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IntroductionAlthough recent trends currently favor the endoscopic endonasal transcavernous approach (EETA) over the pretemporal transcavernous approach (PTA) for certain cavernous sinus pathologies, dedicated assessment of the surgical exposure and maneuverability is wanting. Toward this aim, this morphometric study quantifies these variables within four cavernous sinus compartments by comparing the PTA, EETA, and a combined approach to achieve a circumferential dissection (EETA-PTA).MaterialIn five latex-injected specimens, exposure volumes of the EETA, PTA, and circumferential EETA-PTA approaches were quantified; the latter combined the most conservative options of both the endoscopic and open approaches. Two clinical cases illustrate the combined approach.ResultsEETA-PTA provided the largest volume of exposure (65.6% vs 35% PTA vs 44.6% EETA, P = 0.01) and eliminated the need to mobilize the ICA or cross cranial nerves. Although EETA and PTA approaches afforded comparable exposure volumes along the entire cavernous sinus (34.9 vs 44.6%), the EETA better exposed medial and inferior compartments (whereas the PTA exposed larger volumes in the lateral and superior compartments. The combined EETA-PTA yielded 66% of total cavernous sinus exposure volumes and eliminated the need to mobilize the ICA or cross cranial nerves.ConclusionsOur methodology aligns with strategies that use a modular concept to divide the skull base into compartments for maximal safe resection. Excluding soft tumors, the EETA is preferred for medial and inferior lesions and the PTA for superior and lateral lesions. A staged combined EETA-PTA may safely yield a 360-degree access for extensive multi-compartment lesions that span neurovascular structures within the cavernous sinus.

Abstract BACKGROUND: Subcortical injury resulting from conventional surgical management of intracranial hemorrhage may counteract the potential benefits of hematoma evacuation. OBJECTIVE: To evaluate the safety and potential benefits of a novel, minimally invasive approach for clot evacuation in a multicenter study. METHODS: The integrated approach incorporates 5 competencies: (1) image interpretation and trajectory planning, (2) dynamic navigation, (3) atraumatic access system (BrainPath, NICO Corp, Indianapolis, Indiana), (4) extracorporeal optics, and (5) automated atraumatic resection. Twelve neurosurgeons from 11 centers were trained to use this approach through a continuing medical education–accredited course. Demographical, clinical, and radiological data of patients treated over 2 years were analyzed retrospectively. RESULTS: Thirty-nine consecutive patients were identified. The median Glasgow Coma Scale (GCS) score at presentation was 10 (range, 5-15). The thalamus/basal ganglion regions were involved in 46% of the cases. The median hematoma volume and depth were 36 mL (interquartile range [IQR], 27-65 mL) and 1.4 cm (IQR, 0.3-2.9 cm), respectively. The median time from ictus to surgery was 24.5 hours (IQR, 16-66 hours). The degree of hematoma evacuation was ≥90%, 75% to 89%, and 50% to 74% in 72%, 23%, and 5.0% of the patients, respectively. The median GCS score at discharge was 14 (range, 8-15). The improvement in GCS score was statistically significant (P < .001). Modified Rankin Scale data were available for 35 patients. Fifty-two percent of those patients had a modified Rankin Scale score of ≤2. There were no mortalities. CONCLUSION: The approach was safely performed in all patients with a relatively high rate of clot evacuation and functional independence.

Background Conventional method of using carbide burs for caries removal has long been shown to be quite successful. Nevertheless, it has some disadvantages, including excessive dentin removal, and patient discomfort. Objective The aim of this study was to compare and assess time consumption and the caries removal effectiveness of Smart prep bur II and Brix 3000 in addition to carbide bur (as a control group). Materials and methodology 60 newly extracted carious human permanent premolars were collected from patients between 14 and 24 years old. Teeth were extracted for orthodontic reasons. Caries should be deep but without pulp involvement and all teeth have only one surface caries (mesial or distal class II carious lesions). Samples have been collected, cleaned and stored in distilled water until starting the experiment. Teeth were divided into two groups in addition to third group that represent a control group ( n  = 20). Infected carious dentin for each group was removed using Smart prep bur II (polymer bur) or Brix 3000 (caries dissolving enzymes). Conventional carbide bur was used to remove carious dentin in the control group. Two parameters were assessed: time consumption and caries removal efficacy. Cavities were inspected by stereomicroscopy and caries removal was categorized after application of caries detector dye. Results Regarding the amount of time needed for soft caries removal and the efficacy of total amount removed of infected dentine, there was no statistically significant difference (P ˂ 0.001) found between the two minimally invasive groups. While for carbide bur group, recorded values were considered statistically significant ( P  > 0.001) when compared to the two minimally invasive groups. Conclusion within the limitation of this in-vitro study, both Smart Prep bur II and BRIX 3000 are efficient methods for caries removal by minimally invasive approach. However, both are less effective and time-consuming methods when compared to conventional carbide bur.

