Bifrontal Craniotomy Research Articles

Multidisciplinary approach to severe intracranial, intraorbital allergic fungal sinusitis

BackgroundAllergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and can extend into the orbit and anterior skull base. Intracranial and intraorbital involvement are published but not both in each included patient of a series. The purpose of the present study was to review cases of extensive AFS with orbital or/and skull base erosion, including the presenting symptoms, patient socioeconomic background, imaging features, surgical technique, and post-operative outcomes. MethodsThe records of 30 patients with the histological diagnosis of AFS and both intracranial and intraorbital involvement were reviewed. ResultsThe average age of the patients was 25.2 years. 83 % of patients were male. 70 % were African American. 66 % of patients had Medicaid or were uninsured. Presenting symptoms were headaches (80 %), nasal obstruction (33 %), proptosis (40 %), vision change (23 %), facial pressure (10 %), and decreased sense of smell (7 %). 100 % of patients had bone erosion observed on computerized tomography scans with disease extending intracranially through the anterior skull base or posterior wall of the frontal sinus along with disease that eroded through the lamina papyracea. All patients had failed medical management. All patients underwent surgery by Otolaryngology, Ophthalmology, and Neurosurgery with transnasal endoscopic approaches and orbitotomy. 80 % also underwent a bifrontal craniotomy for removal of intracranial extradural disease with cranialization. 53 % of patients had orbital implants remaining after surgery; 23 % had nasal stents. There were no postoperative cerebrospinal fluid leaks. Average hospital stay was 4.8 days. Preoperatively, 13 % of patients underwent allergy testing. 94 % saw an Allergist postoperatively. 21 % required follow up surgery. ConclusionsA team approach of Otolaryngologists, Ophthalmologists, and Neurosurgeons is recommended for this slowly growing but locally destructive disease. Most patients with AFS will present with headaches and nasal obstruction. While most cases of AFS can be successfully managed with transnasal endoscopic techniques, orbitotomy and craniotomy represents an effective treatment for severe AFS cases with extensive intracranial and intraorbital involvement. This disease is found most commonly in young African American males and in the underinsured.

Frontal sinus reconstruction with overlapping sinus mucosa and vascularized pericranial flap Coverage after modified transbasal bifrontal craniotomy: Novel technique and clinical outcomes

BackgroundThe modified transbasal bifrontal craniotomy is a variant of the bifrontal craniotomy with a wider surgical corridor than the standard approach. There are several methods for frontal sinus repair in bifrontal craniotomy. This study reports a novel method for frontal sinus repair in the modified transbasal interhemispheric approach by precisely overlapping the frontal sinus mucosa margin (without frontal sinus mucosa exenteration) with packing the frontal sinus with povidone-soaked gel foam and covering it with a vascularized pericranial flap. MethodsIn this case series, we retrospectively collected the clinical outcomes regarding cerebrospinal fluid (CSF) leakage, meningitis, and mucocele formation of patients who underwent modified transbasal bifrontal craniotomy at Vara Hospital. ResultsFrom January 2016 to December 2021, 65 patients with anterior skull-base lesions were treated with a modified transbasal interhemispheric approach with frontal sinus repair by overlapping frontal sinus mucosa with gel foam packing and vascularized pericranium flap covering. There was no case of postoperative CSF leakage, meningitis, or mucocele formation during the follow-up period of 19.2 months (min 1, max 73). ConclusionsWe demonstrated that the modified transbasal interhemispheric approach with frontal sinus repair using gel foam packing and pericranial flap is effective in preventing postoperative CSF leakage and meningitis.

