1. Falcine and parasagittal meningiomas arise from the falx cerebri and superior sagittal sinus respectively. They are classified based on their location and involvement of surrounding structures like the sinus.
2. Preoperative evaluation focuses on assessing the tumor's relationship to the superior sagittal sinus and collateral vein development, the extent of bone involvement, and presence of edema or brain invasion.
3. Treatment decisions depend on factors like symptoms, tumor growth rate, age and location. Observation may be appropriate for asymptomatic or slowly growing tumors while surgical resection is indicated if the tumor is symptomatic or growing rapidly.
This document provides an overview of spinal arteriovenous malformations (AVMs). It discusses the classification, anatomy, presentation, diagnosis and treatment of different types of spinal AVMs. The main types discussed are:
1. Dural AVFs, the most common type which are slow flow fistulas between dural arteries and veins.
2. Intramedullary AVMs, which resemble brain AVMs and can cause hemorrhage or progressive myelopathy.
3. Juvenile/metameric AVMs, an extremely rare congenital lesion involving skin, vertebrae and spinal cord with multiple arterial feeders.
4. Conus medullaris AVMs, which are location-specific
o plexo venoso cerebroespinal, ou plexo de batson, é o principal responsável pela drenagem encefálica e pela sua natureza venosa, plexiforme, avalvular e bidirecional é responsável pela compensação de retorno venoso de mudanças de postura e uma via hematogênica direta justificando estados patológicos.
This document discusses chemotherapy trials and regimens for colon cancer. It summarizes several landmark trials that established the benefit of 5-FU-based adjuvant chemotherapy for stage III colon cancer. The MOSAIC, NSABP C-07 and NO16968 trials showed that adding oxaliplatin to 5-FU improves disease-free survival for stage III disease. For stage II, the benefit of oxaliplatin is unclear. The document also discusses staging, risk factors, treatment guidelines, neoadjuvant therapy and radiation therapy options for colon cancer.
1) The use of induction chemotherapy in oral cancer aims to improve locoregional control, survival, organ preservation and resectability.
2) Studies on resectable oral cancer show that 2-3 cycles of induction chemotherapy did not improve overall survival or disease-free survival compared to upfront surgery.
3) Induction chemotherapy can increase resectability and achieve R0 resection in borderline resectable or technically unresectable oral cancers, translating to better survival outcomes.
This document summarizes findings from a review of 66 studies comparing outcomes of nephron sparing surgery (NSS) versus radical nephrectomy (RN) for Wilms' tumor in children. The studies included data from 4022 patients, 1040 of whom underwent NSS. NSS was associated with smaller tumor sizes but a higher rate of neoadjuvant chemotherapy use compared to RN. Reported rates of tumor rupture, recurrence, end stage renal disease, and overall survival were similar between the two surgical approaches. Outcomes have improved over time for both RN and NSS. While NSS appears to provide comparable oncologic outcomes to RN, limitations in the available data prevent direct comparison between the surgical techniques.
1. Falcine and parasagittal meningiomas arise from the falx cerebri and superior sagittal sinus respectively. They are classified based on their location and involvement of surrounding structures like the sinus.
2. Preoperative evaluation focuses on assessing the tumor's relationship to the superior sagittal sinus and collateral vein development, the extent of bone involvement, and presence of edema or brain invasion.
3. Treatment decisions depend on factors like symptoms, tumor growth rate, age and location. Observation may be appropriate for asymptomatic or slowly growing tumors while surgical resection is indicated if the tumor is symptomatic or growing rapidly.
This document provides an overview of spinal arteriovenous malformations (AVMs). It discusses the classification, anatomy, presentation, diagnosis and treatment of different types of spinal AVMs. The main types discussed are:
1. Dural AVFs, the most common type which are slow flow fistulas between dural arteries and veins.
2. Intramedullary AVMs, which resemble brain AVMs and can cause hemorrhage or progressive myelopathy.
3. Juvenile/metameric AVMs, an extremely rare congenital lesion involving skin, vertebrae and spinal cord with multiple arterial feeders.
4. Conus medullaris AVMs, which are location-specific
o plexo venoso cerebroespinal, ou plexo de batson, é o principal responsável pela drenagem encefálica e pela sua natureza venosa, plexiforme, avalvular e bidirecional é responsável pela compensação de retorno venoso de mudanças de postura e uma via hematogênica direta justificando estados patológicos.
This document discusses chemotherapy trials and regimens for colon cancer. It summarizes several landmark trials that established the benefit of 5-FU-based adjuvant chemotherapy for stage III colon cancer. The MOSAIC, NSABP C-07 and NO16968 trials showed that adding oxaliplatin to 5-FU improves disease-free survival for stage III disease. For stage II, the benefit of oxaliplatin is unclear. The document also discusses staging, risk factors, treatment guidelines, neoadjuvant therapy and radiation therapy options for colon cancer.
1) The use of induction chemotherapy in oral cancer aims to improve locoregional control, survival, organ preservation and resectability.
2) Studies on resectable oral cancer show that 2-3 cycles of induction chemotherapy did not improve overall survival or disease-free survival compared to upfront surgery.
3) Induction chemotherapy can increase resectability and achieve R0 resection in borderline resectable or technically unresectable oral cancers, translating to better survival outcomes.
