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PubMed1991

Intracranial arachnoid cysts in children. A comparison of the effects of fenestration and shunting.

The best operative intervention for children with arachnoid cysts remains the subject of controversy. Recent reports stress that craniotomy for cyst fenestration is associated with a low incidence of morbidity and mortality and may leave the child shunt-independent. The cases of 40 pediatric patients with arachnoid cysts treated between 1978 and 1989 are reported. Five children with mild symptoms and small cysts that remained stable on follow-up studies have not required surgical intervention. Of 15 patients with cysts initially treated by fenestration, 10 (67%) showed no clinical or radiographic improvement postoperatively and have undergone cyst-peritoneal (eight patients) or ventriculoperitoneal (VP) shunting (one patient), or revision of a VP shunt placed for hydrocephalus before cyst fenestration (one patient). Two other patients with existing VP shunts required no further procedures. Thus, only three (20%) of 15 patients initially treated by fenestration remain shunt-independent after a median follow-up period of 8 years. The 20 other patients were initially treated by cysts shunting and all improved postoperatively; shunt revision has been necessary in six (30%) of these 20 patients because of cysts recurrence. Cyst location influenced the success of shunt treatment; none of the seven middle cranial fossa cysts treated by shunting have required revision, but results with cysts in other locations were less favorable. In all locations, though, shunting was more successful than fenestration. It is concluded that cyst-peritoneal or cyst-VP shunting is the procedure of choice for arachnoid cysts in most locations, including those in the middle cranial fossa.

Arachnoid↗
PubMed1993

Multiloculated hydrocephalus: craniotomy and fenestration of intraventricular septations.

Ten pediatric patients with multiloculated hydrocephalus caused by neonatal meningitis, ventriculitis, or intraventricular hemorrhage were surgically treated over a 14-year period (January 1, 1976, to December 31, 1990). Six patients underwent craniotomy and transcallosal fenestration of intraventricular septations followed by placement of a shunt, while the other four were treated by shunting procedures alone. Craniotomy resulted in reduction of the shunt revision rate from a median of 2.75 per year prior to fenestration to 0.25 per year following fenestration, with median observation periods of 44.5 and 27 months, respectively. This was compared to a median revision rate of 0.55 per year for patients treated with shunting procedures alone. There were no deaths in either group. Although no surgical complications were encountered, one patient did require a second fenestration procedure. The important aspects of multiloculated hydrocephalus, including pathophysiology, radiographic correlates, and treatment options, are discussed. The goal of treatment is to eliminate the need for multiple shunt revisions, minimizing the accompanying morbidity and expense. It is concluded that craniotomy and transcallosal fenestration of intraventricular septations is a successful treatment of multiloculated hydrocephalus.

Cerebral Ventricles↗
PubMed1999

[Occipital neuralgia caused by the compression of the fenestrated vertebral artery: a case report].

A case is presented of fenestration of the vertebral artery in a 36-year-old woman who had various neurological symptoms with Basedow's disease. We also review 7 cases from the literature. Our patient had had occipital neuralgia and numbness of the left side of the neck and left upper limb several weeks before admission. On admission she had hyperthyroidism. MRI, left vertebral angiography, and 3D-CT scans demonstrated a fenestrated vertebral artery compressing the upper cervical cord. The patient's symptoms gradually improved as her thyroid function was controlled. A possible explanation is that the fenestrated vertebral artery might have compressed the neural structures, resulting in her various symptoms. Occipital neuralgia was apparently caused by the fenestrated artery compressing the C1 and C2 sensory roots. A fenestrated vertebral artery is usually of no clinical significance. The reason for the late onset of symptoms in the present case is unknown, but it may have been due to hemodynamic stress caused by her hyperthyroidism. After her thyroid function was controlled, the hemodynamic stress presumably decreased and the symptoms resolved spontaneously.

Adult↗
PubMedDate not supplied

Endovascular management of basilar artery aneurysms associated with fenestrations.

