Publications by authors named "Matías Baldoncini"

21 Publications

  • Page 1 of 1

Transcondylar Fossa Approach for Resection of Anterolateral Foramen Magnum Meningioma: 2D Operative Video.

World Neurosurg 2021 Jul 21. Epub 2021 Jul 21.

Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2021.07.058DOI Listing
July 2021

Morphometric analysis of posterior cranial fossa and surgical implications.

J Craniovertebr Junction Spine 2021 Apr-Jun;12(2):178-182. Epub 2021 Jun 10.

Department of Neurosurgery, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Background: Posterior cranial fossa (PCF) is an important area in terms of anatomy and surgery. It is a common site of many neoplastic, vascular, and degenerative lesions. Craniovertebral surgeries require special attention regarding detailed information about the morphology and morphometry of this region. The aim of this study was to analyze the morphometric characteristics of PCF and distances between the inner base of the skull.

Materials And Methods: An observational, retrospective cross-sectional study was made. Fifty-five dry human skulls of unknown sex were measured ascertained using digital Vernier caliper with 0.01 mm precision.

Results: The morphometric analysis of the mean length and width of the FM was 34.51 mm and 29.85 mm, respectively. We found a significant difference ( < 0.05) among the distance between the posterior tip of occipital condyle and basion of the right and left sides.

Conclusion: According to our observations, the present study yielded detailed morphometry of the PCF and neurovascular relationship. It can facilitate successful instrumentation and minimize neurovascular injuries. Furthermore, it provides safe and suitable data for guiding neurosurgical procedures. The major limitation of this study was the lack of knowledge regarding the age and gender of the participants whose skull base was studied.
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http://dx.doi.org/10.4103/jcvjs.jcvjs_205_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214228PMC
June 2021

Interhemispheric Contralateral Transfalcine Approach for Subparacentral Arteriovenous Malformation: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jun 29. Epub 2021 Jun 29.

LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina.

Neurovascular procedures along the interhemispheric fissure harbor unique features differentiating them from those arteriovenous malformations (AVMs) located at the lateral surface of the brain.1-4  The aim of this 3-dimensional operative video is to present a microsurgical resection of an AVM in a subparacentral location, operated through an interhemispheric contralateral transfalcine approach.1,3,5  This is a case of a 29-yr-old female, with headaches and history of seizures. The patient presented an interhemispheric bleeding 6 mo before the surgery. The magnetic resonance imaging (MRI) showed a vascular lesion located on the medial surface of the right hemisphere at the confluence between the cingulate sulcus and its ascending sulcus. In the cerebral angiography, a right medial AVM was observed, receiving afference from the right anterior cerebral artery and draining to the superior longitudinal sinus. The patient signed an informed consent for the procedure and agreed with the use of her images and surgical video for research and academic purposes.  The patient was in a supine position, and a left interhemispheric contralateral transfalcine approach was performed,1-3 a circumferential dissection of the nidus, and, finally, the AVM was resected in one piece.  The patient evolved without neurological deficits after the surgery. The postoperative MRI and angiography showed a complete resection of the AVM.  In the case presented, to avoid exposing the drainage vein first and to use the gravity of the exposure, the contralateral transfalcine interhemispheric approach was used,1,2 which finally accomplished the proposed objectives.
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http://dx.doi.org/10.1093/ons/opab198DOI Listing
June 2021

Optic Nerve Mobilization as an Alternative to Anterior Clinoidectomy for Superior Carotid-Ophthalmic Aneurysms: Operative Technique.

World Neurosurg 2021 Jun 12;152:137-143. Epub 2021 Jun 12.

Department of Neurosurgery, Padilla Hospital, Tucumán, Argentina.

Background: Carotid-ophthalmic aneurysms arise from the internal carotid artery between the distal dural ring and the origin of the posterior communicating artery. The surgical treatment of these aneurysms usually requires anterior clinoidectomy. However, this procedure is not without complications. In the present report, we have described optic nerve mobilization after optic foraminotomy as an alternative to anterior clinoidectomy to clip superior carotid-ophthalmic aneurysms.