This document summarizes findings from a review of 66 studies comparing outcomes of nephron sparing surgery (NSS) versus radical nephrectomy (RN) for Wilms' tumor in children. The studies included data from 4022 patients, 1040 of whom underwent NSS. NSS was associated with smaller tumor sizes but a higher rate of neoadjuvant chemotherapy use compared to RN. Reported rates of tumor rupture, recurrence, end stage renal disease, and overall survival were similar between the two surgical approaches. Outcomes have improved over time for both RN and NSS. While NSS appears to provide comparable oncologic outcomes to RN, limitations in the available data prevent direct comparison between the surgical techniques.
This document provides information on the diagnosis and management of cerebellopontine angle tumors, specifically vestibular schwannomas. It discusses the history, clinical presentation, imaging findings, classification systems, differential diagnosis, and treatment options including observation, surgery, and radiotherapy. Treatment is typically individualized based on factors like tumor size, hearing status, and patient preferences. A multidisciplinary approach is emphasized.
This document discusses the anatomy of the cavernous sinus (CS). It describes the CS as being located on either side of the sella turcica and extending from the sphenoid fissure to the petrous apex. It contains the internal carotid artery as well as cranial nerves III, IV, V1 and V2. The CS drains into the inferior petrosal sinus and receives blood from various veins including the sphenoparietal sinus and ophthalmic veins. The document discusses the osseous structures surrounding the CS and details the arterial, venous and neural compartments within the sinus.
Brain stem surgical anatomy and approachesKode Sashanka
This document discusses the surgical anatomy and safe entry zones of the brain stem for tumor removal. It describes the anatomy of the midbrain, pons, and medulla oblongata. Several safe entry zones are outlined for each region, including the anterior mesencephalic zone and intercollicular region for the midbrain, the peritrigeminal and supratrigeminal zones for the pons, and the anterolateral sulcus and posterior median sulcus for the medulla. The document also reviews important tenets of brainstem surgery, such as using the two-point method, lighted bipolar cautery, autolock systems, and careful preservation of venous anatomy.
1. Pituitary adenomas can be classified as benign, invasive, or carcinomas based on their biological behavior and ability to invade local structures. Surgery and radiation are the main treatment options, while medication is used for functioning tumors.
2. Management involves reducing hormone levels, relieving mass effect, and preserving pituitary function through surgery, radiation, or medication depending on the tumor type and individual factors.
3. Treatment goals are tumor control as well as normalization of hormone levels and reversal of symptoms for functioning tumors.
RADIO LOGICAL ANATOMY OF HEAD AND NECK CANCERSIsha Jaiswal
Imaging plays an important role in head and neck cancer by aiding in diagnosis, staging, treatment planning, response evaluation, and detecting recurrence. Common imaging modalities used include panoramic x-ray, x-ray of the paranasal sinuses, ultrasound of the neck, CT, MRI, and PET-CT. Each modality has advantages and limitations for evaluating the oral cavity, neck lymph nodes, and distant metastases. CT is often the initial study due to its wide availability and ability to detect bone invasion and lymph node metastases. MRI provides better soft tissue contrast for evaluating nerve and muscle involvement. PET-CT can detect occult primary tumors and distant metastases.
This document discusses hemostatic agents used in neurosurgery. It begins by explaining that control of bleeding without ligatures is important in neurosurgery. It then categorizes topical hemostats as chemical, mechanical, or thermal agents. Specific agents are discussed, including gelatin sponge, microfibrillar collagen, oxidized cellulose, thrombin, fibrin sealants, and hydrogen peroxide. Their mechanisms of action, appropriate usage, and potential complications are described. The document concludes by stating that all hemostatic agents are foreign bodies that can cause infection, and that proper surgical technique remains key, along with judicious use of hemostatic agents.
This document describes the anatomy of the neck relevant to neck dissection surgery. It outlines the boundaries of the neck, key muscles and structures like the platysma, sternocleidomastoid, trapezius and vessels. It discusses the lymph node levels and types of neck dissection surgeries like radical and selective dissections. The document provides details of the surgical approach including skin incisions and dissection of structures to completely remove lymph nodes while preserving nearby nerves and vessels.
1) Advanced lesions of cancer of the oral tongue are best managed with a combination of surgery and radiation.
2) The 5-year survival rate for oral tongue cancer is less than 50%, and a key to better survival is early detection and treatment.
3) The management of oral tongue cancer involves tailoring treatment based on the stage of cancer, with smaller early-stage cancers treated with either radiation or surgery, and larger cancers treated with a combination of both.
This document discusses parasagittal meningiomas, which are tumors that arise near the superior sagittal sinus. It describes the typical presentation, imaging characteristics, surgical approaches, and factors to consider during resection, such as venous anatomy and arterial feeders. The goal of surgery is to remove as much tumor as possible while preserving the superior sagittal sinus and draining veins when feasible.
Hemostasis in neurosurgery online.pptxkushal790662
This document provides an overview of hemostatic agents used in neurosurgery. It begins by explaining why hemostasis is so important in neurosurgery, noting that even small hematomas can cause devastating neurological damage. It then discusses the normal hemostasis process and challenges with hemostasis related to brain injuries or abnormalities. The document reviews various hemostatic agents used in neurosurgery, including general measures, thermal measures, mechanical agents, chemical agents, mixed coated patches, and provides examples for each category. It concludes by emphasizing the importance of understanding pathophysiological mechanisms to take a targeted approach and notes that novel biosurgical agents are critical for optimal patient outcomes.
