Petroclival meningiomas originate in the petroclival region near the internal auditory canal and displace cranial nerves VII and VIII. The goal of surgical management is complete resection without additional neurological deficits. Three main approaches are used - the anterior petrosal, posterior petrosal, and lateral suboccipital approaches - depending on the location and extent of the tumor. Postoperative outcomes depend on factors like preoperative deficits, tumor size and involvement of surrounding structures.
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.
Surgical approach to thalamus explained in details their surgical anatomy and lesion, Preop post op results with different surgical approach for thalamic lesions
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.
Surgical approach to thalamus explained in details their surgical anatomy and lesion, Preop post op results with different surgical approach for thalamic lesions
Before embarking on an approach, the surgeon should be familiar with both the ventricular anatomy and the options for optimally Accessing lesions in third ventricle is a surgical challenge because of its difficult corridor as well as deeper location, need of neural incision, preservation of vascular, thalamus and hypothalamus and likely risk of fornix injury.
Pineal gland is essentially an extra axial midline structure lying at the roof of dienchephalon rostral to the quadrigeminal cistern surrounded by important neurovascular structure, occurring in the geometric center of brain with same depth of trajectory had made the surgery in this region a formidable challenge to neurosurgeons, however radical resection must be the goal in selected pathologies, if not pure germ cell tumor.
Before embarking on an approach, the surgeon should be familiar with both the ventricular anatomy and the options for optimally Accessing lesions in third ventricle is a surgical challenge because of its difficult corridor as well as deeper location, need of neural incision, preservation of vascular, thalamus and hypothalamus and likely risk of fornix injury.
Pineal gland is essentially an extra axial midline structure lying at the roof of dienchephalon rostral to the quadrigeminal cistern surrounded by important neurovascular structure, occurring in the geometric center of brain with same depth of trajectory had made the surgery in this region a formidable challenge to neurosurgeons, however radical resection must be the goal in selected pathologies, if not pure germ cell tumor.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Sch.40 surgical management of petroclival meningioma
1. Surgical Management of
Petroclival Meningiomas
Schmidek chapter 40
Khaled M. Aziz Sebastien,Froelich,Sanjay Bhatia,
Alexander K. Yu,Albino Bricolo,Todd Hillman,Raymond F. Sekula Jr.
3. Natural history
• The position of cranial nerves VII and VIII is the critical
landmark to differentiate petroclival meningiomas from
cerebellopontine angle meningiomas
• Petroclival meningiomas originate anterior to the IAC
and displace cranial nerves VII and VIII posteriorly.
• Cerebellopontine angle meningiomas originate posterior
to the IAC and displace cranial nerves VII and VIII
anteriorly
• Slow growing skull base meningioma
4. Recurrence rate
• Depend on location, cavernous sinus involvement, brain
stem infiltration, grade of resection, and histopathologic
result
Simpson After 5 Yrs
(%)
After 15 Yrs
(%)
After 25 Yrs
(%)
Grade 1 3.5 7-10 13-16
Grade 2 4 11-15 15-20
Grade 3 25 37-43 39-76
Grade 4-5 36-45 63-100 -
6. Clinical Picture
• Involvement of cranial nerves
– V, VIII, VI, VII, IX, and X
• Cerebellar compression
– Gait ataxia
• Brain stem compression
– Motor and sensory deficit
• Increased intracranial pressure
– Dementia
– Duu to secondary to hydrocephalus
7. Neurologic evaluation
• CT for transpetrosal approach
– Anatomy of the inner ear
– Height of jugular bulb
– Pneumatization of mastoid bone
• MRI
– T1 : delinate tumor,its relationship to other structure
– T2 : arachnoid cleavage plane,brain stem edema and infiltration
– Flow void : location of major vertebrobasilar vessel
• MRV
– Torcula, transverse sinus, sigmoid sinus
– Vein of Labbe(posterior temporal venous drainage)
8. Neuroradiologic evaluation
• Cerebral angiography
– Tumor blood supply
• meningohypophysial trunk of the internal carotid artery
• the posterior branch of the middle meningeal artery
• the meningeal branch of the vertebral artery
• the clivus artery from the carotid siphon
• the petrosal branches of the meningeal arteries
• the ascending pharyngeal branches of the external carotid
artery
– Mass effect on vertebrobasilar systems
9. Anesthetic consideration
• Brain relaxation
• Monitor nerve and tract : Muscle relatant is not use
• Remifentanil or sufentanil infusion for analgesia