Methods: We have reported the cases of 3 patients with superior carotid-ophthalmic aneurysms who had undergone surgical clipping. Instead of an anterior clinoidectomy, the optic nerve was mobilized after performing optic foraminotomy. The optic canal was carefully unroofed with a 3-mm, high-speed, diamond drill under constant cold saline irrigation to avoid thermal damage to the optic nerve. After incision of the falciform ligament and optic sheath, the optic nerve was gently mobilized with a No. 6 Penfield dissector, facilitating aneurysmal neck exposure and clipping through a widened opticocarotid triangle.

Results: The postoperative course was uneventful for all 3 patients, without any added visual defect. Optic nerve mobilization allowed us to safely widen the opticocarotid triangle and dissect the aneurysm off the optic nerve, without the need for clinoidectomy. This alternative technique permitted, not only early decompression of the optic nerve, but also dissection of the arachnoid between the inferior surface of the optic nerve and the superior surface of the ophthalmic-carotid artery and aneurysm dome.

Conclusions: Optic nerve mobilization after optic foraminotomy proved to be a safe and relatively easy technique for exposing and treating superior carotid-ophthalmic aneurysms.
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http://dx.doi.org/10.1016/j.wneu.2021.06.008DOI Listing
June 2021

Use of Neuroanatomic Knowledge and Neuronavigation System for a Safe Anterior Petrosectomy.

Brain Sci 2021 Apr 12;11(4). Epub 2021 Apr 12.

LINT, Facultad de Medicina, Universidad Nacional de Tucumán, T4000 Tucumán, Argentina.

Introduction: The petroclival region is among the most challenging anatomical areas to deal with in skull base surgery. Drilling of the anterior part of the petrous bone during the anterior transpetrosal approach involves the risk of injury of the cochlea, superior semicircular canal, internal carotid artery, and internal auditory canal. A thorough understanding of the microneurosurgical anatomy of this region is mandatory to execute the transpetrosal approaches, decreasing the risk of complications. The aim of this study is to describe the anatomical structures of the petroclival region, highlighting the importance of neuronavigation for safe performance of the anterior transpetrosal approach.

Methods: Three adult cadaveric human heads were formalin-fixed and injected with colored silicone. They underwent an axial 1 mm slab CT scan, which was used for neuronavigation during the surgical approaches. The anterior petrosectomy was performed with the aid of neuronavigation during the drilling of the petrous bone. The surgical management of a patient harboring a petroclival meningioma, operated on using an anterior transpetrosal approach, was reported as an illustrative case.

Results: The anterior petrosectomy was completed accurately with wide exposure of the surgical target without injuring the cochlea and other structures in all three cadaveric specimens. In the surgical case, no approach-related complications occurred, and a gross total resection of the tumor was achieved.

Conclusions: Deep knowledge of the location and relationships of the vital elements located within the temporal bone, along with the use of neuronavigation, are the key aspects to perform the anterior transpetrosal approach safely, reducing the risk of complications.
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http://dx.doi.org/10.3390/brainsci11040488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8069204PMC
April 2021

Microsurgical Resection of a Chiasmatic Cavernoma: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jun;21(1):E46-E47

Department of Neurological Surgery, Hospital San Fernando, Buenos Aires, Argentina.

According to reports from the literature,1,2 depending on the location where cavernomas appear, range from the very common locations to unusual. Cavernous malformations arising from the optic nerve and chiasm are rare, with only few cases reported to date.3-5  We present a case of a 28-yr-old man who suddenly started with sever visual loss in the right eye and homonymous lateral hemianopia in the left eye. Because of the acute symptomatology, a brain MRI was immediately performed in order to diagnose the etiology. The MRI showed a chiasmatic mass with right extension, heterogeneous on T1 and T2 sequences, without enhancement after gadolinium. The surgery was carried out a week after the diagnosis. A right pterional transsylvian approach was performed and the cavernoma was resected with microsurgical maneuvers, preserving the optic nerve fibers, chiasm, and optic tract.  The patient evolved favorably, improving the visual deficit in the postoperative period as can be observed in the postoperative visual field study 7 mo after the surgery.  The patient signed an informed consent for the procedure and agreed with the use of his images and surgical video for research and academic purposes.  Our surgical case emphasizes the importance of a prompt diagnosis and surgery for chiasmatic cavernomas3 associated to visual loss, providing early decompression of the optic apparatus and improvement of the visual field defects after surgery.
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http://dx.doi.org/10.1093/ons/opab063DOI Listing
June 2021