Primary brain tumours are a diverse group of neoplasm arising from different cells of the central nervous system.
It accounts for about 2% of all cancers with an overall annual incidence of 22 per 1,00,000 population.
Most common brain tumour in adults is Brain Metastasis.
Liliequist membrane may be understood as a projection formed by an arachnoid membrane extending from the dorsum sellae to the mammillary bodies coined after Liliequist (1956). It has surgical importance in Endoscopic third ventriculostomy and cisternostomy.
This document summarizes the history and current practices of neck dissection. It discusses the evolution of neck dissection from the 19th century, when it was considered incurable, to the 21st century, where it remains an important prognostic indicator. It outlines the modern classification of neck dissection levels and types, including radical, modified radical, selective, and extended dissections. Finally, it reviews sentinel lymph node biopsy for early stage head and neck cancers, noting various techniques used and sensitivity ranges reported.
This document discusses management of the clinically node-negative neck in early-stage oral squamous cell carcinoma. The risk of occult nodal involvement is estimated to be 20-30% for T1/T2 tumors. Main management approaches are upfront elective neck dissection, watch and wait, or sentinel node biopsy. Tumor depth of invasion is a better predictor of nodal metastasis than thickness. Elective neck dissection provides accurate staging and optimal locoregional control, while sentinel node biopsy carries risk of missing occult disease and delaying adjuvant treatment. Floor of mouth tumors have early nodal spread necessitating bilateral neck dissection.
Subarachnoid hemorrage –eso guidelines for managementAbdulgafoor MT
1. Intracranial aneurysms have an incidence of 9 per 100,000 people, with a mortality rate of 60% within 6 months if left untreated.
2. Clinical grading scales like Hunt-Hess, WFNS, and PAASH are used to assess patients presenting with subarachnoid hemorrhage, with PAASH showing slightly better correlation with outcome.
3. Risk factors for poor outcomes from aneurysmal subarachnoid hemorrhage include older age, hypertension, aneurysm size and location, rebleeding, delayed cerebral ischemia, and hydrocephalus.
The document discusses various surgical approaches to the temporal bone, including:
1. The anterior, posterior, superior, and inferior boundaries of the temporal bone.
2. Ten triangles of the temporal bone - four in the cavernous sinus and six in the middle fossa.
3. The Kawase vs modified Dolenc-Kawase approach - which differs in the drilling sequence and angle of approach.
4. Several cranial fossa approaches - simple middle cranial fossa, anterior petrosectomy, extended middle fossa, presigmoid, and various modifications.
5. Anatomic landmarks and surgical techniques for the postauricular transtemporal, combined presigmoid
This document describes various craniometric points and landmarks that are used as references in neurosurgery. It defines points such as the pterion, asterion, euryon, stephanion, vertex, nasion, inion, glabella, bregma, lambda, and others. It explains the location and anatomical relationships of each point. It also discusses how some craniometric points are used to localize structures like the ventricles, cortical areas such as the motor cortex, venous structures, and for strategically placing burr holes during craniotomies. Understanding the location of these points is important for surgical planning and navigation.
A variety of neoplasms can arise in the ventricular system, including ependymomas, medulloblastomas, subependymomas, central neurocytomas, subependymal giant cell astrocytomas (SGCA), choroid plexus papillomas, choroid plexus carcinomas, and intraventricular meningiomas. These lesions present variably with increased intracranial pressure, focal neurologic deficits, or incidentally found on imaging. Location within the ventricles and patient age, gender, and underlying conditions can help narrow the differential diagnosis.
Approach to a vertiginous patient - clinical Dr Safika Zaman
This document discusses the anatomy and physiology of the vestibular system and its role in spatial orientation and balance. It describes the components of the vestibular system including the semicircular canals, otolith organs, vestibular nerve and nuclei. It outlines the vestibulo-ocular reflex and how different head motions activate each semicircular canal. The document also discusses the examination of patients with dizziness or vertigo, including tests for nystagmus, positional nystagmus and dynamic visual acuity. Common peripheral and central causes of vertigo like BPPV, vestibular neuritis and Meniere's disease are also mentioned.
This document provides information on the diagnosis and management of cerebellopontine angle tumors, specifically vestibular schwannomas. It discusses the history, clinical presentation, imaging findings, classification systems, differential diagnosis, and treatment options including observation, surgery, and radiotherapy. Treatment is typically individualized based on factors like tumor size, hearing status, and patient preferences. A multidisciplinary approach is emphasized.
This document discusses the anatomy of the cavernous sinus (CS). It describes the CS as being located on either side of the sella turcica and extending from the sphenoid fissure to the petrous apex. It contains the internal carotid artery as well as cranial nerves III, IV, V1 and V2. The CS drains into the inferior petrosal sinus and receives blood from various veins including the sphenoparietal sinus and ophthalmic veins. The document discusses the osseous structures surrounding the CS and details the arterial, venous and neural compartments within the sinus.