Olfactory Nerve Schwannoma: a case series with a systematic review of the literature focusing risk factors, etiology, clinical presentation, and management

Abstract Objective Olfactory Nerve Schwannomas (ONS) affect cranial nerve I (CN I), responsible for the sense of smell. This systematic review aims to comprehensively examine the risk factors, etiology, clinical presentation, and management of ONS by analyzing 44 case reports/series published from 1978 to 2022. Methods Our systematic review utilized a comprehensive search strategy across various scientific databases, including PubMed, Scopus, and Web of Science in March 2023. The inclusion and exclusion criteria included minimum information on demographics (i.e., age), clinical presentation, syndrome, area involved, and extent of resection. The selected articles were case reports, so there is no question about bias. Articles were meticulously reviewed for the above information and underwent both qualitative and quantitative analysis. Results A total of 44 case reports/series, consisting of 45 patients, were included in this study (mean: 38.45). The anterior cranial fossa was the most frequently involved area (48 %). The most common surgical procedure was bifrontal craniotomy (n=16), followed by left frontal craniotomy (n=7). Approximately 95.5 % of patients underwent Gross Total Resection (GTR), while 4.5 % had Subtotal Resection (STR). Radiotherapy was applied to two patients. Olfactory function varied, with 35.5 % preserving it and 28.88 % experiencing damage or loss. Positive outcomes were observed in approximately 66.6 % of cases, with complications reported in 15 % of instances, including cerebrospinal fluid (CSF) rhinorrhea and diplopia. Conclusions Long-term follow-up and regular screening of patients are imperative. Further research is essential to elucidate the precise pathogenesis and to develop improved treatment modalities for ONS. This review provides a comprehensive overview of the current state of knowledge regarding ONS; however, as the disease is very rare, only case reports are available as a primary study, making it difficult to reach a strong conclusion.

Glioblastoma Presenting with the Radiological Features of a Meningioma: A Case Report and Literature Review

Glioblastomas, which are the most common primary malignant brain tumors in adults, occasionally exhibit radiological features similar to those of other diseases. However, instances of them mimicking meningiomas are rare. This article describes a rare case of a glioblastoma presenting with radiological features similar to those of a meningioma. A 55-year-old man was admitted following 2 months of gait disturbance, mild dysarthria, and dizziness. Magnetic resonance imaging suggested an extra-axial tumor in the interhemispheric fissure exhibiting a cerebrospinal fluid cleft sign, which was indicative of a meningioma. Bifrontal craniotomy for tumor resection revealed a highly vascularized, yellowish-gray friable mass within the interhemispheric fissure. The pathological diagnosis was glioblastoma. The patient’s symptoms improved following treatment with whole-brain radiotherapy and temozolomide chemotherapy, and his condition was stable during a 5-month follow-up period. Glioblastomas may present with radiological features similar to those of meningiomas, making it challenging for physicians to establish an accurate diagnosis and effective treatment plan.

Congenital transsphenoidal meningocele in a newborn: A case report

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

Widening the Operative Corridor–Evaluating the Transcortical Approach to Giant Falcine Meningiomas

BackgroundGiant falcine meningiomas are surgically complex as they are deep in location, concealed by normal brain parenchyma, in close proximity to various neurovascular structures, and frequently involve the falx bilaterally. Although classically accessed using a bifrontal craniotomy and interhemispheric approach, little data exists on alternative operative corridors for these challenging tumors. ObjectiveTo evaluate perioperative and long-term outcomes in patients undergoing transcortical resections of giant bilateral falcine meningiomas. MethodsFrom 2013-2022, fourteen patients with giant bilateral falcine meningiomas treated via a transcortical approach at our institution were identified. Perioperative and long-term outcomes were evaluated to determine predictors of adverse events. Corticectomy depth was also analyzed to determine if it correlated with increased postoperative seizure rates. Results57.1% of cases were WHO grade 2 meningiomas. Average tumor volume was 77.8 ± 46.5 cm3 and near/gross total resection was achieved in 78.6% of patients. No patient developed a venous infarct or had seizures in the 6 months after surgery. Average corticectomy depth was 0.83 ± 0.71 cm and increasing corticectomy depth did not correlate with higher risk of postoperative seizures (p = 0.44). Increasing extent of tumor resection correlated with lower tumor grade (p = 0.011) and only 1 patient required repeat resection during a median follow-period of 24.9 months. ConclusionsThe transcortical approach is a safe alternative corridor for accessing giant, falcine meningiomas and postoperative seizures were not found to correlate with increasing corticectomy depth. Further prospective studies are necessary to determine the best approach to these surgically complex lesions.