Double-Stage Complete Removal of Dumbbell-Shaped Trigeminal Schwannoma: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jun;21(1):E51

LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina.

Intracranial trigeminal schwannomas are rare tumors.1-4 The aim of this 3-dimensional operative video is to present a double stage complete removal of a dumbbell-shaped trigeminal schwannoma. This is a 25-yr-old male with headaches, diplopia, and facial pain. The MRI shows a big tumor located at the level of the cerebellopontine angle, petroclival region, and middle fossa. Because of the size of the tumor and its growth within the cerebellopontine angle, we decided to operate the patient in two stages. For the first surgery, the patient was in a semi-sitting position, and a retrosigmoid approach was performed. The second surgery was performed 2 mo after the first operation in a supine position for a pretemporal transzygomatic approach. The pathological study was reported as a schwannoma, and the histological findings were spindle cell lesion with a storiform pattern and histiocytes. The patient evolved without neurological deficit after the surgeries, and the postoperative MRI shows a complete resection of the tumor. The patient gave the consent to use the images and surgical video. Preoperative imaging plays an important role in diagnosis and surgical planning.3-6 For these cases of trigeminal schwannomas with a large extension in the posterior fossa and middle fossa, we believe that the most prudent thing is to perform the surgery in 2 stages.3.
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http://dx.doi.org/10.1093/ons/opab062DOI Listing
June 2021

An alternative path to atrial lesions through a contralateral interhemispheric transfalcine transcingular infra-precuneus approach: A case report.

Surg Neurol Int 2020 25;11:407. Epub 2020 Nov 25.

Department of Neuropsychology, Hospital Privado de Rosario, Rosario, Santa Fe, Argentina.

Background: The surgical management of lesions located in the trigone of the lateral ventricle remains a neurosurgical challenge. Previously described approaches to the atrium include the transtemporal, parietal transcortical, parietal trans intraparietal sulcus, occipital transcingulate, posterior transcallosal, and transfalcine transprecuneus. However, reaching this area specifically through the cingulate cortex below the subparietal sulcus has not been described thus far.

Case Description: We present here the removal of a left atrial meningioma through a right parietal "contralateral interhemispheric transfalcine transcingular infra-precuneus" approach and compare it with previously described midline approaches to the atrium. To accomplish this, a right parietal craniotomy was performed. After the left subprecuneus cingulate cortex was exposed through a window in the falx, a limited corticotomy was performed, which allowed the tumor to be reached after deepening the bipolar dissection by 8 mm. Postoperative magnetic resonance imaging showed complete resection of the lesion sparing the corpus callosum, forceps major, and sagittal stratum. Although this approach disrupts the posterior cingulate fasciculus, no deficits have been described so far after unilaterally disrupting the posterior cingulate cortex or the posterior part of the cingulate fasciculus. In fact, a thorough postoperative cognitive examination did not show any deficits.

Conclusion: The "contralateral interhemispheric transfalcine transcingular infra-precuneus" approach combines the advantages of several previously described approaches. Since it conserves the major white matter tracts that surround the atrium and has a shorter attack angle than the contralateral transfalcine transprecuneus approach, we believe that it could be a potentially new alternative path to reach atrial lesions.
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http://dx.doi.org/10.25259/SNI_608_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749951PMC
November 2020

Extradural Remodeling in Empty Sella Syndrome: 3-Dimensional Operative Video.

World Neurosurg 2021 03 6;147:66. Epub 2021 Jan 6.

LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina; Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina.

