Anterior Fossa Research Articles

Alterations in Sphenoid Anatomy in Craniosynostosis: Implications for Fronto-Orbital Advancement.

Fronto-orbital advancement involves removal of the fronto-orbital bandeau. Visualization of the saw blade is lost as it passes through the fronto-orbital-sphenoid junction (FOSJ), placing the temporal lobe at risk of injury. We aim to provide a 3D analysis of the space surrounding this osteotomy to differentiate various types of craniosynostoses. Retrospective cohort. Institutional. Thirty patients with isolated unicoronal synostosis, nonsyndromic bicoronal synostosis, metopic synostosis, Apert syndrome, Crouzon syndrome, and Muenke syndrome. CT scans conducted between 2 months to 2 years of age were 3D reconstructed to compare craniometrics against normal controls. Craniometrics. The mean bone thickness of the FOSJ at the level of the supraorbital rim was significantly small for the Apert, unicoronal and bicoronal groups. The mean vertical height of the middle cranial fossa from the lesser sphenoid wing was significantly greater in the unicoronal group. The mean vertical height of the tip of the temporal lobe from the lateral sphenoid ridge was greater in the unicoronal, isolated bicoronal, and Apert groups. The mean corneal protrusion beyond the lateral orbital rim was significantly greater in the Apert and unicoronal groups. The mean horizontal depth of the orbit was smallest in the Apert group. The mean vertical distance between the dacryon and the foramen cecum, and the mean volume of temporal lobe beneath the sphenoid shelf were the largest in the Apert group. Patients with Apert syndrome have the most unfavorable morphology of the anterior and middle cranial fossae.

Epilepsy in Association with Giant Skull Base Tumors: A Retrospective Case Series of Giant Skull Base Tumors in the Anterior and Middle Fossa.

Objective This study aims to investigate the association between giant anterior and middle fossa skull base tumors and epilepsy, and implications for clinical management. Methods A retrospective analysis was conducted on a cohort of patients diagnosed with anterior skull base tumors between 2016 and 2023. Radiologic data was used to identify tumors with major diameter larger than 5cm involving skull base with intracranial involvement. Relevant demographic information, tumor characteristics, seizure type, seizure frequency, and treatment outcomes were analyzed. Results Among the 236 patients diagnosed and operated with skull base tumors by senior author, 7.63 percent (n=18) had giant skull base tumors of anterior and middle fossa, and 2.96 percent (n=7) presented with concurrent epilepsy. Overall, in giant anterior and middle fossa skull base tumors, epilepsy was present in 38% of cases. The average age at operation was 47.56 ±16.96, with 44.4% of cases male and 55.6% of the cases female. The majority of these cases exhibited focal epilepsy (71 %), characterized by seizures originating from the proximity of the tumor location suggesting a potential correlation between tumor location and seizure generation. Of the remaining, 29% were generalized seizures. Tumors of the anterior fossa included 11 meningiomas, 3 pituitary adenomas, 1 chondrosarcoma, 1 hemangioperycitoma, 1 schwannoma, and 1 adenoid cyst carcinoma, half of which (n=9) were of low grade. Conclusion Our findings provide evidence of low frequency of epilepsy in skull base tumors in general, although a significant association among giant anterior and middle fossa skull base tumor and epilepsy.

Anterolateral keyhole transorbital routes to the skull base: a comparative anatomical study.

