Basal Interhemispheric Approach Research Articles

Basal interhemispheric approach for sellar and juxta-sellar lesions

BackgroundSellar and juxta-sellar lesions represent a surgical challenge due their deep and complex relationships to surrounding important neurovascular structures. The basal interhemispheric (BIH) approach, as a midline approach, has an advantage over the lateral approaches as it allows for the safe removal of these challenging tumors.AimTo describe the technique of BIH approach in a prospective cohort of 17 patients with sellar and juxta-sellar lesions with different pathologies presented to Alexandria Main University and affiliated hospitals. As well as the clinical outcome and complications of this technique, these cases were followed up for a mean period of 20 weeks.ResultsGross total resection was achieved in 9 cases (52.9%), subtotal resection was achieved in 5 cases (29.5%), while partial resection was carried out in 3 cases (17.6%). Visual status improved following surgery in 10 patients (58.8%), remained stationary in 5 patients (29.4%) and worsened in 2 cases. Post-operative shunt was needed in three cases, and severe water and electrolyte disturbance was recorded in 3 cases and pan-hypopituitarism in a single case. A single mortality was recorded, but it was due to pulmonary embolism and was not related to the approach.ConclusionBIH could be a panoramic safe approach that allows tumor removal from multiple corridors with identification of the regional anatomy of the tumor thus elaborating the surgical strategy for gross total tumor removal.

Aggressive resection of craniopharyngioma achieved by drilling the tuberculum sellae/planum sphenoidale using a frontal basal interhemispheric approach: A review of 55 cases

ObjectiveThe frontal basal interhemispheric approach (FBIA) is preferable for resection of craniopharyngioma (CP), achieving desirable total resection rates in early reports of lesions located in the suprasellar region to the third ventricle. For tumours that have created a larger obstruction of the tuberculum sellae and planum sphenoidale, aggressive resection in the intrasellar region and medial wall of the cavernous sinus is not feasible compared to improving tumour visualization by drilling the tuberculum sellae and planum sphenoidale. In a report of drilling the sellar tuberculum and sphenoid planum, drilling allowed the direct visualization of tumours invading the intrasellar region and medial wall of the cavernous sinus. Reconstructing the opening of the sellar-sphenoid cavity is achieved by microsuturing a piece of the pericranium/dura around the dural edge of the defective dura of the open sphenoid sinus and sellar cavity to prevent cerebrospinal fluid (CSF) leakage. Patients and methodsThe FBIA with drilling of the tuberculum sellae and planum sphenoidale was performed to remove the tumours that invaded the intrasellar region and cavernous sinus in 55 patients from January 2014 to October 2019 at our institution. The pre- and postoperative pituitary hormone levels and vision were evaluated as effective standards after surgery and compared using paired t-tests. The different rates of CSF leakage between the packing and microsuture groups were compared by χ2 test, p < 0.05. ResultsIn all patients with a mean 37-month follow-up (range, 3–2 months), 43 (78.2%) patients returned to their normal life or school independently, 7 (12.7%) patients were able to perform normal activities with minor complaints or effort, and 4 (7.3%) patients could care for themselves or only required occasional assistance. One (1.8%) death occurred, attributed to CSF leak-related meningitis at 5 months after surgery. Postoperative CSF leakage occurred in eight (19.0%) of 42 patients with packed bone wax or pieces of muscle to the sphenoid sinus. Of 13 patients with a piece of the periosteum/dura microsutured around the defective dura of the sellar region and open sphenoid sinus, one (7.7%) of 13 patients experienced CSF leakage in the perioperative period. With statistical analysis, there was a potential risk for postoperative CSF leakage in the bone wax and muscle piece in the open sphenoid sinus, whereas microsuture manoeuvres were effective for avoiding the risk of postoperative CSF leakage (χ2 = 8.865, p < 0.005). The microsutures closed the open sphenoid sinus such that it was water-tight. Postoperative visual acuity and the visual field were not affected by the increased intrasellar exposure or the open sphenoid sinus achieved by drilling the tuberculum sellae and planum sphenoidale. ConclusionTuberculum sellae/planum sphenoidale drilling via FBIA is feasible to enhance the direct visualization of CP resection, which expands the intrasellar region with a direct resection of recurrent tumours in the sellar cavity and adhering to the medial wall of the cavernous sinus. The potential risk of a CSF leakage seemed to be mitigated when using water-tight microsutures on a piece of the pericranium/dura around the edge of the defective dura in the sellar region and the open sphenoid sinus cavity.