Brain stem surgical anatomy and approachesKode Sashanka
This document discusses the surgical anatomy and safe entry zones of the brain stem for tumor removal. It describes the anatomy of the midbrain, pons, and medulla oblongata. Several safe entry zones are outlined for each region, including the anterior mesencephalic zone and intercollicular region for the midbrain, the peritrigeminal and supratrigeminal zones for the pons, and the anterolateral sulcus and posterior median sulcus for the medulla. The document also reviews important tenets of brainstem surgery, such as using the two-point method, lighted bipolar cautery, autolock systems, and careful preservation of venous anatomy.
1. Pituitary adenomas can be classified as benign, invasive, or carcinomas based on their biological behavior and ability to invade local structures. Surgery and radiation are the main treatment options, while medication is used for functioning tumors.
2. Management involves reducing hormone levels, relieving mass effect, and preserving pituitary function through surgery, radiation, or medication depending on the tumor type and individual factors.
3. Treatment goals are tumor control as well as normalization of hormone levels and reversal of symptoms for functioning tumors.
RADIO LOGICAL ANATOMY OF HEAD AND NECK CANCERSIsha Jaiswal
Imaging plays an important role in head and neck cancer by aiding in diagnosis, staging, treatment planning, response evaluation, and detecting recurrence. Common imaging modalities used include panoramic x-ray, x-ray of the paranasal sinuses, ultrasound of the neck, CT, MRI, and PET-CT. Each modality has advantages and limitations for evaluating the oral cavity, neck lymph nodes, and distant metastases. CT is often the initial study due to its wide availability and ability to detect bone invasion and lymph node metastases. MRI provides better soft tissue contrast for evaluating nerve and muscle involvement. PET-CT can detect occult primary tumors and distant metastases.
This document discusses hemostatic agents used in neurosurgery. It begins by explaining that control of bleeding without ligatures is important in neurosurgery. It then categorizes topical hemostats as chemical, mechanical, or thermal agents. Specific agents are discussed, including gelatin sponge, microfibrillar collagen, oxidized cellulose, thrombin, fibrin sealants, and hydrogen peroxide. Their mechanisms of action, appropriate usage, and potential complications are described. The document concludes by stating that all hemostatic agents are foreign bodies that can cause infection, and that proper surgical technique remains key, along with judicious use of hemostatic agents.
This document describes the anatomy of the neck relevant to neck dissection surgery. It outlines the boundaries of the neck, key muscles and structures like the platysma, sternocleidomastoid, trapezius and vessels. It discusses the lymph node levels and types of neck dissection surgeries like radical and selective dissections. The document provides details of the surgical approach including skin incisions and dissection of structures to completely remove lymph nodes while preserving nearby nerves and vessels.
1) Advanced lesions of cancer of the oral tongue are best managed with a combination of surgery and radiation.
2) The 5-year survival rate for oral tongue cancer is less than 50%, and a key to better survival is early detection and treatment.
3) The management of oral tongue cancer involves tailoring treatment based on the stage of cancer, with smaller early-stage cancers treated with either radiation or surgery, and larger cancers treated with a combination of both.
This document discusses parasagittal meningiomas, which are tumors that arise near the superior sagittal sinus. It describes the typical presentation, imaging characteristics, surgical approaches, and factors to consider during resection, such as venous anatomy and arterial feeders. The goal of surgery is to remove as much tumor as possible while preserving the superior sagittal sinus and draining veins when feasible.
Hemostasis in neurosurgery online.pptxkushal790662
This document provides an overview of hemostatic agents used in neurosurgery. It begins by explaining why hemostasis is so important in neurosurgery, noting that even small hematomas can cause devastating neurological damage. It then discusses the normal hemostasis process and challenges with hemostasis related to brain injuries or abnormalities. The document reviews various hemostatic agents used in neurosurgery, including general measures, thermal measures, mechanical agents, chemical agents, mixed coated patches, and provides examples for each category. It concludes by emphasizing the importance of understanding pathophysiological mechanisms to take a targeted approach and notes that novel biosurgical agents are critical for optimal patient outcomes.
Primary brain tumours are a diverse group of neoplasm arising from different cells of the central nervous system.
It accounts for about 2% of all cancers with an overall annual incidence of 22 per 1,00,000 population.
Most common brain tumour in adults is Brain Metastasis.
Liliequist membrane may be understood as a projection formed by an arachnoid membrane extending from the dorsum sellae to the mammillary bodies coined after Liliequist (1956). It has surgical importance in Endoscopic third ventriculostomy and cisternostomy.
This document summarizes the history and current practices of neck dissection. It discusses the evolution of neck dissection from the 19th century, when it was considered incurable, to the 21st century, where it remains an important prognostic indicator. It outlines the modern classification of neck dissection levels and types, including radical, modified radical, selective, and extended dissections. Finally, it reviews sentinel lymph node biopsy for early stage head and neck cancers, noting various techniques used and sensitivity ranges reported.
This document discusses management of the clinically node-negative neck in early-stage oral squamous cell carcinoma. The risk of occult nodal involvement is estimated to be 20-30% for T1/T2 tumors. Main management approaches are upfront elective neck dissection, watch and wait, or sentinel node biopsy. Tumor depth of invasion is a better predictor of nodal metastasis than thickness. Elective neck dissection provides accurate staging and optimal locoregional control, while sentinel node biopsy carries risk of missing occult disease and delaying adjuvant treatment. Floor of mouth tumors have early nodal spread necessitating bilateral neck dissection.