Although keyhole transorbital approaches are gaining traction, their indications have not been adequately studied comparatively. In this study the authors have defined them also as transwing approaches-meaning that they use the different facies of the sphenoid wing for cranial entry-and sought to compare the four major ones: 1) lateral orbitocraniotomy through a lateral canthal incision (LatOrb); 2) modified orbitozygomatic approach through a palpebral incision (ModOzPalp); 3) modified orbitozygomatic approach through an eyebrow incision (ModOzEyB); and 4) supraorbital craniotomy through an eyebrow incision (SupraOrb), coupled with its expanded version (SupraTransOrb). Cadaveric dissections were performed at the neuroanatomy lab. To delineate the skull base exposure, four formalin-fixed heads were used, with two sides dedicated to each approach. The outer limits were assessed via image guidance and were mapped and illustrated accordingly. A fifth head was dissected purely endoscopically, just to facilitate an overview of the transwing concept. Qualitative features were also rigorously examined. The LatOrb proves to be more versatile in the middle cranial fossa (MCF), whereas the anterior cranial fossa (ACF) exposure is limited to a small area above the sphenoid ridge. An anterior clinoidectomy is possible; however, the exposure of the roof of the optic canal is suboptimal. The ModOzPalp adequately exposes both the ACF and MCF. Its lateral trajectory allows the inferior to superior view, yet there is restricted access to the medial anterior skull base (olfactory groove). The ModOzEyB also provides extensive exposure of the ACF and MCF, but has a more superior to inferior trajectory compared to the ModOzPalp, making it more appropriate for pathology reaching the medial anterior skull base or even the contralateral side. The anterior clinoidectomy is performed with improved visualization of the optic canal. The SupraOrb provides mainly anterior cranial base exposure, with minimal middle fossa. An anterior clinoidectomy can be performed, but without any direct observation of the superior orbital fissure. Some MCF access can be accomplished if the lateral sphenoid wing is drilled inferiorly, leading to its highly versatile variant, the SupraTransOrb. All the aforementioned approaches use the sphenoid wing as skull base corridor from a specific orientation point; hence these are designated as transwing approaches. Their peculiarities mandate careful case selection for the effective and safe completion of the surgical goals.

Open-door extended endoscopic transorbital technique to the paramedian anterior and middle cranial fossae: technical notes, anatomomorphometric quantitative analysis, and illustrative case.

The superior eyelid endoscopic transorbital approach (SETOA) provides a direct and short minimally invasive route to the anterior and middle skull base. Nevertheless, it uses a narrow corridor that limits its angles of attack. The aim of this study was to evaluate the feasibility and potential benefits of an "extended" conservative variant of the "standard" endoscopic transorbital approach-termed "open-door"-to enhance the exposure of lesions affecting the paramedian aspect of the anterior and middle cranial fossae. First, the authors described the technical nuances of the open-door extended transorbital approach (ODETA). Next, they documented its morphometric advantages over standard SETOA. Finally, they provided a clinical-anatomical application to demonstrate enhanced exposure and better angles of attack to treat lesions occupying the paramedian anterior and middle cranial fossae. Five adult cadaveric specimens (10 sides) initially underwent standard SETOA and then extended open-door SETOA (ODETA to the paramedian anterior and middle fossae). The adjunct of hinge-orbitotomy, through three surgical steps and straddling the frontozygomatic suture, converted conventional SETOA to its extended open-door variant. CT scans were performed before dissection and uploaded to the neuronavigation system for quantitative analysis. The angles of attack on the axial plane that addressed four key landmarks, namely the tip of the anterior clinoid process (ACP), foramen rotundum (FR), foramen ovale (FO), and trigeminal impression (TI), were calculated for both operative techniques and compared. Hinge-orbitotomy of the extended open-door SETOA resulted in several surgical, functional, and esthetic advantages: it provided wider axial angles of attack for each of the target points, with a gain angle of 26.68° ± 1.31° for addressing the ACP (p < 0.001), 29.50° ± 2.46° for addressing the FR (p < 0.001), 19.86° ± 1.98° for addressing the FO (p < 0.001), and 17.44° ± 2.21° for addressing the lateral aspect of the TI (p < 0.001), while hiding the skin scar, avoiding temporalis muscle dissection, preserving flap vascularization, and decreasing the rate of bone infection and degree of orbital content retraction. The extended open-door technique may be specifically suited for selected patients affected by paramedian anterior and middle fossae lesions, with prevalent anteromedial extension toward the anterior clinoid, the foremost compartment of the cavernous sinus and FR and not completely controlled with the pure endoscopic transorbital approach.

Transpalpebral mini-orbitozygomatic approach for nonvascular skull base lesions: a single neurosurgeon's experience.