BACKGROUND AND PURPOSE: Arterial fenestrations are associated with saccular aneurysms that are often difficult to treat with open surgical techniques. We evaluated our experience with endovascular treatment of such aneurysms. METHODS: Ten consecutive patients with 11 basilar artery aneurysms associated with fenestrations were treated with coils by means of the endovascular route between November 1994 and February 2000. All patients underwent endovascular embolization by the femoral approach, under general anesthesia. Twelve embolization procedures were perfomed in the 10 patients. RESULTS: Nine proximal and two distal basilar artery fenestration aneurysms were treated successfully. The embolization was complete in 10 of the 11 aneurysms. It was incomplete in one case, and complete occlusion could not be achieved at the second attempt. There was one regrowth at 1-year follow-up, which was successfully treated again. Four of the aneurysms were treated initially with balloon remodeling, whereas one aneurysm with regrowth and one with incomplete occlusion were treated with balloon remodeling at the second embolization procedure. In one case, one limb of the fenestration was sacrificed. CONCLUSION: Endovascular treatment of basilar artery aneurysms associated with fenestrations appears to offer advantages over traditional open surgical techniques.

Adult↗
PubMed1991

Comparison of the width of the intervertebral disk space and radiographic changes before and after intervertebral disk fenestration in dogs.

Intervertebral disk space widths were measured on lateral radiographs of 73 anesthetized dogs. Weight was found to have a significant (P less than 0.01) effect on disk space width. Using weight-adjusted disk space width measurements for all subsequent studies, older (7- to 16-year-old) dogs and males had consistently, but not significantly, wider, disk spaces than did alternative groups. Cervical and lumbar intervertebral disk spaces tended to be wider than those in the caudal thoracic region. The widest cervical intervertebral disk spaces were C4-5 and C5-6 and the narrowest was C2-3. In the lumbar region, L2-3 was the widest disk space and L4-5 was the narrowest. Dachshunds generally had greater mean intervertebral disk space width than did other breeds of dogs. Cervical (n = 6 dogs) and thoracolumbar (n = 6 dogs) disk fenestration resulted in narrow intervertebral disk spaces, regardless of breed. When a ventral approach was used in thoracolumbar fenestration, the mean intervertebral disk space was narrower than that resulting from use of a dorsolateral approach. Spondylosis was found radiographically 1 to 4 years after intervertebral disk fenestration in 3 of 6 dogs that had cervical fenestrations and in 5 of 6 dogs that underwent thoracolumbar fenestration.

Age Factors↗
PubMedDate not supplied

Fenestration. Pros and cons.

Fenestration of canine intervertebral discs is a time-honored, yet controversial, procedure used by veterinarians in the management of degenerative disc disease. It has been touted for both its supposed therapeutic effects and for its purported role in preventing future episodes of disc-related clinical signs. In spite of its long-standing reputation and wide use by many, fenestration may lack a firm scientific basis for its continued incorporation in the repertoire of the veterinary spine surgeon. This chapter will explore the key issues that impinge on the role fenestration plays and discuss the pros and cons attendant with its use. The author feels that, with the ability to diagnose and treat intervertebral disc prolapse in more sophisticated and scientific ways, fenestration should largely be abandoned. The evidence for this conclusion and the limited role that may still be reserved for fenestration are discussed.

Animals↗
PubMed1984

[Multiple anomalies of cerebral vessels. A case of multiple aneurysms associated with fenestration of the middle cerebral artery and persistent primitive trigeminal artery].

A case of multiple intracranial anomalies was reported. They consisted of fenestration of the middle cerebral artery (MCA), persistent primitive trigeminal artery and four intracranial aneurysms. The patient, 45-year-old male, had an attack of subarachnoid hemorrhage on July 15, 1982. He was transferred and admitted to our Dept. of Neurosurgery on July 27. On admission neurological examinations revealed retinal hemorrhage, bilateral papilledema and abducens nerve paresis on the left. Cerebral angiography demonstrated multiple aneurysms, one in the left vertebral artery, one in the left MCA, one in the right IC-PC junction and one in the fenestrated right MCA and persistent primitive trigeminal artery. Computed tomography (CT) demonstrated high density areas in the basal cistern and bilateral sylvian fissures, and cavum septi pellucidi and cavum Vergae as well. Surgical intervention was done and all aneurysms were clipped or coated successfully. The aneurysm in the fenestrated right MCA had originated from the proximal end of the fenestration of the MCA. The cavum septi pellucidi and cavum Vergae were asymptomatic. The postoperative course was uneventful. The authors discussed the pathogenesis and clinical meanings of fenestration of the MCA and persistent primitive trigeminal artery, and inferred that the genetic abnormality at the stage of development of cerebral vessels could play one part of the formation of intracranial aneurysms, because of the fact that the cerebrovascular anomalies showed high incidence of coexistence of intracranial aneurysms.