BACKGROUND:Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches. OBJECTIVE:To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery. METHODS:Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed. RESULTS:Based on anatomic correlations, the ICA may be described as 6 distinct segments(1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment. CONCLUSION:The proposed endoscopic classification outlines key anatomic reference points independent of the vesselʼs geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system. ABBREVIATIONS:DOA, distal osseous archEEA, expanded endoscopic approachICA, internal carotid arteryLOCR, lateral opticocarotid recessLTR, lateral tubercular recessMOCR, medial opticocarotid recessSOF, superior orbital fissure

Introduction Cytotoxic (CD8+) and natural killer (NK) cells play critical roles in anti-tumor immunity. Dysfunction in these cells is considered as one of the extrinsic mechanisms for tumor relapse. Aim We aimed in this study to assess cytotoxic activities of CD8 + T and NK cells in the peripheral blood from lung cancer patients before and after induction of chemotherapy. Subjects and methods Healthy (n = 5) volunteers and lung cancer patients (n = 15:5 before, 5 during, and 5 after induction of chemotherapy) were recruited. Flow cytometry was used to analyze the numbers of CD8 + T cells, NK and CD56 + T cells and their intracellular expression of granzyme B (GzB) in fresh peripheral blood mononuclear cells (PBMCs) and after 72 h of their culture in vitro and stimulation with 5 µg/ml Concanavalin A (Con A) and 50ng/ml IL-2). In addition, the plasma levels of inflammatory cytokines were measured using luminex. Results After culture, significant increases in the number of GzB expressing cells gated on CD3+, CD4+, CD8 + and NKCD8 + T cells in the PBMCs from lung cancer patients before induction of chemotherapy as compared to control individuals as well as patients during and after induction of chemotherapy. Serum levels of IL-1 and CXCL8 in patients before induction of chemotherapy showed 37- and 40-fold increases, respectively, as compared to control individuals. Both GzB expression and cytokines levels in patients during and after chemotherapy were similar. Conclusion Polyclonal stimulation of PBMCs can restore the cytolytic activities of cytotoxic CD8 and NK cells from lung cancer patients even after chemotherapy.

ObjectivesTo compare the success, survival and costs of selective versus stepwise carious tissue removal (SE/SW) in permanent teeth with deep (>2/3 dentine depth) carious lesions.DesignRandomised controlled, unicentre, clustered two-arm superiority trial.SettingOutpatient clinic of a private university in Cairo, Egypt.ParticipantsOne hundred and fifteen participants (n=132 teeth), aged 18–47 years, from Cairo, Egypt, were enrolled. Premolars/molars with occlusal/occlusal-proximal deep lesions (radiographically >2/3 dentine), sensible pulps, without spontaneous pain, were included.InterventionsPeripheral carious tissue removal to hard dentine was performed. Pulpo-proximally, soft dentine was left. A glass ionomer (GI) restoration was placed. After 3–4 months, teeth were randomly allocated to SE (n=66), with reduction of the GI into a base and no further tissue removal, followed by a composite resin restoration, or SW (n=66), with full removal of the GI, additional excavation until firm dentine pulpo-proximally, followed by a GI-based composite restoration. Mean follow-up was 1 year.Primary and secondary outcome measuresPrimary outcome was success (absence of endodontic/restorative complications). Secondary outcomes were tooth survival and initial and total treatment costs.ResultsZero/five pulp exposures occurred during SE/SW, and seven/five SE/SW teeth required endodontic therapy. Success after 12 months was 89.4% for SE and 84.9% for SW. The estimated mean time free of complications was 23 and 18 months for SE and SW, respectively, without significant differences between SE and SW (p>0.05/Cox). Initial treatment costs were significantly higher for SW (mean (SD): 507.5 (123.4) Egyptian pounds (EGP)) than SE (mean (SD): 456.6 (98.3) EGP), while total costs showed no significant difference (p>0.05).ConclusionWithin the limitations of this interim analysis, and considering the depth of these lesions (>2/3 dentine), SE and SW showed similar risk of failure and overall costs after 1 year.Trial registration numberPACTR201603001396248.

