.org/f130000847.html
October 4, 2018 — October 8, 2018
Association of Neurosurgeons of Russia
Russian Association of Spinal Surgeons
Serbian Neurosurgical Society
4th Meeting of the Serbian Neurosurgical Society
Joint Meeting with the Souteast Europe Neurosurgical Society
October 6, 2018 — October 10, 2018
Chicago, IL, USA
October 9, 2018 — October 14, 2018
Annual Meeting of the European Association of Neuro-oncology
October 11, 2018 — October 12, 2018
Leiden, The Netherlands
October 21, 2018 — October 25, 2018
October 25, 2018 — October 28, 2018
October 27 — October 29
New Delhi, India
Taking place at the All India Institute of Medical Sciences.
November 2, 2018 — November 6, 2018
November 15, 2018 — November 18, 2018
New Orleans, LA, USA
Society for Neuro-Oncology (SNO) Annual Meeting 2018
January 25, 2019 — January 27, 2019
April 13, 2019 — April 17, 2019
San Diego, CA, USA
September 24, 2019 — September 28, 2019
(9/9/2019 – 12/9/2019) / Beijing, China
October 16, 2019 — October 18, 2019
Please click HERE for more information.
October 19, 2019 — October 23, 2019
San Francisco, CA, USA
November 20, 2018 — November 24, 2018
Phoenix, AZ, USA
Society for Neuro-Oncology (SNO) Annual Meeting 2019
They are invasive, uncontrolled by surgery, and respond poorly to medical treatment. Aggressive multimodal therapy is critical for their management, enhancing control rate and biochemical remission 1).
Giordano et al., present the clinical, radiological and hormonal status of three patients affected by invasive GH-secreting pituitary adenomas without clinical signs and symptoms of acromegaly with elevation of serum IGF-1 from a series of 142 pituitary adenomas operated in the Department of Neurosurgery, International Neuroscience Institute-Hannover, Germany with the aid of intraoperative magnetic resonance imaging(MRI). Total tumor removal was possible in two of the three cases; the patients show normal hormonal status and no recurrence at long-term follow-up. In the third case, due to the different features of the tumor, complete resection was not possible and a multimodal treatment was performed that allowed regularization of the hormonal status and control of the residual tumor. GH-secreting adenomas without clinical manifestation of acromegaly are uncommon lesions. Total microsurgical excision can be curative. However, in case of partial removal, a tailored adjuvant treatment should be considered to preserve the quality of life of the patient and avoid regrowth of the lesion. In not resectable tumors, preoperative medical treatment with somatostatin analogues is always an option 2).
Shimon et al. identified 34 patients (15 men and 19 females) with giant adenomas among 762 subjects (4.5%) with acromegaly, and characterized their clinical characteristics and response to treatment.
Mean age at diagnosis was 34.9±12.5 years (range, 16-67 years). Mean adenoma size was 49.4±9.4 mm (range, 40-80 mm); 30 adenomas showed cavernous sinus invasion and 32 had suprasellar extension. Twenty-nine (85%) patients had visual field defects. Mean baseline IGF1 was 3.4±1.8×ULN. All patients except one underwent pituitary surgery (one to three procedures), but none achieved hormonal remission following first surgery. Among the 28 subjects with visual disturbances, 14 recovered post-operatively and 13 improved. Treatment with somatostatin analogs was given to all patients after surgical failure. Six achieved remission, nine others were partially controlled (IGF1<1.5×ULN; 3/9 when combined with cabergoline), and 17 did not respond (two were lost). Nine patients were treated with pegvisomant, alone (n=4) or in combination with somatostatin analogs (n=5); five are in remission and two are partially controlled. Pasireotide-LAR achieved hormonal remission in one of the six patients. Currently, after a mean follow-up period of 8.9 years, 17 patients are in biochemical remission, eight are partially controlled, and seven are uncontrolled (two were lost to follow-up).
Giant GH-secreting adenomas are invasive, uncontrolled by surgery, and respond poorly to medical treatment. Aggressive multimodal therapy is critical for their management, enhancing control rate and biochemical remission 3).
A 23-year-old male patient presented with continuous increase in height during the past 6 years due to a GH-secreting giant pituitary adenoma. Because of major intracranial extension and failure of octreotide treatment to shrink the tumour, the tumour was partially resected by a trans-frontal surgical approach. At immunohistochemistry, the tumour showed a marked expression of GH and a sparsely focal expression of prolactin. Somatostatin receptors (sst) 1-5 were not detected. Tumour tissue weakly expressed dopamine receptor type 2. The Gs alpha subunit was intact. Conversion from somatostatin analogue to pegvisomant normalized insulin-like-growth-factor-I (IGF-I) levels and markedly improved glucose tolerance.
Pegvisomant is a potent treatment option in patients with pituitary gigantism. In patients who do not respond to somatostatin analogues, knowledge of the SST receptor status may shorten the time to initiation of pegvisomant treatment 4).