Anterior Fossa Research Articles

Orbitocranial penetrating injury with a lawnmower blade: case report

The aim of this study is to present the management of a patient with orbitocranial penetrating injury by a large foreign body. The case described in the article was taken from the work of the Regional Specialist Hospital No. 5 in Sosnowiec. The patient was hit by a fragment broken off a lawnmower blade. The patient was transported to a district Hospital in Raciborz by the emergency medical team . After performing basic imaging diagnostics and temporary surgical management at another unit, the patient was transported to a multispecialty center for further treatment, where the surgical treatment was applied. A foreign body embedded in the craniofacial region penetrating the orbit and bordering the anterior cranial fossa constitutes a challenging case requiring the cooperation of a team composed of neurosurgeons, otolaryngologists, ophthalmologists, maxillofacial surgeons. The treatment of the patient should be preceded by a thorough analysis of imaging studies.

Exoscopic resection of giant olfactory groove meningioma.

Olfactory groove meningiomas represent 8%-13% of all intracranial meningiomas. Gross-total resection for large (4-6 cm) and giant (> 6 cm) cases remains challenging due to their relationship with critical neurovascular structures and extensive frontal lobe edema. A variety of transcranial and endoscopic approaches have been described. This 2D operative video shows the use of a digital 3D exoscope in the removal of a giant olfactory groove meningioma through a lateral supraorbital approach in a 57-year-old woman with visual impairment and apathy. The exoscope provides a very good angulated view of the subfrontal area on both sides of the anterior cranial fossa even through a small craniotomy. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23125.

Conservative and Surgical Management Strategies of Intracranial Arachnoid Cysts: A Single Institution Experience of 136 Cases

Aim: Intracranial arachnoid cysts develop from the arachnoid membrane between the membranes called pia mater and dura mater, located on the brain and cerebellum. The aim of this retrospective study is to reveal our clinic's approach to intracranial arachnoidal cysts, which can be seen incidentally in all age groups, in the light of current literature. Materials and Methods: In our study, we retrospectively analyzed the clinical and radiological findings of a total of 136 patients diagnosed with intracranial arachnoid cysts in both genders and all age groups between January 1, 2017 and December 31, 2023. The localization of the arachnoid cyst was examined in the electronic medical records of the patients who had brain tomography and magnetic resonance imaging during the said interval. The gender, age groups, symptoms, treatment approaches and prognoses of the patients were analyzed. Results: The number of patients diagnosed with arachnoid cyst in our radiological examinations was 136. The prevalence was higher in men than in women; 94 patients were male (69.1%) and 42 patients were female (30.1%). 72 patients were 20 years of age or younger (52.9%). Among 136 patients, only 11 patients were found to have more than one arachnoid cyst in terms of localization (8.1%). In terms of localization, the most common locations were the middle fossa, 52 patients (38.2%). Retrocerebellar location was in 43 patients (31.6%), convex location was in 9 patients (6.6%), and anterior fossa location was in 32 patients (23.5%). Only 42 (30.9%) of 136 patients with radiologically detected arachnoid cysts had clinically significant symptoms. Other patients were detected incidentally during neuroradiological examinations performed for trauma or other reasons. During follow-up, an increase in the size of the cyst was observed in only 9 patients (6.6%). The number of patients operated on in our clinic was only 7 (5.1%). During the follow-up period of the remaining patients, only 3 patients had clinical improvement in their symptoms (2.2%). Conclusion: Arachnoid cysts are frequently encountered incidentally in radiological intracranial imaging today, and their incidence increases in the first 20 years of life. While very few patients show clinically significant neurological symptoms, asymptomatic patients do not require surgical treatment. It is recommended that asymptomatic patients be protected from head trauma and periodic neurosurgery outpatient clinic follow-up.

Compressive optic neuropathy in the setting of tumors of the chiasmal and sellar region: a review

This is a review on compressive optic neuropathy (CON) in the setting of tumors of the chiasmal and sellar region. CON is a difficult to manage neuro-ophthalmological condition that occurs when the optic nerve is damaged due to compression of the anterior visual pathway, commonly by scull-base tumors of the middle and anterior fossae. Compression of the optic nerve/chiasm complex is accompanied by reduced vision, visual field defects and descending optic atrophy, which, if not treated properly, can lead to permanent vision loss and blindness. The literature data on the prevalence and features of visual disturbances in chiasmal-sellar tumors which differ in histology have been reviewed.

