SUMMARY: Dr. Noriko Salamon reviews a series of cases of Skull base lesions from their radiographic appearance. These are well presented and Dr. Salamon points out the challenges in their appearance on Imaging. Excellent talk. 60 Minutes Best for Video.

SUMMARY: Drs Tiffany Grace Perry from USA and Hugues Dokoponou from Benin, Africa review their experience with the management of Thoraco Lumbar Spine Fractures in this Symposium with global discussion. Cases of Spondyloptosis,  all with and without neurological deficit are presented for discussion. How would you manage these cases?  Join the discussion to see what others would do. From Subsaharan African Grand Rounds.  2 hours- Good for Video.  

SUMMARY: This is the recording of the 1st Latin American International Grand Rounds with SNI Digital® and the Latin American Neurosurgeons exchanging their experiences with a world audience. This meeting was organized by Joham Choque-Velasquez, MD, PhD of Cuzco, Peru. The title of the presentations were “Management of Middle Cerebral Aneurysms: Microsurgery vs Interventional Neurosurgery.”

The first lecture discussion was given by Dr. Kléber Eduardo González Echiverria of Ecuador. Dr Gonzales-Echiverria discussed the anatomy of the Middle Cerebral vessels and his use of a Pterional or a Supra-orbital approaches related to cerebral swelling.He mentioned he uses intra-operative neuronal monitoring-evoked potentials, to help him determine the length of temporary clipping. There was a wide discussion of the use of brain protection measures for temporary clipping from none, to intermittent clip release, to chemical cardiac arrest, which Professor Hernesniemi used frequently with success. Joham describe this technique in detail and Ramisis Ghaly, a boarded neurosurgeon, anesthesiologist and Critical care and Pain specialist, commented on the use of Cardiac Arrest during aneurysm surgery. Also discussed was how to treat SAH with an aneurym and AVM.

The second lecture was given by Dr. Giancarlo Saal Zapata MD, of Lima, Peru who has a very large experience with interventional neurosurgery techniques. He presented a series of cases of MCA aneurysms and reviewed his experience with coiling , etc, which was very good. There is some selection in his series because of referrals. Yet his experience is very good. There was a wide discussion with the international audience on how each approached Middle Cerebral Aneurysm Management. Each neurosurgeon has to do what his/her environment and resources will allow, anywhere. Given the best surgeon and interventional doctor's approaches, coiling appears to be the first choice, but many factors have to be considered in each case separately. There is no consensus because there are too many variables to consider. Like for basilar tip aneurysms, intervention is the preferred choice and each aneurysm location may have a preferred choice; See SNI Digital discussion among neurosurgeons on this subject:

Excellent Discussion of a controversial topic everywhere. Best for Video; Images needed for podcast but Discussion is valuable. In two parts 60 minutes each for 120 minutes total. Need to be seen together to benefit from the Discussion. (JIA)

SUMMARY: Sub-Saharan African International Neurosurgery Grand Rounds; Professors N. Mwang'ombe (Kenya) presents two interesting cases of penetrating injuries of the skull and brain. He and the International audience comment on how these cases are treated in different places around the world. Questions & Answers from the global audience  cover the spectrum of  challenges faced by neurosurgeons in this on this topic. Should the Projectile or Bullet be removed; How?; leaving the bullet; removing the bullet with Neuro-navigation and ultra-sound guided surgery; What tests are needed before surgery?; time, cost, geographical location, location in brain or spinal canal, age of patient; compromising circumstances; antibiotics; and needs for drainage and more are discussed.  (JIA) 

Dr. Epstein follows with a review of the disc lesions in the lumbar spine and their clinical presentations; and the prevention and management of CSF leaks. 100 minutes all with Discussion.  (JIA)   

This presentation includes 2 cases of transplanum transtubercle transsellar approach, used for endonasal endoscope-controlled removal of small to moderate sized tuberculum sellae meningiomas. The importance of arachnoid-meningioma dissection plane emphasized: case 1 (2023; slides only) with well preserved arachnoid and case 2 (2012; video) with invaded and absent arachnoid.

Presentation includes detailed close-view of anatomical details of suprasellar region. Preserved arachnoid plane makes dissection easier and safer. Arachnoid protects microvasculature to anterior optic apparatus, to stalk and optic nerves and chiasm and results in better outcome. At the end of slide show, there is a bonus video of another opposite early case from 2012, where arachnoid was invaded and dissection of meningioma from the flattened optic nerves and chiasm and preservation of chiasmatic vasculature was more challenging and difficult (resulted in new bitemporal hemianopsia). Opening of the dural sleeve of optic nerve and it relation to distal dural ring is shown. The dural attachment of TBS meningioma (the outgrowth point), tipically from tuberculum sellae dura medial to optic nerve, was excised (no recidiv till today - after 14 years). The evolution of surgical technique is also obvious. Debulking first is always recommended and would ease removal.