The authors aim to describe the advantages, utility, and disadvantages of the transpalpebral mini-orbitozygomatic (MOZ) approach for tumors of the lateral and superior orbit, orbital apex, anterior clinoid, anterior cranial fossa, middle cranial fossa, and parasellar region. The surgical approach from skin incision to closure is described while highlighting key technical and anatomical considerations, and cadaveric dissection demonstrates the surgical steps and focuses on important anatomy. Intraoperative images were included to supplement the cadaveric dissection. A retrospective review of adults who had undergone the MOZ approach for nonvascular pathology performed by a single neurosurgeon from 2017 to 2023 was included in this institutional review board-approved study. Descriptive statistics was used to summarize the data. Four representative cases were included to demonstrate the utility of the MOZ approach. The study included 65 patients (46 female, 19 male), average age 54.84 years, who had undergone transpalpebral MOZ surgery. Presenting symptoms included visual changes (53.8% of cases), vision loss (23.1%), diplopia (21.8%), and proptosis (13.8%). The optic nerve and optic chiasm were involved in 32.3% and 10.8% of cases, respectively. The most common pathology was meningioma (81.5% of cases), and gross-total resection was achieved in 50% of all cases. Major complications included an infection and a carotid injury. Improvement of preoperative symptoms was reported in 92.2% of cases. Visual acuity improved in 12 patients. The mean follow-up was 8.57 ± 8.45 months. The MOZ approach is safe and durable. The transpalpebral incision provides better cosmesis and functional outcomes than those of standard anterolateral approaches to the skull base. Careful consideration of the limits of the approach is paramount to appropriate application on a case-by-case basis. Further quantitative anatomical studies can help to define and compare the utility of the approach to open cranio-orbital and endoscopic transorbital approaches.

360° around the orbit: key surgical anatomy of the microsurgical and endoscopic cranio-orbital and orbitocranial approaches.

Several pathologies either invade or arise within the orbit. These include meningiomas, schwannomas, and cavernous hemangiomas among others. Although several studies describing various approaches to the orbit are available, no study describes all cranio-orbital and orbitocranial approaches with clear, surgically oriented anatomical descriptions. As such, this study aimed to provide a comprehensive guide to the microsurgical and endoscopic approaches to and through the orbit. Six formalin-fixed, latex-injected cadaveric head specimens were dissected in the surgical anatomy laboratory at the authors' institution. In each specimen, the following approaches were modularly performed: endoscopic transorbital approaches (ETOAs), including a lateral transorbital approach and a superior eyelid crease approach; endoscopic endonasal approaches (EEAs), including those to the medial orbit and optic canal; and transcranial approaches, including a supraorbital approach, a fronto-orbital approach, and a 3-piece orbito-zygomatic approach. Each pertinent step was 3D photograph-documented with macroscopic and endoscopic techniques as previously described. Endoscopic endonasal approaches to the orbit afforded excellent access to the medial orbit and medial optic canal. Regarding ETOAs, the lateral transorbital approach afforded excellent access to the floor of the middle fossa and, once the lateral orbital rim was removed, the cavernous sinus could be dissected and the petrous apex drilled. The superior eyelid approach provides excellent access to the anterior cranial fossa just superior to the orbit, as well as the dura of the lesser wing of the sphenoid. Craniotomy-based approaches provided excellent access to the anterior and middle cranial fossa and the cavernous sinus, except the supraorbital approach had limited access to the middle fossa. This study outlines the essential surgical steps for major cranio-orbital and orbitocranial approaches. Endoscopic endonasal approaches offer direct medial access, potentially providing bilateral exposure to optic canals. ETOAs serve as both orbital access and as a corridor to surrounding regions. Cranio-orbital approaches follow a lateral-to-medial, superior-to-inferior trajectory, progressively allowing removal of protective bony structures for proportional orbit access.

