Anterior Skull Base Research Articles

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

Abstract 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 were used to identify tumors with major diameter larger than 5 cm 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% (n = 18) had giant skull base tumors of anterior and middle fossa, and 2.96% (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 being male and 55.6% of the cases being 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 hemangiopericytoma, 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, with an association among giant anterior and middle fossa skull base tumor and epilepsy.

Interdisciplinary Management of Skull Base Tumors.

Endoscopic endonasal skull base surgery has gained acceptance worldwide. Comparative analysis has demonstrated that endoscopic skull base surgery may have advantages for many pathologies of the anterior skull base, e. g., sinonasal malignant tumors; pathologies of the central skull base, e. g., pituitary adenomas, craniopharyngiomas; well-selected cases of planum sphenoidale and tuberculum sellae meningiomas; or for clival lesions, e. g., chordomas, chondrosarcomas, or selected meningiomas. Over the past three decades, interdisciplinary surgical teams, consisting of otolaryngologists and neurosurgeons, have provided detailed anatomical knowledge, suggested new approaches or modifications of established surgical techniques, and offered continued surgical education. A review of pertinent literature was conducted with an emphasis on interdisciplinary endoscopic surgery of skull base lesions. Based on the authors̓ surgical experience in two different interdisciplinary endoscopic skull base centers, the authors classify approaches for endoscopic endonasal skull base surgery, describe indications, and key anatomic landmarks for common pathologies, and highlight surgical techniques to avoid complications. Interdisciplinary endonasal endoscopic surgery combines surgical expertise, improves resection rates for many pathologies, and minimizes morbidity by reducing the incidence of surgical complications.

Supraorbital Keyhole Approach: Opening of the Frontal Sinus and Cerebrospinal Fluid Rhinorrhea

Introduction: The supraorbital keyhole approach (SOKHA) 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 analyzed our data and reviewed 89 consecutive cases who underwent the SOKHA. We included the clinico-radiological parameters, pathology, use of endoscope, complications, etc. for analysis. Results: A total of 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 two cases in which a small part of the tumor was left behind as the tumor 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 arteriovenous malformation (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 cerebrospinal fluid (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. Intraoperative obliteration of the frontal sinus can reduce the risk of postoperative CSF leak. A large frontal sinus needs not be a contraindication for SOKHA.

Endoscopic Endonasal Anterior Skull Base Meningoencephalocele and Cerebrospinal Fluid Leak Repair: Our Intraoperative and Postoperative Protocol and Long-term Outcomes

Abstract Objective We evaluated the long-term outcomes from a single neurosurgeon and otolaryngologist team using a specific operative protocol for repair and postoperative evaluation. Design The charts of patients undergoing endoscopic endonasal repair of meningoencephaloceles (MECs) and cerebrospinal fluid (CSF) leaks were retrospectively reviewed from 2015 to 2023. Intraoperative steps of the repair and reconstruction were analyzed. Patients' postoperative assessments and complications were analyzed. Setting Loyola University Medical Center's electronic medical record database. Participants Forty-three patients (32 female) aged between 11 and 81 years. Main Outcome Measures Long-term outcomes of patients who underwent endoscopic endonasal repair of MECs and CSF leaks by a single team and protocol. We hypothesized that there would be minimal complications and no recurrences, requiring secondary operation. Results The most common site for MECs was the cribriform plate. Lumbar drain opening pressures ranged from 10 to 35 cm H2O with 18 out of 34 patients having the lumbar drain removed immediately postoperatively. The median hospital stay was 3 days. The average length of follow-up was 3.8 years. No recurrences or secondary operations were noted in all patients. One patient had a sinonasal infection that was successfully treated. Eight patients were noted to have venous stenosis and underwent further evaluation. Conclusion This study represents one of the largest long-term analyses of outcomes by a single team. Our specific protocol for the endoscopic endonasal repair of anterior skull base MECs and CSF leaks is safe and effective. These patients should be evaluated and treated for elevated intracranial pressure following the repair.

Pediatric Congenital Anterior Skull Base Encephaloceles and Surgical Management: A Comparative Review of 22 Patients Treated With Transnasally, Transcranially, or Combined Approach With a Review of the Literature.

