Bifrontal Craniotomy Research Articles

Sellar region extramedullary plasmacytoma – A rare skull base tumour

Plasma cell neoplasms can present either as multiple myeloma, or in <10% of cases, as solitary plasmacytoma. Extramedullary plasmacytoma, a subtype of solitary plasmacytoma, only accounts for <5% of all plasma cell neoplasms, and <1% of all head and neck tumours. Extramedullary plasmacytoma usually arises from aerodigestive tract, and infrequently, from skull base and calvarium. Sellar region extramedullary plasmacytoma is a relatively rare tumour in the sellar region. Sellar region extramedullary plasmacytoma is usually asymptomatic until the lesion is large enough to impinge on surrounding structures, most commonly the cranial nerves. Radiological findings for extramedullary plasmacytoma are rather non-specific, but MR pituitary provides essential information with regards to its origin and its content, which aid in ruling out other diagnoses. The tumour usually enhanced homogenously post-Gadolinium, without involvement of surrounding bones. Due to the rarity of sellar region extramedullary plasmacytoma, tumour histo-pathological examination is recommended to achieve an accurate tissue diagnosis. Apart from neuroimaging, evaluations for plasma cell neoplasms include total body skeletal survey, serum and urine electrophoresis, routine blood count, serum calcium level and bone marrow biopsy. Principally, the diagnosis of plasmacytoma is confirmed by ruling out the presence of multiple myeloma. As for management of extramedullary plasmacytoma, local irradiation is the treatment of choice. Nonetheless, surgery is required for tissue diagnosis and tumour debulking in patients with neurological deficit due to mass effect.A 48-year-old lady presented with 5 months history of progressive bilateral poor vision and worsening headache. Clinically, she had severe visual acuity and visual field defect, but no other neurological deficit. MR imaging showed a large lobulated sellar mass, homogenously enhanced with extension and invasion to surrounding structures. She had undergone bifrontal craniotomy and tumour debulking. Intraoperatively, the tumour was highly vascularised. Tumour histopathological result was reported as extramedullary plasmacytoma. Serial plasma and urine investigations showed negative results for multiple myeloma. Hence, the final diagnosis of skull base extramedullary plasmacytoma was established. She was then scheduled for adjuvant radiotherapy. Unfortunately, her vision impairment persists.

Sudden bilateral vision loss due to third ventricular cavernous angioma with intratumoral hemorrhage - case report

BackgroundWe report a rare case of sudden bilateral vision loss due to third ventricular cavernous angioma with intratumoral hemorrhage.Case presentationA 45-year-old woman presented decreased visual acuity in both eyes. Her best corrected visual acuity was 0.1 in the right eye and 0.15 in the left eye. Goldmann perimetry showed bilateral central scotomas and bitemporal visual field defects. MRI demonstrated a lesion with mixed hypo- and hyperintensity at the optic chiasm, which was thought to be an intratumoral hemorrhage. The patient underwent bifrontal craniotomy. The tumor was exposed via an anterior interhemispheric approach, and histological evaluation of the mass led to a diagnosis of cavernous angioma. Six months after the surgery, her best corrected visual acuity was 0.9 in the right eye and 0.9 in the left, with slight bitemporal visual field defects.ConclusionThird ventricular cavernous angioma is considered in the differential diagnosis of chiasmal syndrome. Contrast-enhanced MRI and FDG-PET might be useful for differential diagnosis of cavernous angioma from other chiasmal tumors including glioblastoma.

Tension Pneumocephalus from Endoscopic Endonasal Surgery: A Case Series and Literature Review