Title: Supra-Orbital Keyhole Approach: Opening Of The Frontal Sinus And CSF Rhinorrhea

Introduction: The supraorbital keyhole approach has been a less invasive alternative for anterior and middle skull base lesions. We aimed to review our data and understand the advantages and limitations of the approach. Methods: We analysed our data and reviewed 89 consecutive cases who underwent supra-orbital keyhole approach. We included the clinic-radiological parameters, pathology, use of endoscope, complications, etc. for analysis. Results: 47 patients were of aneurysm with a total of 48 aneurysms (39 were ruptured and 9 were unruptured) and Acomm artery aneurysm was the most common site. Meningiomas were the second most common pathology encountered (n=29). Tuberculum sella meningioma being the most common type of meningiomas operated through this approach. Gross total resection was done in all except 2 cases in which a small part of the tumour was left behind as the tumour was adhered to blood vessels. Among the remaining cases, craniopharyngiomas(n=7), optic pathway gliomas (n=2) hypothalamic hamartomas(n=2), dermoid (n=1) and AVM (n=1) were the other pathologies operated upon. Eight patients had opening of the frontal sinus. Four patients had wound bulge and one patient had CSF rhinorrhea. All these cases were managed conservatively. Conclusion: SOKHA is an excellent approach for anterior cranial fossa lesions especially with properly chosen cases. Incidence of CSF leak in our study is 1.1% and majority can be managed by placement of lumbar drain. Intra-operative obliteration of the frontal sinus can reduce the risk of post-operative CSF leak. A large frontal sinus need not be a contraindication for supra-orbital keyhole approach.

Endoscopic-Assisted Microsurgical Meningioma Resection in the Skull Base via Minicraniotomy: Is There a Difference in Radicality and Outcome between Anterior Skull Base and Posterior Fossa?

Background: Keyhole-based approaches are being explored for skull base tumor surgery; aiming for reduced complications while maintaining resection success rates. This study evaluates skull base meningiomas resected using an endoscopic-assisted microsurgical keyhole approach, comparing outcomes with standard procedures. Methods: Between 2013 and 2019; 71 out of 89 patients were treated using an endoscopic-assisted microsurgical procedure. A total of 42 meningiomas were localized at the anterior skull base and 29 in the posterior fossa. The surgical techniques and use of an endoscope were analyzed and compared in terms of complications, surgical radicality, outcome, and recurrences in the patients' follow-up. Results: The two different cohorts yielded similar rates of GTR (anterior skull base: 80% versus posterior fossa: 82%). The complication rate was 31% for the posterior fossa and 16% for the anterior skull base. An endoscope was used in 79% of all cases. Tumor remnants were detected by means of endoscopic visualization in 58.6% of posterior fossa and 33% of anterior skull base meningiomas. The statistical analysis revealed significantly higher benefits from endoscope use in the posterior fossa cohort (p < 0.05). Conclusions: The results revealed that endoscopy was beneficial in both locations. The identification of remnant tumor tissue and the benefit of endoscopy were clearly higher in the posterior fossa. Endoscopic assistance is a very helpful tool for increasing radicality, providing a better anatomical overview during surgery, and better identifying remnant tumor tissue in skull base meningioma surgery.

Assessment of crista galli morphology and morphometry in individuals with cleft lip and palate: A three‐dimensional analysis

AbstractObjectiveThe crista galli (CG), located in the anterior cranial fossa and associated with the cranial structures here, is a bony prominence on the ethmoid bone. In this study, we aimed to examine the anatomical variations and pneumatization status of the CG in individuals with cleft lip and palate (CLP) and to compare them with those of individuals without CLP.Material and methodsData from 16‐ to 25‐year‐old individuals with non‐syndromic cleft lip and palate and control individuals without any syndrome or disease who underwent cone beam computed tomography were used. Measurement of the CG height (superoinferior, on the coronal section), width (laterolateral, on the axial section), and length (anteroposterior, on the axial section) dimensions. In addition, a categorical evaluation of CG morphology, CG pneumatization, olfactory fossa depth, and position of the CG in the ethmoid area (Keros classification) was performed.ResultsAlthough the superoinferior diameter and laterolateral diameter values of the CG did not differ between the groups, the anteroposterior diameter values were found to be significantly (p = 0.047) lower in individuals with CLP (11.95 ± 2.57 mm) compared with control (13.23 ± 2.05 mm). There was no difference in the morphology or pneumatization status of the CG between the groups.ConclusionExcept for the anteroposterior length, there was no difference in CG morphometric measurements between individuals with CLP and control. The anteroposterior length was shorter in individuals with CLP.