• Sevoflurane or propofol for hypnosis
10. Intraoperative
Neurophysiologic monitoring
• Somatosensory evoked potentials (SSEPs)
– Record peripheral nerve afferent
• Motor evoked potentials (MEPs)
– Recording electromyogram activity in muscle
• Brain stem auditory evoked potentials (BSAEPs)
– Cortical response to auditory stimuli
• EMG
11. Goal of surgical management
• Goal of surgery is complete resection of the tumor
without causing additional deficits to the patient
• Tumor with brain stem compression
– decompression with either total or subtotal excision
• Tumor with neurovascular invasion
– Excision of tumor that leaves the part infiltrating the
neurovascular structure
15. Clivus and petroclival zone
• Zone I (upper zone)
• dorsum sellae to the upper border of the IAC
• retrosellar region, region medial to the trigeminal
impression down to the IAC
• exposed via the Kawase approach (anterior petrosal
approach)
• Zygomatic osteotomy can be added
• If tumor involve only retrosellar region of zone I : trans-
sylvian transcavernous approach
16. Clivus and petroclival zone
• Zone II (middle zone)
• IAC to the upper border of the jugular tubercle
• exposure provided via the posterior petrosal approach
• tumor involve Zone I and II : combined petrosal
approach
• Zone III (lower zone)
• jugular tubercle to the lower edge of the clivus
• Exposed via lateral suboccipital–transcondylar
approaches
17. Clivus and petroclival zone
• Petroclival angle
• angle between the petrous
bone and the clivus at the
level of IAC
• Central clival depression
• relationship between
intermeatal
plane(superior) and
jugular tubercle(inferior)
• The less obtuse the
petroclival angle, the more
difficult the exposure of
the central clival
depression
19. Anterior petrosal approach
• allows exposure
– the middle fossa floor
– the petrous bone apex,
– zone I of the petroclival region
• subtemporal or frontotemporal craniotomy and anterior
petrosectomy
• lumbar drain
20. Anterior petrosal approach
• Position
– Supine position and rotate 90
– Ipsilateral shoulder is elevated
– Head tilt 15 degrees downward
– Patient’s upper back is elevated 25-30 degrees
• Skin incision
– initiated posterior to the midpoint of the mastoid
process extends superiorly and anteriorly
– traversing the superior temporal line and ending at the
middle of the zygomatic arch for a subtemporal
anterior petrosal approach
22. Anterior petrosal approach
• The dura is elevated from the middle fossa floor, and
petrous bone via a posterior to anterior approach;
elevation starts at the arcuate eminence and proceeds
anteriorly
• The middle meningeal artery is controlled with bipolar
cautery and sectioned, the foramen spinosum is packed
with bone wax
• Greater superficial petrosal nerve(GSPN) is identified
and keep intact : dissection follows the GSPN from
posterior to anterior until it courses under the third
division of the trigeminal nerve (V3)
23. • Glasscock’s triangle
– Laterally : foramen spinosum to the facial hiatus
– Medially : GSPN
– Base : V3
• Kawase’s triangle
– Laterally : GSPN
– Medially : petrous ridge
– Base : Arcuate eminence
24. Anterior petrosal approach
• Anteriorly, the mandibular division (V2) is identified at the
foramen rotundum
• Dissection continues medially to the petrous ridge
indenting the superior petrosal sinus
• Separation of the dura propia continues until the
connective tissues sheath over V2,V3 and the Gaserian
ganglion is visible(Meckel’s cave)
25. Anterior petrosal approach
• Kawase’s quadrilateral is drilled under microscope at
petrous ridge to identify the IAC
– The arcuate eminence forms a 120-degree angle to
the GSPN (or the internal carotid artery), and the IAC
bisects this angle
– Follow the geniculate ganglion to the labyrinthine
segment of the facial nerve(high incidence of facial
nerve injury)
• Drilling of the IAC continues to the bone crest dividing
the facial nerve and the superior vestibular nerve (Bill’s
bar)
26. Anterior petrosal approach
• The bone overlying the cochlea is drilled until the
cochlea appears as a blue line
• After identify of the dura covering the IAC posterior
• the Kawase’s quadrilateral is drilled to the
– GSPN (preserved) laterally
– the petrous segment of the internal carotid artery anterolaterally
– V3 anteriorly
– the superior petrosal sinus medially
– the posterior fossa dura and inferior petrosal sinus inferiorly
27. Anterior petrosal approach
• The inferior temporal lobe dura is open above and
parallel to the superior petrosal sinus. The dura is
reflected inferiorly
• The superior petrosal sinus is secured with titanium
hemoclips and is split
• The tentorium is cut medially toward the tentorial incisura
posterior to the dural entry of the trochlear nerve
• The posterior fossa dura is further split inferiorly
28.