Classification of crista galli pneumatization and clinical considerations for anterior skull base surgery

Cerebrospinal fluid (CSF) leakage caused by frontal sinus exposure is a serious complication in the basal interhemispheric approach (BIHA). Crista galli pneumatization (CGP) is often observed on preoperative computed tomography (CT) scan. The aim of this study was to classify and describe variations in anatomical measurements of CGP. We examined CT images of 300 patients with brain tumors to assess the morphology and incidence of CGP. Crista galli were classified according to their location relative to the cribriform plate and the presence of pneumatization. The paranasal sinuses were investigated as the origin of CGP. We assessed 24 patients using the BIHA for skull base tumors; these patients were included as clinical cases to assess the range of skeletonization of the crista galli and determine the route of CSF leakage in the other 276 patients. CGP was found in 28/300 CT scans, including upper, middle, and lower type CGPs. The origin of CGPs was the frontal sinus or ethmoid sinus. All CGPs were localized in the anterior half of the crista galli. In the 24 consecutive clinical cases, there were 13 tuberculum sellae meningiomas, 3 craniopharyngiomas, and 8 with other pathologies. The preoperative crista galli height was 12.3 mm and the distance from the top of the skeletonization to the cribriform plate was 5.2 mm. CGP originating from the paranasal sinuses can lead to CSF leakage. In cases where CGP originates from the ethmoid sinus, care should be taken to seal the exposed crista galli intradurally.

Anterior Interhemispheric Approach in Craniopharyngiomas : Personal Experience of Operative Technique and Results

Introduction: Removal of intracranial supra-sellar masses continues to be a surgical challenge. Various approaches have been used by different authors with varying results. Anterior basal interhemispheric approach is most suitable with better results than other approaches for craniopharyngiomas&#x0D; Materials and methods: Fifteen patients with large craniopharyngiomas having third ventricular and or retro or supra-sellar extensions or reaching the interpeduncular cisterns were operated by this approach, over a period of seven years since the first use of this approach at our institute. The data of patients opearated by this approach were then retrospectively analysed. There were eleven males and four females with five patients in the pediatric age group. Follow up range was from 2 to 83 months with a mean of 21.6 months.&#x0D; Results: Total excision was achieved in seven (46.6%) and near total excision in another seven (46.6%), partial excision was done in only one (6.66%). Seven patients with total excision were disease free at mean follow up of 6.8 months. There was asymptomatic recurrence in two (13.33%) patient with near total excision at 11 and 63 months respectively and were given radiotherapy post-operatively. All patients were symptom free except one with diabetes insipidus (DI) and one mortality, and one with post operative visual deterioration.&#x0D; Conclusion: Anterior basal interhemispheric approach is a useful alternative to other transcranial approaches in the management of the craniopharyngiomas. It has the advantage of being a midline approach and displays the tumour brain interface better.

Anterior communicating artery division in the endoscopic endonasal translamina terminalis approach to the third ventricle: an anatomical feasibility study.