Sellar arachnoidocele is a term used to define the herniation of the subarachnoid space to the sella. This is a rare radiologic finding that, in most cases, does not require treatment. When symptoms appear, the term empty sella syndrome is used. Two varieties exist: primary and secondary empty sella syndrome. The aim of this 3-dimensional operative video (Video 1) is to demonstrate the extradural microsurgical remodeling of the sellar fossa with autologous bone in 2 cases of primary empty sella syndrome. Both patients signed an informed consent for the procedures and agree with the use of their images for research purposes. In both cases, magnetic resonance imaging scans showed herniation of the subarachnoid space into the pituitary fossa and an anchor-like silhouette on coronal view. Patients evolved favorably, improving their visual deficit after the surgery, as can be observed in the postoperative visual field study. If surgery is indicated due to visual loss, the procedure is known as chiasmapexy. Recently, Guinto et al described a technique for chiasmapexy. Our team considers this procedure to be useful, technically simple, and low cost. Being autologous, rejection possibilities are almost null. This 3D video serves as a complement to illustrate the technique.
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http://dx.doi.org/10.1016/j.wneu.2020.12.065DOI Listing
March 2021

Meningo-orbital band detachment: A key step for the extradural exposure of the cavernous sinus and anterior clinoid process.

J Clin Neurosci 2020 Nov 23;81:367-377. Epub 2020 Oct 23.

LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina; Servicio de Neurocirugía, Hospital Padilla, Tucumán, Argentina.

The meningo-orbital band (MOB) is the most superficial dural band that tethers the fronto-temporal dura to the periorbita. It is usually encountered when performing a pterional or fronto-temporo-sphenoidal approach, and it disrupts surgical access to deeper regions. Our objective was to perform a detailed anatomy study and a stepwise method to successfully detach the MOB using cadaveric specimens. We used six formalin-fixed, silicone-injected cadaveric heads. On each side, we performed a pterional approach plus mini-peeling of the anterior third of the middle fossa and/or extradural anterior clinoidectomy. We also applied this technique in three clinical cases to prove its safety and efficacy. The detachment of the MOB consists in four steps, 1) detachment of the temporal and frontal dura, 2) cutting of the MOB, 3) exposure and drilling of the anterior clinoid process, and 4) pealing of the lateral wall of the cavernous sinus. Using clinical cases, we explain how to adapt the technique depending on the localization of the lesion. The detachment of the MOB is the key to safely expose the cavernous sinus and the anterior clinoid process. The authors proposed a step-by-step method for the safe and effective detachment of the MOB. It is recommended, particularly to less experienced neurosurgeons that are starting with skull base surgery, and also to experts that want to expand their knowledge.
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http://dx.doi.org/10.1016/j.jocn.2020.09.055DOI Listing
November 2020

Safe Zones for Temporal Muscle Hook Retraction: A Technical Note.

World Neurosurg 2020 10 27;142:63-67. Epub 2020 Jun 27.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: The temporal muscle (TM) needs to be dissected and reflected downward in some anterolateral cranial approaches, and failing to preserve its integrity could have severe functional and cosmetic consequences. Most articles focus on techniques to prevent vascular injury during retrograde dissection or techniques to preserve the facial nerve; however, information on how to take care of the muscle during hook retraction is limited. We presented an anatomic study of vascularization of the TM, and we established safe areas for muscular hook retraction.

Methods: We dissected 16 TMs in 8 cadaveric heads. The TM was reflected downward, and we measured the distance between the anterior branch of the posterior deep temporal artery (PDTA) and the frontozygomatic suture and the distance between the posterior branch of the PDTA and the external auditory meatus projection.

Results: The average distance between the anterior branch of the PDTA and the frontozygomatic suture was 19.5 mm (range, 14-26 mm). The average distance between the posterior branch of the PDTA and the external auditory canal was 37.1 mm (range, 31-43 mm). We established 2 safe zones for hook placement: an anterior safe zone 14 mm posterior to the frontozygomatic suture and a posterior safe zone 30 mm anterior to the external auditory meatus.