Surgical Treatment of Complex Craniofacial Fractures

Severe craniofacial fractures may present different needs in treating intracranial lesions over facial injuries. This paper examines the results of our strategy, consisting of a single-stage combined neurosurgical-maxillofacial treatment. A retrospective review was conducted of 33 consecutive patients with complex fractures of the anterior cranial fossa and facial skeleton, who required elective surgery for craniofacial reconstruction. Patients who required emergency surgery for intracranial clots or penetrating wounds were excluded. In all cases, all or almost all the anterior skull-base was injured with compound fractures of the frontal sinus, the orbital roofs, the lamina cribrosa, and the planum sphenoidale. In all cases, the prioritization of treatment was carefully discussed, and surgical timing and strategy were agreed. There was one dead. Olfactory injuries were always found intraoperatively. There were no mucoceles, CSF-leak recurrences, cranial infections, or neurological worsening. The functional and neurological results were highly satisfactory. The one-stage surgical treatment of complex craniofacial fractures has numerous advantages, including the possibility of reducing facial fractures without the risk of CSF leaks. It also eliminates the need for repeated procedures in fragile patients, and the need to dismantle the facial reconstruction if the skull base repair is performed later. The main issue is the surgical timing, considering that the maxillofacial surgeon usually favors early facial repair, whereas the neurosurgeon generally prefers delayed manipulation of the contused frontal lobes. A timeframe of 10-14 days after trauma may be a good compromise for safe procedures with excellent neurological and functional outcomes.

Factors determining the requirement of surgical intervention and prognosis in cases of traumatic bifrontal contusions: A prospective observational study

Background: Traumatic brain injury, being a notorious cause of mortality and morbidity across the globe, presents with a variety of lesions. One of the distinct patterns of injury is characterized by contusions of both frontal lobes, labeled “traumatic bifrontal contusions” (TBCs). TBC is often associated with the presence of significant edema and mass effect leading to rapid clinical deterioration after a usually benign presentation at the time of first evaluation. Formulating a management plan in a patient with TBC is often more difficult than in a patient with a major intracranial hematoma. Methods: A prospective observational study with aims and objectives to identify predictors of an unfavorable outcome, analysis of the evolution of TBC, evaluation of the specific indications for surgery, and determination of the prognosis. All head trauma patients harboring bifrontal contusions were included in the study. Patients with other associated operable injuries involving blunt trauma abdomen and orthopedic injuries, counter-coupe injuries, and obvious open fractures noted over calvaria were excluded from the study. Glasgow coma scale (GCS) was recorded during the first assessment, followed by non-contrast computerized tomography (NCCT) Head. Results: A total of 53 patients satisfying inclusion and exclusion criteria were included in the study. The average GCS score recorded before surgical intervention was 9. The mean and median best motor response noted was M5. The interval from the time of injury to the first NCCT of the brain at the study hospital ranged from 3 h to 163 h, averaging 17.66 h. The median category w.r.t Marshall’s CT classification observed was “Diffuse Injury IV.” The volume of the contusions in each scan was estimated, and the average anterior cranial fossa volume observed was 125 mL. “Upfront surgery” (“Bifrontal decompressive craniectomy” or “unilateral Fronto-Temporo-Parietal [FTP] decompressive hemicraniectomy”) was carried out on the day of admission based on the findings on the first NCCT brain. About 49% of patients at presentation needed surgical intervention as per existing protocols. The duration of observation for patients who were initially observed but eventually had to undergo surgery ranged from 1 to 5 days, with an average observation period of 2 days. The duration of observation in those who did not subsequently need surgery ranged from 7 to 10 days, with an average duration of 9 days. Conclusion: What leads to the poorly predictable, delayed, and rapid deterioration that sets TBCs apart from other traumatic brain injuries is still unclear. Our study finds that having a low threshold for repeat CT imaging of the patient led to earlier identification of progression, and a low threshold for surgical intervention led to favorable outcomes.

