Browsing by Subject "Microneurosurgery"

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  • Kozyrev, Danil; Thiarawat, Peeraphong; Rezai Jahromi, Behnam; Intarakhao, Patcharin; Choque-Velasquez, Joham; Hijaz, Ferzat; Teo, Mario K.; Hernesniemi, Juha (2017)
    Meticulous haemostasis is one of the most important factors during microneurosurgical resection of brain arteriovenous malformation (AVM). Controlling major arterial feeders and draining veins with clips and bipolar coagulation are well-established techniques, while managing with bleeding from deep tiny vessels still proves to be challenging. This technical note describes a technique used by the senior author in AVM surgery for last 20 years in dealing with the issue highlighted. "Dirty coagulation" is a technique of bipolar coagulation of small feeders carried out together with a thin layer of brain tissue that surrounds these fragile vessels. The senior author uses this technique for achieving permanent haemostasis predominantly in large and/or deep-seated AVMs. To illustrate the efficacy of this technique, we retrospectively reviewed the outcome of Spetzler-Martin (SM) grade III-V AVMs resected by the senior author over the last 5 years (2010-2015). Thirty-five cases of AVM surgeries (14 SM grade III, 15 SM grade IV and 6 SM grade V) in this 5-year period were analysed. No postoperative intracranial haemorrhage was encountered as a result of bleeding from the deep feeders. Postoperative angiograms showed complete resection of all AVMs, except in two cases (SM grade V and grade III). "Dirty coagulation" provides an effective way to secure haemostasis from deep tiny feeders. This cost-effective method could be successfully used for achieving permanent haemostasis and thereby decreasing postoperative haemorrhage in AVM surgery.
  • Choque-Velasquez, Joham; Colasanti , Roberto; Rezai Jahromi, Behnam; Hernesniemi, Juha (2017)
    OBJECTIVE: The preservation of normal peri/intralesional bridging veins is extremely important in every micro-neurosurgical operation. The purpose of our study was to describe the "squeeze maneuver"assisted by indocyanine green videoangiography (ICGV), a simple technique to "resuscitate" partially occluded bridging veins during microneurosurgical operations. METHODS: When a bridging vein is inadvertently stretched up to its collapse during microneurosurgical procedures, a precise identification of the partially occluded zone is carried out under high magnification (10-153), as well as with the aid of the ICGV. If a continuous irrigation with isotonic saline solution does not allow one to reestablish the venous flow, the "squeeze maneuver" is carried out. This consists of squeezing and sliding with the bipolar forceps the occluded vessel along the normal venous flow direction. This procedure is repeated several times, while a continuous saline irriga-tion is applied. The ICGV is performed to confirm an adequate patency of the vein. RESULTS: This maneuver permits to restore the normal diameter of the vein and blood flow inside it. CONCLUSION: The "squeeze maneuver"assisted by ICGV represents a safe, clean, fast, and even cheap method for restoring the flow of partially occluded bridging veins during microneurosurgical operations.
  • Choque-Velasquez, Joham; Resendiz-Nieves, Julio; Jahromi, Behnam Rezai; Colasanti, Roberto; Raj, Rahul; Vehviläinen, Juho; Tynninen, Olli; Collan, Juhani; Niemelä, Mika; Hernesniemi, Juha (2019)
    BACKGROUND: Pineal region tumors represent challenging surgical lesions with wide ranges of survival reported in different surgical series. In this article, we emphasize the role of complete microsurgical resection (CMR) to obtain a favorable long-term outcome of pineal region tumors. METHODS: We report a retrospective study of pineal region tumors operated on in Helsinki Neurosurgery between 1997 and 2015. Information was obtained from the hospital records, and an evaluation of the Finnish population register was conducted in July 2018 to determine the current status of the patients. RESULTS: A total of 76 pineal region tumors were operated on. The survival was 62% at a mean follow-up of 125 +/- 105 months (range, 0-588 months), and the disease-related mortality was limited to 14 patients (18.4%). Up to July 2018, 29 patients had died. Two patients died 1 and 3 months after surgery of delayed thalamic infarctions, 12 patients of disease progression, and 15 had non-disease-related deaths. Only 1 patient was lost in the long-term follow-up. Ten of 14 disease-related deaths occurred during the first 5 years of follow-up: 5 diffuse gliomas, 3 germ cell tumors, 1 grade II-III pineal parenchymal tumor of intermediate differentiation, and 1 meningioma. CMR was linked to better tumor-free survival and long-term survival, with the exception of diffuse gliomas. CONCLUSIONS: CMR, in the setting of a multidisciplinary management of pineal region tumors, correlates with favorable survival and with minimal mortality. Surgically treated grade II-IV gliomas constitute a particular group with high mortality within the first 5 years independently of the microsurgical resection.
