Anterior Cranial Fossa Meningiomas Research Articles

The importance of the optic nerves unlocking during the resection of anterior skull base meningiomas for visual function preservation: surgical nuances and clinical outcome

Anterior skull base meningiomas can determine optic nerves (ONs) impingement leading visual disturbances as presenting symptoms. According to the relationship between tumour origin and ON course, different “vectors of compression” can be identified: lateral-to-medial, medial-to-lateral, inferior-to-superior, and anterior-to-posterior. As visual function preservation represents the main goal of surgery, we designed a procedural algorithm concerning approach, cisterns dissection, falciform ligament section, ON mobilization and tumour debulking aimed to reduce ONs manipulation during surgery. We included 40 patients harbouring meningiomas compressing ONs with mean age 61.7 ± 12.4 years. Sixteen originated from anterior clinoidal process (40%), 10 from sphenoid-ethmoidal planum (27.5%), 10 from tuberculum sellae (25%), and 4 from sphenoid-orbital region (7.5%). A decline in visual acuity was observed in 34/40 (85%) of patients and in visual field in 28/40 (70%). Mean age appeared significantly lower in patients with intact visual field (p = 0.006). No differences were observed between symptomatic and asymptomatic patients according to tumour origin, whereas a significantly lower rate of visual field impairment was observed among patients with inferior-to-superior compression. On the contrary, tumour determining a superior-to-inferior compression showed a trend of higher risk of visual field cut. Falciform ligament opening was performed in 82.5% of cases, optic canal unroofing in 27%, anterior clinoidectomy in 32% and optic strut removal in 5%. At 6-month follow-up, none among patients treated before of visual acuity onset disturbances showed worsening. Among those showing preoperative alterations, an improvement was observed in 17/34 (50%), 14 (41.2%) had an unchanged deficit, and 3 (8.8%) a worsening. Optic canal unroofing was the only significant predictor of postoperative non-improvement at multivariate analysis (p = 0.03, AUC = 0.796; OR = 0.163; 95%CI:0.027–0.983; p = 0.04). Similarly, none patient developed visual field cut when treated before it clinical appearance, and only 28.6% of those with a pre-operative deficit showed post-operative improvement. Worsening was seen in 5/28 of patients with a preoperative visual field deficit (17.6%), with the remaining 15 (53.6%) with unchanged visual field at 6-month. Comparing patients with post-operative visual field improvement and non-improvement, only a younger age and a better preoperative mRS status showed a significant association with a positive outcome. Age emerged as unique significant risk factor for lack of post-operative improvement at stepwise binomial logistic regression model (OR = 0.855, 95%CI: 0.743–0.983, p = 0.028). The surgical management of anterior cranial fossa meningiomas associated with optic nerve compression should prioritize visual preservation over radical tumor resection and a timely decompression reducing the risk of post-operative visual acuity deterioration. The surgical techniques should be also modified to include all the necessary unlocking strategies limiting the ON stress during the tumor manipulation.

Foster-Kennedy Syndrome and Optochiasmatic Glioma - A Case Report

Abstract Foster–Kennedy Syndrome presents with optic atrophy in one eye and papilledema in the contralateral eye. It originates from a variety of intracranial pathologies, but most often a subfrontal mass. There is compression of the ipsilateral optic nerve by the intracranial mass, often an anterior cranial fossa meningioma. Females are mostly affected. Progressive visual loss, headache, vomiting, seizure episodes, psychiatric illness, diplopia, anosmia, and loss of consciousness are the common presenting features. We present a case of Foster–Kennedy syndrome in a 13-year-old girl child with optochiasmatic Glioma.