Conclusions: We delimited 2 safe zones for hook placement during TM retraction aiming to avoid direct vascular damage in anterolateral cranial approaches.
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http://dx.doi.org/10.1016/j.wneu.2020.06.187DOI Listing
October 2020

Neuroanatomical basis of Wallenberg syndrome.

Cir Cir 2020 ;88(3):376-382

Facultad de Medicina, Universidad Autónoma de México (UNAM), Ciudad de México, México.

Wallenberg syndrome, or lateral medullar syndrome, is the clinical presentation of the infarct in the territory of posterior inferior cerebellar artery. Its signs and symptoms include vertigo, nystagmus, diplopia, ipsilateral Horner syndrome, facial ruddiness and dry skin, dysphonia, dysphagia, dysarthria, ipsilateral loss of gag reflex, ipsilateral ataxia, ipsilateral impaired taste, ipsilateral facial pain and paresthesia, decreased ipsilateral blink reflex, contralateral hypoalgesia and thermoanaesthesia in the trunk and limbs; and ipsilateral facial hypoalgesia and thermoanaesthesia. Neuroanatomical knowledge is essential to its comprehension, study and diagnosis, because the classic neurological manifestations are easy to explain and understand if function and localization of affected anatomical structures are known as if the posterior cerebral circulation is.
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http://dx.doi.org/10.24875/CIRU.19000801DOI Listing
May 2021

Orbitomeningeal Band in Transcavernous Dissection and Anterior Clinoidectomy: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 Sep;19(4):E414

LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina.

The orbitomeningeal or meningo-orbital band (MOB) has been described as the most superficial dural band responsible for tethering the frontotemporal basal dura to the periorbita.1,2 The MBO usually interferes with the surgical approach to the most profound areas of the anterior and middle skull base. It is known that there are no cranial nerves on the lateral surface of the superior orbital fissure; therefore, the neurosurgeon can cut the MOB without causing any neurological deficit and, at the same time, achieving fully exposure of the anterior clinoid process1-4 and/or the lateral wall of the cavernous sinus.5 The purpose of this video is to describe the microsurgical anatomy of the MOB and illustrate the technique for its detachment, accompanied by 2 illustrative cases. To achieve this, we use 3-dimensional recordings of 2 cadaveric specimens' dissections performed by the senior author. Case 1: 58-yr-old female with left blindness. Magnetic resonance imaging (MRI) shows an anterior and middle skull base lesion with orbital compression. Case 2: 32-yr-old male presenting with headache and trigeminal neuralgia. The MRI revealed an hourglass-shaped lesion in the posterior and middle fossa. Both patients signed an informed consent and agree with the use of their images for research purposes. We used a step-by-step approach for an adequate and secure dissection of the MOB highlighting the anatomic structures involved in the process. This approach allows safe and adequate access to the deeper structures of the anterior and middle skull base.
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http://dx.doi.org/10.1093/ons/opaa037DOI Listing
September 2020

Anterior peri-insular quadrantotomy: a cadaveric white matter dissection study.

J Neurosurg Pediatr 2019 Dec 20:1-9. Epub 2019 Dec 20.

2Department of Neurosurgery, University Hospital of Lausanne, Switzerland.

Objective: Anterior quadrant disconnection represents a safe surgical option in well-selected pediatric patients with a large frontal lobe lesion anterior to the motor cortex. The understanding of the anatomy of the white matter tracts connecting the frontal lobe with the rest of the cerebrum forms the basis of a safe and successful disconnective surgery. The authors explored and illustrated the relevant white matter tracts sectioned during each surgical step using fiber dissection techniques.

Methods: Five human cadaveric hemispheres were dissected to illustrate the frontal connections in the 3 planes. The dissections were performed from lateral to medial, medial to lateral, and ventral to dorsal to describe the various tracts sectioned during the 4 steps of this surgery, namely the anterior suprainsular window, intrafrontal disconnection, anterior callosotomy, and frontobasal disconnection.

