Virtual Endoscopic Simulations in Neurosurgery: Technical Considerations and Methodology

Virtual Endoscopic Simulations in Neurosurgery: Technical Considerations and Methodology AbstractBACKGROUND:Parasagittal meningiomas, especially when associated with the middle or posterior third of the superior sagittal sinus, pose difficult management challenges. Initial surgical excision is associated with high morbidity and frequent tumor recurrence after subtotal resection. Neurological deficits are cumulative when multiple resections are required. No consistent management approach exists for patients with such tumors. In addition to observation, management options include resection, stereotactic radiosurgery, or fractionated radiation therapy used alone or in combination.METHODS:Sixteen centers where resection, gamma knife radiosurgery, and/or radiation therapy were available provided management data on 203 patients with histologically benign meningiomas from the time of initial diagnosis through follow-up after radiosurgery. The timing of resections, parameters of radiosurgery, rates of tumor control, morbidity, and functional patient outcomes were studied. The median follow-up duration in this study was 3.5 years (maximum, 33 yr after presentation and 6 yr after radiosurgery).RESULTS:The tumors were located in the anterior superior sagittal sinus in 52 patients, at the middle of the sinus in 91, and at the posterior portion of the sinus in 60. The mean tumor volume at the time of radiosurgery was 10 cc. In patients who underwent radiosurgery as the primary therapy (n = 66), the 5-year actuarial tumor control rate was 93 ± 4%. No clinical failure (need for additional therapy or worsened neurological function) occurred in patients who had smaller tumors (> 7.5 cc) and who had never undergone resection (n = 41). The 5-year control rate for patients with previous surgery was only 60 ± 10%; the control rate for the radiosurgerytreated volume was 85%. Most failures resulted from remote tumor growth. Multivariate analyses identified significantly decreased tumor control with increasing tumor volume (P - 0.002) and previous neurological deficits (P = 0.002). The rate of transient, symptomatic edema after radiosurgery was 16%, was more common with larger tumors, and occurred within 2 years. Of 33 patients who were employed at the time of radiosurgery ter whom a minimum of 1 year of follow-up data were available, 30 remained employed (91%). A decrease in functional status after radiosurgery was noted in only 3 of 33 (9%) employed and 7 of 77 (9%) unemployed patients.CONCLUSION:In patients with smaller tumors (< 3 cm in diameter) and patent sagittal sinuses, we advocate radiosurgery alone as the first surgical procedure. Patients with larger tumors and those with progressive neurological deficits resulting from brain compression should first undergo resection. Planned second-stage radiosurgery should be performed soon afterward for any residual tumor nodule or neoplastic dural remnant. Multimodality management may enhance long-term tumor control, reduce the need for multiple resections, and ma'ntain the functional status of the patient. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Virtual Endoscopic Simulations in Neurosurgery: Technical Considerations and Methodology

Virtual Endoscopic Simulations in Neurosurgery: Technical Considerations and Methodology

538 Auer and Auer the unusual case of a colloid cyst beneath a distorted veil of shorter hospitalization will be more greatly valued com pared fornix and midline septum. The simulation would undoubt­ with open craniotomy. edly alter the su rg eo n 's approach in this instance. Without This article by Auer and Auer reviews a software sim u la ­ that information, the conventional coronal approach burr hole tion package that allows the virtual perform ance of an e n d o ­ would have been an unsatisfactory trajectory. scopic procedure on a patient through a b u rr hole, alerting the C o m m e n ts regarding the use of the software in simulation physician to the appropriateness of his or her elected trajec­ versus incorporation of this software in frameless stereotaxy tory path, anatomic landm arks for orientation along this path, apparatus with the n eu ro en d o sco p e w ould be of value in and potential pitfalls of the trajectory for adequate access. em p h asizin g som e of the unusual ap proaches that are dis­ Further, the software package allows the surgeon to therefore cussed. Specifically, the authors discuss the evacuation of an customize or individualize the approach by exploring a vari­ intracerebellar hem ato m a using a posterior fossa burr hole ety of trajectories and the anatom y encountered toward the approach. Although sim ple in concept, this procedure is ex­ target. H owever, the present software package is limited by ceedingly d angerous adjacent to the floor of the fourth ven­ inadequate coloration of tissues, as well as vasculature a p ­ tricle without accurate intraoperative real-time guidance for pearance. The latter may be of key im portance in executing an the positioning of the en d o sco p e and the use of irrigation endoscopic procedure safely because of the lack of good h e ­ fluids to evacuate the hem atom a. I think that this artide mostatic tools. This limitation represents perhaps the...
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Publisher
Oxford University Press
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© Published by Oxford University Press.
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1097/00006123-199809000-00075
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Abstract

AbstractBACKGROUND:Parasagittal meningiomas, especially when associated with the middle or posterior third of the superior sagittal sinus, pose difficult management challenges. Initial surgical excision is associated with high morbidity and frequent tumor recurrence after subtotal resection. Neurological deficits are cumulative when multiple resections are required. No consistent management approach exists for patients with such tumors. In addition to observation, management options include resection, stereotactic radiosurgery, or fractionated radiation therapy used alone or in combination.METHODS:Sixteen centers where resection, gamma knife radiosurgery, and/or radiation therapy were available provided management data on 203 patients with histologically benign meningiomas from the time of initial diagnosis through follow-up after radiosurgery. The timing of resections, parameters of radiosurgery, rates of tumor control, morbidity, and functional patient outcomes were studied. The median follow-up duration in this study was 3.5 years (maximum, 33 yr after presentation and 6 yr after radiosurgery).RESULTS:The tumors were located in the anterior superior sagittal sinus in 52 patients, at the middle of the sinus in 91, and at the posterior portion of the sinus in 60. The mean tumor volume at the time of radiosurgery was 10 cc. In patients who underwent radiosurgery as the primary therapy (n = 66), the 5-year actuarial tumor control rate was 93 ± 4%. No clinical failure (need for additional therapy or worsened neurological function) occurred in patients who had smaller tumors (> 7.5 cc) and who had never undergone resection (n = 41). The 5-year control rate for patients with previous surgery was only 60 ± 10%; the control rate for the radiosurgerytreated volume was 85%. Most failures resulted from remote tumor growth. Multivariate analyses identified significantly decreased tumor control with increasing tumor volume (P - 0.002) and previous neurological deficits (P = 0.002). The rate of transient, symptomatic edema after radiosurgery was 16%, was more common with larger tumors, and occurred within 2 years. Of 33 patients who were employed at the time of radiosurgery ter whom a minimum of 1 year of follow-up data were available, 30 remained employed (91%). A decrease in functional status after radiosurgery was noted in only 3 of 33 (9%) employed and 7 of 77 (9%) unemployed patients.CONCLUSION:In patients with smaller tumors (< 3 cm in diameter) and patent sagittal sinuses, we advocate radiosurgery alone as the first surgical procedure. Patients with larger tumors and those with progressive neurological deficits resulting from brain compression should first undergo resection. Planned second-stage radiosurgery should be performed soon afterward for any residual tumor nodule or neoplastic dural remnant. Multimodality management may enhance long-term tumor control, reduce the need for multiple resections, and ma'ntain the functional status of the patient.

Journal

NeurosurgeryOxford University Press

Published: Sep 1, 1998

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