Transorbital and supraorbital uniportal multicorridor approach to the orbit, anterior, middle and posterior cranial fossa: Anatomic study

IntroductionThe transorbital route has been proposed for addressing orbital and paramedian skull base lesions. It can be complemented by further marginotomies, as per “extended-transorbital approach” and combined with others ventro-basal approaches featuring the concept of “multiportal surgery”. Nevertheless, it cannot address some anatomical regions like the clinoid, carotid bifurcation and the Sylvian fissure. Therefore, we propose a combined transorbital and a supraorbital approach, attainable by a single infra-brow incision, and we called it “Uniportal multicorridor” approach. Research questionThe aim of our study is to verify its feasibility and deep anatomical targets through a cadaveric study. Materials and methodsAnatomic dissections were performed at the Laboratory of ICLO Teaching and Research Center (Verona, Italy) on four formalin-fixed cadaveric heads injected with colored neoprene latex (8 sides). A stepwise dissection of the supraorbital and transorbital approaches (with an infra-brow skin incision) to the anterior tentorial incisura, clinoid area, lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure is described. ResultsWe analyzed the anatomic areas reached by the transorbital corridor dividing them as follow: lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure; while the anatomic areas addressed by the supraorbital craniotomy were the clinoid area and the anterior tentorial incisura. ConclusionsThe described uniportal multi-corridor approach combines a transorbital corridor and a supraorbital craniotomy, providing a unique intra and extradural control over the anterior, middle, and posterior fossa, tentorial incisura and the Sylvian fissure, via an infra-brow skin incision.

Introducing next-generation transcranial surgery with the head-mounted 3D View Vision display in extracorporeal microsurgery: illustrative cases.

Exoscopy in neurosurgery offers various advantages, including increased freedom of the viewing axis while the surgeon maintains a comfortable upright position. However, the optimal monitor positioning to avoid interference with surgical manipulation remains unresolved. Herein, the authors describe two cases in which a three-dimensional head-mounted display (3D-HMD) was introduced into a transcranial neurosurgical procedure using an exoscope. Case 1 was a 50-year-old man who presented with recurrent epistaxis and was diagnosed with an olfactory neuroblastoma that extended from the nasal cavity to the anterior cranial base and infiltrated the right anterior cranial fossa. Case 2 was a 65-year-old man who presented with epistaxis and was diagnosed with a left-sided olfactory neuroblastoma. In both cases, en bloc tumor resection was successfully performed via a simultaneous exoscopic transcranial approach using a 3D-HMD and an endoscopic endonasal approach, eliminating the need to watch a large monitor beside the patient. This is the first report of using a 3D-HMD in transcranial surgery. The 3D-HMD effectively addressed issues with the field of vision and concentration while preserving the effectiveness of traditional microscopic and exoscopic procedures when observed on a 3D monitor. Combining the 3D-HMD with an exoscope holds the potential to become a next-generation surgical approach.

Modified orbitozygomatic craniotomy with a single burr hole in the alternative sphenoid ridge keyhole

BackgroundOne-piece modified orbitozygomatic approach (OZA) is an extended version of the pterional approach that also includes orbital walls and frontal process of the zygomatic bone. For this craniotomy one burr hole must be placed in MacCarty keyhole and another - in the temporal region. ObjectiveTo develop a technique of the one-piece modified OZA with single a burr hole in the alternative sphenoid ridge keyhole that allows access to orbit, anterior cranial fossa and middle cranial fossa and apply it intraoperatively. MethodsA single human head specimen was used. The dissection was performed using standard surgical instruments high-speed Stryker drill. Every stage of the approach was photographed. We also report a surgical case of a patient with orbital cavernous hemangioma that was resected using the described technique. ResultsThe technique of the one-piece modified OZA with a single burr hole in the alternative sphenoid ridge keyhole is described, and its advantages and limitations are analyzed. The technique is used to totally resect an orbital cavernous hemangioma with good functional and cosmetic result. ConclusionModified OZA with a single burr hole in the sphenoid ridge keyhole is possible and may be an alternative to the classic technique. The advantages of this variation are the placement of just one burr hole and the preservation of a larger portion of the orbital roof. The latter facilitates better bone reconstruction and better cosmetic outcome. Disadvantages are the difficulty of identifying the location of the sphenoid ridge keyhole and risk of damaging the dura.