Background: Tension pneumocephalus (TP) caused by endoscopic endonasal surgery is a serious complication. We report 4 cases of TP caused by endoscopic surgery and review other cases in the literature, with special attention given to the symptoms, imaging manifestations, therapeutic approaches. Methods: We performed a retrospective chart review of patients with TP caused by endoscopic surgery in our institution from 2015 to 2018. Additionally, the MEDLINE database was searched for all case series or reports of TP caused by endoscopic surgery. Findings: Seventeen articles were identified for review, including the 4 cases from the authors' institution. Ultimately, a total of 25 cases were included in this study. The main symptoms of TP were headache and change in mental status. Cerebrospinal fluid (CSF) leakage was reported in 21 patients (21/25, 84.0%). Eight patients (8/25, 32.0%) presented with the Mount Fuji sign imaging characteristic. Twenty-three patients were treated with surgical intervention for TP (endoscopic multilayer closure of skull base defect, cranial burr hole, bifrontal craniotomy). In addition, we first reported that 2 patients with TP were successfully given conservative treatment. Interpretation: The therapeutic method of TP should depend on the degree of the mass effect and clinical symptoms. When patients with TP presented with obvious symptoms of CSF leakage and intracranial hypertension, urgent surgical multilayer repair of the skull base defects or/and release of the intracranial pressure were the keys to treating these patients. However, conservative treatment under close observation was also feasible when the related symptoms were not obvious. Funding Statement: This work was financially supported by the National Natural Science Foundation of China (No. 81870703). Declaration of Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethical Approval Statement: This study was approved by the Institutional Review Board of AEENTH at Fudan University.

Compartmentalization: An Open Technique for Frontal Sinus Repair and Preservation-Description of Technique and Early Case Series.

Background Cranialization or obliteration is widely accepted intervention for traumatic or intentional breach of the frontal sinus. These techniques, however, result in the loss of frontal sinus function and have a persistent risk of cerebrospinal fluid (CSF) leak and mucocele. Compartmentalization is an open technique for repair of the frontal sinus using allograft onlay and a vascularized periosteal flap that allows for preservation of frontal sinus function. Objective The main objective of this article is to describe the technique for compartmentalization of the frontal sinus and demonstrate its efficacy and complication rate with an early patient series. Methods Our technique includes the following key components: harvesting of a pedicled periosteal flap, frontal sinus repair through a bifrontal craniotomy with minimal mucosa removal, ensuring the patency of the nasal frontal outflow tract, and separation of the brain from the frontal sinus with a dual layer of periosteum and allograft. All cases of frontal sinus repair using the compartmentalization technique at our institution were reviewed. Charts were reviewed for CSF leak, mucocele, and other complications. Results Twenty-three patients underwent the described frontal sinus repair technique 17 for tumor and 6 for trauma. There were no CSF leaks and no mucoceles. One patient experienced postoperative anemia and a "parameningeal reaction" that were managed with a short course of antibiotics. Conclusions Compartmentalization, due to its sinus preservation and low complication rate, represents a meaningful step forward in neurosurgical technique for open frontal sinus repair. However, long-term outcomes are necessary to fully evaluate risk of mucocele.

P14.115 A Neurologist’s Foray into Gamma Knife: Lessons Learned from the first 100 cases:

Abstract BACKGROUND Gamma Knife Radiosurgery typically involves a neurosurgeon, radiation oncologist and physicist. Neurologists performing Gamma Knife provides a potential paradigm shift. METHODS The first 100 Gamma Knife procedures were completed on an Elekta Perfexion or ICON system between October 2015 and August 2018. Head frames were placed by the treating neurologist who also completed the contouring and targeting. The Radiation Oncologist defined the prescription dose and verified the plan, along with the physicist. RESULTS Of the first 100 cases completed by the treating neurologist, 52 were females and 48 males. The average age was 61.4 years. There were 64 metastatic cases, 25 meningiomas, 8 gliomas, 2 hemangioblastoma and 1 pituitary adenoma. There were 245 individual lesions targeted. No frame related placement complications occurred. Five large metastasis were treated as a staged procedure 1 month apart. A bolus was used on 4 occasions for lesions invading the skull. Secondary to large bifrontal craniotomies, cheek posts were used on 2 occasions, and 3 posts were used in 5 cases secondary to large unilateral frontal craniotomies. Four cases were completed under general anesthesia. In one patient with a very large head, the frame would not fit and was deconstructed, placed around the neck, reconstructed with pins placed in the cheeks. 64 of the treated patients are still alive. CONCLUSION While unconventional, neurologists can function as a surgical surrogate to treat intracranial neoplasms with Gamma Knife. This offers unique advantages, especially in regards to continuity of care as many of these patients had been followed and will continue to follow with neurology. With the advent of the ICON frameless based system, concerns about frame placement also become less of an issue and more facile for neurologists to perform these procedures.

