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Surgical Management of Extracranial Carotid Artery Disease

Since the first description of a carotid endarterectomy (CEA) for the prevention of stroke, the operation has been widely debated and often criticized; yet the number of endarterectomy procedures performed annually has steadily increased. Early studies suggested that medical management was superior to surgical intervention. , This is clearly no longer the case. Gratifying and unimpeachable results from recent multicenter trials have advocated surgical therapy over…

Previously Coiled Aneurysms

Introduction The many advantages of endovascular treatment of cerebral aneurysms are well documented. Acceptance and use of endovascular techniques have steadily increased and has been bolstered by publication of the results of the International Subarachnoid Aneurysm Trial (ISAT) in 2005. This randomized trial demonstrated that endovascular treatment of ruptured intracranial aneurysms is statistically more likely to lead to an increased independent survival at 1 year as…

Bypass Techniques

Introduction Surgical treatment of cerebrovascular disorders with cerebral revascularization procedures has remained a formidable task for neurosurgeons for centuries. Despite remarkable advances in medical management and noninvasive procedures, cerebrovascular revascularization with extracranial-intracranial (EC-IC) bypass procedures has withstood the test of time and continue to represent the mainstay for various neurovascular pathologies. These procedures are generally divided into flow replacement or high-flow and flow supplementation or low-flow…

Hearing Prosthetics: Surgical Techniques

Tumors in the cerebellopontine angle and internal auditory canal can result in hearing loss. In addition, surgical resection of these tumors often leads to hearing impairment due to manipulation and/or sacrifice of the cochlear nerve. Options for restoring hearing include bone conducting devices, cochlear implants, and auditory brain stem implants (ABIs). Hearing Loss Hearing loss can be divided into two broad categories: conductive and sensorineural. In…

Translabyrinthine and Transtemporal Approaches to Posterior Cranial Fossa Lesions

Acknowledgment Portions of this chapter are reproduced with permission from Brodkey J, Vrionis FD: Surgical approaches through the temporal bone. In Robertson JT, Coakham H, Robertson JH (eds): Cranial Base Surgery: Management, Complications and Outcome . Edinburgh, Churchill Livingstone, 2000. The authors are indebted to Bo Jespersen, MD, who provided all illustrations for the translabyrinthine approach. Traditional approaches to the posterior cranial fossa do not permit…

Suboccipital Retrosigmoid Surgical Approach for Vestibular Schwannoma (Acoustic Neuroma)

Introduction Cerebello-pontine angle (CPA) surgery for vestibular schwannomas (VSs) represents a complex surgical setting that requires adequate training, sufficient microsurgical skills and experience, and a meticulous preparation about patient’s anatomy for each case. The surgeon who approaches CPA surgery must be aware that this is a complex and challenging surgery and must be ready to manage and prevent complications. The retrosigmoid approach is one of the…

The OZ Chapter: Original OZ, Modified for Parietal, Modified for Frontal, Cosmetic Results of the OZ

Historical Aspects The “workhorse of skull base neurosurgery,” the orbitozygomatic approach (OZA) is a highly versatile surgical technique that provides access to lesions involving the orbital apex, cavernous sinus, anterior and middle fossa floor, and posterior fossa cisterns, and minimizes the need for fixed brain retraction. The earliest elements of the OZA can be found in the description of surgical approaches to the pituitary by McArthur…

Surgical Management of Parasellar Meningiomas

Introduction Meningiomas are the second most common tumor in the parasellar region, less frequent than only pituitary adenomas. While most often histopathologically benign, their development in close apposition to critical neurovascular structures can render their surgical management challenging, highlighted by risk to these neurovascular structures and by difficulty obtaining complete resection with correspondingly frequent tumor recurrence. This chapter will review salient management considerations including strategies for…

Multimodal Treatment of Orbital Tumors

The surgical management of intraorbital tumors requires a thorough understanding of not only orbital anatomy but also the objectives of surgical intervention. The orbital contents abut the skull base, paranasal sinuses, and intracranial compartment or anterior cranial fossa. The orbit is a quadrangular compartment that can be accessed through a variety of approaches along one of its four walls or posteriorly from its apex. The orbit…

Surgical Management of Tumors of the Foramen Magnum

Acknowledgments The author acknowledges the contributions of Daniel M Prevedello, MD (Columbus, OH – USA) and Cristian Ferrareze Nunes, MD (Passo Fundo, RS – Brazil) to the preparation and completion of this chapter. Introduction The foramen magnum (FM) comprises a bony channel formed anteriorly by the lower third of the clivus, the anterior arch of the atlas, and the odontoid process. The lateral limits are the…

