Intracranial epidural hematoma after use of a 3-pin head clamp in a pediatric case with posterior fossa tumor and hydrocephalus: A case report

The head clamp system is one of the indispensable equipment of neurosurgery in terms of stabilizing the head and positioning it. In addition, in neurosurgery clinics, the use of pin head clamp is required to use the navigation system effectively. In pediatric cases, complications after the use of pins head clamp are rare, as reported in the literature. This paper presents a pediatric patient with posterior fossa tumor and hydrocephalus, who developed depression fracture and epidural hematoma after the use of Mayfield 3-pin clamp head. For this reason, the patient underwent emergency surgery a second time and the epidural hematoma was evacuated to obtain decompression. Epidural bleeding, which is a complication of the pinned clamped head, is frequently described in the literature, often in the pediatric cases accompanied by posterior fossa tumor and hydrocephalus. In this type of pediatric cases, a safe study for the use of pin clamp head is not yet available in the literature.

Increase of the clivus-canal angle in patients with basilar invagination, without atlantoaxial displacement, treated with a simple maneuver of indirect decompression of the odontoid with the head clamp, during posterior occipitocervical arthrodesis

Background: Basilar invagination (BI) can be defined as the insinuation of the content of the craniovertebral junction through the foramen magnum toward the posterior fossa. BI is a prevalent condition in Northeast Brazil. The present study describes the changes in the clivus-canal angle (CCA) in the postoperative period in patients with symptomatic BI operated by a posterior approach, using a simple technique of indirect reduction of the odontoid associated with occipitocervical fixation. Methods: Patients underwent radiological evaluations by magnetic resonance imaging in the pre and postoperative periods, where the height of the odontoid tip was measured in relation to the Chamberlain line and the ACC. All patients underwent posterior occipitocervical fixation with specific maneuvers of distraction and extension of the cephalic segment with the aid of a head clamp with three fixation points for anterior reduction of the odontoid. Results: Among the 8 patients evaluated in the series, all had increased ACC in the postoperative period, with a mean of 14.81 ± 1.54°, and statistically significant difference between the pre and postoperative periods (P < 0.05). Conclusion: The indirect surgical reduction of the odontoid process by a posterior approach through the manipulation (distraction-extension) of a “Mayfield” type of head clamp followed by occipitocervical fixation proved to be effective in improving the ACC, being easily reproducible.

Pinning in pediatric neurosurgery: the modified rubber stopper technique

Head immobilization devices with skull pins are commonly used by neurosurgeons to stabilize the head for microsurgical techniques and to maintain accurate intraoperative neuronavigation. Pediatric patients, who may have open fontanelles, unfused sutures, and thin skulls, are vulnerable to complications during placement in pins. We review the various methods of pinning in pediatric neurosurgery and revisit the modified rubber stopper technique using a commonly available rubber stopper from a medication bottle over a standard adult pin of a Mayfield head clamp to prevent the pins from plunging through the thin pediatric skull.

Extradural Devascularization for Resection of a Lesser Sphenoid Wing Meningioma: 2-Dimensional Operative Video

We describe the case of a 42-yr-old female patient with a 2-yr history of headache that has progressively worsened. Physical examination revealed no neurological deficit. Magnetic resonance imaging showed a large tumor of the left lesser sphenoid wing that enhanced with gadolinium and produced displacement of the midline and the Sylvian fissure. A thorough analysis of the origin of the tumor was done to establish the surgical strategy. With the patient positioned supine with the head slightly turned to the right side, fixed in a 3-pin head clamp, a pterional craniotomy was performed. Since the origin of the tumor is in the lesser wing an early extradural devascularization of the tumor was done with drilling out all the hyperostotic bone of the lesser sphenoid wing, including the lateral base of the anterior clinoid process. Intradural debulking and resection showed the effect of extradural devascularization with an important decrease in bleeding, allowing the total resection of the tumor. An immediate postop magnetic resonance showed a complete removal of the tumor. The patient presented a paresis of the oculomotor nerve that completely resolved in the 3-mo follow-up. In the following video illustration, we narrate this operative case and highlight the nuances of this approach.1 The patient has given assent and written consent for videos, images, or clinical or genetic information to be published.

Endoscopic Endonasal Approach to a Suprasellar Craniopharyngioma

We present the case of a 57-year-old male who presented with progressive right side vision loss whose workup revealed a large suprasellar lesion with invasion of the third ventricle. The pituitary stalk was not visible.Hormonal panel showed no hormonal deficits. The initial diagnosis was of a type II transinfundibular craniopharyngioma (as classified by Kassam et al).An endoscopic endonasal transplanum transtuberculum approach was done using a standard binostril four-hand technique, with the patient positioned supine with the head turned to the right side and tilted to the left, fixed in a three-pin head clamp, under imaging guidance. The tumor was carefully dissected away from the optic apparatus while preserving the vessels, mainly the superior hypophyseal artery. The stalk was identified around the tumor and preserved. The third ventricle was entered and inspected at the end of the procedure and a near-total resection (a small residual in the right hypothalamus) with decompression of the optic apparatus was achieved. Reconstruction was done in a multilayered fashion, using collagen matrix and a nasoseptal flap. Patient had an uneventful postoperative stay and was discharged on POD 4, neurologically stable with no hormonal deficits. Pathology confirmed an adamantinomatous craniopharyngioma. Due to a small growth of the residual, patient underwent fractionated stereotactic radiation (50.4Gy in 28 sessions). He presented with panhypopituitarism 2 years after radiation therapy. At 3-month follow-up, his vision was back to normal and 6-year postoperative magnetic resonance imaging showed no signs of recurrence.The link to the video can be found at: https://youtu.be/chG7XIz7a_A.

The Use of Intraoperative Navigation for Percutaneous Procedures at the Skull Base Including a Difficult-to-Access Foramen Ovale

ABSTRACT BACKGROUND: We describe the use of an intraoperative CT scan obtained using the Medtronic O-arm (Littleton, Massachusetts) for image-guided cannulation of the foramen ovale not previously accessible with the use of fluoroscopy alone. Unlike previously described procedures, this technique does not require placement of an invasive head clamp and may be used with an awake patient. OBJECTIVE: To describe the use of intraoperative neuronavigation for accessing skull base foramina and, specifically, cannulating of the foramen ovale during percutaneous rhizotomy procedures using an intraoperative image guidance CT scanner (Medtronic O-arm, Littleton, Massachusetts). METHODS: A noninvasive Landmark Fess Strap attached to a spine reference frame was applied to the heads of 4 patients who harbored a difficult-to-access foramen ovale. An intraoperative HD3D skull base scan using a Medtronic O-arm was obtained, and Synergy Spine software was used to create 3D reconstructions of the skull base. Using image guidance, we navigated the needle to percutaneously access the foramen ovale by the use of a single tract for successful completion of balloon compression of the trigeminal nerve. RESULTS: All 4 patients (3 females and 1 male; ages 65-75) underwent the procedure with no complications. CONCLUSION: Based on our experience, neuronavigation with the use of intraoperative O-arm CT imaging is useful during these cases.