Endonasal Endoscopic Treatment of Esthesioneuroblastoma

Introduction: Esthesioneuroblastoma is a malignant neoplasm that originates from the olfactory epithelium. Treatment is established according to its extension and the histological degree of atypia and may include surgery, surgery more radiotherapy or more chemoradiation therapy. Different surgical approaches have been used, including facial incisions and craniotomy, but with the greater experience acquired with endoscopic sinus surgery and teamwork with the neurosurgeon, endonasal techniques have been developed that make it possible to perform oncological resections in selected patients, with less morbidity, brief hospitalization and without compromising local control of the disease. Objectives: To determine the rate of local control in patients treated for esthesioneuroblastomas by the endonasal approach with endoscopes or through an endonasal approach with bifrontal craniotomy. Methods: A review of the electronic medical records of patients who were treated for esthesioneuroblastomas in the ENT Department of the Italiano Hospital of Buenos Aires between March 2005 and May 2022 was carried out. Results: Five patients were treated with an endonasal approach with endoscopes. Two patients with an endonasal approach only (Kadish B and C) and three with an endonasal approach combined with bifrontal craneotomy (Kadish C and one D). In four cases, chemotherapy-radiotherapy or radiotherapy was also used. Local control in the treated group was 80% (4/5) and specific survival was 60% (3/5). Conclusions: The local control that we obtained in patients treated for esthesioneuroblastomas through a single endonasal approach or combined with bifrontal craniotomy and adjuvant treatments was 80% and survival without local, regional or distant disease was 60%.

Rare case of mortality after hemorrhagic property of esthesioneuroblastoma

Esthesioneuroblastoma is a tumor arising from olfactory neuroepithelium with an incidence of four per million. This case presents a rare nasal cavity neoplasm with hemorrhagic properties that may lead to significant sequelae. We present a 69-year-old male patient who presented with worsening altered mental status over the past 6-7 months. His Glasgow coma scale was a nine, showing a large mass centered at the cribriform plate with extension intracranially, sinonasal cavity, and bilateral orbits on diagnostics. Bifrontal craniotomy was performed one day after admission with resection of the tumor in the cranial fossa and intranasally, and decompression of the brainstem, frontal lobes, and third ventricle. After surgery, the patient was managed in the intensive care unit but continued to deteriorate. He was confirmed to have no meaningful brain activity and eventually deceased seven days after admission. Depending on the tumor stage, esthesioneuroblastoma can have a favorable prognosis with proper therapies. Different surgical techniques for ENB lead to the question of which therapeutic modality is the best because of the tumor's gross hemorrhagic properties. With adjunctive radiation therapy and/or chemotherapy, more research can bring light to proper surgical techniques.

Olfactory groove meningiomas: supraorbital keyhole versus orbitofrontal, frontotemporal, or bifrontal approaches.

Olfactory groove meningiomas (OGMs) often require surgical removal. The introduction of recent keyhole approaches raises the question of whether these tumors may be better treated through a smaller cranial opening. One such approach, the supraorbital keyhole craniotomy, has never been compared with more traditional open transcranial approaches with regard to outcome. In this study, the authors compared clinical, radiographic, and functional quality of life (QOL) outcomes between the keyhole supraorbital approach (SOA) and traditional transcranial approach (TTA) for OGMs. They sought to examine the potential advantages and disadvantages of open/TTA versus keyhole SOA for the resection of OGMs in a relatively case-matched series of patients. A retrospective, single-institution review of 57 patients undergoing a keyhole SOA or larger traditional transcranial (frontotemporal, pterional, or bifrontal) craniotomy for newly diagnosed OGMs between 2005 and 2023 was performed. Extent of resection, olfaction, length of stay (LOS), radiographic volumetric assessment of postoperative vasogenic and cytotoxic edema, and QOL (using the Anterior Skull Base Questionnaire) were assessed. Thirty-two SOA and 25 TTA patients were included. The mean EOR was not significantly different by approach (TTA: 99.1% vs SOA: 98.4%, p = 0.91). Olfaction was preserved or improved at similar rates (TTA: 47% vs SOA: 43%, p = 0.99). The mean LOS was significantly shorter for SOA patients (4.1 ± 2.8 days) than for TTA patients (9.4 ± 11.2 days) (p = 0.002). The authors found an association between an increase in postoperative FLAIR cerebral edema and TTA (p = 0.031). QOL as assessed by the ASQB at last follow-up did not differ significantly between groups (p = 0.74). The keyhole SOA was associated with a statistically significant decrease in LOS and less postoperative edema relative to traditional open approaches.