Results: At the beginning of each surgical step, the U fibers were cut. During the anterior suprainsular window, the superior longitudinal fasciculus (SLF), the uncinate fasciculus, and the inferior fronto-occipital fasciculus (IFOF) were visualized and sectioned, followed by sectioning of the anterior limb of the internal capsule. During the intrafrontal disconnection, the SLF was cut, along with the corona radiata. At the medial surface the cingulum was sectioned. The anterior callosotomy disconnected the anterior third of the body of the callosum, the genu, and the rostrum. The frontobasal disconnection addressed the last remaining fibers connecting the frontal lobe with the rest of the hemisphere, namely the anterior limb of the anterior commissure.

Conclusions: The anterior peri-insular quadrantotomy aims at effectively treating children with large lesions of the frontal lobe anterior to the motor cortex. A precise understanding of the gyral anatomy of this lobe along with the several white matter connections is crucial to avoid motor complications and to ensure complete disconnection.
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http://dx.doi.org/10.3171/2019.10.PEDS19472DOI Listing
December 2019

Supracerebellar-Infratrochlear Approach for Midbrain Cavernoma: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 08;19(2):E151

LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina.

Gravity retraction is an underutilized adjunct in neurosurgery. Gravity is gentler than retractor blades; it does not cause brain edema or injury, and it tends to open natural subarachnoidal plans to deep lesions.1-3 A good example of this is the supracerebellar infratrochlear approach4-7 in semisitting position for resection to a midbrain cavernous malformation. This approach was selected because the cavernous malformation was 1 mm under the lateral mesencephalic sulcus. The procedure was developed with the use of transesophageal ultrasound and physiological neuromonitoring. We present a 3-dimensional video of this surgery with all the tricks and details used in the procedure. The patient consented to the procedure and to publication of the photos and surgical video.
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http://dx.doi.org/10.1093/ons/opz386DOI Listing
August 2020

Anterolateral Approach for Retrostyloid Superior Parapharyngeal Space Schwannomas Involving the Jugular Foramen Area: A 20-Year Experience.

World Neurosurg 2019 Dec 11;132:e40-e52. Epub 2019 Sep 11.

Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Background: Schwannomas encompassing the superior parapharyngeal space are challenging lesions because of the anatomical complexity of this region and the frequent involvement of the neurovascular structures of the jugular foramen. The purpose of this study is to report the technical aspects and the advantages of the anterolateral approach, here proposed for schwannomas of this complex area.

Methods: The main steps of the anterolateral approach are described in detail, along with the results of a consecutive series of 38 patients with a retrostyloid superior parapharyngeal schwannoma involving the jugular foramen operated on by means of this route between 1999 and 2019.

Results: The supine position is generally preferred. The medial border of the sternocleidomastoid muscle, mastoid tip, and superior nuchal line are the landmarks for the hockey-stick skin incision. The accessory nerve is retrieved and mobilized cranially. Detachment of the sternocleidomastoid, digastric, and nuchal muscles allows for a 180° exposure of the extracranial side of the jugular foramen. Three working corridors, namely the pre-carotid, pre-jugular, and retro-jugular, allow access to the deeper part of the jugular foramen area and the superior parapharyngeal space. In the present series, a gross total resection was achieved in 89.4% of the patients. Three recurrences occurred after an average follow-up of 80.5 ± 51 months.

Conclusions: The anterolateral approach is highly effective in the treatment of retrostyloid superior parapharyngeal space schwannomas involving the jugular foramen. Its simplicity of execution, versatility, and very low morbidity are among its main strengths.
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http://dx.doi.org/10.1016/j.wneu.2019.09.006DOI Listing
December 2019

Microsurgical Resection of Vestibular Schwannomas, Presentation of Cases in 3D: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 07;19(1):E61-E62

Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina.