Calcified Planum Sphenoidale Meningioma Mimicking Stroke in A 64-Year-Old Known Hypertensive: A Case Report

Background: Planum sphenoidale meningiomas are benign, slow-growing intracranial tumours with varied manifestations at any age group. Although it is rare, they usually present late when the size of the tumour is 4cm or more with headache, cognitive impairment, seizure, anosmia, nasal congestion and discharge, and visual disturbances. This type of meningioma constitutes a clinical diagnostic chal-lenge due to the non-specific nature of the subtle signs associated with it. Radiological investigations such as magnetic resonance imaging and computed tomography (CT scan) represent an imaging mo-dality used in the assessment of patients suspected of anterior cranial fossa meningioma and stroke. Case Presentation: We present a 64-year-old retired civil servant who presented to the Emergency Unit of the National Hospital, Abuja, with a history of sudden onset of seizure and loss of conscious-ness that lasted for over 6 hours. The patient had been having a history of recurrent nasal discharge for ten (10) years and one episode of seizure one month before presentation. There is also prior history of nasal discharge that was usually scanty, yellowish, and sometimes purulent. There was an associated feeling of nasal congestion. A clinical diagnosis of transient ischaemic stroke in a known hypertensive was made. However, the further radiological evaluation revealed a tumour mass with histological fea-tures consistent with planum sphenoidale psammomatous grade I meningioma. Conclusion: The clinical presentation of this tumour could mimic other cerebrovascular diseases. Thus, physicians need a high index of suspicion of other possible differential diagnoses, and appropri-ate radiological assessment is crucial with histopathologic examination.

Extended Unifrontal craniotomy for midline anterior cranial fossa meningiomas: A better shot at preservation of neurovascular structures

Thirteen patients with anterior cranial fossa meningioma were operated on using the novel technique of unilateral extended frontal skull base approach. The clinical presentation, radiological studies, intraoperative findings, and outcome at follow-up were recorded. Gross total tumor resection could be achieved in 12 out of 13 patients. At least one of the olfactory tracts could be anatomically preserved in all patients, and superior sagittal sinus was preserved in all patients. Functional olfaction preservation was achieved in 8 patients. No patient developed new-onset anosmia. The extended unilateral frontal approach is a viable and reliable alternative for extended bifrontal techniquefor the resection of large midline anterior cranial fossa meningiomas with avoidance of SSS ligation, decreased brain handling withbetter olfaction preservation while achievingcomparable tumor resection and acceptable cosmetic outcomes.

Assessment of nasal outcomes after endoscopic removal of large midline skull base tumors with nasoseptal flap reconstruction

BackgroundThere have been several reconstructive methods with free flaps or vascular pedicled flaps constituting a large portion of the rebuilding of the skull base. The vascularized pedicled nasoseptal flap, however, appears to be the “gold standard” flap in the restoration of the integrity of the cranial base among all of the foregoing alternatives. This study aimed to assess the postoperative outcomes of endoscopic removal of large midline skull base tumors with nasoseptal flap reconstruction in 21 patients. Patients were assessed at 1 week postoperative using Sinonasal Outcome Test 22 (SNOT 22) to assess postoperative nasal symptoms. An endoscopic assessment of the nose was done at 1 week postoperative to assess the degree of crusting and at 4 weeks postoperative to assess the degree of nasal adhesions and the presence or absence of gangrene of the nasoseptal flap. Postoperative complications were assessed.ResultsThe study patients included 12 cases with pituitary macroadenoma, five cases with anterior cranial fossa meningioma, and four cases with petroclival chordoma. The skull base defect size ranged from 2.5 to 4.5 cm. The most troublesome postoperative symptoms were decreased sense of smell/taste. Postoperatively, 10 patients had mild, 7 patients had moderate, and 4 patients had severe nasal crusting. Three cases had epistaxis and two cases had postoperative cerebrospinal fluid rhinorrhea. Ten cases had no nasal adhesions, four cases had mild, four cases had moderate, and three cases had severe nasal adhesions. No cases had gangrene of the nasoseptal flap.ConclusionThe nasoseptal flap is an effective option for large skull base defect reconstruction after endoscopic resection of large skull base tumors with an acceptable postoperative patient quality of life and a low incidence of postoperative complications.