Anterior basal encephaloceles are considered a rare entity and are often associated with midline cerebral abnormalities. Those with a large skull base defect and herniation of brain parenchyma in the neonate or young infant present unique challenges for surgical management. We analyzed the neurosurgical administrative and operative databases between 1986 and 2022 to determine clinical presentation, operative approach, and outcome of basal encephaloceles. Over the 36-year period, 27 pediatric anterior basal encephaloceles were managed, of which 22 had full documentation and images allowing comprehensive review. Mean age at presentation was 5 years (SD 4.94). The majority were transethmoidal encephaloceles (59%), followed by the transsphenoidal-sphenoethmoidal type (32%). Overall, 91% were managed surgically by a transcranial, endoscopic, or combined approach. Four children required subsequent procedures, predominantly for persistent cerebrospinal fluid leak. No significant differences in proportion of patients requiring interval/revision surgery after initial conservative, endoscopic endonasal, or transcranial surgery was identified. Neither age at surgery nor size of the defect on computed tomography scan was associated with the need for revision surgery. Size of cranial defect was significantly smaller in the endoscopic group (P = .01). There was a historic tendency for younger children with larger defects to have a transcranial approach. With the addition of endoscopic skull base expertise, smaller defects in older children were more recently treated endoscopically. Basal encephaloceles are rare and complex lesions and are optimally managed within a skull base multidisciplinary team able to provide multiple approaches. Large skull base defects with brain parenchymal involvement often require a transcranial or combined transcranial-endoscopic approach.

Nasosinusal Teratocarcinosarcoma: Case Report and Literature Review

Sinonasal cancers are the most common malignant tumors of the anterior skull base. Teratocarcinosarcomas are extremely unusual malignat tumors involving nasosinusal area, they are characterized by their poor prognosis and high likelihood of recurrence and potentiel intracranial extension. Because of its histological heterogeneity, the diagnosis is very difficult and therefore requires a sufficient sample to avoid erroneous diagnoses. The most commonly used treatment option is radical surgery resection followed by radiotherapy +/- chemotherapy. We report herein the case of 44-year-old woman, presented with sinonasal teratocarcinosarcoma revealed by nasal obstruction and intermittent epistaxis. The diagnosis was confirmed by a histopathological study of surgical specimen. Pre-treatment workup was negative for metastasis disease. She has received adjuvant radiotherapy and chemotherapy after radical endoscopic sinonasal surgery. A follow-up examination at 2 years showed no evidence of recurrence.

Free temporalis muscle fascia graft in dural reconstruction following surgical resection of intermediate and malignant skull base tumors: A 10-year experience from a single center.

Data from patients with post-ablative dural defects reconstructed using a free temporalis muscle fascia graft (FTFG) after resection of anterior or central skull base tumors were retrospectively analyzed. The primary predictor and outcome variables were the reconstructive methods for dural repair and postoperative cerebrospinal fluid (CSF) leakage rate, respectively. Eighty patients were included, and 94 postoperative dural reconstructions were performed using FTFG. The postoperative CSF leakage rate was 3.19%. The postoperative CSF leakage rates did not significantly differ between open and endonasal endoscopic surgeries (1.92% vs. 4.88%; p > 0.05). In cases completed using the endonasal endoscopic approach, the postoperative CSF leakage rate was significantly associated with the intraoperative CSF leak flow (p < 0.05). Post-ablative dural defect reconstruction using FTFG resulted in low postoperative CSF leakage and complication rates comparable to those of free fascia lata graft from available literature.

Endoscopic Repair of Anterior Skull Base Cerebrospinal Fluid Leaks is Successful in Frail Patients.

Surgical frailty estimates a patient's ability to withstand the physiologic stress of an intervention. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair. Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indices, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission. A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average body mass index was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). A total of 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes, surgical outcomes, or readmission (all p > 0.05). Endoscopic CSF leak repair in a frail population, including lumbar drain placement and bed rest, was not associated with an increased rate of complications. Previous data suggests increased complications in open craniotomy procedures in patients with significant comorbidities. This study suggests that the endoscopic approach to CSF leak repair is well tolerated in the frail population. IV Laryngoscope, 2024.