COMPARATIVE ANALYSIS OF COMPLEX INFORMATION SYSTEM TESTING METHODS


 
 
 
 The research has been based on surgical experience of multiple decades and on retrospect study of more that 4000 clinical cases, among them 3500 surgical invasion due to different types of traumas. Since it relies on the latter, it shows the evolution of our approaches towards severe cerebral cranial traumon includes different matters regarding diagnostics and surgical treatment with neuropathogenetic approach. We have shown the advantages of certain surgical procedures in cases of cerebral cranial trauma and also the way approaches were changing after introduction of high medical technology and taking into consideration bio mechanisms and pathological data. Computer diagnostics changed several surgical procedures and opportunities. In cases of traumas impacted in immobilized condition method of choice used to be plastic craniotomy, when in cases of cerebral congestion would cause decompression, placing bone fragment under the skin. 902 surgeries were performed among 1990. In 894 cases surgeries were performed using plastic trepanation, 217 among them was performed with improved modified method. In cases of negligible brain congestion, bone fragment was left in its place without suture fixation and after the congestion resolution fragment would return to its anatomical location. In several times it would be ligated in 2-3 points. This method was the most efficient in bi-frontal low craniotomy. The need of removing bone fragment was observed in zero cases.
 In cases of acceleration traumas, which is characterized by diffuse damage, multifocal hemorrhages and bruises, in 157 cases double decompression method was used, in some case with falcostomy, effective in 49 cases. Trafination and resection trepanation were removed from practice.
 Trafination method was sometimes use in cases of chronic hematomas and acute hydromas. In Recurrent and chronic hydromas method was less effective, in such conditions plastic trepanation method was used in order to create extra space for fluid. In singular cases of collapsed brain and for resolving tunica arachnoidea broken surface, we used to infuse 25-35 cubic oxygen or 20-25 distillate in spinal cord. This method was proved effective in 70 cases. Therefore, taking into consideration patho-mechanisms and pathology data, using differential pathogenetic methods of surgical invasion and computer monitoring of post-operative period we managed to decrease mortality in severecerebro-cranial traumas to 29-30% comparing to pre computer periods 36-38 % and comparing to data of other clinics 35-45%.
 
 
 

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.

FRI318 A Case Of Mixed Growth Hormone And Prolactin-secreting Giant Pituitary Macroadenoma