Endoscopy-Assisted Microneurosurgery for Sella and Optic Foramen Invading Anterior Cranial Fossa Base Meningiomas

Anterior skull base meningioma produces symptoms as a result of mass effect and neurovascular compression. The bony anatomy of the anterior skull base is complex and houses the critical cranial nerves and vessels. Traditional microscopic approaches remove these tumors effectively but require extensive brain retraction and bone drilling. Endoscope assistance offers the advantages of a smaller incision, less brain retraction, and bone drilling. The most significant advantage of endoscope-assisted microneurosurgery for lesions invading the sella and optic foramen is the complete resection of the sellar and foraminal components frequently responsible for recurrence. In this report, we describe the technique of endoscope-assisted microneurosurgical resection of anterior skull base meningiomas invading the sella and foramen. We present 10 cases and 3 case examples of endoscope-assisted microneurosurgery for meningiomas invading the sella and optic foramen. This report presents the operating room setup and surgical details to resect sellar and foraminal tumors. The surgical procedure is presented as a video. Endoscope-assisted microneurosurgery yielded excellent clinical and radiologic results and no recurrence at the last follow-up of meningiomas invading the sella and optic foramen. The present article discusses the challenges faced with endoscope-assisted microneurosurgery, techniques, and challenges in the procedure. Endoscope assistance enables complete tumor excision under vision with less retraction and bone drilling in anterior cranial fossa meningioma, invading the chiasmatic sulcus, optic foramen, and sella. The mixed use of microscope and endoscope makes it safer and saves time and is like bringing out the best of both worlds.

Clinical outcome and complication of anterior cranial Fossa meningiomas in tertiary care Hospital Peshawar

Objectives: We examined the surgical outcome and complications of anterior cranial Fossa meningiomas. Materials and Methods: A prospective study was conducted at the Department of Neurosurgery Prime Teaching Hospital, Peshawar, KPK, Pakistan from June 2019 to June 2021. A total of 31 patients were selected through non-probability consecutive sampling. After clinical examination and radiological findings, the patients were diagnosed with anterior cranial Fossa meningiomas. Microsurgical Trans cranial approaches did. Clinical outcomes and complications were documented. Tumor anterior cranial fossa meningiomas. A low Karnofsky performance scale index was used to analyze the functional impairment of the patients. Results: 9 (29.03%) were male and 22 (70.96%) patients were female. The mean age of presentation was 42 ± 5 years. Headache 25 (80.6%) and Visual loss were the main presenting symptoms 24 (77.5%), and Tuberculum sellae meningioma patients 08 (25.08%). The most common approach was Bifrontal craniotomy for OGM in 9 patients and two small OGM were operated on utilizing frontolateral craniotomy. The rest of the cases were operated through Pterional craniotomy. Tuberculamsalle meningiomas surgery results in a visual improvement in 6 patients (75%), Complete tumor resection was achieved in 22 (70.9%) patients and subtotal resection is achieved in 6 (19.3%) patients. In a few patients 03 (9.67%) only safe debulking and biopsy were taken. Postoperative hemorrhage was in 4 (12.9%) patients. Conclusion: Transcranial approach for microsurgical resection of anterior cranial fossa meningiomas is an effective and feasible approach in terms of visual outcome and extent of resection. Keywords: Anterior cranial Fossa Meningioma, Bifrontal Craniotomy, Front-lateral craniotomy.