Cerebral Angiography↗
PubMed1980

Middle cerebral artery fenestration.

Fenestration of the middle cerebral artery (MCA) is an unusual anomaly. We recognized and photographed MCA fenestration during an operation performed to clip an internal carotid artery aneurysm. The incidence of angiographic demonstration of this anomaly has been reported to be 0.26%. The clinical significance of fenestration of the vertebral and basilar arteries has primarily been the relationship of fenestration with other intracranial vascular anomalies. This is the first report of MCA fenestration associated with an aneurysm.

Cerebral Angiography↗
PubMed1995

[Infantile brainstem infarction due to vertebral artery fenestration: a case report].

The patient was a 10-year-old boy. He had a sudden onset of generalized tonic-clonic convulsion. On admission, he presented with mild disturbance of consciousness and right hemiparesis. The electroencephalogram showed diffuse spike and slow wave complex. Three days later, magnetic resonance imaging (MRI) showed high signal intensity areas in the left cerebellar hemisphere and pons. On cerebral angiograms, coiling of the bilateral carotid arteries, occlusion of the basilar artery at the distal site, and fenestration of the left vertebral artery at the atlanto-axis level were shown. According to these findings, the patient was diagnosed with brainstem and cerebellar infarction. On the follow-up angiograms, recanalization of the basilar artery on the right vertebral angiogram, occlusion of the left vertebral artery at the distal site of the posterior inferior cerebellar artery origin, and occlusion of one of the duplicated vertebral arteries were recognized. Fenestration of the vertebral artery is presented in about 1-2% at angiography and autopsy and the clinical significance is controversial. In this case, the fenestration may have played a role as an embolic source because there was no probable cause of the cerebral infarction, and the vascular occlusion and recanalization occurred near the distal site of the fenestration. These findings suggest the clinical significance of vertebral artery fenestration as an embolic source.

Brain Stem↗
PubMed1993

[A large vertebrobasilar junction aneurysm grown at the proximal end of basilar artery fenestration--usefulness of balloon occlusion test with 99mTc-HMPAO SPECT under induced hypotension and consideration in therapeutic strategies].

A 48-year-old lady suffered a transient loss of consciousness. CT and MRI revealed a large vascular lesion compressing the left lower pons. Angiography revealed a large aneurysm at vertebro-basilar junction, dome of which projected anteriorly and left to midline. Her previous vertebral angiogram taken 10 years ago when she suffered a subarachnoid hemorrhage from the left MCA aneurysm, had showed a fenestration of lower basilar artery without apparent aneurysm. Bilateral super-selective vertebral angiograms revealed that the aneurysm arose at the proximal end of the fenestration, and vertebrobasilar junction was incorporated into the aneurysm indicating broad neck aneurysm. The left posterior communicating artery was well developed. Balloon test occlusion (BTO) of bilateral vertebral artery was performed under normotension and induced hypotension. 99mHM-PAO SPECT was used to examine cerebral blood flow (CBF) during hypotensive BTO. The patient tolerated the test and CBF imaging showed insignificant sight decrease in bilateral cerebellar hemispheres. Exploration of the aneurysm was carried out by the right far lateral suboccipital approach. Bilateral vertebral arteries and the right segment of the basilar artery fenestration were identified. Neck clipping of the aneurysm with reconstruction of the parent vessels were tried with fenestrate clip. However, narrow operative field and large dome of the aneurysm made it hard to identify the left segment of the fenestration. Neck clipping was given up and clipping of bilateral vertebral arteries were performed distal to posterior inferior cerebellar artery with three body clippings. The patient showed moderate postoperative left lower nerve palsy, which was gradually improved in several weeks. Follow-up angiography revealed no opacification of the aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)

Basilar Artery↗
PubMed1996

Pharmacological control of pulmonary blood flow with inhaled nitric oxide after the fenestrated Fontan operation.