Subarachnoid hemorrage –eso guidelines for managementAbdulgafoor MT
1. Intracranial aneurysms have an incidence of 9 per 100,000 people, with a mortality rate of 60% within 6 months if left untreated.
2. Clinical grading scales like Hunt-Hess, WFNS, and PAASH are used to assess patients presenting with subarachnoid hemorrhage, with PAASH showing slightly better correlation with outcome.
3. Risk factors for poor outcomes from aneurysmal subarachnoid hemorrhage include older age, hypertension, aneurysm size and location, rebleeding, delayed cerebral ischemia, and hydrocephalus.
The document discusses various surgical approaches to the temporal bone, including:
1. The anterior, posterior, superior, and inferior boundaries of the temporal bone.
2. Ten triangles of the temporal bone - four in the cavernous sinus and six in the middle fossa.
3. The Kawase vs modified Dolenc-Kawase approach - which differs in the drilling sequence and angle of approach.
4. Several cranial fossa approaches - simple middle cranial fossa, anterior petrosectomy, extended middle fossa, presigmoid, and various modifications.
5. Anatomic landmarks and surgical techniques for the postauricular transtemporal, combined presigmoid
This document describes various craniometric points and landmarks that are used as references in neurosurgery. It defines points such as the pterion, asterion, euryon, stephanion, vertex, nasion, inion, glabella, bregma, lambda, and others. It explains the location and anatomical relationships of each point. It also discusses how some craniometric points are used to localize structures like the ventricles, cortical areas such as the motor cortex, venous structures, and for strategically placing burr holes during craniotomies. Understanding the location of these points is important for surgical planning and navigation.
A variety of neoplasms can arise in the ventricular system, including ependymomas, medulloblastomas, subependymomas, central neurocytomas, subependymal giant cell astrocytomas (SGCA), choroid plexus papillomas, choroid plexus carcinomas, and intraventricular meningiomas. These lesions present variably with increased intracranial pressure, focal neurologic deficits, or incidentally found on imaging. Location within the ventricles and patient age, gender, and underlying conditions can help narrow the differential diagnosis.
Approach to a vertiginous patient - clinical Dr Safika Zaman
This document discusses the anatomy and physiology of the vestibular system and its role in spatial orientation and balance. It describes the components of the vestibular system including the semicircular canals, otolith organs, vestibular nerve and nuclei. It outlines the vestibulo-ocular reflex and how different head motions activate each semicircular canal. The document also discusses the examination of patients with dizziness or vertigo, including tests for nystagmus, positional nystagmus and dynamic visual acuity. Common peripheral and central causes of vertigo like BPPV, vestibular neuritis and Meniere's disease are also mentioned.
yeditepe universitesi uluslararası kafa tabanı sempozyumu - Mustafa BozbuğaAbdurrahman Şimşek
This document summarizes 4 different cranial base surgery cases performed by Dr. Mustafa Bozbuğa at Kartal Dr. Lütfi Kırdar Education and Research Hospital in Turkey. Case 1 involved the removal of a transitional meningioma and cavernoma in the left cranial base via a combined anterior temporal and pterional approach. Case 2 was a large left cranial base tumor removed using a combined transsylvian, anterior temporal, suboccipital and transpetrosal approach. Case 3 involved the total removal and later recurrence of a chordoma in the right cranial base, which was again fully excised. Case 4 described the total resection of a right cere
This document describes several patients who presented with headaches and underwent surgery to clip aneurysms. It provides details about each patient's age, symptoms, neurological exam findings, surgical approaches used, and in some cases pre- and post-operative imaging. Surgeries included pterional, retrosigmoid, infratentorial, and occipital craniotomies to clip aneurysms located on vessels such as the anterior communicating artery. The goal of the procedures was to relieve pressure from ruptured aneurysms causing headaches or other neurological symptoms.
This document describes several patient cases seen at a neurosurgery clinic. It includes details of symptoms, examination findings, surgical procedures, pathology results, and outcomes for patients presenting with meningioma, chordoma, and other conditions. Surgical approaches and total tumor removal are described for most cases. Post-operative courses involved improvement of symptoms or remaining neurologically intact in follow-up for several years.
The document describes the department of neurosurgery at a university hospital. It includes sections on the center of neurosciences and its constituent specialties. It also provides details on the educational background and international training of the head of the department, Prof. Dr. Mustafa Bozbuğa. The document concludes by presenting several case studies covering neuro-oncology and cerebrovascular conditions treated by the department.
1. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Prof. Dr. Mustafa BOZBUĞAProf. Dr. Mustafa BOZBUĞA
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
2. Beyin ve Sinir Cerrahisi Kliniği2. Beyin ve Sinir Cerrahisi Kliniği
Trakya Üniversitesi Tıp FakültesiTrakya Üniversitesi Tıp Fakültesi
Nöroşirürji Anabilim DalıNöroşirürji Anabilim Dalı
2. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Cushing H, Eisenhardt L: Meningiomas: Their Classification, RegionalCushing H, Eisenhardt L: Meningiomas: Their Classification, Regional
Behaviour, Life History, and Surgical End Results. Springfield, IL: Charles CBehaviour, Life History, and Surgical End Results. Springfield, IL: Charles C
Thomas, 1938.Thomas, 1938.