The Use of Finite Element Method Analysis for Modeling Different Osteotomy Patterns and Biomechanical Analysis of Craniosynostosis Correction.

Several post-processing algorithms for 3D visualization of the skull in craniosynostosis with their specific advantages and disadvantages have been already described. The Finite Element Method (FEM) described herein can also be used to evaluate the efficacy of the cutting patterns with respect to an increase in the projected surface area under assumed uniform loading of the manipulated and cut bone segments. The FEM analysis was performed. Starting with the classic cranial osteotomies for bifrontal craniotomy and orbital bandeau a virtually mirroring of the unaffected triangular shaped frontal bone was performed to achieve a cup-shaped sphere of constant thickness of 2.5 mm with a radius of 65 mm. Mechanical properties required for the analysis were Young's modulus of 340 MPa and Poisson's ratio of 0.22. Four different cutting patterns from straight to curved geometries have been projected onto the inner surface of the sphere with a cutting depth set to 2/3rds of the shell thickness. The necessary force for the deformation, the resulting tensions and the volume loss due to the osteotomy pattern were measured. Better outcomes were realized with pattern D. The necessary force was 73.6% smaller than the control group with 66N. Best stress distribution was achieved. Curved cutting patterns led to the highest peak of stress and thus to a higher risk of fracture. Straight bone cuts parallel to the corners or to the thighs of the sphere provided a better distribution of stresses with a small area with high stress. Additionally, also with pattern D a surface increase of 20.7% higher than reference was registered. As a proof of concept for different cutting geometries for skull molding in the correction of craniosynostosis, this computational model shows that depending of the cutting pattern different biomechanical behavior is achieved.

Endoscopic endonasal superomedial orbitectomy: How far is safe and possible?

During the endoscopic endonasal approach (EEA) to the anterior cranial base, the lateral boundaries are the lamina papyracea (medial orbital walls) bilaterally but further extension in the coronal plane is possible by performing a superomedial orbitectomy. The aims of this study are to describe the technique of the endoscopic endonasal transethmoidal supraorbital approach to the anterior cranial base and to calculate the extension in the coronal plane added with the superomedial orbitectomy. Thirty superomedial orbitectomies via EEA were completed in 15 fresh-frozen heads. After finishing the procedure, a bifrontal craniotomy with removal of both frontal lobes was performed in order to measure the width of the supraorbital EEA in the coronal plane. We divided the anterior cranial base into five zones related to distinct anatomical segments: sinusal zone, post-sinusal zone, anterior ethmoidal, inter-ethmoidal zone, and posterior ethmoidal zone. Measurements of each segment of the anterior cranial base were taken. In all specimens, it was possible to perform a superomedial orbitectomy without excessive retraction of the orbital contents. The inter-ethmoidal zone is the segment where the lateral extension was widest. The mean total width in this area was 45.4 mm. The superomedial orbitectomy added a mean of 8 mm on each side to the total anterior skull base exposure. The endoscopic endonasal superomedial orbitectomy added important extension in the coronal plane during an EEA to the anterior cranial base. The inter-ethmoidal zone has shown the greatest lateral extension. N/A Laryngoscope, 130:1151-1157, 2020.

Tailored approach for the resection of planum sphenoidale meningiomas

Background and importance. Planum sphenoidale meningiomas are relatively rare tumours that can grow to a considerable size before determining noticeable symptoms. Modern imaging techniques can detect these tumours of varying size. Surgical resection of planum sphenoidale meningiomas can be performed by adapting the approach to the size of the tumour.Clinical presentation. A 56-year-old woman presented with a small (2 cm in diameter) planum sphenoidale meningioma that was resected through a frontal craniotomy performed with a 4,5 cm trephine at the level of the frontal sinus. The second case is that of a 55-year-old woman that presented with a large planum sphenoidale meningioma (5,6 cm in the antero-posterior plane and 5,5 cm cranio-caudally) extending to the tuberculum sellae and sellar diaphragm, reaching the anterior wall of the third ventricle. In this case, a bifrontal craniotomy was performed with frontal sinus cranialization and resection of falx cerebri, achieving a Simpson II resection. Both cases presented a favourable postoperative evolution, without any deficits and an excellent cosmetic result.Conclusion. The approach for tumours of the anterior skull base must be tailored to the size of the tumour. A minimally invasive approach through the frontal sinus should not be avoided in cases with small tumours.