TUMOR FIBROSO SOLITARIO CEREBRAL: A PROPÓSITO DE UN CASO

Introduction: Solitary fibrous tumors (SFTs) are rare mesenchymal neoplasms that, although typically develop in the visceral pleura, occasionally occur in the intracranial cavity. Furthermore, they are characterized by high rates of metastasis and recurrence. Case Report: We present the case of a 59-year-old male patient with a 3-month history of headache and bradyphrenia. Computed tomography revealed a neoformative tumor infiltrating the nasal cavity, ethmoid sinuses, and anterior cranial fossa, involving the left frontal lobe. The patient underwent two exploratory craniectomies, during which diagnoses suggestive of high-grade glial neoplasia and SFT were made. For precise diagnosis, immunohistochemistry was performed, which was consistent with solitary fibrous tumor. The case is analyzed, focusing particularly on histopathological aspects, the unusual location of this tumor, and its variable clinical manifestations.

Patient with AIP gene mutation presenting with pituitary adenomatosis

Abstract Introduction/Objective Familial isolated pituitary adenoma (FIAP) is frequently associated with germline mutation in the AIP gene. Clinically, it is characterized by the occurrence of isolated pituitary adenoma in 2 or more members of a family. In this case report, we describe a patient who presented with a pituitary adenoma and concurrent disseminated leptomeningeal adenomatosis. Methods/Case Report A 17-year-old female presented with amenorrhea and visual impairment. Brain MRI showed a 2.6 x 2.8 x 2.4 cm mass in the sella turcica extending to the suprasellar region. Multiple separate smaller (5-7 mm) masses in the leptomeninges of the anterior and middle cranial fossa, and small enhancing masses within the internal auditory canals bilaterally were also seen. She underwent craniotomy for resection of the pituitary tumor which was diagnosed pathologically as sparsely granulated somatotroph adenoma with co-expression of human growth hormone and prolactin. Postoperatively, she was found to have persistent hormone imbalance for which she received proton beam therapy. Genetic testing revealed mutations in the AIP gene. No mutations were detected in NF2, MEN1, and CDKN1B. At age 21, radiologic follow-up revealed recurrent pituitary adenoma, for which she underwent trans- sphenoidal resection, revealing the same histopathologic diagnosis. At age 22, MRI showed diffuse nodular enhancement throughout the subarachnoid spaces, most pronounced within the Sylvian fissures. Cytologic examination of cerebrospinal fluid (CSF) showed several loose aggregates of neuroendocrine cells, positive for synaptophysin by immunocytochemistry, consistent with the diagnosis with dissemination of pituitary adenoma cells in the leptomeninges. Results (if a Case Study enter NA) N/A Conclusion In all 136 previously reported cases, leptomeningeal dissemination of pituitary adenoma has been exclusively described in post-surgical settings or after pituitary apoplexy. To our knowledge, this is the first case of disseminated pituitary adenomatosis noted at initial clinical presentation

Hemophilic Pseudotumor of Paranasal Sinuses in a Child with Severe Hemophilia a Receiving Emicizumab: A Case Report