Abstract BACKGROUND The advent of the operating microscope (OM) revolutionized the field of neurosurgery. It allowed surgeons to operate on and effectively treat diseases previously inaccessible with conventional eyesight because of magnification and illumination. Improvements in the essential methods of visualization and the quality of the optics have plateaued. Another main limitation of the OM remains its ergonomics because of the need of the surgeon and assistant to directly interface with the OM objective. Recently, exoscopes have been introduced to overcome some shortcomings of the conventional OM. OBJECTIVE To subjectively review the individual authors experience with the current exoscope platforms in an attempt to provide a resource to the neurosurgeon when considering imaging options. METHODS Experts with previous use of each individual platform were contacted and asked to contribute their experiences. RESULTS In total, 4 systems are discussed. They include the VITOM (Karl Storz, Tuttlingen, Germany), the Olympus ORBEYE (Olympus, Tokyo, Japan), the Synaptive Modus V (Synaptive Medical, Toronto, Canada), and the Zeiss KINEVO (Carl Zeiss AG, Oberkochen, Germany). CONCLUSION The advent of exoscopes has the potential to begin to allow surgeons to move beyond solely the microscope for intraoperative visualization while improving upon its ergonomic disadvantages.

Background Psoriasis is a prevalent autoimmune skin disorder; however, the mechanism of its pathogenesis remains fully understood. The imbalance of regulatory T (T reg ) cells and effector T cells represents one potential mechanism, where a low dose of IL-2 is important. Aim of the work Given that IL-2/IL-12 complex is considered as an immune modulator for antigen-activated lymphocyte proliferation, this study aimed to compare the immunophenotypic, clinical, and histological effects of anti-IL-2/IL-2 complex to a low dose of free IL-2 on experimental psoriasis-like skin inflammation induced by imiquimod. Materials and methods Thirty-five Balb/c male mice were left without treatment, or were received topical application of imiquimod (IMQ, 3.125 mg/mouse) to induce psoriasis-like skin inflammation, and then the mice were treated with intraperitoneal (i.p.) injection of 100 µL containing anti-IL-2/IL-2 complex (2.5 µg /0.5 µg/mouse), or topical steroids (62.50 mg/mouse), or low dose of free IL-2 (i.p.; 0.5 µg/mouse). The expression levels of CD4, CD25, and Foxp3 in the leukocytes were assessed by multiparametric flow cytometry. The effects of different treatments on the histology and pathology of the induced psoriasis were also assessed. Results IMQ-induced hyperkeratosis, parakeratosis and mild papillomatosis with the retained nuclei in the keratin layer, whereas acanthosis with exocytosis was prominent in the epidermal layer. Lymphocyte infiltration was profusely all over the dermis. Additionally, there were some degrees of Munro micro abscesses were observed in the keratin layer with a collection of neutrophils in the group treated with standard betamethasone cream which showed mild improvement clinically, histopathological with no significant difference between this group and the naïve and positive control groups. After 7 days from the onset of treatment, we found that treatment of mice with anti-IL-2/IL-2 complex decreased the thickness of the epiderms as compared to their groups. Furthermore, the relative number of CD4 + Foxp3 + CD25 +  cells showed increases in psoriasis mice treated with anti-IL-2/IL-2 complex as compared to other groups. In conclusion Anti IL-2/IL-2 complex therapy effectively ameliorated the clinical manifestations of psoriasis, with no apparent side effects, providing a new strategy for treating psoriasis.

Purpose To summarize the clinical features and outcomes of petroclival meningioma patients treated with stereotactic radiosurgery (SRS) as either a primary or an adjuvant modality. Methods Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane. A systematic review and meta-analysis of treatment outcomes comparing primary and adjuvant SRS was conducted. Results Seven articles comprising 722 cases were included. The mean tumor marginal dose was 13.5 Gy. After SRS, symptoms improved in 28.7%, remained unchanged in 61.3%, and worsened in 10.0% of the cohort. Tumor control was achieved in 94.8% of patients. The mean tumor volume change was −6.4 cm 3 . The 5-year and 10-year progression-free survival (PFS) rates were 91–100% and 69.6–89.9%, respectively. Overall, 61.9% of patients underwent primary radiosurgery, and 38.1% had adjuvant radiosurgery. Patients who had primary SRS reported higher rates of tumor control (94.3% vs. 88.2%) and fewer SRS-related complications (3.7% vs. 10.3%) than those who received adjuvant SRS (not accounting for microsurgical complications). The functional status of patients who had primary SRS was more likely to improve or remain unchanged, with an effect size of 1.12 (95% CI 1.1–1.25; I 2  = 0). Neither group displayed superiority in worsening functional outcomes or tumor control rate. Conclusion SRS of petroclival meningiomas was associated with excellent long-term PFS and local tumor control rates. Primary SRS was highly effective for patients with smaller volume lesions without clinically symptomatic mass effect. In patients who warrant initial resection, adjuvant radiosurgery remains an important modality to prevent regrowth while maintaining postresection function.