29 vak’ada dikkatli gözlemleri ile,29 vak’ada dikkatli gözlemleri ile,
Olfaktor oluk meningiomlarının:Olfaktor oluk meningiomlarının:
- Orijinini,- Orijinini,
- Anatomisini,- Anatomisini,
- Semptomatolojisini,- Semptomatolojisini,
- Patolojisini,- Patolojisini,
- Cerrahi tedavisini- Cerrahi tedavisini
(önce tümörün internal dekompresyonu, daha sonra tümör kapsülünün diseksiyonu,(önce tümörün internal dekompresyonu, daha sonra tümör kapsülünün diseksiyonu,
muhtemel ACA’ların yapışıklıklarının önemi/korunması, fasya grefti ile kaidenin tamiri)muhtemel ACA’ların yapışıklıklarının önemi/korunması, fasya grefti ile kaidenin tamiri)
tanımlamışlardır.tanımlamışlardır.
5. Resim 2 ilaveResim 2 ilave
Neuro-oncology sayfa 324 Figure 30-3Neuro-oncology sayfa 324 Figure 30-3
6. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Tüm intrakranyal meningiomlarınTüm intrakranyal meningiomların
%5.4-18 (ort. %10)’unu oluşturur.%5.4-18 (ort. %10)’unu oluşturur.
7. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
CERRAHİ ANATOMİCERRAHİ ANATOMİ-1-1
Bazal orta hat meningiomlarıdır.Bazal orta hat meningiomlarıdır.
• Orijin:Orijin: Anterior kranyal fossa tabanında, etmoid kemiğin lamina cribrosasıAnterior kranyal fossa tabanında, etmoid kemiğin lamina cribrosası
üzerinde ve bu yapının sfenoid kemik ile birleşme yeri üzerinden –crista gallidenüzerinde ve bu yapının sfenoid kemik ile birleşme yeri üzerinden –crista galliden
planum sfenoidaleye kadar- orta hattan ünilateral/bilateral, yoğun araknoidplanum sfenoidaleye kadar- orta hattan ünilateral/bilateral, yoğun araknoid capcap hücrehücre
yığınlarından çıkar.yığınlarından çıkar.
• Frontobazal hemisferik bir biçimde büyüyerek tek ya da çift taraflı olfaktorFrontobazal hemisferik bir biçimde büyüyerek tek ya da çift taraflı olfaktor
sinirlerin deplasmanına ve kompresyonuna yol açar.sinirlerin deplasmanına ve kompresyonuna yol açar.
• Daha ileri aşamada epidural plana uzanabilir; dural kaidesi kalınlaşır, kemikDaha ileri aşamada epidural plana uzanabilir; dural kaidesi kalınlaşır, kemik
dokuya penetrasyon gösterebilir, etmoid ve sfenoid sinüslere girebilir.dokuya penetrasyon gösterebilir, etmoid ve sfenoid sinüslere girebilir.
• Posterior yüzünde anterior serebral arter (ACA) kompleksi, optikokiazmatikPosterior yüzünde anterior serebral arter (ACA) kompleksi, optikokiazmatik
aparatus, hipofiz sapı,… ile komşuluk gösterir.aparatus, hipofiz sapı,… ile komşuluk gösterir.
8. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
CERRAHİ ANATOMİCERRAHİ ANATOMİ-2-2
• Arteriyel kanlanması:Arteriyel kanlanması:
– Primer olarak kafa tabanından etmoidal, meningeal ve oftalmik arterlerinPrimer olarak kafa tabanından etmoidal, meningeal ve oftalmik arterlerin
dallarından,dallarından,
– Leptomeningeal besleyicilerdenLeptomeningeal besleyicilerden
• Nörovasküler komşuluk:Nörovasküler komşuluk:
– Frontal loplar,Frontal loplar,
– Olfaktor sinirler,Olfaktor sinirler,
– ACA ve dalları (ACA kompleksi),ACA ve dalları (ACA kompleksi),
– Optik sinirler ve optik kiazma,...Optik sinirler ve optik kiazma,...
19. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
PREOPERATİF ÖNEMLİ NOKTALARPREOPERATİF ÖNEMLİ NOKTALAR
• İleri yaş tek başına karar verdirecek bir kriter değildir,İleri yaş tek başına karar verdirecek bir kriter değildir,
• Kitle dev büyüklükte/Majör arteriyel-nörovasküler tutulum/yapışıklıkKitle dev büyüklükte/Majör arteriyel-nörovasküler tutulum/yapışıklık
(+leptomeningeal kanlanma gelişmiş)(+leptomeningeal kanlanma gelişmiş) olduğunda morbidite artar,olduğunda morbidite artar,
• Tümörün vaskülaritesi,Tümörün vaskülaritesi,
• Kaidedeki bağlantının geniş olması,Kaidedeki bağlantının geniş olması,
• Serebral ödem,Serebral ödem,
• Meningiomun histopatolojik derecesi,Meningiomun histopatolojik derecesi,
• Preoperatif anosmi var mı?Preoperatif anosmi var mı? (hasta risk yönünden uyarılmalı; tat duyusu da etkilenir),(hasta risk yönünden uyarılmalı; tat duyusu da etkilenir),
• Steroidler, antiepileptikler,…Steroidler, antiepileptikler,…
20. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
CERRAHİ TEDAVİNİN HEDEFLERİCERRAHİ TEDAVİNİN HEDEFLERİ
• Cerrahi total rezeksiyonCerrahi total rezeksiyon (Simpson Grade I/II –(Simpson Grade I/II –İntrakranyal kitleİntrakranyal kitle
ile birlikte, tümörün paranazal sinüs uzanımı da varsa rezeksiyon-ile birlikte, tümörün paranazal sinüs uzanımı da varsa rezeksiyon-))
+ Nörovasküler yapıların korunması+ Nörovasküler yapıların korunması
(Nörolojik fonksiyonların korunarak maksimum cerrahi rezeksiyon)(Nörolojik fonksiyonların korunarak maksimum cerrahi rezeksiyon)
• Frontobazal rekonstrüksiyonFrontobazal rekonstrüksiyon
21. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
CERRAHİ YAKLAŞIM NASIL OLMALI?CERRAHİ YAKLAŞIM NASIL OLMALI?