  • Lehto, Hanna; Niemela, Mika; Kivisaari, Riku; Laakso, Aki; Jahromi, Behnam Rezai; Hijazy, Ferzat; Andrade-Barazarte, Hugo; Dashti, Reza; Hernesniemi, Juha (2015)
    BACKGROUND: Vertebral artery (VA) aneurysms comprise approximately one-third of posterior circulation aneurysms. They are morphologically variable, and located critically close to the cranial nerves and the brainstem. We aim to represent the characteristics of these aneurysms and their treatment, and to analyze the outcome. METHODS: We reviewed retrospectively 9709 patients with intracranial aneurysms. Of these, we included 190 with aneurysms at the VA or VA posterior inferior cerebellar artery junction. The patients were treated in the Department of Neurosurgery, Helsinki, Finland, between 1934 and 2011. RESULTS: The 190 patients had 193 VA aneurysms, among which 131 (68%) were ruptured, The VA aneurysm caused a mass effect in 7 and ischemia in 2 patients. Compared to 4387 patients with a ruptured aneurysm in other locations, those with a VA aneurysm were older, their aneurysms were more often fusiform, and more often caused intraventricular hemorrhages. Among surgically treated aneurysms, clipping was the treatment in 91 (88%) saccular and 11 (50%) fusiform aneurysms. Treatment was endovascular in 13 (9%), and multimodal in 6 (4%) aneurysms, Within a year after aneurysm diagnosis, 53 (28%) patients died. Among the survivors, 104 (93%) returned to an independent or to their previous state of life; only 2 (2%) were unable to return home. CONCLUSIONS: Microsurgery is a feasible treatment for VA aneurysms, although cranial nerve deficits are more common than in endovascular surgery. Despite the challenge of an often severe hemorrhage, of challenging morphology, and risk for laryngeal palsy, most patients surviving the initial stage return to normalcy.
  • Choque-Velasquez, Joham; Resendiz-Nieves, Julio; Colasanti, Roberto; Collan, Juhani; Hernesniemi, Juha (2018)
    BACKGROUND: Vascular pineal malformations are rare and technically demanding lesions. Because the locations of these lesions, endovascular techniques and radiosurgery have been increasingly used in the recent decades to accomplish safe occlusion. Nevertheless, microsurgical treatment may be required sometimes. METHODS: We present a retrospective review of the vascular pineal malformations operated by the senior author. Moreover, we report illustrative cases for the various types of vascular lesions with a careful analysis of the different microsurgical stages. RESULTS: Eighteen patients with pineal vascular lesions were operated on between 1980 and 2015: 6 patients had vein of Galen malformations, 5 plexiform arteriovenous malformations, 6 cavernous malformations, and 1 patient had a ruptured medial posterior choroidal artery aneurysm. A complete resection and occlusion was possible in all vascular malformations. CONCLUSIONS: The pineal region is an infrequent but challenging location for vascular lesions. A careful and step-wise operative strategy for the different types of vascular lesion is paramount to accomplish an effective and safe microsurgical treatment when other alternatives fail or are not available.
  • Choque-Velasquez, Joham; Resendiz-Nieves, Julio; Jahromi, Behnam Rezai; Colasanti, Roberto; Baluszek, Szymon; Muhammad, Sajjad; Hernesniemi, Juha (2020)
    OBJECTIVE: The midline supracerebellar infratentorial (SCIT) approach and its paramedian development are commonly used for dealing with pineal lesions. Comparative clinical studies are lacking, however. We aim to establish the better performance of the paramedian SCIT approach in terms of clinical safety in surgically treated pineal cysts and pineal region tumors. Procedural functionality and effectiveness have been also analyzed. METHODS: A comparative analysis of clinical, radiologic, pathologic, and surgical features, and outcome was performed between 55 midline and 57 paramedian SCIT approaches that were exclusively performed in 112 patients (57 pineal cysts and 55 tumors of the pineal region) operated in sitting position by a single surgeon. Information was retrieved from hospital records and microsurgical videos. RESULTS: The paramedian SCIT approach linked with fewer postoperative complications (odds ratio [OR]: 0.40) and fewer approach-related complications (OR: 0.28) than the midline SCIT approach. The SCIT paramedian approach was achieved in a shorter time, by a smaller bone flap, and with fewer complex procedural steps than the midline approach. The SCIT paramedian approach did not require the opening of the falx cerebelli, midline cerebellar retraction, section of the midline cerebellar draining veins, nor wide opening of the dura. Gross total resection, size of the lesion, microsurgical time for removal, histopathological diagnosis and postoperative outcome were statistically similar in both groups. CONCLUSIONS: The SCIT approach represents a safer and more functional approach for the removal of cysts and tumors of the pineal region than the classic midline approach, while maintaining the same effectiveness.