Emicizumab, a bispecific humanized monoclonal antibody, bridges activated factor IX (FIX) and FX to restore the function of missing activated FVIII in individuals with hemophilia A (PwHA). Prophylaxis with subcutaneous emicizumab promotes adequate hemostasis in PwHA. Emicizumab prophylaxis in children with hemophilia A has been approved in the United States for use in PwHA ages newborn and older, with or without FVIII inhibitors. We report a 2-year-old boy with severe congenital hemophilia A who initially received prophylaxis with standard half-life factor VIII but later switched to subcutaneous emicizumab at 6 mg/kg every four weeks due to difficult IV access and parental preference. Shortly after starting emicizumab, the patient presented to the hospital with severe episodic epistaxis from the left nostril, requiring ICU admission and ENT consultation. Despite treatment, the condition did not improve, prompting the need for imaging studies. Subsequently, the patient developed ipsilateral eye proptosis and a mass protruding from the left nostril. CT and MRI imaging of the orbit revealed an expansible soft tissue mass measuring 2 x 2.5 x 4 cm occupying the right sphenoid sinus, extending to the nasal cavity. The mass had caused erosion of the clivus and the anterior cranial fossa floor, extending to the middle cranial fossa (Figures 1 & 2). He underwent endoscopic nasal debulking of the left nostril mass, and the pathological examination revealed a cystic mass with a thick capsule and intra-cystic blood clots, consistent with the characteristics of a hemophilic pseudotumor (HP). The fibrous stroma contained hemosiderin-laden macrophages with no evidence of malignancy. Emicizumab was discontinued before the operation, and the patient received several doses of recombinant FVIII to maintain hemostasis. Despite the debulking procedure, the patient continued to experience episodic epistaxis and joint bleeding. An inhibitor assay was performed at that time and showed high levels, leading to a switch to on-demand FVIII treatment for hemophilia A with an inhibitor. Managing the bleeding episodes with bypassing agents proved challenging, and the family expressed dissatisfaction. A decision was made to resume emicizumab treatment, and the patient eventually stabilized, experiencing no bleeding for nearly six months. Additionally, he regularly follows up with ENT specialty, with no further intervention or progression of the tumor. Notably, he did not receive any bypassing agents concomitantly with emicizumab. HP is characterized by encapsulated blood clots accumulating in extravascular tissues, especially the musculoskeletal system, in patients with bleeding tendencies, particularly hemophiliacs. It is a benign, expansible, soft tissue-like mass that exerts pressure on surrounding structures, mimicking a locally invasive malignancy. HP is a hematoma that grows and causes bone erosion through repeated bleeding episodes. A literature review revealed that HP is a rare hemorrhagic complication that develops in 1-2% of patients with severe hemophilia (Magallón et al. Am J Hematol. 1994). Its occurrence in patients receiving emicizumab prophylaxis is extremely rare. The first reported case involved a Japanese child with hemophilia who presented with a pseudotumor occupying the left maxillary sinus after repeated episodes of epistaxis. The mass caused a downward deviation of the ipsilateral eye and bulged into the buccal cavity. The patient received monthly prophylaxis with emicizumab at 6 mg/kg (Kawahara et al. Int J Hematol. 2022), but unlike our patient, he received bypassing agents concomitantly. Our reported case is unique because HP developed independently of bypassing agent therapies, as the patient did not receive any bypassing agents before the tumor's development. The likely explanation is related to repeated bleeding insults to the same anatomical location, leading to the cumulative development of hematoma and HPs. Another possibility could be attributed to the known adverse thrombotic effects of emicizumab treatment. Physicians treating hemophilia should remain vigilant for abnormal clinical signs, such as new masses in patients receiving emicizumab, which could indicate HP.