Abstract Disclosure: A. Khan: None. I. Alpertunga: None. V. Kantorovich: None. Introduction Co-secretion of prolactin (PRL) and growth hormone (GH) from a single pituitary adenoma is an established entity in the medical literature and present in about 5% of the cases. Guidelines recommend to obtain an insulin-like growth factor-1 (IGF-1) in patients with prolactinoma at the time of initial diagnosis. Our case describes the management of a giant pituitary macroadenoma co-secreting PRL and GH. Case A 20-year-old male with history significant for schizophrenia presented with visual disturbances and discharge from his left nipple. His prolactin level (PRL) was noted to be elevated at 12,396 (4.0-15.2) ng/ml on work-up during recent prior investigation. On physical exam, he had bilateral temporal visual field deficit as well as dysfunction in upward gaze of left eye. Head imaging showed a 7.5 x 6.2 x 5 cm associated with remodeling of the sella turcica and expanding into the suprasellar space and significant mass-effect on the adjacent frontal lobes bilaterally, mild mass-effect on the adjacent optic chiasm with significant surrounding vasogenic edema and compressing the bilateral anterior cerebral arteries. Patient was started on low dose cabergoline in caution of prevention of possibility of rapid response-related significant volume contraction of the tumor with possibility of reactive edema. The dose of cabergoline was rapidly titrated up to 3 mg bi-weekly with minimal prolactin fluctuation of PRL between 12,000 and 16,000 ng/ml. Because of mild atypical acromegalic facial features, patient had GH axis assessment. IGF-1 level came back elevated at 529 (83-456) ng/ml with a high IGF Binding Protein- 3 of 8.9 (2.9-7.2) mg/l. He was started on octreotide titrated up to a dose of 150 mcg three times daily. Repeat MRI brain did not show tumor shrinkage. Subsequently, patient underwent bifrontal craniotomy for resection/debulking of parasellar tumor. PRL dropped to 931 ng/ml immediately after surgery. At the time of writing, pathology of the tumor and repeat IGF-1 level is pending. Patient was monitored closely in the ICU with a steroid taper postoperatively. Discussion Dopamine agonists are the first-line therapy for medical treatment of hyperprolactinemia but can also suppress GH and IGF-1 levels. However, in acromegaly, cabergoline is utilized mostly for small adenomas with mild elevation of IGF-1. In our case, we decided to use a combination of cabergoline and somatostatin receptor analog, octreotide. However, given the giant adenoma with very high PRL and IGF-1 levels, patient showed a poor response to medical therapy, and given the impending threat to patient’s vision, he underwent surgical debulking. Our case highlights the management of a giant, mixed hormone-secreting pituitary adenoma. Presentation: Friday, June 16, 2023

Two Cases of Frontal Sinus Inverted Papilloma Treated With a Combined Bifrontal Craniotomy and Endonasal Endoscopic Approach

An inverted papilloma of the frontal sinus is a challenging lesion for surgeons, for both anatomical and pathological reasons. Despite the trend away from an external approach and towards an endonasal endoscopic approach, indications for an external approach remain. The options for an external approach include endoscopic frontal trephination, transpalpebral orbital craniotomy, a supraorbital transeyebrow approach, an osteoplastic flap, and bifrontal craniotomy with cranialization. Each approach has advantages and disadvantages. Deciding on the appropriate approach is important for the patient’s prognosis and risk of complications. We report two cases of frontal sinus inverted papilloma treated with a combined bifrontal craniotomy with cranialization and endonasal endoscopic approach. We also present a general review of the external approaches mentioned above.

Craniofacial malignant tumors, their extensions, and surgical strategy for their treatment

Purpose: To identify extension routes of craniofacial malignancies and formulate a surgical treatment plan based thereupon. Material and Methods: We retrospectively reviewed the medical records of 253 patients with craniofacial malignancies who underwent surgical treatment at the Romodanov Neurosurgery Institute from 2002 through 2022. Of the 253 patients, 112 had a primary tumor, and 141, a secondary tumor. Preoperative Karnofsky performance scores ranged from 50 to 70 points. Patients underwent neurological and ophthalmological status assessment, as per routine protocols. Results: Epithelial malignancies were the most common (53.7%), whereas anaplastic meningioma and embryonal malignancies were rather uncommon (1.2% and 0.4%, respectively) craniofacial malignancies. The presence of certain clinical symptoms was associated primarily with tumor origin and extension. A high rate of general brain and rhinological symptoms in our study sample was caused by a high percentage of intracranial and paranasal sinus tumors. Craniofacial malignancies most commonly originate from the midline (particularly, anterior midline skull base). Ethmoidal labyrinth was the most common site of origin (45.0%), followed by a sphenoid sinus (12.2%), pterygopalatine and infratemporal fossae (9.9%), whereas the cavernous sinus and olfactory fossa were the least common sites of origin (0.4% and 1.2%, respectively). Craniofacial tumors extended most commonly intracranially (transdurally, epidurally, via adhesion to the dura mater, and/or cavernous sinus growth) or intraorbitally. Anterior craniofacial resection (bifrontal craniotomy with combined with either lateral rhinotomy or supraorbital advancement; or a subcranial approach) was the most common surgical treatment. Postoperative cerebrospinal fluid rhinorrhea and infectious complications (meningitis and meningoencephalitis) were the most frequent complications. The overall postoperative mortality rate was 2.0%. Conclusion: First, compared to the transcranial and facial approaches, the craniofacial resection is advantageous in terms of the radicality of tumor excision. Second, the subcranial approach is preferable to the bifrontal approach in the presence of marked extracranial tumor component, whereas the transbasal Derome approach is effective in the presence of marked extracranial and/or intracranial tumor components. Finally, both the orbitozygomatic and infratemporal approaches allow for the radicality of excision of lateral skull base malignancies, but the latter approach is associated with a lower rate of complications.