BACKGROUND: A transient increase in pulmonary vascular resistance can result in hemodynamic compromise after a Fontan operation. An interatrial fenestration is designed to maintain cardiac output in these circumstances but may result in severe hypoxemia and a vicious circle due to hypoxemia induced pulmonary vasoconstriction. Our aim was to determine whether inhaled nitric oxide (iNO), a selective pulmonary vasodilator, could be used to reduce pulmonary vascular resistance in desaturated patients (SaO2 < or = 85%) after a fenestrated Fontan operation. METHODS AND RESULTS: Responses to iNO (20 ppm for 15 min) were assessed in 10 consecutive children with SaO2 < or = 85% and compared with 5 with SaO2 > 85% after a fenestrated Fontan operation. Exposure to iNO resulted in a significant increase in SaO2 (from 64 +/- 5% to 82 +/- 2%, P < .01) and reduction in transpulmonary gradient (TPG) (from 12.2 +/- 1 [SEM] to 9.6 +/- 1.1, P < .01) in patients with baseline SaO2 < or = 85%. Baseline saturation was a predictor of response to iNO, with a greater response in those with lower saturations (r = -.86, P < .01). In contrast, no significant effects were noted in PaO2 or TPG (from 122 +/- 46 mm Hg and 8 +/- 1.8 to 123 +/- 43 mm Hg and 7 +/- 1.2, respectively) in patients with baseline SaO2 > 85%. CONCLUSIONS: iNO improved both oxygenation and TPG in desaturated patients after the fenestrated Fontan operation, possibly by counteracting hypoxemia-induced pulmonary vasoconstriction. A trial of iNO should be considered in clinically unstable desaturated patients after the fenestrated Fontan operation.

Administration, Inhalation↗
PubMed2006

The influence of Er. YAG laser application in fenestration to the inner ear.

OBJECTIVE: Erbium (Er.) YAG laser may be usable for middle ear surgery because of its ability to ablate bony tissue. We investigated the inner ear damage caused by the fenestration to the inner ear with Er. YAG laser. DESIGN: We investigated the influence of Er. YAG laser on the inner ear using electrophysiological technique. RESULTS: Several cases had a decrease in endocochlear potential (EP) and cochlear microphonics (CM) after the fenestration to the inner ear. CONCLUSIONS: Er. YAG laser is safe if it is used for the small and superficial fenestration to the stapes footplate. However, a few extra pulses after fenestration are dangerous.

Acoustic Stimulation↗
PubMed1999

Labyrinthine fenestration in the guinea pig.

OBJECTIVE: To evaluate the auditory effects of single, double, and triple semicircular canal fenestration procedures, with and without sealing the labyrinthine defect. BACKGROUND: Violation of the inner ear remains a feared complication in otologic surgery because it commonly leads to profound sensorineural hearing loss. It has been assumed that the natural history of labyrinthine injury in the guinea pig is similar to that in human beings; however, this assumption has not been rigorously studied. DESIGN: Prospective, randomized, and controlled animal study. SUBJECTS: Sixty pigmented guinea pigs. OUTCOME: Click-evoked electrocochleographic response, with same-ear prefenestration control. RESULTS: All of the fenestration groups had elevated auditory thresholds at 1 hour when compared with controls (P < 0.01); however, this difference lost statistical significance at 1 and 4 weeks. The degree of labyrinthine injury did not correlate with the degree of hearing loss or with the incidence of anacusis. Hearing remained stable during the study period. Sealing the fenestration had no significant audiologic effect (P > 0.40). CONCLUSIONS: The guinea pig model of labyrinthine fenestration may not be representative of the human condition.

Animals↗
PubMed2003

Bone wax prevents nystagmus after labyrinthine fenestration in guinea pigs.

OBJECTIVE: We examined the effect of 3 methods of closure of labyrinthine fenestrations. STUDY DESIGN AND SETTING: A guinea pig animal model was developed to examine the effect of 3 methods of closure of labyrinthine fenestrations. These methods included bone wax alone, fascia and fibrin glue, and fascia alone. Nystagmus, a reproducible sign of labyrinthine injury, was chosen as an end point for comparing materials commonly used in human ear surgery. RESULTS: Animals repaired with bone wax showed no postoperative nystagmus, whereas animals repaired with other materials or that underwent canal fenestration without repair showed 3 to 5 days of postoperative nystagmus. CONCLUSIONS: Although it is premature to extrapolate our results to human surgery, postoperative nystagmus can be eliminated in guinea pigs by sealing labyrinthine fenestrations with bone wax. SIGNIFICANCE: Given the intimate relationship between the vestibular and cochlear systems, it is possible that prevention of vestibular irritation might be associated with preservation of cochlear function.

Animals↗
PubMed2002

Robot-assisted stapedotomy: micropick fenestration of the stapes footplate.