C4: Anterior and middle skull base meningiomas: Experience from a sub-Saharan country of a serie of 56 cases

INTRODUCTION: Skull base meningiomas represent 25% of all meningiomas. Mostly slow-growing, the challenge lies in their relationship with the circle of Willis and cranial nerves. The objective of our study was to evaluate the management of meningiomas of the anterior and middle cranial fossa in a sub-Saharan setting. MATERIALS AND METHODS: A serie of 56 patients hospitalized for meningiomas of the anterior and middle cranial fossa were retrospectively reviewed and analyzed, from January, 2012 to December, 2018. RESULTS: Anterior and middle cranial fossa meningiomas represented 32.7% of intracranial meningiomas in the department. The mean age was 50.5 years and the sex-ratio were 0.3. Clinical manifestations were dominated by visual disorders (57.1%) and intracranial hypertension (26.8%). The mean tumor size was 54.3 mm. The pterional approach was used on 94.6% of patients. The quality of resection was SIMPSON grade II in 71.4% of cases. Postoperative mortality was 14.2%. The pathology was grade I in 91.1% of cases. Over a three-year follow-up, complete recovery was noted in 67.8% of cases. Two cases had recurrence. CONCLUSION: Meningiomas are the most common tumor of the anterior and middle cranial fossa in the institution. Microsurgical excision was the only treatment performed. Complete recovery without sequelae was observed in 67.8% of cases. The improvement in the instrumentation and neuro-intensive care helped to reduce mortality and morbidity, but efforts still need to be made, especially in the development of complementary treatments.

Abstract 1122‐000148: Rare Anterior Inferior Cerebellar Artery Origin of Middle Meningeal Artery

Introduction : Middle meningeal artery (MMA) anatomy has very important surgical implications during endovascular and open based skull procedures. Various anatomical origins have been identified in the literature besides its most common origin as the largest branch of the maxillary artery. It runs parallel and close contact of the lateral skull face therefore during trauma to this area is prone to rupture resulting in subdural hemorrhage(SDH). In our case report, we present its peculiar origin from anterior inferior cerebellar artery which has never been reported before. The origin of MMA may reflects the risk involved with embolization therapy for chronic SDH. Methods : A case of MMA originated form AICA. A literature review was conducted of reports of MMA origins. Results : A 35‐year‐old male with a history of alcohol abuse presented to the ED after falling down from the stairs. In the ED, the patient had multiple episodes of seizures along with respiratory distress therefore was intubated due to concern of airway protection. CT head showed bilateral SDH. Patient underwent diagnostic angiogram for possible bilateral embolization of MMA. During the procedure, the left MMA origin was seen from the AICA whereas the right MMA arising from the external carotid artery. Embolization of the left MMA was aborted. Patient remained intubated and was later transferred to a long term care facility. Conclusions : In the last 80 years, the anatomy of the MMA has been part of the discussion of various literature. Seeger et.al, highlighted the embryological changes manifested as anastomosis between Sphenomaxillary artery and lateral pontine artery resulting in origin of MMA from Basilar artery along with absence of foramen spinosum. Since 1973, multiple literature highlighted the origin of MMA including the lacrimal artery, ICA, ascending pharyngeal artery, opthalmic and occipital arteries. Recently, In 2011 Kuruvuilla et.al showed the origin of MMA from posterior inferior cerebellar artery. MMA clinical significance can be seen in multiple diseases. Older populations with chronic subdural hematomas, embolization of MMA has shown to be a less invasive and cost effective procedure. In patients with anterior and middle cranial fossa meningiomas embolization of MMA has been a crucial part of management. Similarly, understanding of its anatomy is also important while treating MMA aneurysm or pseudoaneurysms. In our case, the origin of middle meningeal artery from AICA has been significant as it supplies the posterior fossa structures and was not reported in the literature before, hence the procedure was aborted. This anatomical variant has shown us a new light upon embryological evolution and has helped us widen the horizons of our approach towards brain vasculature. This finding will help the future Interventionists to develop new ways of embolization of the MMA and understanding its anatomy.

Transnasal Endoscopic Surgery for Suprasellar Meningiomas.