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.

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.

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.

Endoscopic endonasal decompression of the optic nerve in the setting of compressive lesions: how I do it.

Many lesions in the anterior skull base may compress the optic nerve (ON), leading to vision loss, and even irreversible blindness. Although decompression of the optic nerve has traditionally been achieved transcranially, the endoscopic endonasal approach (EEA) is gaining traction as a minimally invasive approach recently. We describe the key steps of an EEA ON decompression. The relevant surgical anatomy with illustration is described. Additionally, a video detailing our technique and instruments on an illustrative case is provided. Endoscopic endonasal approach ON decompression with a straight feather blade is a feasible, minimally invasive procedure to decompress the ON in the setting of anterior skull base mass lesions.

The Effects of Nasal Septal Deviation on Anterior Skull Base Parameters

Abstract Introduction Functional endoscopic sinus surgery and endoscopic skull base surgery are frequently performed surgeries today. Nasal septal deviation is a common finding and can affect the surgical area. Therefore, it is important to examine the effect of this deviation on other anatomical structures. Objectıve The aim of the present study was to determine whether there is a relationship between the degree of nasal septal deviation and anterior skull base structures using computed tomography (CT). Methods A total of 312 patients (aged 18 to 65 years old) whose paranasal sinus CT images were available were included in the study. Measurements were obtained on images retrieved from Picture Archiving and Communication System (PACS) and Horos image archive systems in the bone window in the coronal and axial plane. Results The mean age of 312 patients was 33.00 years old (standard deviation [SD] 11.22 years). The presence of septal deviation was not associated with changes in olfactory fossa (OF) depths, Keros degrees, and the angle between the lateral lamella and the cribriform lamella. However, OF depths and Keros degrees on the deviated side of the septum were found to change at a significant level (p &lt; 0.05). No significant association was observed between the degree of septal deviation and cribriform lamella-lateral lamella angle. Conclusion The study showed significantly increased OF depth and Keros degree on the deviated side of the nasal septum. Performing CT scans before endoscopic sinus surgery and endoscopic skull base surgery is important to increase the chances of a successful surgical outcome and to reduce complications.

Surgical Navigation in the Anterior Skull Base Using 3-Dimensional Endoscopy and Surface Reconstruction

Image guidance is an important adjunct for endoscopic sinus and skull base surgery. However, current systems require bulky external tracking equipment, and their use can interrupt efficient surgical workflow. To evaluate a trackerless surgical navigation system using 3-dimensional (3D) endoscopy and simultaneous localization and mapping (SLAM) algorithms in the anterior skull base. This interventional deceased donor cohort study and retrospective clinical case study was conducted at a tertiary academic medical center with human deceased donor specimens and a patient with anterior skull base pathology. Participants underwent endoscopic endonasal transsphenoidal dissection and surface model reconstruction from stereoscopic video with registration to volumetric models segmented from computed tomography (CT) and magnetic resonance imaging. To assess the fidelity of surface model reconstruction and accuracy of surgical navigation and surface-CT model coregistration, 3 metrics were calculated: reconstruction error, registration error, and localization error. In deceased donor models (n = 9), high-fidelity surface models of the posterior wall of the sphenoid sinus were reconstructed from stereoscopic video and coregistered to corresponding volumetric CT models. The mean (SD; range) reconstruction, registration, and localization errors were 0.60 (0.24; 0.36-0.93), 1.11 (0.49; 0.71-1.56) and 1.01 (0.17; 0.78-1.25) mm, respectively. In a clinical case study of a patient who underwent a 3D endoscopic endonasal transsphenoidal resection of a tubercular meningioma, a high-fidelity surface model of the posterior wall of the sphenoid was reconstructed from intraoperative stereoscopic video and coregistered to a volumetric preoperative fused CT magnetic resonance imaging model with a root-mean-square error of 1.38 mm. The results of this study suggest that SLAM algorithm-based endoscopic endonasal surgery navigation is a novel, accurate, and trackerless approach to surgical navigation that uses 3D endoscopy and SLAM-based algorithms in lieu of conventional optical or electromagnetic tracking. While multiple challenges remain before clinical readiness, a SLAM algorithm-based endoscopic endonasal surgery navigation system has the potential to improve surgical efficiency, economy of motion, and safety.