Clipping of bilateral supply to a midline ethmoidal dural arteriovenous fistula at the origin of the superior sagittal sinus using a bifrontal approach

Dural arteriovenous fistulas (dAVFs) in the anterior cranial fossa represent only 10% of all dAVFs. Anterior fossa or ethmoidal dAVFs have a unique angioarchitecture, with cortical vein drainage, associated with a significant risk of hemorrhage. Treatment of ethmoidal dAVFs is challenging due to the ethmoidal artery origin and branch of the ophthalmic artery (OpA), which makes this lesion a difficult target for endovascular route.We present management of a 59-year-old female with a recent history of migraine. Angiography demonstrated bilateral supply with shunting directly into the superior sagittal sinus (SSS) at its origin adjacent to the crista galli via ethmoidal arteries arising from both OpA, and a 5 mm basilar tip aneurysm projecting postero-superiorly. Since the fistula had a higher risk of hemorrhage, aneurysm occlusion was deferred for treatment at a later time. Endovascular occlusion of the dAVF was not feasible due to the high risk of catherization of OpA, and the patient agreed to microsurgical treatment. A bifrontal craniotomy with ligation of SSS in its proximal third was required to allow access to the crista galli. After occlusion of the arterial feeders, clips were placed to occlude the origin of SSS and avoid fistula recurrence. The patient was discharged without complications, and post-operative angiography showed complete occlusion of the fistula and no further shunting into the SSS. This facilitated future antiplatelet therapy for endovascular treatment of the basilar aneurysm.

Craniofacial dermoid cyst: a case report

&lt;p class="abstract"&gt;We describe a case of a craniofacial dermoid cyst in a 16-month boy treated at our tertiary referral centre. The patient presented with a soft tissue swelling in the mid forehead extending down to the glabella. Computed tomography and magnetic resonance imaging scans demonstrated a peripherally enhancing cystic lesion with a defect in the underlying frontal bone. The clinical and imaging features were suggestive of a dermoid cyst with intracranial extension. The cyst became infected pre-operatively and this episode was managed by aspiration and antibiotics. Definitive management was by excision of the extra and intra-cranial components of the lesion via a bifrontal craniotomy. The presentation, investigations and management of this lesion is discussed.&lt;/p&gt;

Bifrontal Interhemispheric Approach Involving Cutting the Superior Sagittal Sinus for Distal Anterior Cerebral Artery Aneurysms

The unilateral interhemispheric approach for distal anterior cerebral artery aneurysms presents several risks, such as postoperative venous infarction due to occasional sacrifice of parasagittal bridging vein and postoperative frontal lobe damage due to retraction force. To overcome these risks, we used a bifrontal craniotomy with straight dural incision and cutting of the superior sagittal sinus. We retrospectively reviewed 61 patients (42 unruptured and 19 ruptured A2 and A3 aneurysms) who under aneurysm clipping through bifrontal interhemispheric approach between March 2007 and December 2017. There were 35 A2 aneurysms and 27 A3 aneurysms, and mean size of aneurysms was 5.45 mm. The modified bifrontal interhemispheric approach involved 3 steps: bifrontal craniotomy of centrobasal portion of the frontal bone, ligation and division of anterior one third of the superior sagittal sinus, and approaching the aneurysm via the interhemispheric space. All patients underwent computed tomography on postoperative days 3 and 7 for evaluation of brain retraction damage or venous infarction. Among patients with ruptured aneurysms, 79% had a favorable outcome (Glasgow Outcome Scale score 4 or 5) 6 months after primary subarachnoid hemorrhage; all patients with unruptured aneurysms had favorable outcomes. Surgical outcome was strongly related to preoperative neurologic Hunt and Hess grade. Three patients had poor outcomes due to poor Hunt and Hess grade on admission (grade 3 in 2 patients, grade 4 in 1 patient). Follow-up CT showed that venous infarction did not occur in any of the patients. Modified bifrontal interhemispheric approach may be a safe and effective method for treating A2 and A3 aneurysms with relatively good clinical outcome and no surgery-related complications.