Vestibular schwannomas are the most common benign tumors of the pontocerebellar angle,1,2 their microsurgical complexity is related to their size and neurovascular relationships. The purpose of this work is to analyze the clinical, anatomic characteristics, microsurgical treatment, and the postoperative results according to the Hannover gradual scale in 4 patients with vestibular schwannomas. The 4 patients gave their consent to the procedure and all consented to the use of their surgical videos, preoperative and postoperative studies, and postoperative pictures. Case 1: A 39-yr-old woman, with left ear hearing loss. Magnetic resonance imaging (MRI) showed small Intracanalicular schwannoma (T1 classification by Hannover). Microsurgery was performed and resection through a retrosigmoid approach2,3 with anatomic and functional preservation of the facial and cochlear nerve. Case 2: A 40-yr-old woman, with left ear hypoacusia. MRI showed an extrameatal schwannoma reaching the brainstem (T3b Hannover classification). The complete re-section through retrosigmoid approach were performed. Case 3: A 69-yr-old woman, without hearing in the right ear. RM: Medium schwannoma (T4a classification of Hannover). Microsurgery was performed with anatomic and functional preservation of the facial nerve.4-6 Case 4: A 32-yr-old woman, without hearing in the left ear. In addition, cerebellar syndrome and headache. RM: Large schwannoma (T4b classification of Hannover). Sur-gery was performed, anatomic preservation of the facial nerve, with moderate paresis in the postoperative period. Microsurgical resection with functional preservation of the facial and cochlear nerve is the main objective7 when addressing this pathology.
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http://dx.doi.org/10.1093/ons/opz271DOI Listing
July 2020

Three-Dimensional Microscopic Surgical Videos: A Novel and Low-cost System.

World Neurosurg 2019 Dec 30;132:188-196. Epub 2019 Aug 30.

Department of Neurosurgery, Hospital General of Alicante, Spain.

Introduction: Three-dimensional (3D) imaging and videos are a very useful tool in the neurosurgical training, although unfortunately the 3D systems available have a very high cost. The objective of this study is to describe a novel and low-cost 3D microsurgical video system.

Methods: To obtain the 3D videos we use a surgical microscope, 2 video adapters, 2 cameras, and an HDMI cable. A video editor program is used for processing the videos. For the projection we use a computer with PowerPoint (Microsoft, Inc, Redmond, WA) software, a video splitter, DVI cables, 2 projectors, 2 polarization filters, and a "silver screen" with polarized glasses.

Results: By using 2 equal cameras and video adaptors in each beam splitter port it was possible for us to obtain 2 videos that were equivalent to the images received by both surgeon's eyes. Using the video signal of both cameras during processing resulted in a 3D stereoscopic recording with Final Cut (Apple, Inc, Cupertino, CA) software. The polarized 3D format provided the best projection conditions. It does not alter the original colors of the videos and its prolonged visualization was more comfortable. The main advantage of this method is the ability to show in a realistic way the spatial relationships and the depth of the structures captured with the microscope.

Conclusions: This paper presents in a clear and detailed way how to create and use a low-cost 3D surgical video system.
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http://dx.doi.org/10.1016/j.wneu.2019.08.139DOI Listing
December 2019

White Matter Topographic Anatomy Applied to Temporal Lobe Surgery.

World Neurosurg 2019 Dec 20;132:e670-e679. Epub 2019 Aug 20.

Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina.

Background: The temporal lobe is an important and complex anatomic region of the brain. Accurate knowledge of anatomic relationships becomes extremely relevant when deciding surgical strategy, such as epilepsy or oncologic surgery, involving this lobe. To our knowledge, there is no strong literature highlighting the relationship between white matter tracts and craniometric landmarks applied to temporal lobe surgery. We aim to describe the topographic relationship between the craniometric points and white matter tracts of the temporal lobe through dissection of cadaveric specimens and describe the potential preoperative usefulness of diffusion tensor imaging in relation to the anatomic features found during the dissections.

Methods: Fifteen formalin-fixed whole cadaveric heads were dissected by the Klingler technique in a stepwise manner across the temporal and sphenoid bone windows. The white matter pathways were identified in their different planes and their position was described in relation to craniometric landmarks. Diffusion tensor studies were performed in 2 healthy volunteers to analyze the temporal fasciculi in vivo.

Results: We identified the topographic relationships between craniometric points and relevant association tracts that lie within the cranial corridors (superior and inferior frontal, parietal, occipital, sphenoidal, and temporal). Important landmarks were defined in correspondence to these different fasciculi.