Sinonasal adenocarcinoma presented as a giant anterior cranial fossa mass: a case report and review of the literature

BackgroundIntestinal adenocarcinoma accounts for less than 0.1–4% of all malignancies in the region. It is common among woodworkers and leather workers. Sinonasal adenocarcinoma usually arises from the ethmoid sinus (40%) or nasal cavity (25%). Extension to nearby structures is common, but intracranial spread is very rare. These tumors are usually treated with surgery, with a reported 5-year survival rate of 59% to 80%.Case presentationThis is a 60-year-old Black African male patient who presented with globalized headache, nasal obstruction with snoring during sleep, anosmia, change in mentation, sometimes agitation and left-side visual loss of one-year duration with worsening his above symptoms over the last one month. He couldn’t smell soap bilaterally; in his left eye he could see only hand movement at nearly 30 cm. On brain magnetic resonance imaging, there was a T1 hypo- and T2 hyper-intense anterior cranial fossa mass arising from the left ethmoid sinuses and sphenoid sinuses and compressing the left optic structures, and brain computed tomography demonstrated heterogeneous hypo- to isodense mass. Complete tumor excision achieved and discharged with significant improvement and linked to oncology unit for radiotherapy.ConclusionThe management of these patients is multidisciplinary, involving neurosurgeons, otolaryngologists, oncologists, and maxillofacial surgeons. Surgical resection is the main treatment strategy, followed by radiotherapy, particularly intensity-modulated therapy. Chemotherapy is used in highly advanced, metastatic, and unresectable tumors.

The lateral transorbital approach to the medial sphenoid wing, anterior clinoid, middle fossa, cavernous sinus, and Meckel's cave: target-based classification, approach-related complications, and intermediate-term ocular outcomes.

The lateral transorbital approach (LTOA) is a relatively new minimal access skull base approach suited for addressing paramedian pathology of the anterior and middle fossa. The authors define target zones for this approach and describe a series of cases with detailed measurements of visual outcomes, including those obtained with exophthalmometry. The authors performed a retrospective analysis of a consecutive series of LTOA patients. Seven target zones were identified: 1) the orbit, 2) the lesser sphenoid wing and anterior clinoid, 3) the middle fossa, 4) the lateral wall of the cavernous sinus and Meckel's cave, 5) the infratemporal fossa, 6) the petrous apex, and 7) the anterior fossa. The authors used volumetric analyses of preoperative and postoperative MR and CT imaging data to calculate the volume of bone and tumor removed and to provide detailed ophthalmological, neurological, and cosmetic outcomes. Of the 20 patients in this cohort, pathology was in zone 2 (n = 10), zone 4 (n = 6), zone 3 (n = 2), zone 1 (n = 1), and zone 5 (n = 1). Pathology was meningioma (n = 10), schwannoma (n = 2), metastasis (n = 2), epidermoid (n = 1), dermoid (n = 1), encephalocele (n = 1), adenoma (n = 1), glioblastoma (n = 1), and inflammatory lesion (n = 1). The goal was gross-total resection (GTR) in 9 patients, all of whom achieved GTR. Subtotal resection (STR) was the goal in 8 patients (5 spheno-orbital meningiomas, 1 giant cavernous sinus/Meckel's cave schwannoma, 1 cavernous sinus prolactinoma, and 1 cavernous sinus dermoid), 7 of whom achieved STR and 1 of whom achieved GTR. The goal was biopsy in 2 patient and repair of encephalocele in 1. Visual acuity was stable or improved in 18 patients and worse in 2. Transient early postoperative diplopia, ptosis, eyelid swelling, and peri-orbital numbness were common. All 9 patients with preoperative diplopia improved at their last follow-up. Seven of 8 patients with preoperative exophthalmos improved after surgery (average correction of 64%). There were no cases of clinically significant (> 2 mm) postoperative enophthalmos. The most frequent postoperative complaint was peri-orbital numbness (40%). There was 1 CSF leak. Most patients were satisfied with their ocular (84%-100% of patients provided positive satisfaction-related responses) and cosmetic (75%-100%) outcomes. The LTOA is a safe minimal access approach to a variety of paramedian anterior skull base pathologies in several locations. Early follow-up revealed excellent resolution of exophthalmos with little risk of clinically significant enophthalmos. Transient diplopia, ptosis, and peri-orbital numbness were common but improved. Careful case selection is critical to ensure good outcome.