CSF Rhinorrhea Following Medical Treatment for Prolactinoma: Management and Challenges.

Objective Cerebrospinal fluid (CSF) rhinorrhea following medical management of prolactinoma is a rare complication. We evaluated the clinical background of this condition, identify potential risk factors, and discuss the management options and challenges involved. Methodology We retrospectively reviewed clinical details of patients who were treated for CSF leaks among patients treated for prolactinoma between 2013 and 2017. Results Seven patients were treated for CSF rhinorrhea in the context of prolactinoma, with the age range between 24 and 56 years. Six patients had CSF leak following initiation of cabergoline, while one patient presented with CSF rhinorrhea. The time of onset of leak following medical treatment ranged from 14 days to 5 years. The mean preoperative serum prolactin level was 12,638 ng/mL (range: 1,000-26,287 ng/mL). All patients underwent repair of skull base defect. (four endoscopic, two microscopic, and one bifrontal craniotomy). The site of defect in the majority of patients was the sellar floor. Two patients who were initially managed with acetazolamide alone, eventually required surgical repair. Three patients were cured of CSF leak with a single procedure. Three patients had to undergo re-exploration and endoscopic repair after their first surgery failed. Two patients required lumboperitoneal (LP) shunt after a failed endoscopic transsphenoidal repair. Conclusion Surgical management for medically-induced CSF rhinorrhea is necessary; however, it can pose significant issues. Endoscopic repair of the defect should be considered at the earliest. Multiple surgical procedures are often required because of skull base erosion. LP shunt can be considered if CSF leak persists following multiple surgeries.

Small Extended Bifrontal Approach for Midline Anterior Skull Base Meningiomas: Our Experience with 54 Consecutive Patients

To describe the technique of a small extended bifrontal approach and review the clinical outcome of patients with midline anterior skull base (MASB) meningiomas treated using this technique. The small extended bifrontal craniotomy extends inferiorly to the nasofrontal suture without entering the orbit, superiorly 3 cm above the supraorbital rim, and laterally 3 cm to the midline on both sides. A review of a prospectively acquired database was performed of 54 consecutive patients with MASB meningiomas who underwent this craniotomy. Twenty-nine patients with olfactory groove meningiomas, 2 with planum sphenoidale meningiomas (PSMs), and 23 with tuberculum sellae meningiomas (TSMs) were treated using this technique. Gross total resection was achieved in all patients. Of 29 patients with olfactory groove meningiomas, 12 (41.4%) had normal olfaction at presentation and 8 had preservation of olfaction postoperatively. Of 25 patients with TSMs/PSMs, 23 (92.0%) had preoperative visual impairment, with 13 showing improved vision (56.5%), 8 unchanging (34.8%), and 2 deteriorating (8.7%) after surgery. The most common complications were anosmia and hyposmia, which occurred in 5 patients (20.0%) and 3 patients (12.0%) with TSMs/PSMs, respectively. No mortality was reported. There was no recurrence in all patients after a mean follow-up of 39.5 months (range, 16-64 months). The small extended bifrontal approach is a safe and effective technique for resection of MASB meningiomas, which provides adequate surgical exposure with less approach-related morbidity. It is an excellent alternative for surgeons who favor the bifrontal approach and its extended variations.

Frontal Bone Fractures and Frontal Sinus Injuries: Treatment Paradigms.