Primary Cranio-Orbital Presentation of Multiple Myeloma.

A 49-year-old man presented with left upper eyelid ptosis noted after minor head trauma. Clinical examination revealed a soft, mildly tender mass of the superior orbit with left hypoglobus and relative proptosis. He had moderate limitation in supraduction, without visual or pupillary deficit. MRI imaging showed a superior extraconal cystic mass (Fig. 1C, D), and CT demonstrated erosion of the superior orbital roof and invasion of the frontal sinus (Fig. 1A, B).FIG. 1Excisional biopsy was performed via a bifrontal craniotomy with a frontal bone flap, exposing a well-encapsulated vascular lesion eroding through the orbital roof and frontal sinus (Fig. 2A). The mass was dissected from the surrounding dura, sinus mucosa, and periorbita, and removed in toto (Fig. 2B). The frontal sinus was obliterated and a split-thickness calvarial bone graft was used to reconstruct the orbital rim and roof, secured with mini plate fixation (Fig. 2C).FIG. 2Pathological analysis revealed plasma cell neoplasm (Fig. 2D) with clonal kappa-light proliferation (Fig. 2E), consistent with an extramedullary plasmacytoma. The full-body PET scan revealed multiple lytic lesions of the clavicle, rib, and vertebrae, conferring a diagnosis of multiple myeloma. He underwent an autologous stem cell transplant and started maintenance Bortezomib therapy with a good serologic response. Multiple myeloma accounts for 10% of hematologic malignancies and presents as a malignant plasma cell proliferation leading to bone marrow destruction. There are few reports of multiple myeloma initially presenting in the orbit. Solitary plasmacytoma without systemic disease may be treated with radiation therapy. Systemic disease mandates oncologic evaluation and consideration of chemotherapy or transplant.

An unusual diffuse CD34 staining in an olfactory groove cellular schwannoma: Case report

Background: Intracranial schwannomas are benign lesions, expected to exhibit characteristic ultrastructural features and immunophenotypic profile, typically being S-100, SOX10 and collagen-IV positive, while other markers, including CD34, are not usually expressed and are employed in the diagnostic elimination process. Case presentation: A 51-year-old female presented with a rapidly deteriorating neurological status. MRI showed a heterogeneous enhancing neoplasm of the anterior fossa. Preoperative differential diagnosis predilected an esthesioneuroblastoma. A bifrontal craniotomy with total excision of the lesion was performed. Dural infiltration was present. There was no association with the olfactory system. Microscopic examination revealed a uniform population of spindled to slightly epithelioid cellular proliferation with no significant atypia, low mitotic activity, and foci of necrosis. Upon immunohistochemical investigation the tumor was consistent with cellular schwannoma. Diffuse positivity for CD34 was an unusual finding. Discussion: Cellular schwannoma should be considered in the presence of an anterior fossa tumefaction. Olfactory nerve is not directly associated with these lesions. Various theories have been proposed, with the meningeal trigeminal branches’ origin being the most probable. The characteristic ultrastructural Antoni formations may be scarce or even absent in cellular schwannomas creating potential diagnostic difficulties. Unusual diffuse CD34 positivity should not be employed for excluding the diagnosis.