OBJECTIVE: Micropick fenestration of the stapes footplate, a difficult step in stapedotomy, was selected for trials evaluating the potential for robotic assistance (RA) to improve clinical measures of surgical performance. STUDY DESIGN: In a surgical model of stapedotomy, we measured accuracy of fenestration to a desired point location and force applied to the stapes footplate. Performance variables were measured for 3 experienced and 3 less-experienced surgeons. RESULTS: RA significantly reduced the maximum force applied to the stapes footplate. For fenestration targeting, RA significantly improved accuracy for less-experienced surgeons and significantly worsened targeting for more-experienced surgeons. CONCLUSIONS: RA significantly improves performance for micropick fenestration in a surgical model of stapedotomy. For certain tasks, RA differentially affects performance for users of different experience levels. CLINICAL SIGNIFICANCE: These are the first results showing quantitative improvements in performance during simulated ear surgery using RA and differential effects of RA on performance for users of different experience levels.

Clinical Competence↗
PubMed2024

Unplugging lateral fenestrations of NALCN reveals a hidden drug binding site within the pore region.

The sodium (Na+) leak channel (NALCN) is a member of the four-domain voltage-gated cation channel family that includes the prototypical voltage-gated sodium and calcium channels (NaVs and CaVs, respectively). Unlike NaVs and CaVs, which have four lateral fenestrations that serve as routes for lipophilic compounds to enter the central cavity to modulate channel function, NALCN has bulky residues (W311, L588, M1145, and Y1436) that block these openings. Structural data suggest that occluded fenestrations underlie the pharmacological resistance of NALCN, but functional evidence is lacking. To test this hypothesis, we unplugged the fenestrations of NALCN by substituting the four aforementioned residues with alanine (AAAA) and compared the effects of NaV, CaV, and NALCN blockers on both wild-type (WT) and AAAA channels. Most compounds behaved in a similar manner on both channels, but phenytoin and 2-aminoethoxydiphenyl borate (2-APB) elicited additional, distinct responses on AAAA channels. Further experiments using single alanine mutants revealed that phenytoin and 2-APB enter the inner cavity through distinct fenestrations, implying structural specificity to their modes of access. Using a combination of computational and functional approaches, we identified amino acid residues critical for 2-APB activity, supporting the existence of drug binding site(s) within the pore region. Intrigued by the activity of 2-APB and its analogues, we tested compounds containing the diphenylmethane/amine moiety on WT channels. We identified clinically used drugs that exhibited diverse activity, thus expanding the pharmacological toolbox for NALCN. While the low potencies of active compounds reiterate the pharmacological resistance of NALCN, our findings lay the foundation for rational drug design to develop NALCN modulators with refined properties.

Binding Sites↗
PubMed1978

A comparison of fenestration of the horizontal canal and stapedectomy in the opposite ear.

The Lempert one stage horizontal semicircular canal fenestration was the surgical procedure of choice for otosclerosis from 1939 to 1954. Subsequently, mobilization and stapedectomy replaced fenestration. In the offices of Drs. Day, Jordan, and Caparosa, the horizontal semicircular canal fenestration was performed from 1940 to 1955; the mobilization, two years; and, thereafter, the stapedectomy. A significant number of patients have had fenestration on one side and stapedectomy on the opposite ear. Fifty patients seen consecutively were reviewed. Reliable office audiological testing has been available only in the more recent years; and, therefore, audiological statistical comparison has limited reliability. It is felt, however, that a review of these patients and the study of their surviving hearing results is a worthwhile inferential comparison.

Bone Conduction↗
PubMed2000

Transcatheter closure of fontan fenestrations using the Amplatzer septal occluder: initial experience and follow-up.

We have recently used the Amplatzer septal occluder to close Fontan fenestrations. Between June 1998 and December 1999, 13 patients underwent transcatheter occlusion of their Fontan fenestrations. Systemic blood flow decreased significantly without a concomitant decrease in pulmonary blood flow. All residual shunts detectable by oximetry were at sites separate from those into which occlusion devices were implanted. One patient developed severe tricuspid regurgitation following the procedure requiring surgical removal of the device. At the last follow-up, all patients were doing well clinically. There were no shunts detectable through or around the devices by echocardiography. Our experience indicates that the location of the fenestration within the Fontan baffle is critical to avoiding device interference with other intracardiac structures. The Amplatzer septal occluder offers an effective means of transcatheter closure of Fontan baffle fenestrations. Although more experience is needed, our current follow-up data suggest that long-term outcomes will be favorable. Cathet. Cardiovasc. Intervent. 51:301-304, 2000.

Adult↗