Surgical Management of Posterior Fossa Meningiomas

Introduction and Classification Meningiomas in the posterior fossa are a heterogeneous group of lesions in which anatomic location in relationship to the bony and neurovascular structures is key to predict their complexity during resection and to choose the most favorable approach. Many meningiomas also extend but are not primarily located in the posterior fossa. Depending on location and size, the symptoms that can be attributed to…

Surgical Management of Lesions of the Clivus

Anatomy of the Clivus The clivus a midline osseous anatomic structure in the skull base formed by the body of the sphenoid bone and the clival part of the occipital bone. Both bones join in a flat surface, the spheno-occipital synchondrosis. The upper part of the clivus is formed by the sphenoid bone, whereas the middle and inferior part of the clivus are mainly formed by…

Surgical Management of Cavernous Lesions

Surgical Methods and the History Surgery of the cavernous sinus was first developed by pioneers Parkinson and Dolenc in the 1960–80s, mainly for cavernous sinus aneurysms. , It was gradually applied to cavernous sinus tumors, by parallel development of bypass of the carotid artery. In the 1990s cavernous sinus surgery was the hottest surgical subject in neurosurgery, with parallel development of microsurgical anatomy. , However the…

Surgical Management of Sphenoid Wing Meningiomas

Sphenoid wing meningiomas (SWMs) constitute about 14% to 20% of intracranial meningiomas. Although they originate from arachnoid cells, they are usually attached to dural thickening or folding, from which they receive their blood supply. Infiltration of the adjacent bone is not unusual; neither is growth around or inside the cranial base foramina. Most SWMs are relatively easy to remove; however, they are sometimes challenging, especially when…

Supraorbital Approach Variants for Intracranial Tumors

Acknowledgment In memory of Axel Perneczky. The authors and the editors thank Dr. Shaan Raza and Dr. Rodrigo Ramos-Zuniga for their contribution in the previous edition. The fundamental basis of “keyhole” neurosurgery lies in the fact that, if designed and tailored to the lesions, deep lesions can be approached via smaller incisions and craniotomies providing essentially the same anatomic visualization as the larger, more traditional cranial…

Surgical Management of Midline Anterior Skull Base Meningiomas

Acknowledgment We are very grateful to Marc Matthes, M.Sc., for helping with the creation of Figs. 25.8–25.14 . Surgical Anatomy Meningiomas arising in the midline of the anterior fossa are generally separated into the more rostral olfactory groove meningiomas and the more dorsal planum sphenoidale and tuberculum sellae meningiomas (TSM). Planum sphenoidale/TSM occur at similar rates as olfactory groove meningiomas in our series of meningiomas, with…

Surgical Approach to Falcine Meningiomas

Meningiomas are intracranial, extra-axial lesions that represent about one-third of all primary brain tumors, and over a half of noncancerous central nervous system (CNS) neoplasms. Falcine meningiomas are relatively rare. They arise from the falx cerebri and make up approximately 5% to 9% of all intracranial meningiomas. , Falcine meningiomas differ from parasagittal meningiomas in that they arise from the dense fibrous tissue of the falx,…

Surgical Management of Parasagittal and Convexity Meningiomas

Acknowledgment The Intramural Research Program of the National Institute of Neurological Disorders and Stroke at the National Institutes of Health supported portions of this manuscript. Epidemiology and Significance Meningiomas are the most common primary brain and central nervous system tumors (incidence: 8.41 per 100,000 persons). Data from the 2010 to 2014 Central Brain Tumor Registry reveal that these tumors account for approximately 37% of all primary…

Management of Tumors of the Fourth Ventricle

Tumors of the fourth ventricle offer a unique challenge to the neurosurgeon because they lie deep in the brain in proximity to a number of vital structures. Although recent diagnostic and therapeutic advances have dramatically improved outcome for patients affected with these tumors, there are still many difficulties for which new solutions are always being offered. The purpose of this chapter is to provide a systematic…

Management of Pineal Region Tumors

History Pineal region tumors encompass a diverse group of tumors that can arise from pineal parenchymal cells, supporting cells of the pineal gland, or glial cells from the midbrain and medial walls of the thalamus. These tumors occupy a central position that is equidistant from various cranial points traditionally used as routes of exposure. The surgical management of these lesions remains complex and intimidating despite many…