29. Anterior petrosal approach
• After completion of surgical resection
• Watertight dural closure is demanding
• The IAC bony opening is plugged with a small piece of
fat or muscle
• The dura is approximated utilizing a synthetic dural graft
and is sprayed with fibrin glue. If there is a big filling
defect, it can be judiciously obliterated with pieces of fat
graft to prevent postoperative fluid collection and
cerebrospinal fluid (CSF) leak
30. Anterior petrosal approach
• Closure
• Bone flaps are connected and fixed with titanium plates
and secures
• Bony defects are filled with bone cement for cosmetic
reconstruction and prevention of CSF leak
• We prefer to keep the lumbar drain in place for 48 hours
after obtaining an immediate postoperative CT scan
32. Posterior petrosal approach
• Temporal craniotomy + presigmoid craniectomy + a
small lateral retrosigmoid craniectomy
• Depending on the preoperative hearing
– retrolabyrinthine or translabyrinthine bony temporal bone drilling
is added
• Sectioning of the superior petrosal sinus and tentorium,
and a relaxing incision in the dura above the lateral
transverse sinus
– frees the sigmoid sinus and allows mobilization of the sigmoid
sinus posteriorly to expand the presigmoid space : crucial step
33. Posterior petrosal approach
• Position
– Same in anterior petrosal approach
– Lateral oblique position
• Skin Incision
– three fingerbreadths circumferentially around the
edge of the ear pinna
34. Posterior petrosal approach
• The transverse sinus and the transverse–sigmoid
junction are dissected from the overlying bone
• Retrolabyrinthine mastoidectomy
• Landmark
– Spine of Henle : Antrum
– After drilling the bone over the sinodural angle, the
sigmoid sinus, superior petrosal sinus, and posterior
semicircular canal are exposed
– Floor of Antrum : Cortical bone of the lateral
semicircular canal
35. Posterior petrosal approach
• Landmark
– Follow lateral semicircular canal : posterior
semicircular canal
– Follow posterior semicircular canal : superior
semicircular canal
• The air cells of the mastoid tip are removed to expose
the digastric ridge : landmark for the stylomastoid
foramen and the beginning of the fallopian canal
36. Posterior petrosal approach
• Dura openings
– Below temporal lobe : parallel to the superior petrosal
sinus
– Posterior fossa dura in presigmoid space :
longitudinally between superior petrosal sinus and the
jugular bulb
– Gentle traction on temporal lobe and cerebellum :
superior petrosal sinus is sectioned and clipped
– Incision dura along transverse sinus
– The tentorium is sectioned into the incisura at a point
posterior to entrance of the trochlear nerve
38. Posterior petrosal approach
• Closure
– Pericranium or a synthetic dural graft for close
– Open mastoid air cell : wax
– The antrum : muscle
– The mastoidectomy : abdominal fat graft and sprayed
with fibrin glue
– Bone flaps : titanium plates
39. Posterior petrosal approach
• Closure
– Bony defect : bone cement
– Temporalis m. is closed
– Keep lumbar drain for 48 hrs
– Immediate post-op CT scan
41. Lateral Suboccipital Approach
• For
– petroclival meningiomas involving zones I, II, and III
• Exposure
– posterior surface of the petrous bone
– the anterolateral brain stem
– craniocervical junction.
42. Lateral Suboccipital Approach
• The lateral oblique position
• Key hole : inferomedial to asterion to avoid injury to
transverse sigmoid junction
• Mastoid bone is drilled to expose medial edge of the
sigmoid sinus and the inferior edge of sinus
• For tumor extend to zone III : C1 laminectomy and
drilling of the posteromedial third of the occipital
condyle and lateral mass of C1
43. Lateral Suboccipital Approach
• V3 segment of vertebral artery : groove of the C1
lamina
• Dural incision : C1, extends superiorly through the
foramen magnum, and extends superolaterally to
the top of craniotomy edge
• Closure
– dura is closed watertight
– pericranial graft or a synthetic graft
– suture line is sprayed with fibrin glue
44. Radiosurgery
• < 3 cm in diameter
• adjuvant treatment to prevent tumor regrowth and
recurrence after maximal safe surgical resection
45. Outcome
• Increase post operative morbidity
• Preoperative neurologic deficits (diminished
Karnofsky Performance Scale score
• tumor size of 2.5 cm or more
• multiple cranial fossae involvement and cavernous
sinus infiltration
• absence of arachnoid cleavage plane
46. Outcome
• brain stem compression and invasion, brain stem
edema
• adhesions to and encasement of vascular structures
• high vascularity and direct tumor blood supply from
the basilar artery
• firm tumor consistency affecting the extent of tumor
resection
Editor's Notes
Hatch area คือ central clival depression
trans-sylvian transcavernous approach : which involves mobilization of the oculomotor nerve and drilling of the posterior clinoid process and the dorsum sellae