Endonasal endoscopic approaches (EEA) to the third ventricle are well described but generally use an infrachiasmatic route since the suprachiasmatic translamina terminalis corridor is blocked by the anterior communicating artery (AComA). The bifrontal basal interhemispheric translamina terminalis approach has been facilitated with transection of the AComA. The aim of the study is to describe the anatomical feasibility and limitations of the EEA translamina terminalis approach to the third ventricle augmented with AComA surgical ligation. Endoscopic dissections were performed on five cadaveric heads injected with colored latex using rod lens endoscopes attached to a high-definition camera and a digital video recorder system. A stepwise anatomical dissection of the endoscopic endonasal transtuberculum, transplanum, translamina terminalis approach to the third ventricle was performed. Measurements were performed before and after AComA elevation and transection using a millimeter flexible caliper. Multiple comparison statistical analysis revealed a statistically significant difference in vertical exposure between the control condition and after AComA elevation, between the control condition and after AComA division and between the AComA elevation and division (p < 0.05). The mean difference in exposed surgical area was statistically significant between the control and after AComA division and between elevation and AComA division (p < 0.01), whereas it was not statistically significant between the control condition and AComA elevation (NS). The anatomical feasibility of clipping and dividing the AComA through an EEA has been demonstrated in all the cadaveric specimens. The approach facilitates exposure of the suprachiasmatic optic recess within the third ventricle that may be a blind spot during an infrachiasmatic approach.

Outcome of Radical Surgical Resection for Craniopharyngioma with Hypothalamic Preservation: A Single-Center Retrospective Study of 1054 Patients.

A retrospective review of the surgical outcome for patients with craniopharyngioma (CP) treated in a single neurosurgical center with surgical resection using visualization to ensure hypothalamic preservation. The study included 1054 patients. Before 2003, a pterional cranial approach was preferred for 78% of patients; after 2004, the unifrontal basal interhemispheric approach was performed in 79.1% of patients. Complete tumor resection was achieved in 89.6% of patients; vision improved in 47.1% of patients who had preoperative vision impairment. However, diabetes insipidus worsened in 70.4% of patients and new-onset diabetes insipidus occurred in 29.7% of the remaining patients. Pituitary stalk preservation occurred in 48.9% of cases. There were 89.6% of patients with total tumor removal; 13.3% of patients showed tumor recurrence within an average of 2.8 years. Of 69 follow-up patients with a subtotal or partial resection, 94.2% showed tumor recurrence within an average of 4.3 months. Of the total patients, 82.3% fully recovered. This study has shown that radical surgical resection of CP using microsurgical excision can be effective with a good patient outcome without more limitations on each individual tumor of distinct features despite the impact of recent endoscopic techniques on CP surgery. The surgical approach depends on a direct and wider visualization of CP located in the midline with preserving hypothalamic structures by identifying some hypothalamic landmark structures. After surgery, most patients can resume their normal activities even after aggressive tumor removal, although patients require postoperative hormonal replacement.

Predicting the necessity of anterior communicating artery division in the bifrontal basal interhemispheric approach.

BackgroundThe anterior communicating artery (ACoA) often limits surgical exposure in the anterior interhemispheric approach. Although division of the ACoA has been proposed occasionally, it is rarely practiced, and criteria for such a surgical maneuver remain unknown. Our purpose was to identify key factors that allow for predicting the necessity of controlled ACoA division in the bifrontal basal interhemispheric approach.MethodTwenty-two consecutive patients who underwent surgery via the bifrontal basal interhemispheric approach for removal of various pathologic brain lesions were examined. First, tumors were dichotomized into central and lateral lesions. Next, three tumor parameters were compared between cases with and without ACoA division in each, the central and lateral lesion groups, respectively: tumor volume, tumor depth (defined as distance between the ACoA and posterior tumor margin) and tumor laterality angle (defined as the geometric angle between the lateral tumor margin and sagittal midline).ResultsTumor volume was not related in a statistically significant manner to ACoA division in both the central (P = 0.06) and lateral (P = 0.13) lesion groups, respectively. However, tumor depth was significantly correlated with ACoA division in the central lesion group (P = 0.01), whereas in the lateral lesion group, the tumor laterality angle showed a significant correlation with ACoA division (P = 0.04).ConclusionsOur results suggest that controlled ACoA division may be required in central lesions with a depth of 38 mm or more and in lateral lesions with an angle of 23 degrees or more as defined in this study. Two key factors were thus identified that may predict the necessity of controlled ACoA division before surgery.