Topographic Anatomy and Pneumatization of the Posterior Clinoid Process in Chiari Type I Malformation

ObjectiveThis study aimed to examine pneumatization and topographic location of the posterior clinoid process (PCP) in Chiari type I malformation (CIM) for skull base approaches. MethodsComputed tomography images of 52 (23 males / 29 females) CIM subjects aged 23.87±16.09 years, and 71 (26 males / 45 females) healthy subjects aged 42.48±21.48 years constituted the study universe. ResultsThe distances of PCP to the foramen magnum (p=0.037), superior orbital fissure (p<0.001), foramen rotundum (p<0.001), and foramen ovale (p<0.001) were smaller, but the distance of PCP to the crista galli (p=0.038) was greater in CIM patients, compared to normal subjects. In CIM, the fusion between PCP and the anterior clinoid process was observed in nine sides (8.70%), while in controls, in 12 sides (8.50%). PCP pneumatization was observed in 40 sides (38.50%) in CIM patients, while in 28 sides (19.70%) in normal subjects. This data displayed that PCP pneumatization was affected by CIM (p<0.001). ConclusionThe distances of PCP to the crista galli and foramen magnum indicate the anterior fossa length and the posterior fossa depth, respectively; thus, CIM patients have longer anterior fossa and shallow posterior fossa. In addition, the distances of PCP to superior orbital fissure, foramen rotundum and foramen ovale indicate the middle fossa width; thence, CIM patients have less middle fossa width than normal individuals. CIM patients have approximately 50% higher PCP pneumatization rate, and this may increase the risk of complications such as cerebrospinal fluid fistula during the application of posterior clinoidectomy.

One-Piece versus Two-Piece Fronto-Temporo-Orbito-Zygomatic Craniotomy: A Narrative Overview of Evolution.

The fronto-temporo-orbito-zygomatic (FTOZ) craniotomy is a commonly utilized surgical approach for many complex skull base lesions, especially lesions traversing skull base compartments. This craniotomy has evolved over multiple stages, originating from the classic pterional craniotomy and has undergone many variations over time. The FTOZ craniotomy provides access to the orbit as well as to multiple compartments in the cranium (anterior, middle and upper third posterior cranial fossae). The one-piece and two-piece fronto-temporo-orbito-zygomatic craniotomies are two particularly notable variations that have stood the test of time. Selection between the two variations is mostly surgeon preference and comfort with the technique; however, there are few clinical and anatomic studies that have both shaped these craniotomies as well as provided immense information about instances in which they are most useful. The authors review the origin and history of the one-piece and two-piece fronto-temporo-orbito-zygomatic craniotomy and deliberate their advantages and disadvantages. Additionally, a pictorial review has been crafted to clearly illustrate the osteotomies to be made in the FTOZ craniotomy.

Congenital transsphenoidal meningocele in a newborn: A case report

IntroductionCongenital transsphenoidal meningocele is extremely rare.AimWe present a newborn who was found to have a large midline cystic mass protruding from a cleft palate.Case studyRadiological imaging showed a large cerebrospinal fluid mass herniating through a large anterior cranial fossa defect into the sphenoid sinus with extension to the nasal cavity through a cleft palate into the oral cavity.Results and discussionA bifrontal craniotomy and decompression of meningocele with dura repair was performed.ConclusionsThe child was discharged healthy postoperatively and on monthly follow-up and subsequently thriving well with improving neurological recovery.