Conclusions: Through this kind of microsurgical anatomic study, a better understanding of the different anatomic layers of the temporal region might be achieved. This factor is essential in planning adequate surgery and strategies to operate in the temporal lobe, improving surgical results and minimizing functional deficits.
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http://dx.doi.org/10.1016/j.wneu.2019.08.050DOI Listing
December 2019

Microsurgical Anatomy of the Central Retinal Artery.

World Neurosurg 2019 Oct 25;130:e172-e187. Epub 2019 Jun 25.

Microsurgical Neuroanatomy Laboratory-LaNeMic- II Division of Anatomy, Medicine School, University of Buenos Aires, Buenos Aires, Argentina.

Background: The central retinal artery (CRA) has been described as one of the first branches of the ophthalmic artery.It arises medial to the ciliary ganglion and after a sinuous path within the orbital cavity it penetrates the lower surface of the dura mater that covers the optic nerve, approximately 1 cm behind the eyeball. However, the numerous anatomic descriptions that were made of the CRA have been insufficient or unclear in relation to certain characteristics that are analyzed in the present study.

Methods: An electronic literature search was made in the PubMed database and a cadaver dissection was performed on 11 orbits fixed in formaldehyde.

Results: Results were obtained regarding the source, collateral branches, curves, direction, length of the optic nerve, dural perforation site, distance, path and relations, diameter, and area of the central artery of the retina.

Conclusions: Our anatomic study innovates in 2 aspects of the CRA: area and curves. Not only was there a simple count of the number of curves, but it also analyzed the angle presented by each of the curves based on photos obtained in high definition, with a digital program to reduce the margin of error. These curvatures of the CRA were classified according to their spatial disposition within the orbital cavity based on a pattern that was easy to understand. Data were obtained from the area of the CRA on the penetration of the CRA into the dural sheath of the optic nerve.
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http://dx.doi.org/10.1016/j.wneu.2019.06.026DOI Listing
October 2019

Microsurgical Anatomy and Approaches to the Cerebral Central Core.

World Neurosurg 2019 Sep 17;129:e23-e34. Epub 2019 May 17.

Department of Neurosurgery, Hospital General of Alicante, Alicante, Spain.

Objective: Through a cadaveric study, we divided the cerebral central core (CCC) into different areas and have proposed a corresponding neurosurgical approach for each sector. As a secondary objective, we analyzed the cortical and subcortical microsurgical anatomy of the CCC. The CCC includes the insula, extreme capsule, claustrum, external capsule, lenticular nucleus, internal capsule, caudate nucleus, and thalamus.

Methods: Twelve adult human brain hemispheres and one cadaveric head specimen were dissected and studied at the Laboratory of Neuroanatomic Microsurgical of the University of Buenos Aires. Nine cases of CCC neurosurgical pathologies were included in the present study and analyzed. Digital drawings were created of the approaches proposed for each sector of the CCC showing the most relevant surgical details. Photographs of each dissection and measurements obtained were taken.

Results: We divided the CCC into a medial, intermediate, and lateral sector, with specific subdivisions for the lateral and medial sectors. The lateral projection of the foramen of Monro was found deep to the third short gyri of the insula with the following distances: anterior insular limen margin, 23.95 mm; posterior insular limen margin, 22.92 mm; superior limiting sulcus, 14.99 mm, and inferior limiting sulcus, 13.76 mm. We have proposed the following approaches: an ipsilateral transcallosal approach, a contralateral transcallosal approach, a choroidal transfissure approach, a trans-splenial approach, transparietal access entering the intraparietal sulcus, and trans-sylvian approach. The preoperative imaging studies should be analyzed using our method to select the most accurate and safe approach.

Conclusions: We have provided a description of the limits and anatomy of the CCC using brain dissection, an analysis of operated cases, and useful measurements for the neurosurgeon.
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http://dx.doi.org/10.1016/j.wneu.2019.04.139DOI Listing
September 2019
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