SURG-42. FACTORS INFLUENCING TUMOR RECURRENCE AFTER RESECTION OF SKULL-BASE MENINGIOMAS

Abstract BACKGROUND Resection of skull-base meningiomas is challenging, given the proximity of and adherence to neurovascular structures. We characterize the benefits of neurosurgical resection of meningiomas, comparing clinical and surgical outcomes based upon tumor location within and outside the skull base. METHODS Data were retrospectively collected from 85 patients who underwent surgical resection of meningioma between 2008 – 2018, for whom long-term follow-up was available. Outcomes were compared between locations: non-skull base, anterior fossa, middle fossa, and posterior fossa. Logistic regression analysis was used to analyze pre-operative and pathologic factors influencing recurrence. RESULTS Forty-five (54.1%) tumors were located on the skull base: 29 anterior fossa, 22 middle, and 6 posterior. Simpson grade 1 or 2 resection was achieved in 63 patients. Mean Ki-67 showed a statically significant difference between all tumor locations: non-skull base (7.1), anterior fossa (4.0), middle fossa (10.8), posterior fossa (2.8) (p = 0.009). Simpson grade differed significantly by tumor location with percentage of Simpson grade 1 resections as follows: non-skull base supratentorial (45.7%), non-skull base infratentorial (0.0%), anterior (71.5%), middle (30.0%), posterior (16.7%) (p = 0.022). Tumors recurred in 11 patients with recurrence differing significantly between locations: non-skull base (18.2%), anterior (3.8%), middle (36.4%), posterior (0.0%) (p = 0.046). Median progression-free survival was 115.5 months and did not significantly differ by location. Larger tumor volumes (p = 0.018), Simpson grade 3 resection (p = 0.016), and increased Ki67 (p = 0.046) were associated with higher recurrence risk. No variables predicted post-operative neurological deficits. CONCLUSIONS High variability exists within skull-base meningiomas, depending on the cranial fossa of origin. Location may impact the molecular make-up, extent of resection, and patient outcomes. Due to the high-risk anatomy of the skull base, confirming these predictors of recurrence is vital to optimize initial treatment and decrease the risk associated with salvage treatment.

TMET-21. PROTON MAGNETIC RESONANCE SPECTROSCOPY (1H MRS) FOR THE DIAGNOSIS OF AGGRESSIVE MENINGIOMAS WITH RECURRENCE POTENTIAL

Abstract In our previous study, we have observed elevated steady state levels of both alanine and glutamine in surgically resected tissue specimens from atypical meningioma (grade-II) patients compared to the benign (grade-I) meningioma patients. We have shown that meningioma cells utilize glutamine for the biosynthesis of alanine and other amino acids which may help in the cellular proliferation. While the role of elevated alanine in meningiomas is not well understood, this metabolite may serve as a metabolic marker for the diagnosis of aggressive meningiomas which may recur in the future. Here, we present a case of a large meningioma (7 cm x 4 cm x 8 cm) in a male patient (age: 68 years) who was diagnosed with an anterior cranial fossa, dural based extra-axial enhancing mass with the sinonasal extension compatible with a meningioma. The patient underwent multiple surgeries for the resection of the original tumor mass. Tumor tissue was collected from 2 regions: Nasal cavity and deeper tumor. Surgical pathology classified the tumor as a grade-I meningioma with MIB-1 index of ~10%. However, 1H MRS analysis of the tumor specimen showed elevated levels of alanine (Nasal cavity = 9.57 mM/g, tissue; Deep tumor = 5.50 mM/g, tissue), which are greater than the alanine levels reported for grade-II meningiomas (4.23 ± 1.92 mM). The elevated levels of alanine detected by 1H MRS suggested aggressive behavior of the tumor. After about 11 months, the repeat MRI examination showed tumor recurrence, and the patient underwent surgery again for the resection of the recurrent tumor. Surgical pathology of the recurrent tumor classified the tumor as a grade-I meningioma with increased proliferation rate (MIB-1 index of 10-12%). In conclusion, 1H MRS has potential to predict aggressive behavior of meningiomas and alanine can be used as a molecular marker for the differential diagnosis of meningiomas.

TO THE ISSUE OF A DIFFERENTIATED, BIOPATHOGENETIC APPROACH TO THE SELECTION OF INTERVENTION FOR VARIOUS CLINICAL AND ANATOMICAL FORMS OF SEVERE TRAUMATIC BRAIN INJURY