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

Numerous surgical approaches have been described for the resection of anterior cranial fossa meningioma. The common problems associated with these approaches are excessive brain retraction, injury to neurovascular structures, transection of superior sagittal sinus (SSS), and a higher risk of new-onset anosmia. The authors describe a unilateral extended frontal approach with the aim to minimize brain handling without the need for SSS transection and possibly better olfaction preservation. Methods: 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. Results: 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. Conclusions: The extended unilateral frontal approach is a viable and reliable alternative for extended bifrontal technique for the resection of large midline anterior cranial fossa meningiomas with avoidance of SSS ligation, decreased brain handling with better olfaction preservation while achieving comparable tumor resection and acceptable cosmetic outcomes.

Transpalpebral/Blepharoplasty Incision and Supraorbital Craniotomy for the Treatment of Ethmoidal Dural Arteriovenous Fistulas: A Case Series.

Inherent complex angioarchitecture associated with ethmoidal dural arteriovenous fistulas (dAVFs) can make endovascular treatment methods challenging. Many surgical approaches are accompanied by unfavorable cosmetic results such as facial scarring. Blepharoplasty incision of the eyelid offers a minimal, well-hidden scar compared with other incision sites while offering the surgeon optimal visualization of pathogenic structures. This case series aims to report an initial assessment of the safety and efficacy of supraorbital craniotomy by blepharoplasty transpalpebral (eyelid) incision for surgical disconnection of ethmoidal dAVFs. Retrospective chart review was conducted for all patients who underwent blepharoplasty incision and craniotomy for disconnection of ethmoidal dAVFs at our institution between October 2011 and February 2023. Patient charts and follow-up imaging were reviewed to report clinical and angiographic outcomes as well as periprocedural and follow-up complications. Complete obliteration and disconnection of ethmoidal dAVF was achieved in all 6 (100%) patients as confirmed by intraoperative angiogram with no resulting morbidity or mortality. Periprocedural complications included one case of transient nasal cerebrospinal fluid leak that was self-limiting and resolved before discharge without intervention. Surgical treatment for ethmoidal dAVFs, specifically by transpalpebral incision and supraorbital craniotomy, is a safe and effective treatment option and affords the surgeon greater access to the floor of the anterior fossa when necessary. In addition, blepharoplasty incision addressed patient concerns for facial scarring compared with other incision sites by creating a more well-hidden, minimal scar in the natural folds of the eyelid for patients with an eyelid crease.

Anosmia due to bilateral papillary atrophy : a case report

Abstract&#x0D; Introduction : Papillary atrophy refers to degeneration of the optic nerve, which occurs as an end result of a pathological process that damages the axons, with ophthalmoscopic observation showing pallor of the optic nerve papillae which generally accompanies permanent damage to the optic nerve.&#x0D; Case Illustration : It was reported that a 36 year old woman came to the polyclinic with complaints of not being able to see in both eyes since 8 months ago. Complaints of blurred vision in both eyes are followed by smell that cannot smell. This complaint has been getting worse for the past 2 weeks. On brain MRI examination, results were obtained with SOL impressions in the midline frontalis area with perifocal edema ec, suspected olfactory groove meningioma.&#x0D; Discussion : In this case SOL is located in the midline frontal area so that the patient complains of loss of smell sensation (anosmia). The presence of a frontal or subfrontal tumor can compress the optic tract and optic nerve together. Optic tract compression will cause anosmia. Olfactory disturbances are strongly associated with anterior cerebral fossa tumors.&#x0D; Conclusion : Secondary papillary atrophy is caused by increased intracranial pressure caused by a mass tumor which is preceded by papilledema signs and eventually becomes papillary atrophy, and gives a pale optic papillae with blurred boundaries. Brain CT scan examinations are important to estimate the location of the lesion.