Endoscopic trans-nasal surgery has evolved a long way from the days of narrow corridors with high rates of cerebrospinal fluid (CSF) leak to the present state of HD optics with better tissue differentiation, extended approaches, and use of vascularized flaps for defect closure. Trans-nasal approach is an established technique for pituitary tumors practiced worldwide. However, trans-nasal endoscopic excision of suprasellar meningiomas provides a tougher challenge in terms of instrument manipulation, tumor excision with good visual outcome, and a robust defect closure to prevent CSF leaks. Out of 83 cases of midline anterior cranial fossa meningiomas operated over 14 years, our experience in 12 cases of suprasellar meningiomas for radical resection via the trans-nasal endoscopic route is discussed. Amongst these, six were excised via primary extended endoscopic trans-sphenoidal surgery, four cases had a residual lesion or recurrence after primary transcranial surgery, and two cases involved a combined transcranial and extended endoscopic approach. Visual improvement along with resolution of headache was seen in all patients postoperatively. None of the patients had CSF leak requiring further repair. Syndrome of inappropriate antidiuretic hormone was found in one patient, which was transient and easily corrected. Trans-nasal endoscopic surgery for suprasellar meningiomas is an effective technique that provides results of tumor excision comparable to the transcranial approach in suitable cases. Visual outcome was found to be superior, and rates of CSF leak were remarkably reduced with vascularized flap. However, each case must be assessed individually and lateral extension beyond the optic canals with internal carotid artery encasement must be considered before planning surgery.

Anatomical Variations in the Location of Veins Draining Into the Anterior Superior Sagittal Sinus: Implications for the Transbasal Approach.

Many approaches are used for midline anterior cranial fossa meningioma resection. In the subfrontal approach, the anterior superior sagittal sinus (SSS) is commonly ligated to release the anterior falx. The transbasal approach allows access to the origin of the anterior SSS, allowing for maximum venous preservation. To investigate variations in the first and second veins draining into the SSS. We performed stepwise dissections for a transbasal level 1 approach on 8 anatomic specimens. We visualized the first and second veins draining into the sinus and measured the distance from the foramen cecum to these veins. We also measured the orbital bar height to determine the length of sagittal sinus that could be preserved with orbital bar removal. The distance between the foramen cecum and the first vein ranged from 4 to 36 mm while the distance to the second vein ranged from 6 to 48 mm. The mean orbital bar height was 26.4 mm. Based on these measurements, with a traditional bicoronal craniotomy without orbital bar removal, 81% of first veins and 58% of second veins would be sacrificed. A supraorbital bar or nasofrontal osteotomy, part of the transbasal skull base approach, is helpful to preserve the first and second veins when ligating the anterior SSS. Based on this study, it may be difficult to preserve these veins without orbital bar removal. Preservation of these veins may be of clinical importance when approaching midline anterior fossa pathologies.

SUN-292 Life-Threatening Hypernatremia in Partial Diabetes Insipidus with Adipsia Due to Cranial Radiation: Diagnostic and Therapeutic Challenges