  • Choque-Velasquez, Joham; Colasanti, Roberto; Kozyrev, Danil A.; Hernesniemi, Juha; Kawashima, Akitsugu (2017)
    BACKGROUND: Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors. CASE DESCRIPTION: Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patient's motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru. CONCLUSIONS: The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.
  • Choque-Velasquez, Joham; Colasanti, Roberto; Resendiz-Nieves, Julio; Jahromi, Behnam Rezai; Tynninen, Olli; Collan, Juhani; Niemelä, Mika; Hernesniemi, Juha (2018)
    BACKGROUND: Papillary tumor of the pineal region (PTPR) is a rare grade II-III pineal lesion with peculiar histological and immunohistochemical features. These tumors mostly occur in adults, only rarely in children, with 19 cases reported up to now. CASE DESCRIPTION: We present a 3-year-old boy who underwent reoperation for a recurrent PTPR (grade II). Gross total resection of the lesion through an occipital interhemispheric approach with the patient in a sitting position was followed by adjuvant radiotherapy and chemotherapy. Histological examination revealed tumor progression (grade III) and an MIB-1 proliferation index >25%. The patient continues to do well with no evidence of recurrence more than 3 years following surgery. A comprehensive literature review regarding the PTPR, including the current management in children, is reported. CONCLUSIONS: PTPRs are extremely rare in children, and immunohistochemistry is needed to differentiate them from other pineal tumors. These tumors show a high rate of recurrence, and a multidisciplinary management approach (microsurgical resection followed by radiotherapy and/or chemotherapy) can help achieve a favorable outcome.
  • Choque-Velasquez, Joham; Resendiz-Nieves, Julio C.; Jahromi, Behnam Rezai; Colasanti, Roberto; Raj, Rahul; Tynninen, Olli; Collan, Juhani; Hernesniemi, Juha (2019)
    BACKGROUND: Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare lesions with particular features compared with other pineal parenchymal tumors. METHODS: We present a retrospective review of patients with histologically confirmed PPTIDs who were operated on in our department between 1997 and 2015. A demographic analysis and an evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiologic outcomes were conducted. RESULTS: Fifteen patients with PPTIDs were operated on between 1997 and 2015. Gross total removal was achieved in 11 cases; 2 patients underwent near-total resection, 1 partial resection, and 1 received brachytherapy after an endoscopic biopsy. Nine patients required external radiation therapy (4 due to a pleomorphic histology of their lesion including pineoblastoma features in 3 of them; 3 after a subtotal resection; and 2 for tumor recurrence). No patient received chemotherapy. The survival rate of our patients was 57.1% at a mean follow-up of 137.2 +/- 77.6 months (39-248 months). CONCLUSIONS: A proper multidisciplinary management of PPTIDs based on a gross total removal of the lesion, and an adjuvant radiotherapy in selected cases, may improve the overall survival of these aggressive tumors.
  • Choque-Velasquez, Joham; Resendiz-Nieves, Julio C.; Jahromi, Behnam Rezai; Colasanti, Roberto; Tynninen, Olli; Collan, Juhani; Niemelä, Mika; Hernesniemi, Juha (2019)
    Background Pineoblastomas are very rare malignant lesions with a bad prognosis and high mortality during the first five years from diagnosis. Report of cases We present a retrospective review of three patients with histologically confirmed pineoblastomas consecutively operated on between 1997 and 2015. One of our patients died >14 years after surgery, and the other 2 patients are still alive and in good condition without recurrence of the disease >12 years after surgery. All of them underwent gross total resection and craniospinal radiotherapy. Individualized scheme of chemotherapy was administered in two cases. The cornerstones for the surgical resection of pineoblastomas are reported. Conclusions A proper multidisciplinary management of pineoblastomas, which associates gross total microsurgical resection of the lesion and an adjuvant therapy determined by our neurooncology team based on accurate craniospinal adjuvant radiotherapy with boost of radiation on the tumoral bed, and when needed, an adequate but aggressive medulloblastoma-like chemotherapy, may improve the overall survival of these malignant lesions.
