Advances in Cranial Surgery

Abstract

The landscape of the cranial neurosurgery has changed tremendously in past couple of decades. The main frontiers including introduction of neuro-endoscopy, minimally invasive skull base approaches, SRS, laser interstitial thermal therapy and use of tubular retractors have revolutionized the management of intracerebral hemorrhages, deep seated tumors other intracranial pathologies. Introduction of these novel techniques is based on smaller incisions with maximal operative corridors, decreased blood loss, shorter hospital stays, decreased post-operative pain and cosmetically appealing scars that improves patient satisfaction and clinical outcomes. The sophisticated tools like neuroendoscopy have improved light source, and better visualization around the corners. Advanced navigated tools and channel-based retractors help us to target deeply seated lesions with increased precision and minimal disruption of the surrounding neurovascular tissues. Advent of stereotactic radiosurgery has provided us alternative feasible, safe and effective options for treatment of patients who are otherwise not medically stable to undergo complex cranial surgical interventions. This paper review advances in treatment of intracranial pathologies, and how the neurosurgeons and other medical providers at the University of Missouri-Columbia (UMC) are optimizing these treatments for their patients.

Figure 1

Pre-op CT; tubular retractor; Post-op CT. 33-year-old male with history of hypertension presented with acute neurological decline with decreased level of consciousness and dense right hemiparesis. A. Non-contrast axial computed tomography (CT) of head large left hemisphere and basal ganglia increased density consistent with acute intracerebral hemorrhage (ICH). B. Tubular brain retractor (Nico BrainPath device, Indianapolis, IN). C. Tubular brain retractor inserted into brain for ICH evacuation using a small 4-centimeter craniotomy. D. Immediate postoperative CT of head demonstrating evacuation of hematoma. Patient had persistent hemiparesis, but had rapid improvement of level of consciousness and make expeditious progress to rehabilitation.

Figure 2

Pre-op and Post-op MRI A. Pre-op MRI of left frontal glioma operated via left eyebrow approach. B. Pre-operative marking of eyebrow skin incision. C. Keyhole right frontal craniotomy and dural opening for exposure and resection of tumor. D. Tumor resection using eyebrow keyhole exposure. E. Surgical closure of eyebrow incision to achieve favorable cosmetic healing. F. Post-operative scan of left frontal lesion operated via left eye-brow approach.

Figure 3

Patient presents with bi-temporal hemianopsia, and laboratory testing reveals normal pituitary function. T-1 weighted MRI studies. A and B. Pre-operative sagittal (A) and coronal (B) images demonstrating large sellar, suprasellar mass. C and D. Post-operative sagittal (C) and coronal (D) demonstrating resection of mass and decompression of optic chiasm. Pathology confirms pituitary adnenoma.