Background: Anterior pituitary dysfunction is a known, time and dose dependent effect of cranial radiotherapy but central diabetes insipidus (CDI) has been rarely reported. We present a patient with partial CDI (PCDI) and adipsia, months after subtotal resection and radiation therapy for a large anterior cranial fossa meningioma. Clinical Case: A 53-year-old woman with history of subtotal resection of a 7 cm meningioma ~2 years ago and radiation therapy (54 Gy, completed 15 months ago), was admitted to the ICU with obtundation, tachycardia (120/min), hypotension (87/52 mmHg, on vasopressors in the first 24 hours), severe hypernatremia (serum Na 170 mmol/L), and acute kidney injury (creatinine 2.11 mg/dL; baseline 1.0 mg/dL). Plasma osmolality (pOSM) was 385 mOsm/kg and urine osmolality (uOSM) was 982 mOsm/kg. MRI brain 3 months ago showed frontal lobe encephalomalacia, residual meningioma at the planum sphenoidale (1.8x3.5x2.8 cm) with cavitary lesion compatible with post-radiation necrosis. After receiving 4 litres (L) isotonic fluids and 5 L hypotonic fluids in the first 38 hours, serum Na was 168 mmol/L, creatinine 1.35 mg/dl and uOSM 386 mOsm/kg. Urine output was 2.6 L on day-1 and 1.9 L during first 7 hours on day-2. After an IV dose of 2 mcg DDAVP, uOSM increased to 784 mOsm/kg, and Na decreased to 164 mmol/L, supporting CDI diagnosis. ACTH stimulation test was normal. Levothyroxine 50 mcg daily was started for central hypothyroidism. By day-6, her mental status returned to baseline (alert only to person). DDAVP dose adjustment was challenging due to frequent fluctuation in her serum Na (130s to 150s), adipsia and urinary incontinence. On day-44, she was discharged on subcutaneous (subQ) DDAVP 0.25 mcg every 36 hours, with a serum Na of 145 mmol/L. She was readmitted 3 days later with serum Na of 164 mmol/L, followed by another prolonged hospitalization complicated by acute kidney injury and popliteal DVT. On day-64, she was discharged to a nursing facility on DDAVP 0.25 mcg subQ twice daily. Clinical Lesson: Delayed PCDI with adipsia is an exceedingly rare but challenging complication of cranial radiation therapy. The initial uOSM (twice as high as pOSM) in our case caused a delay in diagnosis. This could reflect enhanced antidiuretic response to low circulating ADH levels, possibly due to lower rate of solute extraction in dehydration, upregulation of ADH receptors due to chronic hormone deficiency, and to a fall in glomerular filtration rate. Decrease in uOSM after hydration could be due to ADH exhaustion.

Endoscopic Endonasal Approaches for Anterior Skull Base Meningiomas.

Anterior skull base meningiomas are a diverse group of tumors that involve different locations. The role of the expanded endoscopic transnasal approach in the management of anterior cranial fossa meningiomas has significantly changed over the past 2 decades. Patient selection is paramount to benefit from the advantages of endoscopic transnasal surgery such as direct access to ventral skull base lesions avoiding brain and brainstem retraction, early de-vascularization, removal of bone infiltrated by tumor, near-field magnification, better surgical field illumination, and minimal manipulation of neurovascular structures. Here we discuss some of the main limitations and advantages of the endoscopic transnasal approach related to patient selection, including nuances of their management, discussing preoperative imaging and planning, the surgical approach, and future perspectives in the treatment of these tumors.

Bundle Payment, Health Care Utilization, and Outcomes Following Surgery for Anterior, Middle, and Posterior Cranial Fossa Skull Base Meningioma: A Market Scan Analysis

Abstract INTRODUCTION Meningioma is the most common benign intracranial brain tumor accounting for approximately one-third of all primary brain tumors. The aim of our study was to compare the bundle payment, health care utilization, and outcomes following surgery for anterior (AFM), middle (MFM), and posterior cranial fossa meningioma (PFM) across the United States. METHODS We queried the Market Scan database using ICD-9 and CPT-4, from 2000 to 2016. We included adult patients who had at least 24 mo of enrollment following the surgical procedure. The outcome of interest was length of hospital stay, disposition, complications, and reoperation following the procedure. RESULTS A cohort of 1,188 patients was identified from the database. In all 43.86% of tumors were AFM, 32.32% were MFM, and only 23.8% were PFM. Patients who underwent surgery for PFM had significant longer hospital stay (P = .0013), higher complication rate (P = .0009), and less likely to be discharged home (P = .0013) during index hospitalization. Patients with MFM and PFM incurred higher outpatient services with no differences in corresponding payments compared to those with AFM at 12 mo (P < .0001) and 24 mo follow-up (P < .0001). There were no differences in overall payments at 12 mo (AFM: $19,702; MFM: $20,671; PFM: $20,922) and 24 mos (AFM: $37,142; MFM: $44,133; PFM: $36,601) among the cohorts. There was no significant difference in 90-d median bundle payments among the groups, $66,173 (AFM) vs $65,602 (MFM), and $71,837 (PFM), P = .1955. CONCLUSION Ninety-day bundle payment and overall payments (at 12 mo and 24 mo) were not significantly different among the cohorts. Patients with PFM had longer hospital stay, higher complication rate, and less likely to be discharged home with higher utilization of outpatient services at 12 mo and 24 mo.