  • Choque-Velasquez, Joham; Colasanti, Roberto; Resendiz-Nieves, Julio C.; Gonzales-Echevarria, Kleber E.; Raj, Rahul; Jahromi, Behnam Rezai; Goehre, Felix; Lindroos, Ann-Christine; Hernesniemi, Juha (2018)
    BACKGROUND: The sitting position has lost favor among neurosurgeons partly owing to assumptions of increased complications, such as venous air embolisms and hemodynamic disturbances. Moreover, the surgeon must assume a tiring posture. We describe our protocol for the "praying position" for pineal region surgery; this variant may reduce some of the risks of the sitting position, while providing a more ergonomic surgical position. METHODS: A retrospective review of 56 pineal lesions operated on using the praying position between January 2008 and October 2015 was performed. The praying position is a steeper sitting position with the upper torso and the head bent forward and downward. The patient's head is tilted about 30 degrees making the tentorium almost horizontal, thus providing a good viewing angle. G-suit trousers or elastic bandages around the lower extremities are always used. RESULTS: Complete lesion removal was achieved in 52 cases; subtotal removal was achieved in 4. Venous air embolism associated with persistent hemodynamic changes was nonexistent in this series. When venous air embolism was suspected, an immediate reaction based on good teamwork was imperative. No cervical spine cord injury or peripheral nerve damage was reported. The microsurgical time was CONCLUSIONS: A protocolized praying position that includes proper teamwork management may provide a simple, fast, and safe approach for proper placement of the patient for pineal region surgery.
  • Choque-Velasquez, Joham; Colasanti, Roberto; Fotakopoulos, George; Elera-Florez, Humberto; Hernesniemi, Juha (2017)
    BACKGROUND: Treatment of multiple intracranial aneurysms is particularly demanding and even more so in a developing country where access to specialized centers may be prevented by different factors. METHODS: Single-stage surgical treatment of 7 cerebral aneurysms was performed in a 58-year-old woman from the northern Peruvian Andes. RESULTS: All 7 aneurysms were successfully and safely clipped through 2 lateral supraorbital craniotomies. The double clip technique was used in 3 aneurysms to prevent any residual aneurysmai neck. CONCLUSIONS: Good teamwork and correct application of microsurgical principles may allow effective treatment in complex neurosurgical cases even in resourcechallenged environments.
  • Choque-Velasquez, Joham; Colasanti, Roberto; Baluszek, Szymon; Resendiz-Nieves, Julio; Muhammad, Sajjad; Ludtka, Christopher; Hernesniemi, Juha (2020)
    Introduction We present a consecutive case series and a systematic review of surgically treated pediatric PCs. We hypothesized that the symptomatic PC is a progressive disease with hydrocephalus at its last stage. We also propose that PC microsurgery is associated with better postoperative outcomes compared to other treatments. Methods The systematic review was conducted in PubMed and Scopus. No clinical study on pediatric PC patients was available. We performed a comprehensive evaluation of the available individual patient data of 43 (22 case reports and 21 observational series) articles. Results The review included 109 patients (72% females). Ten-year-old or younger patients harbored smaller PC sizes compared to older patients (p<0.01). The pediatric PCs operated on appeared to represent a progressive disease, which started with unspecific symptoms with a mean cyst diameter of 14.5 mm, and progressed to visual impairment with a mean cyst diameter of 17.8 mm, and hydrocephalus with a mean cyst diameter of 23.5 mm in the final stages of disease (p<0.001). Additionally, 96% of patients saw an improvement in their symptoms or became asymptomatic after surgery. PC microsurgery linked with superior gross total resection compared to endoscopic and stereotactic procedures (p<0.001). Conclusions Surgically treated pediatric PCs appear to behave as a progressive disease, which starts with cyst diameters of approximately 15 mm and develops with acute or progressive hydrocephalus at the final stage. PC microneurosurgery appears to be associated with a more complete surgical resection compared to other procedures.
  • Choque-Velasquez, Joham; Resendiz-Nieves, Julio C.; Rezai Jahromi, Behnam; Colasanti, Roberto; Raj, Rahul; Lopez-Gutierrez, Kenneth; Tynninen, Olli; Niemelä, Mika; Hernesniemi, Juha (2019)
    Background: Microsurgical resection represents a well-accepted management option for symptomatic benign pineal cysts. Symptoms such as a headache, hydrocephalus, and visual deficiency are typically associated with pineal cysts. However, more recent studies reported over the past years have characterized additional symptoms as a part of the clinical manifestation of this disease and represent additional indications for intervention. Methods: We present a retrospective review of patients with histologically confirmed benign pineal cysts that were operated on in our department between 1997 and 2015. A demographic analysis, evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiological outcomes were conducted. Results: A total of 60 patients with benign pineal cysts underwent surgery between 1997 and 2015. Gross total resection was achieved in 58 cases. All patients except one improved in their clinical status or had made a full recovery at the time of the last follow-up. The key steps for surgical resection of pineal cysts are reported, based on an analysis of representative surgical videos. Conclusions: We describe in this paper one of the largest series of microsurgically treated pineal cysts. In our opinion, judicious microsurgery remains the most suitable technique to effectively deal with this disease.