The work, based on many years of experience and in-depth analysis of significant clinical material - 3500 surgical interventions for various clinical and anatomical forms of severe traumatic brain injury (TBI), carried out in 1515 cases in the pre-computer period and in 1990 - in the post-computer period, shows the evolution views on neurotrauma and the advantage of a differentiated approach to the choice of intervention, taking into account the biomechanism and neuropathomorphological features of various clinical and anatomical forms of TBI; shows how they have changed, with the introduction of adequate diagnostic tools and neuroimaging (CT and MRI) approaches to the choice of interventions depending on and taking into account the biomechanism and pathomorphological basis of various clinical and anatomical forms of severe traumatic brain injury. With the introduction of computer diagnostics, the possibilities of various methods of intervention were revised: if possible, preference was given to osteoplastic trephination, which, in case of swelling and prolapse of the brain - in case of gross violations of the craniocerebral volume-capacitive relationships, in the computer period, the intervention ended with decompressive craniotomy with subcutaneous preservation bone flap – in 1096 cases out of 1990 interventions. In the remaining 894 cases, the intervention was completed using the osteoplastic method. In 217 of them, it was carried out in an improved, modified form: a wide bone flap, with moderate cerebral edema, was not removed. On top of the plastically extended hard shell, it was guided to the sawing site, as if in the form of an “apron,” and loosely fixed with periosteal sutures. When the edema subsided, the bone flap was placed in place, and if necessary, it was easily connected with ligatures passed through microholes along the edge of the craniotomy and in symmetrical places of the sawed bone flap and brought out. In case of inertial injuries, with multihemispheric-multifocal brain damage and with a volumetric hemorrhagic component, in 939 cases one was performed - and in 157 observations - two-sided optimally extended decompressive craniotomy, among which in 49 cases bilateral hemicranectomy was successful. After 1096 decompressive interventions, 554 (41.4%) of the victims died; in the remaining 894 cases, a wide traditional and modified craniotomy with loose fixation of the bone flap was also performed, involving the parabasal sections of the anterior and middle cranial fossa; in 84 cases - bifrontal craniotomy with falxotomy, in 593 - extended traditional osteoplastic trepanation, and in 217 cases - also extended, but modified osteoplastic craniotomy. Death was noted in 27 (32.1%), 110 (18.5%) and 11 (5.1%) cases, respectively. The overall mortality rate in this group - among 894 cases with osteoplastic craniotomy - was 16.6%. Postoperative mortality among all 1990 interventions for various clinical and anatomical forms of TBI in the post-computer period amounted to a total of 30.3%. Thus, taking into account the biomechanism and pathomorphological basis of TBI, a differentiated, biopathogenetic approach to the choice of intervention, it was possible to reduce, from year to year, postoperative mortality from 36-38% in the pre-computer period, to 29-30% in the computer period, at 35-45 % according to various neurosurgical clinics.

Trans-Arterial Embolization of Anterior Cranial Fossa Dural Arteriovenous Fistulas via the Sphenopalatine Artery: A Technique Report

BackgroundTrans-arterial embolization (TAE) via the ophthalmic artery and middle meningeal arterial are the common arterial routes for anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs). However, TAE via the sphenopalatine artery (SPA) to treat ACF DAVFs is rarely reported. Here, we describe 14 cases of ACF DAVFs that were either treated solely or in conjunction with other arterial routes via the SPA. A total of 15 embolization attempts were performed via the SPA. Method14 patients were treated with TAE via the SPA over a 20-year period. There were 13 males and 1 female in total, with a mean age of 57.4 (57.4±6.0) years. The clinical presentation, angiographic features, treatment strategy, and clinical outcomes were all documented. Results14 patients with ACF DAVFs underwent TAE via the SPA. Complete immediate angiographic occlusion was achieved in 78.6% of the fistulas (11/14). Complete embolization via the SPA alone was achieved in 63.6% (7/11) of the fistulas. A total of 15 embolization attempts were performed via the SPA, with a 46.7% (7/15) success rate. After TAE via the SPA, no complications were found. 42.9% (6/14) of the patients had DSA or MRA follow-up. There was no recurrence of the fistulas. ConclusionsThe SPA may be as an alternative arterial route if other appropriate arterial routes are unavailable. However, its safety and efficiency need to be confirmed further.