Secondary Parkinsonism Due to a Large Anterior Cranial Fossa Meningioma.

Secondary Parkinson’s disease or subacute Parkinson’s may occur after stroke, drug overdose carbon monoxide or manganese toxicity, and rarely owing to a brain tumor. Loss of dopaminergic neurons in the substansia negra pars compacta (SNc), or presence of the proteinaceous inclusions called Lewy bodies are thought to be the cause of Parkinson’s disease. Notwithstanding, in the past few decades, many case reports have been published describing Parkinson’s symptoms following either stroke, ischemia, toxicity, brain haemorrhage or rarely neoplasm.LEARNING POINTSBrain tumours can cause secondary parkinsonism.This type of secondary parkinsonism improves when the tumour is removed.

Secondary Parkinsonism due to Large Anterior Cranial Fossa Meningioma (P3.8-023)

Secondary Parkinsonism due to Large Anterior Cranial Fossa Meningioma (P3.8-023)

Preservation of olfaction in anterior midline skull base meningiomas: a comprehensive approach.

Olfaction is an undervalued sense in neurosurgery. Attempted surgical resection of anterior cranial fossa meningiomas puts the olfactory pathway at risk. Preservation of olfaction may increase the postoperative quality of life. Objective assessment of olfaction may inform clinical decision-making and influence the selection of operative approaches for surgical resection. We reviewed all patients who underwent surgical resection for midline anterior skull base meningiomas from July 1, 2014, through December 31, 2017. Patient demographics, tumor size, operative approach, pre- and postoperative deficits, and Simpson grade were collected and analyzed. Postoperative olfaction was assessed by clinical evaluation as well as objective evaluation using the University of Pennsylvania Smell Identification Test (UPSIT). Twenty-eight patients (10 male, 18 female) were included with an average age of 53.8years (range 27-80years). Twenty-six patients underwent craniotomy for resection, while 2 patients had endoscopic approaches. Average tumor volume was 402.1cm3 (6.6-2507.7cm3). Preoperatively, five patients (17.8%) presented with olfactory impairment. Objectively, 50% of patients (14/28) consented and completed the UPSIT. The average postoperative UPSIT score was 25.8/40 (9/40-38/40). Two patients not identified on clinical assessment alone demonstrated postoperative olfactory deficit on UPSIT (2/14). There are limited published studies evaluating olfaction in patients who undergo skull-based approaches for anterior fossa meningiomas. Our series showed the highest olfaction preservation rate (87.5%) using a comprehensive strategy and multitude of surgical approaches based on the olfactory function and tumor characteristics.

The Radiographic Effects of Surgical Approach and Use of Retractors on the Brain After Anterior Cranial Fossa Meningioma Resection.

There is an increasing trend toward skull base (SB) approaches and retractorless surgery to minimize brain manipulation during surgery. We evaluated the radiographic changes over time after surgical resection of anterior cranial fossa meningiomas with and without both SB approaches and/or fixed retractor systems. All adults undergoing primary resection of an anterior cranial fossa World Health Organization grade I meningioma through a craniotomy at a single academic tertiary-care institution from 2010 to 2015 were retrospectively reviewed. Magnetic resonance imaging scans were reviewed and contrast-enhanced tumor and fluid-attenuated inversion recovery (FLAIR) volumes were measured. Matched-pair analyses between patients who underwent SB and non-SB approaches, as well as retractorless and retractor-assisted (RA) surgery, were made. Of the 136 total patients, 20 (15%), 12 (9%), 46 (34%), and 58 (43%) underwent SB/retractorless, SB/RA, non-SB/retractorless, and non-SB/RA surgery, respectively. Patients who underwent non-SB and RA surgery each independently had longer times to FLAIR resolution than those who underwent SB (20.9 vs. 5 months; P= 0.04) and retractorless (12 vs. 5.2 months; P= 0.02) surgery, respectively. Patients who underwent both non-SB and RA surgery had the longest median time to FLAIR resolution (30months vs. 4 months in SB/retractorless, 3.6 months in SB/RA, and 3 months in non-SB/retractorless; P < 0.05). The use of SB approaches in combination with retractorless surgery may decrease the duration needed for FLAIR resolution after surgery. The results from this study therefore advocate SB approaches and retractorless surgery along the anterior SB when possible.

