Browsing by Subject "Supracerebellar infratentorial approach"

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  • 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.
  • 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; Miranda-Solis, Franklin; Colasanti, Roberto; Angel Ccahuantico-Choquevilca, Luis; Hernesniemi, Juha (2018)
    OBJECTIVE: In recent decades endoscopic techniques have been increasingly used in neurosurgery as they may offer a valuable close-up view of the working area through a minimally invasive surgical corridor. Herein, we present an inexpensive and efficient endoscopic surgical model using a borescope, which was used for a "modified pure endoscopic approach" to the pineal region. METHODS: A borescope video camera was connected to a 16-inch personal computer monitor. A standard midline suboccipital craniotomy was performed on 2 cadaveric heads in the Concorde position. Then, a "borescopic" supracerebellar infratentorial approach was executed, thus reaching the pineal region, which was exposed through an extensive arachnoid dissection. RESULTS: Using the previously described model, we were able to provide excellent exposure of the main neurovascular structures of the pineal region, as shown by the intraoperative videos. In 1 specimen we identified an incidental pineal cyst that was meticulously dissected and removed. CONCLUSIONS: Our proposed "borescopic" surgical model may represent an inexpensive and efficient alternative to conventional endoscopic techniques and could be used for training purposes, as well as even for clinical procedures, after a proper validation, particularly in economically challenging environments.
  • 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; 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.