A Unilateral Subfrontal Basal Interhemispheric Approach to Large Craniopharyngiomas

Objective: We report our experience with a unilateral subfrontal basal interhemispheric approach for large craniopharyngiomas that extend into the third ventricle and basal or prepontine cistern. Clinical Materials and Methods: Thirty-two patients were operated on using a unilateral subfrontal basal interhemispheric approach. We analyzed the outcomes of all patients at discharge and at 6 months postoperation and classified these patients according to the Glasgow outcome scale (GOS) score. Results: Twenty-nine (90.1%) patients gained a GOS score of 5 at discharge, and 3 patients (9.4%) gained a GOS score of 4. During the follow-up at 6 months, 31 (96.9%) patients gained a GOS score of 5, and 1 patient (3.1%) gained a GOS score of 4. Total removal of the lesion was achieved in 25 (78.1%) cases, 7 (21.2%) patients underwent subtotal resection. Preservation of the pituitary stalk was possible in 18 (56.3%) cases, severed in 12 (18.3%), and unidentified in 2 (20.7%). In our series, there were no procedure-related complications, such as frontal lobe contusion, a cerebrospinal fluid leak, or bacterial meningitis. No mortalities resulted from the approach. The olfactory nerves were preserved well. After surgery, transient panhypopituitarism developed in 22 patients (68.8%) but resolved within 2 weeks. In 6 of them there was persistent panhypopituitarism during the follow-up at 6 months. Transient diabetes insipidus developed in 23 (71.9%) patients but resolved within 1 month. Permanent postoperative diabetes insipidus was present in 9 (28.1%) patients during the follow-up at 6 months. Visual impairment was found in 10 patients before surgery; in 7 of them there was postoperative visual deterioration. Among the 7 patients, 5 had partial recovery before discharge and 3 patients had recovery during the follow-up at 6 months. Conclusions: The present results suggest that the unilateral subfrontal basal interhemispheric approach provides direct and wide exposure of large craniopharyngiomas. Anatomic preservation of the pituitary stalk, hypothalamic structure, perforating vessels, anterior communicating complex, the visual pathway, and the olfactory nerves is often possible.

Indication and Limitations of Endoscopic Extended Transsphenoidal Surgery for Craniopharyngioma

The transsphenoidal approach has been utilized in intrasellar craniopharyngioma surgeries. However, the advent of endoscopic extended transsphenoidal approach (EETSA) has expanded its indication to suprasellar craniopharyngiomas. We compared the indication and limitations of EETSA to those of uni-lateral basal interhemispheric approach (UBIHA), which presents similar indications for surgery. We analyzed 30 patients with tumors located below the foramen of Monro and the lateral boundary extending slightly beyond the internal carotid artery (UBIHA: N = 18; EETSA: N = 12). Postoperative magnetic resonance imaging (MRI) revealed gross total resection in 10 patients in the EETSA group (83.3%) and 12 in the UBIHA group (66.7%). Postoperative MRI in the EETSA group revealed residual tumor at the cavernous sinus in one patient, at the prepontine in one; in the UBIHA group, residual tumors were located in the retrochiasmatic area in two patients, infundibulum-hypothalamus in one, on the stalk in one, and in the intrasellar region in two. No intergroup differences were observed in the preservation of pituitary function and postoperative improvement of visual function. The extent of resection was better with EETSA than with UBIHA. EETSA is considered the first-line therapy because the distance between the optic chiasm and the superior border of the pituitary is large; the lateral extension does not go beyond the internal carotid artery; and the tumor does not extend inferiorly beyond the posterior clinoid process. However, in patients showing poorly developed sphenoid sinuses or pituitary stalks anterior to the tumor, surgery is difficult regardless of the selection criteria.

Bifrontal basal interhemispheric approach for midline suprasellar tumors: Our experience with forty-eight patients