SUPRAORBITAL KEYHOLE CRANIOTOMY IN SURGERY OF INTRA- AND EXTRA-AXIAL BRAIN TUMORS

Background . Priority objectives of surgical neurooncology (diagnosis verification, tumor cytoreduction, and preservation of patient’s functional status) can be achieved both through traditional neurosurgical approaches and through the use of keyhole surgery. Keyhole surgery allows to minimize unnecessary, extended resection of the skull base and long-term static brain tissue retraction. Objective . The authors present preliminary results of the use of supraorbital keyhole craniotomy in intra- and extra-axial brain tumors. Materials and methods. In 2014–2016, 45 patients were operated through supraorbital craniotomy to treat intra- and extra-axial tumors. The majority of patients (n = 28) was diagnosed with anterior cranial fossa meningiomas. Gliomas of the frontal lobe were diagnosed in 12 patients. The average tumor size ranged from 3 to 3.5 cm. Results . Mortality, disability, or serious permanent access-related complications were not observed in our group. In all cases, the transition to the classical craniotomy was not required. Periorbital edema and transient hypoesthesia were observed in all patients. Permanent frontal hypoesthesia was observed in 3 patients (4 %) for a time period up to six months. According to postoperative MRI performed in all patients at the time of discharge, in the group of intra-axial brain tumor gross-total removal was observed in 8 patients (47 %), in 9 patients (53 %) the tumor was near-totally removed (more than 90 % of the tumor), in the group of meningiomas all 28 patients had gross-total removal. Conclusion. Supraorbital craniotomy can be an effective and safe alternative to classic approaches to treatment of extra-axial tumors of the anterior cranial fossa and intra-axial tumors of the frontal lobe. The approach requires a very careful selection of patients, individualization of surgery, and further critical evaluation.

A Simple Scoring System to Predict the Resectability of Skull Base Meningiomas via an Endoscopic Endonasal Approach

To identify clinico-radiologic factors associated with incomplete anterior cranial fossa (ACF) meningioma resection via an endoscopic endonasal approach. Patients undergoing endoscopic endonasal resection of an ACF meningioma were retrospectively accrued from two university-affiliated centers. Demographic profiles and radiologic findings, including tumor dimensions and morphology, anatomic location, and vascular involvement, were stratified according to the extent of resection. Twenty-five patients were included in this study. Factors associated with incomplete surgical resection via an endonasal route were: presence of hyperostosis (P= 0.04), cavernous internal carotid artery involvement (P= 0.001), maximal dural tail length in the transverse plane (P= 0.006), and its ratio to the inter-fovea ethmoidalis distance (P= 0.01). Using a multiple regression analysis, only cavernous internal carotid artery involvement (P= 0.002) and a large dural tail length to inter-foveal distance ratio (P= 0.04) were significant predictors of incomplete resection (multiple correlation coefficient= 0.71). The combination of predictive factors to determine the likelihood of complete endoscopic resection produced a scoring system with a sensitivity and specificity of85.7% (95% confidence interval [CI], 42.1-99.6] and 100% (95% CI, 81.5-100), respectively. The use of a simple scoring system outlined in our study can facilitate proper patient selection for endoscopic endonasal resection of ACF meningiomas.