Fibrous dysplasia of sphenoid wing with secondary aneurysmal bone cyst: a rare case report

BackgroundAn aneurysmal bone cyst is a locally destructive benign lesion affecting mostly the long bones. Aneurysmal bone cyst of the skull bones is a very rare phenomenon and the involvement of the sphenoid bone of the skull with extension into the orbit is even rarer. We present a case of 15-year-old adolescent with fibrous dysplasia of the sphenoid wing with secondary aneurysmal bone cyst.Case presentationA 15-year-old male presented to us with chief complaints of headache with swelling in the left temporal region of the face and proptosis of the left eye associated with decreased vision for the past 2 months. NCCT showed a large heterogeneous mass in the left temporal region extending into left orbit. Gadolinium-enhanced MRI showed a well-defined multiloculated osteo-expansile lesion in the left middle cranial fossa extending into the anterior cranial fossa consistent with the fibrous dysplasia of the sphenoid bone with associated aneurysmal bone cyst. Digital subtraction angiography brain to look for any feeders to the lesion was done followed by microsurgical gross total excision of the tumor. The histopathology report confirmed it to be fibrous dysplasia secondary to aneurysmal bone cyst.ConclusionAneurysmal bone cyst is a rare entity, commonly affecting the long bones of the body. The involvement of sphenoid wing of skull is very rare occurrence. It can be primary or secondary to fibrous dysplasia, chondroblastoma, giant cell tumor, fibromyomas, etc. Fibrous dysplasia with secondary aneurysmal bone cyst should be kept in mind as one of the differential diagnoses while dealing with osteolytic bone lesions of skull.

Anatomy and microsurgical relevance of the outer arachnoid envelope around the olfactory bulb based on endoscopic cadaveric observations.

Surgical approaches to the anterior cranial fossa have great risk of damaging the olfactory tract and bulb. The goal of this study was to describe the outer arachnoid envelope around the olfactory bulb which plays significant role in the approach-related injury of the nerve. A total of 20 fresh human cadaveric heads were examined as a following: 5 cadaveric heads were used to describe a gross overview of the topographic anatomy of the outer arachnoid cover of the olfactory bulb. In 15 cadaveric heads endoscopic surgical approaches were performed to examine the in situ undisrupted anatomy of the outer arachnoid around the olfactory bulb. Four cadaveric heads were used for lateral subfrontal approach, 5 heads for medial subfrontal, 3 heads for median subfrontal approach and 3 heads for anterior interhemispheric approach. The outer arachnoid membrane of the frontal lobe attaches the olfactory bulb strongly to the above lying olfactory sulcus. Only the most rostral portion of the olfactory bulb became slightly detached from the frontal lobe. The outer arachnoid forms a decent protrusion around the tip of the olfactory bulbs. The fila olfactoria have their own outer arachnoid cover as a continuation of the same layer of the olfactory bulb. The effect of brain retraction and manipulation forces on the olfactory bulb and the role of the here located arachnoid membranes were visually analysed and described in detail through the performed four different neurosurgical approaches. The results of our observations provide important anatomical details for the preservation of smelling during neurosurgical procedures.

Intracranial meningioma: an unusual silent killer—about two cases report and a literature review

BackgroundMeningiomas are common benign intracranial tumors, accounting for 1/3 of all primary intracranial neoplasms, and hence, are not considered the chief cause of death when encountered incidentally during autopsy. These tumors are usually slow-growing, and the clinical course may be asymptomatic to the point of acute complications. Sudden unexpected deaths due to meningiomas are exceptional and rarely reported in the literature.In the present report, we describe two autopsy cases of sudden unexpected death due to meningiomas and we discuss the mechanism of death.Case presentationTwo apparently healthy men were discovered dead in their home. A judicial autopsy was ordered. At dissection, a pedunculated firm mass, attached to the dura was found in both cases. Tumors were located in the anterior and middle fossa. The remaining organs were congestive without any abnormality. A microscopic examination confirmed the diagnosis of meningiomas. Postmortem toxicology analysis was negative. Forensic pathologists concluded to sudden unexpected death due to intracranial meningioma.ConclusionsThese cases illustrate the possibility of meningioma remaining silent till acute complication and fatal outcome. Therefore, clinicians must bear in mind the possibility, albeit extremely rare, of sudden unexpected death in cases of undiagnosed intracranial meningiomas, as documented in the present report. Thus, we emphasize the value of promptly and thoroughly investigating even seemingly minor neurological symptoms, such as headaches or acute epileptic seizures, in adults. We also stress the importance of the early detection and appropriate management of brain tumors in fatal outcome prevention, and we highlight the role of the post-mortem examination to detect such a fatal complication.