Combined simultaneous endoscopic endonasal and transcranial surgery using high-definition three-dimensional exoscope for malignant tumors of the anterior skull base.

Advanced surgical interventions are required to treat malignancies in the anterior skull base (ASB). This study investigates the utility of endoscopic endonasal and transcranial surgery (EETS) using a high-definition three-dimensional exoscope as an alternative to traditional microscopy. Six patients with carcinomas of varying histopathologies underwent surgery employing the EETS maneuver, which synchronized three distinct surgical modalities: harvesting of the anterolateral thigh flap, initiation of the transnasal technique, and initiation of the transcranial procedure. The innovative strategy enabled successful tumor resection and skull base reconstruction without postoperative local neoplastic recurrence, cerebrospinal fluid leakage, or neurological deficits. The integration of the exoscope and EETS is a novel therapeutic approach for ASB malignancies. This strategy demonstrates the potential of the exoscope in augmenting surgical visualization, enhancing ergonomics, and achieving seamless alignment of multiple surgical interventions. This technique represents a progressive shift in the management of these complex oncological challenges.

Utilization of Polydioxanone Plate for Endoscopic Anterior Skull Base Repair: Operative Technique and Long-Term Cohort Outcomes

Abstract Objective The purpose of this study is to report the technical procedure and our experience using a polydioxanone suture (PDS) plate with dural substitute as part of a fully resorbable gasket seal technique to repair anterior skull base defects. Methods A series of patients undergoing anterior skull base reconstruction utilizing our resorbable gasket seal technique from January 2014 to July 2022 was reviewed. Results A total of 155 patients were included. Nine (5.8%) of the included patients developed postoperative cerebrospinal fluid (CSF) leaks requiring reoperation. There were no cases of intraoperative cranial nerve injury or internal carotid artery injury. A total of 103 (66.5%) patients were observed to have an intraoperative CSF leak, including 57 low-flow leaks and 46 high-flow leaks; 1 of 57 (1.8%) patients with low-flow leaks and 8 of 46 (17.4%) patients with high-flow leaks developed a postoperative CSF leak. During the first 3 years that this technique was utilized at our center for the management of high-flow intraoperative CSF leaks, postoperative CSF leaks were documented in 4 of 12 (33.3%) patients, in comparison to 4 of 34 (11.8%) in the following years. Conclusion PDS plate reconstruction confers several advantages and can be used in a diverse set of operative scenarios in conjunction with other reconstruction options. There appeared to be an associated learning curve as surgeons at our center gained experience with this new technique. Our findings show that the PDS plate reconstruction is safe and effective in repairing the skull base.

“Sandwich” Structure in Reconstruction of Traumatic Comminuted Anterior Skull Base Fractures: Surgical Technique and Outcomes

PurposeComminuted fractures of the anterior skull base can easily cause dural damage, leading to cerebrospinal fluid leakage and retrograde infection. Skull base reconstruction is essential. This study aimed to present a novel and simple technique for repairing skull base defects using a self-made fascia-bone fragments-fascia “sandwich” structure made by fascia, fracture fragments, and sutures. MethodFrom 2018 to 2023, we performed self-made sandwich structures for skull reconstruction in 10 patients with anterior skull base comminuted fractures. After debridement, the intracranial bone fragments of the surgical patient were safely removed. In vitro, the bone fragments were spread between two layers of temporal or broad fascia to form a sandwich structure similar to the size of the bone defect, and the periphery was firmly sutured with sutures. The self-made structure was then filled to the defect and fixed with fibrin glue. The periosteum at the top of the forehead was also turned over to the repair area for covering and fixation. Meanwhile, a facial skin cosmetic suture was performed. Finally, we evaluate the feasibility and efficacy of this technique. ResultsAll 10 patients underwent reconstructive surgery using the self-made fascia-fracture fragments-fascia sandwich structure. Five patients with open wounds on the face also underwent cosmetic revisions. No cerebrospinal fluid leakage occurred in all the patients at discharge as well as 3 months later. ConclusionFor patients with comminuted fracture of the anterior skull base, the fascia-bone fragments-fascia structure could repair the skull base and prevent the occurrence of cerebrospinal fluid.