Suprasellar lesions present a surgical challenge due to their complex relationship with surrounding neurovascular structures. Of the approaches for these lesions, bifrontal basal interhemispheric approach (BBIA) gives a midline perspective of suprasellar anatomy and has certain advantages over lateral approaches. We retrospectively reviewed 48 patients with suprasellar lesions operated over 7 years via BBIA. Patient records, operation notes, radiology, and outpatient files were scrutinized to collect data. During the study period 48 patients (mean age 33 years, M:F 1.5:1) were operated by this approach. The clinical features included: Visual field deficits in 33 (69%) patients, with 6 of them being blind, diabetes insipidus in 7, growth retardation in 5, and subarachnoid hemorrhage in three patients. Cranopharyngiomas (52%) and meningiomas (16.7%) were the most common pathologies. Dyselectrolytemia (18, 40%) and diabetes insipidus (15, 33%) were the most common complications. Postoperative seizures, meningitis, subdural effusion, and retraction site contusion were seen in 12 (27%), 5 (11%), 4 (9%), and 1 (2.2%) patient, respectively. Three patients died postoperatively and 19 (40%) patients required hormone replacement therapy. Amongst the patients with preoperative visual deficits, 23 (70%) had improvement in visual functions, in six (20%), there was no change and four (8.3%) patients had visual deterioration. BBIA provides a true midline perspective and orientation, and permits complete and safe removal of midline suprasellar lesions in majority of cases. This approach is especially useful in retrochiasmatic tumors and in residual/recurrent tumors providing virgin plane of dissection.

Comparison of Outcomes for Anterior Communicating Artery Aneurysms Clipped Via a Basal Interhemispheric Approach vs. a Pterional Approach

Introduction: Many approaches for clipping anterior communicating (ACom) artery aneurysms are described in the literature, but controversy remains over the best technique. These techniques can be best divided into lateral (pterional) or interhemispheric. Although the interhemispheric technique has not gained generalized acceptance, we compare our experience between the basal interhemispheric approach and the pterional approach to clipping ACom aneurysms.

前交通動脈瘤に隣接した破裂末梢性前大脳動脈瘤の1手術例

We present a rare case with a ruptured aneurysm of a distal anterior cerebral artery that was adjacent to an anterior communicating artery aneurysm. A 59-year-old male suddenly developed headache and dizziness, and was conveyed to our hospital. Plain CT scans revealed subarachnoid hemorrhage and intracerebral hematoma that was distributed in the right frontal lobe. CT-angiography demonstrated two aneurysms. One was found at A2 segment of right anterior cerebral artery, and the other was found at the anterior communicating artery. The aneurysms came in contact with each other. Because anterior cerebral artery aneurysm had a broad based neck, neck clipping of both aneurysms was performed. It is important to get the A1 segment of proximal to both aneurysms in this case, so we chose a basal interhemispheric approach. This approach provides a wide operative view that improves surgical safety. The postoperative course was uneventful. In this paper, we discuss the strategy of adjacent aneurysms between the distal anterior cerebral artery and anterior communicating artery.

Rare primary tumours of the hypothalamus in adults: clinical course and surgical treatment

Background and purposeThe paper presents the operative technique and the results of treatment of adult patients with primary tumours of the hypothalamus, including rare ones. The aim of the study was to show the possibility of safe surgical treatment of rare tumours of the hypothalamus through a bifrontal basal interhemispheric trans-lamina terminalis approach. Material and methodsFive patients with tumours of the hypothalamus were operated on in the Neurosurgical Clinic in Sosnowiec between 1990 and 2008. There were 2 patients with craniopharyngiomas located exclusively in the third ventricle, and single patients with gemistocytic astrocytoma, Langerhans cell histiocytosis X and hamartoma of the hypothalamus each. The patients were treated surgically with a bifrontal basal interhemispheric trans-lamina terminalis approach. In two cases, the neuronavigation system with the use of tractography (DTI) was used to determine the location of the lamina terminalis, the posterior surface of the optic chiasm and the optic tracts. ResultsAll lesions were resected totally, except for partially resected hamartoma of the hypothalamus. The most common postoperative complication was diabetes insipidus, which was transient in two cases. A long-lasting follow-up of all the patients operated on did not reveal regrowth of the lesion. ConclusionsThe bifrontal basal interhemispheric trans-lamina terminalis approach allows for radical resection of primary tumours of the hypothalamus while avoiding serious postoperative deficits. This approach enabled the preservation of the olfactory bulb and tract and prevented damage of the frontal lobes. The use of DTI helped to establish the location and borders of the lamina terminalis, to establish the posterior surface of the optic chiasm and the optic tracts, and to save the anterior and lateral wall of the hypothalamus.