• Nöral yapıların minimal retraksiyonu ile tümörNöral yapıların minimal retraksiyonu ile tümör
açığa konabilmeli (Tümöre direkt ulaşım),açığa konabilmeli (Tümöre direkt ulaşım),
• Nörovasküler önemli yapıların açığa konması,Nörovasküler önemli yapıların açığa konması,
• BOS fistülünü engellemeye yönelik tedbirler,BOS fistülünü engellemeye yönelik tedbirler,
• Kozmetik problemlerin oluşmaması…Kozmetik problemlerin oluşmaması…
22. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
CERRAHİ AŞAMALAR/STRATEJİ, 1/2CERRAHİ AŞAMALAR/STRATEJİ, 1/2
• Bazal bir yaklaşım, Fizyolojik koridor,Bazal bir yaklaşım, Fizyolojik koridor,
• Tümöre ulaşılması,Tümöre ulaşılması,
• Mikrodiseksiyon,…Oryantasyon/İdentifikasyon,Mikrodiseksiyon,…Oryantasyon/İdentifikasyon,
– (uygun planın bulunması, keskin diseksiyon,…)(uygun planın bulunması, keskin diseksiyon,…)
• Transtümöral yoldan dural besleyicilerin koagülasyonu,Transtümöral yoldan dural besleyicilerin koagülasyonu,
– (Bazal devaskülarizasyon: Kafa tabanında orta hattan etmoidal, meningeal ve oftalmik(Bazal devaskülarizasyon: Kafa tabanında orta hattan etmoidal, meningeal ve oftalmik
arterlerden gelen dalların koagülasyonu ile,…arterlerden gelen dalların koagülasyonu ile,…bazal bir meningiomun adeta birbazal bir meningiomun adeta bir
konveksite meningiomuna dönüştürülmesikonveksite meningiomuna dönüştürülmesi,…),,…),
• Mikrodiseksiyon,…Mikrodiseksiyon,…
• Tümörün internal dekompresyonu,Tümörün internal dekompresyonu,
– (debulking, tümör üzerinde bir pencereden kitlenin küçültülmesi),(debulking, tümör üzerinde bir pencereden kitlenin küçültülmesi),
30. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
POSTOPERATİF KONTROLLERPOSTOPERATİF KONTROLLER
• Nörolojik yönden:Nörolojik yönden:
– Postoperatif mental fonksiyon değerlendirmesi,Postoperatif mental fonksiyon değerlendirmesi,
– Postoperatif koku muayenesi,Postoperatif koku muayenesi,
– Vizyon muayenesi.Vizyon muayenesi.
İlk 2 yıl 6’şar aylık, daha sonra yıllık periyotlarlaİlk 2 yıl 6’şar aylık, daha sonra yıllık periyotlarla
NM. + nöroradyolojikNM. + nöroradyolojik (+gadoliniumlu MRG)(+gadoliniumlu MRG) muayenelermuayeneler
31. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
LİTERATÜRDE REKÜRRENS & TAKİPLİTERATÜRDE REKÜRRENS & TAKİP
• Takipler uzun süreli olmalı (NM + MRG),Takipler uzun süreli olmalı (NM + MRG),
• Paranazal sinüs uzanımlı tümörlerde rekürrens oranı daha yüksek,Paranazal sinüs uzanımlı tümörlerde rekürrens oranı daha yüksek,
32. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
Deneyimi – (Kasım 1994 – 2009)Deneyimi – (Kasım 1994 – 2009)
• İntrakranyal meningiom sayısı:İntrakranyal meningiom sayısı: 372372 hastahasta
• Olfaktor oluk meningiomu:Olfaktor oluk meningiomu: 3333 hastahasta
33. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
Deneyimi – (Kasım 1994 – 2009)Deneyimi – (Kasım 1994 – 2009)
• Olfaktor oluk meningiomu:Olfaktor oluk meningiomu: 3333 hastahasta
• 24 kadın hasta, 9 erkek hasta24 kadın hasta, 9 erkek hasta
• Yaş aralığı: 32-66 yaşYaş aralığı: 32-66 yaş
34. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
Deneyimi – (Kasım 1994 – 2009)Deneyimi – (Kasım 1994 – 2009)
• BAŞVURU NEDENLERİ (BAŞVURU NEDENLERİ (3333 hastadahastada):):
– BaşağrısıBaşağrısı 29 hasta29 hasta
– Görme bozukluğuGörme bozukluğu 21 hasta21 hasta
– Kişilik/Davranış bozukluklarıKişilik/Davranış bozuklukları 8 hasta8 hasta