Variations in the genomic profiles and clinical behavior of meningioma by racial and ethnic group.

The influence of socioeconomic factors on racial disparities among patients with sporadic meningiomas is well established, yet other potential causative factors warrant further exploration. The authors of this study aimed to determine whether there is significant variation in the genomic profile of meningiomas among patients of different races and ethnicities and its correlation with clinical outcomes. The demographic, genomic, and clinical data of patients aged 18 years and older who had undergone surgery for sporadic meningioma between September 2008 and November 2021 were analyzed. Statistical analyses were performed to detect differences across all racial/ethnic groups, as were direct comparisons between Black and non-Black groups plus Hispanic and non-Hispanic groups. This study included 460 patients with intracranial meningioma. Hispanic patients were significantly younger at surgery (53.9 vs 60.2 years, p = 0.0006) and more likely to show symptoms. Black patients had a higher incidence of anterior skull base tumors (OR 3.2, 95% CI 1.7-6.3, p = 0.0008) and somatic hedgehog mutations (OR 5.3, 95% CI 1.6-16.6, p = 0.003). Hispanics were less likely to exhibit the aggressive genomic characteristic of chromosome 1p deletion (OR 0.28, 95% CI 0.07-1.2, p = 0.06) and displayed higher rates of TRAF7 somatic driver mutations (OR 2.96 95% CI 1.1-7.8, p = 0.036). Black patients had higher rates of recurrence (OR 2.6, 95% CI 1.3-5.2, p = 0.009) and shorter progression-free survival (PFS; HR 2.9, 95% CI 1.6-5.4, p = 0.002) despite extents of resection (EORs) similar to those of non-Black patients (p = 0.745). No significant differences in overall survival were observed among groups. Despite similar EORs, Black patients had worse clinical outcomes following meningioma resection, characterized by a higher prevalence of somatic hedgehog mutations, increased recurrence rates, and shorter PFS. Meanwhile, Hispanic patients had less aggressive meningiomas, a predisposition for TRAF7 mutations, and no difference in PFS. These findings could inform the care and treatment strategies for meningiomas, and they establish the foundation for future studies focusing on the genomic origins of these observed differences.

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.

Herbst Appliance for Adolescent Angle Class II Division 1 Malocclusion Long-Term Stability: A Systematic Reviews and Meta-Analysis

Objective: To conduct a systematic and comprehensive literature search to systematically evaluate and meta-analysis the long-term stability of treatment results obtained after treatment with Herbst functional appliance, and to provide scientific evidence. Methods: CNKI, WANFANG, CBM, VIP, PubMed, Embase, The Cochrane Library and other literature databases were searched as comprehensively as possible. The two groups of researchers formulated inclusion criteria and exclusion criteria according to PICOS principles, screened literature, extracted data, and evaluated the quality of the selected literature according to the MINORS evaluation table. Meta-analysis was performed using data extracted from Review Manager 5.3 software. Results: A total of 12 literatures were included, with a total sample size of 490 cases. The long-term stability of Herbst appliance was analyzed by 11 indexes of SNA, SNB, ANB, ANS-PNS/SN, MP/SN, ANS-PNS/MP, OB, OJ, U1/ANS-PNS, L1/MP, U1/L1. The results showed that SNA, SNB, ANB, ANS-PNS/SN, U1/ANS-PNS, L1/MP, molar relationships were stable in the long run from the end of treatment to follow-up (P&gt;0.05). The MP/SN, ANS-PNS/MP angles decrease, and the OB, OJ, and U1/L1 values increase (P&lt;0.05). Conclusion: The long-term stability of the treatment effect of Herbst orthoses in the adolescent patients classified as Class II division 1 shows that the relative position of the upper and lower jaws is relatively stable, while the Angle of the mandibular plane relative to the anterior skull base plane remains relatively unstable.