Osteochondroma of the Sella Turcica Presenting With Intratumoral Hemorrhage -Case Report-

A 29-year-old man presented with a primary sellar turcica osteochondroma manifesting as intratumoral hemorrhage mimicking pituitary apoplexy. The patient suffered sudden onset of headache concomitant with vision loss in the left eye. Radiography and computed tomography detected destruction and calcification of the sellar turcica. Magnetic resonance imaging revealed a heterogeneously enhanced suprasellar mass that had elevated and compressed the optic chiasm. The preoperative diagnosis was hemorrhagic pituitary adenoma, craniopharyngioma, meningioma, or chordoma based on the signal heterogeneity of the lesion. To relieve the symptoms and make a definitive diagnosis, surgical removal via a basal interhemispheric approach was carried out. The tumor was not totally removed because of tight adhesion to the pituitary stalk, but postoperative ophthalmological examination revealed improvement of the visual disturbance. The histological diagnosis was osteochondroma based on the presence of mature chondrocytes and osteomatous tissue. Osteochondroma should be included in the differential diagnosis of tumors with acute hemorrhage in the sella turcica.

Chordoid glioma with calcification and neurofilament expression: case report and review of the literature

Background Chordoid glioma of the third ventricle is a rare type of brain tumor that was recently categorized as a novel tumor entity. Despite low-grade histologic features, the clinical outcome in reported cases was poor. Case Description A 61-year-old woman presented to our institution with a history of syncope. On presentation, she was alert and oriented, and her systemic examination was unremarkable. Computed tomographic scan showed a well-circumscribed, slightly hyperdense mass with calcification and a cystic component in the anterior part of the third ventricle. The mass was homogenously enhancing after the intravenous administration of contrast material, and its maximum diameter was 3.5 cm. The preoperative diagnosis was craniopharyngioma. Because the tumor seemed to invade the hypothalamus bilaterally, the operative plan was to reduce the tumor volume, followed by radiosurgery. The patient underwent partial removal of the tumor via a bifrontal basal interhemispheric approach. The histologic and immunohistochemical findings indicated CG. Surprisingly, tumor cells showed NFP expression. The residual tumor was treated by GKRS and showed no regrowth at 1-year follow-up. Conclusions Chordoid glioma is considered a glial neoplasm with distinct morphological and clinicopathologic features, but there may also be other unknown characteristics because of its rarity. To the best of our knowledge, this is the second reported case of CG with calcification and, at the same time, the second case with NFP expression in the English literature. Calcification and expression of NFP should not exclude CG in the differential diagnosis of a third ventricular tumor. The authors also suggest that the combination of microsurgery and GKRS is a safe and effective treatment strategy for CG.

Ｂａｓａｌ ｉｎｔｅｒｈｅｍｉｓｐｈｅｒｉｃ ａｐｐｒｏａｃｈにおける大脳半球間裂剥離のトレーニング―レジデントが陥る軟膜損傷のパターンとその対策―

Dissection of the interhemispheric fissure via a basal interhemispheric approach (BIHA) is one of the most difficult skills for young neurosurgeons to acquire. We reviewed operative videos of 30 BIHAs performed by 4 residents in our institute, and investigated how the pia mater or pial capillary vessels were injured. Furthermore, after comparing these procedures with those of senior neurosurgeons in our institute, we discussed factors causing injury of the pia mater or pial capillary vessels and effective remedies to improve skills. As a result, causes of pial injury were roughly divisible into 3 types: microscissor problems; excessive tension on trabecullae; and inappropriate hemostatic technique. Learning the transformation of the interhemispheric fissure accompanying cerebrospinal fluid decreases and the anatomical characteristics of interhemispheric fissure is important for acquiring appropriate brain retraction. Training to find trabecullae to be cut in the narrow microsurgical field is also an important skill to acquire for BIHA.