– Hareket güçlükleriHareket güçlükleri 3 hasta3 hasta
– Nöbet geçirmeNöbet geçirme 7 hasta7 hasta
– RinoreRinore 1 hasta1 hasta
35. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
Deneyimi – (Kasım 1994 – 2009)Deneyimi – (Kasım 1994 – 2009)
• NM. BULGULARI (NM. BULGULARI (3333 hastadahastada):):
– Vizyon bulgularıVizyon bulguları 24 hastada24 hastada
– Anosmi/hiposmiAnosmi/hiposmi 33 hastada33 hastada
– Mental bozukluklarMental bozukluklar 12 hastada12 hastada
– Motor defisitlerMotor defisitler 9 hastada9 hastada
– PtozisPtozis 1 hasta1 hasta
– Uvula deviasyonuUvula deviasyonu 1 hasta1 hasta
36. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
Deneyimi – (Kasım 1994 – 2009)Deneyimi – (Kasım 1994 – 2009)
• TÜMÖR BÜYÜKLÜĞÜ (TÜMÖR BÜYÜKLÜĞÜ (3333 hastadahastada):):
– 2 – 4 cm2 – 4 cm 4 hasta4 hasta
– 4 – 6 cm4 – 6 cm 15 hasta15 hasta
– 6 – 8 cm6 – 8 cm 12 hasta12 hasta
– 8 cm.den büyük8 cm.den büyük 2 hasta2 hasta
37. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
Deneyimi – (Kasım 1994 – 2009)Deneyimi – (Kasım 1994 – 2009)
KULLANILAN CERRAHİ YAKLAŞIMLAR (KULLANILAN CERRAHİ YAKLAŞIMLAR (3333 hastadahastada):):
• Bifrontal kranyotomi subfrontal yaklaşım + orbital osteotomiBifrontal kranyotomi subfrontal yaklaşım + orbital osteotomi 3 hasta3 hasta
• Bifrontal kranyotomi subfrontal/bazal yaklaşımBifrontal kranyotomi subfrontal/bazal yaklaşım 8 hasta8 hasta
• Ünilateral subfrontal + Pterional yaklaşım + orbital osteotomiÜnilateral subfrontal + Pterional yaklaşım + orbital osteotomi 2 hasta2 hasta
• Ünilateral subfrontal + Pterional yaklaşımÜnilateral subfrontal + Pterional yaklaşım 16 hasta16 hasta
• (Genişletilmiş pterional yaklaşım, Birbuçuk fronto-orbital yaklaşım)(Genişletilmiş pterional yaklaşım, Birbuçuk fronto-orbital yaklaşım)
• Pterional yaklaşımPterional yaklaşım 4 hasta4 hasta
38. OLFAKTOR OLUK MENİNGİOMLARIOLFAKTOR OLUK MENİNGİOMLARI
Kartal Eğitim ve Araştırma HastanesiKartal Eğitim ve Araştırma Hastanesi
Deneyimi – (Kasım 1994 – 2009)Deneyimi – (Kasım 1994 – 2009)
SONUÇLARSONUÇLAR ((33 hastada33 hastada):):
• Total rezeksiyonTotal rezeksiyon (Simpson gr. 1 / 2)(Simpson gr. 1 / 2) 33/33 hastada33/33 hastada
• MortaliteMortalite 1 hasta (1/33: %3)1 hasta (1/33: %3)
– Dev olfaktor oluk meningiomu, bifrontal yaklaşımDev olfaktor oluk meningiomu, bifrontal yaklaşım
– (Postoperatif beyin ödemi + pnömoni +…)(Postoperatif beyin ödemi + pnömoni +…)
• RekürrensRekürrens 1 hasta (1/33: %3)1 hasta (1/33: %3)
– 12 yıl sonra, tümüyle etmoid sinüsler içinde rekürren kitle12 yıl sonra, tümüyle etmoid sinüsler içinde rekürren kitle
• Majör Komplikasyonlar:Majör Komplikasyonlar:
– Vizyonda bozulmaVizyonda bozulma 1 hasta (1/33: %3)1 hasta (1/33: %3)
39. 35 yaşında bayan hasta
Nöbet geçirme, başağrısı şikayeti ile başvurdu.
NM: Anosmi ve sol alt ekstremitede parezi (4/5) saptandı.
42. • 57 yaşında erkek hasta
• 6 aydır devam eden başağrısı
• Sağ gözde üst nazal ve alt
nazal alanda, periferde hafif bir
daralma, sol gözde üst
kadranda hafif bir hassasiyet
kaybı
43.
44. • Sağda genişletilmiş
pterional yaklaşımla
total kitle
rezeksiyonu
• Patoloji: Mikst tip
meningiom.
• Sorunsuz taburcu
edildi.
45. 57 yaşında bayan hasta.
3 yıldır gittikçe artan sol gözde görme kaybı şikayeti mevcut.
NM: Görme alanında sol gözde optik atrofi ve totale yakın görme kaybı, sağ
gözde nazalde görme kaybı saptandı.