Pterional Approach for Anterior Skull Base Midline Meningiomas against "The More The Merrier" Approach: An Institutional Experience.

Objective Anterior midline skull base meningiomas involving olfactory groove, planum sphenoidale, and tuberculum sellae were usually managed with bifrontal craniotomy until the dawn of advanced microsurgical techniques. With the emergence of microsurgical techniques, midline meningiomas could be tackled solely from a unilateral pterional approach. We present our experience with pterional approach in managing anterior skull base midline meningiomas, including the technical nuances and outcomes. Methods Fifty-nine patients who underwent excision of anterior skull base midline meningiomas through a unilateral pterional craniotomy between 2015 and 2021 were retrospectively analyzed. The surgical technique and patient outcomes in the context of visual, behavioral, olfaction, and quality of life were evaluated during the follow-up. Results A total of 59 consecutive patients were assessed over an average follow-up period of 26.6 months. Twenty-one (35.5%) patients had planum sphenoidale meningioma. Olfactory groove and tuberculum sellae meningioma groups consist of 19 (32%) patients each. Visual disturbance was the predominant symptom with almost 68% of patients presented with it. A total of 55 (93%) patients had complete excision of the tumor with 40 patients (68%) achieving Simpson grade II excision, and 11 (19%) patients had Simpson grade I excision. Among operated cases, 24 patients (40%) had postoperative edema among which 3 (5%) patients had irritability and 1 patient had diffuse edema requiring postoperative ventilation. Only 15 (24.6%) patients had contusion of the frontal lobe and were managed conservatively. Five patients (50%) with seizures had an association with contusion. Sixty-seven percent of patients had improvements in vision and 15% of patients had a stable vision. Only eight (13%) patients had postoperative focal deficits. Ten percent of patients had new-onset anosmia. The average Karnofsky score was improved. Only two patients had recurrence during follow-up. Conclusion A unilateral pterional craniotomy is a versatile approach for the excision of anterior midline skull base meningioma, even for the larger lesions. The ability of this approach in the visualization of posterior neurovascular structures at the earlier stages of surgery while avoiding the opposite frontal lobe retraction and frontal sinus opening makes this approach more preferable over the other approaches.

Tension Pneumocephalus: A Potentially Fatal Complication of Expanded Endoscopic Endonasal Approach.

While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications.

Comparison of Bifrontal Craniotomy and Multiple Burr Hole Encephalogaleoperiosteal-Synangiosis for Pediatric Moyamoya Disease: An Experience of 346 Patients.

Moyamoya disease (MMD) is a steno-occlusive disease treated with revascularization surgery. Craniotomy and multiple burr hole encephalogaleoperiosteal-synangiosis (EGPS) are used for revascularization of the anterior cerebral artery territory. The aim of this study was to compare the clinical outcome between the 2 surgical methods in pediatric patients with MMD. A retrospective review of patients with MMD who underwent bifrontal indirect bypass surgery was performed. Clinical features, perioperative data, and angiographic, perfusion, and functional outcomes were compared between the 2 groups. Propensity score matching was performed to compare the perioperative characteristics and clinical outcomes. A total of 346 patients were included in this study, 111 patients underwent bifrontal craniotomy EGPS, and 235 patients had bifrontal multiple burr hole EGPS. An insignificant higher rate of postoperative infarction (11.7% vs 5.5%, P = .072) and more postoperative hemorrhage occurred in the craniotomy EGPS group (3.6% vs 0%, P = .004). Of the 83 patients selected with propensity score matching for each group, the duration of operation was shorter ( P < .001) and the amount of intraoperative bleeding was significantly less in the multiple burr hole EGPS group ( P = .008). There was no difference in clinical outcomes between the 2 groups. Bifrontal multiple burr hole EGPS has benefits over craniotomy with shorter surgical time, less intraoperative bleeding, fewer postoperative complications, and comparable perfusion and functional outcomes. Multiple burr hole EGPS is a safe and effective method that might be considered for revascularization of the anterior cerebral artery territory in pediatric patients with MMD.

Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training.

Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity. Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey. A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models. The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.