Suggested literature

BOŠNJAK, Roman. Endoscopic endonasal excision of meningiomas. In: DEOPUJARI, Chandrashekhar (ur.), QURESHI, Mahmood (ur.), THOMBRE, Bhushan (ur.). WFNS guide for neuroendoscopy. Mumbai: Salubris Medical Publishers, 2022. Str. 113-124, ilustr. ISBN 978-81-956012-2-6. [COBISS.SI-ID 203555587]
Link: www.neurosurgery-prof-bosnjak.com (see Publications)

Khan OH, Krischek B, Holliman D, et al. Pure endoscopic expanded endonasal approach for olfactory groove and tuberculum sellae meningiomas. J Clin Neurosci. 2014;21:927-933

Magill ST, Morshed RA, Lucas CG, Aghi MK, Theodosopoulos PV, Berger MS, de Divitiis O et al. Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach. Neurosurg Focus. 2018 Apr;44(4):E9. doi: 10.3171/2018.1.FOCUS17753.

Giammattei L , Starnoni D , Cossu G, Bruneau M, Cavallo LM, Cappabianca P et al. Surgical management of tuberculum sellae meningiomas: Myths, facts, and controversies. Acta Neurochir (Wien) 2020 Mar;162(3):631-640. doi: 10.1007/s00701-019-04114-w.

Khan OH, Anand VK, Schwartz TH. Endoscopic endonasal resection of skull base meningiomas: the significance of a "cortical cuff" and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection. Neurosurg Focus 2014;37(4):E7. doi: 10.3171/2014.7.FOCUS14321.  

Kong, D.-S., Hong, C.-K., Hong, S. D., Nam, D.-H., Lee, J.-I., Seol, H. J., … Kim, Y. H. (2018). Selection of endoscopic or transcranial surgery for tuberculum sellae meningiomas according to specific anatomical features: a retrospective multicenter analysis (KOSEN-002). J Neurosurg 2018 May 18;130(3):838-847, doi:10.3171/2017.11.jns171337

Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, et al. ICAR: endoscopic skull base surgery. Int Forum Allergy Rhinol. 2019 Jul;9(S3):S145-S365. doi: 10.1002/alr.22326.

Xiao L, Xie S, Tang B, Hu J, Hong T. Endoscopic endonasal anterior clinoidectomy: surgical anatomy, technique nuance, and case series. J Neurosurg. 2019 Jul 5:1-11. doi: 10.3171/2019.4.JNS183213. Online ahead of print.                           

SUMMARY: Dr. Russell Blaylock discusses the metabolic condition of the patient pre-operatively, during the surgery and post-operatively. 50-90 % of the patients before surgery are nutritionally deficient in essential Vitamins, Minerals, and Co-factors as necessary components of the millions of biochemical reactions in the cells of the body to overcome the metabolic challenges of surgery, which is similar to that of a patient with 30% burns. The preoperative patient may be on the edge of metabolic homeostasis but is not prepared to biochemically to withstand the challenge of the surgical trauma. Similarly the immune systems are compromised even pre-operatively in evaluations of pre-operative patients assumed to be normal. The intense metabolic demands of the surgery and in the post-operative state are unable to be met without compromising the large number of biochemical reactions the patient encounters with surgical trauma. These defects compromise the patient's recovery, most often ignored by and unknown to most physicians. The aging patient is further compromised as they are more deficient in the enzymes required to carry out these biochemical reactions and require more supplementation to overcome these metabolic changes. Millions of cells are mobilized during and after surgery creating a huge dietary demand to support the healing responses and metabolic repair processes.  Sugar water is insufficient to meet these needs without catabolizing other organ systems in the body leading to post complications. A patient's water soluble vitamins are all gone from the body 24 hours after surgery, making this metabolic crisis worse. Biochemical reactions are constantly producing  hyperactive molecules (Free Radicals) which represent a danger to other biochemical reactions. With surgery and metabolic stress many more free radicals are produced and require anti-oxidants which neutralize this hyperactive state. Thus, there is a need in these patients for antioxidants, in addition,  pre- and pos-operatively. He ends with a list of recommended vitamins, anti oxidants, and supplements.

 Part 1 of this 2 part series reviews the essential nutrients to help off-set these major challenges to the body. Part 2 discusses the metabolic challenges during surgery and after surgery which need to be understood to improve outcomes of surgical patients. (Part 1,  37 minutes with discussion)