Giant primary intracranial multi-fossa leiomyosarcoma involving the frontal sinus, ethmoid air cells, anterior fossa, middle fossa, and intraventricular space: A case report and literature review

Background: Leiomyosarcomas (LMSs) is a type of sarcoma that arises from smooth muscle and generally presents in the abdomen. Although intracranial LMS has been identified before, most reported presentations have been in immunocompromised patients. Here, we present an intracranial LMS in an immunocompetent patient. Case Description: A 22-year-old male with a history of an atypical pineal parenchymal tumor of intermediate differentiation resected by suboccipital craniotomy at the age of 12 followed by adjuvant radiation therapy, presented with 3 weeks of decreased appetite, weight loss, and lethargy. He subsequently underwent transbasal approach skull base tumor resection. Histologic examination of the mass along with the patient’s history of radiation was supportive of a low-grade, radiation-induced LMS arising from the anterior fossa of the skull or meninges and extends to the frontal sinus and ethmoid air cells. Conclusion: Primary intracranial LMS is an extremely rare diagnosis and presenting symptoms vary with the location and size of the tumor. Due to the poor specificity of clinical symptoms, diagnosis is often based on histology. The most common treatment is surgical resection. Adjuvant chemotherapy with various agents has been found to be somewhat effective outside the central nervous system. When LMS does occur, a history of immunocompromised state or previous radiation exposure is often present. Pathological confirmation is required for an appropriate diagnosis.

Frontiers of Cranial Base Surgery: Integrating Technique, Technology, and Teamwork for the Future of Neurosurgery.

The landscape of cranial base surgery has undergone monumental transformations over the past several decades. This article serves as a comprehensive survey, detailing both the historical and current techniques and technologies that have propelled this field into an era of unprecedented capabilities and sophistication. In the prologue, we traverse the historical evolution from rudimentary interventions to the state-of-the-art neurosurgical methodologies that define today's practice. Subsequent sections delve into the anatomical complexities of the anterior, middle, and posterior cranial fossa, shedding light on the intricacies that dictate surgical approaches. In a section dedicated to advanced techniques and modalities, we explore cutting-edge evolutions in minimally invasive procedures, pituitary surgery, and cranial base reconstruction. Here, we highlight the seamless integration of endocrinology, biomaterial science, and engineering into neurosurgical craftsmanship. The article emphasizes the paradigm shift towards "Functionally" Guided Surgery facilitated by intraoperative neuromonitoring. We explore its historical origins, current technologies, and its invaluable role in tailoring surgical interventions across diverse pathologies. Additionally, the digital era's contributions to cranial base surgery are examined. This includes breakthroughs in endoscopic technology, robotics, augmented reality, and the potential of machine learning and AI-assisted diagnostic and surgical planning. The discussion extends to radiosurgery and radiotherapy, focusing on the harmonization of precision and efficacy through advanced modalities such as Gamma Knife and CyberKnife. The article also evaluates newer protocols that optimize tumor control while preserving neural structures. In acknowledging the holistic nature of cranial base surgery, we advocate for an interdisciplinary approach. The ecosystem of this surgical field is presented as an amalgamation of various medical disciplines, including neurology, radiology, oncology, and rehabilitation, and is further enriched by insights from patient narratives and quality-of-life metrics. The epilogue contemplates future challenges and opportunities, pinpointing potential breakthroughs in stem cell research, regenerative medicine, and genomic tailoring. Ultimately, the article reaffirms the ethos of continuous learning, global collaboration, and patient-first principles, projecting an optimistic trajectory for the field of cranial base surgery in the coming decade.

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.

NUT carcinoma presenting as retrobulbar optic neuropathy: A lethal masquerade!

A case of a 15-year-old girl with sudden vision loss left eye, left relative afferent pupillary defect, and normal fundus both eyes. Magnetic resonance imaging (MRI) brain and orbits showed a heterogeneous enhancing mass lesion in the left posterior ethmoid sinus with bony invasion and crowding of the optic canal. She underwent left optic nerve decompression with removal of the lesion and was started on systemic steroids. Biopsy was suggestive of NUT carcinoma (NC) and immunohistochemistry (IHC) confirmed the same. Despite chemotherapy, the tumor progressed rapidly in six months invading the left orbit, extending to right side of the midline and left anterior cranial fossa, with subsequent complete loss of vision of right eye also. She eventually underwent a globe sparing orbital exenteration with anterior cranial base resection along with postoperative radiotherapy. A month later, patient developed extensive skeletal and hepatic metastasis and succumbed to the disease; 11 months after the initial diagnosis.