3.前交通動脈瘤に対するbasal interhemispheric approach(MS-1 脳動脈瘤クリッピングの基本手技,モーニングセミナー,第26回 日本脳神経外科コングレス総会)

3.前交通動脈瘤に対するbasal interhemispheric approach(MS-1 脳動脈瘤クリッピングの基本手技,モーニングセミナー,第26回 日本脳神経外科コングレス総会)

Surgical management of the recurrence and regrowth of craniopharyngiomas

The authors performed a retrospective analysis of a consecutive series of craniopharyngiomas and their recurrences, which were managed with surgery alone. In the past 20 years, 37 consecutive patients with craniopharyngiomas underwent surgery without adjuvant radiotherapy. During that period there was a consistent strategy that surgical management was the first choice of treatment whenever possible. Of these 37 patients, 11 experienced tumor recurrence (29.7%) during the mean follow-up period of 11.1 years. Of these 11 patients, seven experienced recurrence after neuroimaging-confirmed total removal, and four patients experienced recurrence after partial or incomplete removal. In these 11 patients, surgical removal was performed 17 times. Using a proper surgical approach (mainly a basal interhemispheric approach) and meticulous microsurgical techniques, total removal of the recurrent tumor was achieved in nine surgeries (52.9). The mortality and morbidity rates associated with these 17 surgeries were 0% and 9.1%, respectively. In most cases, visual function was preserved or improved and intellectual performance was also preserved. Recurrence of craniopharyngioma can be safely managed by using meticulous contemporary microsurgical techniques without additional radiotherapy. The role of surgery and adjuvant radiotherapy for craniopharyngiomas may vary in the future, depending on innovations in treatment and technology. Nevertheless, surgery can be still a major therapeutic option in the management of recurrent craniopharyngiomas.

Role of bifrontal basal interhemispheric approach in recurrent suprasellar tumors; craniopharyngioma and pituitary tumors

Recurrent suprasellar tumors, including craniopharyngiomas and pituitary tumors, can be approached with minimal brain retraction, a wider operative field with better orientation and a good view of important neurovascular structures via a bifrontal basal interhemispheric approach (BFBIHA). The authors present their experience of using BFBIHA for removal of recurrent suprasellar tumors, during which they recorded the size and location of each tumor and the degree of tumor extension. Two hundred fifty-four cases of pituitary tumors and 80 cases of craniopharyngiomas were operated on. Recurrent cases were 25 (9.8%) in pituitary tumors and 14 (17.5%) in craniopharyngiomas. Among recurrent cases, nine patients (five recurrent pituitary tumors, four recurrent craniopharyngiomas) were included. Preoperatively, suprasellar extension of the tumors was measured with the aid of radiological images (MRI, MRA, CT). Using line C (mid-sella), the tumors were divided into three groups according to the direction of tumor growth. Group I (one case) contained those with a prechiasmatic location, group II (two cases), those with a suprasellar location, and group III (five cases), those with a retrochiasmatic location. All of the recurrent patients underwent operations by the same approach. All tumors but one were totally resected. There was no operative mortality. In our experience, recurrent suprasellar tumors were safely manipulated with this BFBIHA, preserving important neurovascular structures and hypothalamo–pituitary functions.

Simple reconstruction of frontal sinus opened during craniotomy using small autogenous bone piece: Technical note

Background Accidental opening of the frontal sinuses during craniotomy can lead to various postoperative complications. We report a simple and reliable reconstruction method using no exogenous or autogenous material obtained from another site. Methods This method involves packing a small wedge-shaped piece of bone obtained from the bone flap of the craniotomy into the nasal recess of the exposed sinus. The large opened frontal sinus is reconstructed as a new minimized frontal sinus with mucous membrane and bony roof in the nasal recess. Results Eleven patients with large frontal sinus opening during craniotomy (7 cases of bifrontal craniotomy for the basal interhemispheric approach) underwent frontal sinus reconstruction by packing of a small bone piece into the nasal recess. No patients suffered postoperative complications related to the opened frontal sinus such as pneumocephalus or cerebrospinal fluid rhinorrhea. Conclusion Packing of a small bone piece from the bone flap is a quick and reliable method to reconstruct the frontal sinus opened during craniotomy.