Background:Timely, expeditious and appropriate management of Frontal bone fractures and associated Frontal Sinus (FS) injuries are both crucial as well as challenging. Treatment options vary considerably, depending upon the nature, extent and severity of these injuries as well as operator skill, expertise and experience. In cases of posterior table fractures of the Frontal Sinus, literature reports have in general, propounded direct visualization and exploration of the sinus via a bifrontal craniotomy, followed by sinus cranialization.Aims and Objectives:To review the standard protocols of management of Frontal bone fractures and Frontal Sinus injuries. To assess the efficacy of a more conservative approach in the management of outer and inner table fractures of the FS.Materials and Methods:Contemporary and evolving management protocols and changing treatment paradigms of different types and severities of frontal bone fractures and frontal sinus injuries, have been presented in this case series. A useful Treatment Algorithm has been proposed to efficiently and effectively manage these injuries.Results:In the present case series, effective and satisfactory results could be achieved in cases of significantly displaced inner and outer table fractures of the Frontal sinus by a more conservative protocol comprising of open reduction and internal fixation carried out via the existing scar of injury, without having to resort to the more radical intracranial approach and sinus cranialization. Nevertheless, presence of complicating factors such as cerebrospinal fluid rhinorrhea, evidence of meningitis or the development of encephalomeningocoeles necessitated the standard protocol of sinus exploration and its cranialization or obliteration.Conclusion:Management protocols of Frontal Sinus injuries vary, based on aspects such as the timing of presentation and intervention, degree of injury sustained, concomitant associated Craniomaxillofacial injuries present, presence of complicating factors or Secondary/Residual deformities & Functional debility, and need to be decided upon on a case to case basis.

Anesthesia challenges in a case of Crouzon syndrome for corrective rigid external distraction frame insertion

Crouzon syndrome is an autosomal dominant disease occurs in approximately 1 in 25,000 births, due to a mutation in the fibroblast growth factor receptor 2 gene on chromosome 10 characterized by craniosynostosis, mid-face hypoplasia, hypertelorism, high-arched palate, skull base abnormalities, and exophthalmos. Patients present in early childhood for cranial reconstructive surgery. We describe here the successful management of a 5-year-old child with Crouzon syndrome with hypertrophic adenoids and Arnold-Chiari malformation type 1 posted for bifrontal craniotomy with fronto-facial advancement and application of a rigid external distraction frame.

Frontal Sinus Repair Using Polymethyl Methacrylate After Bifrontal Craniotomy

In many cases in which bifrontal craniotomy is performed, the frontal sinus is opened, and postoperative complications occur. Various methods to close the frontal sinus have been reported. However, all these methods require skill to perform and take time. The aim of this study was to report results obtained with closure of the frontal sinus using polymethyl methacrylate, which is a simpler method. From December 2008 to June 2018, 122 patients with a ruptured anterior communicating aneurysm were transported to the authors' facility, and 52 patients consecutively underwent bifrontal craniotomy with opening of the frontal sinuses, which were then filled with polymethyl methacrylate. Mean follow-up period was 21.8 months; the longest follow-up was 116 months. No cerebrospinal fluid leakage or other complications were observed. The method of filling the frontal sinus with polymethyl methacrylate reported in this study was safe and had no complications. This method should be considered as a method of frontal sinus closure.

Bifrontal Craniotomy for Resection of Recurrent Fibrous Dysplasia: 2-Dimensional Operative Video.

Fibrous dysplasia, which causes tumor-like growth and weakening of the involved bone, may require neurosurgical intervention to achieve complete resection with subsequent reconstruction. The case described in this video involved a 31-yr-old woman with a history of fibrous dysplasia who had previously undergone extensive craniofacial fibrous dysplasia resection and vault reconstruction. She presented to the emergency department with 1 wk of fever, chills, headache, sinus pain, and proptosis of her right eye. On examination, she had left gaze palsy and diplopia on left lateral gaze. Magnetic resonance imaging (MRI) revealed a right frontal lobe parenchymal abscess and progression of her fibrous dysplasia. Blood cultures were obtained, and treatment with broad-spectrum antibiotics and antiepileptics was initiated. The patient underwent a bifrontal craniotomy with extended transbasal anterior skull base approach for the resection of recurrent fibrous dysplasia, evacuation of the cerebral abscess, and placement of an external ventriculostomy drain. She tolerated the procedure well and was discharged on postoperative day 6 with intravenous antibiotics. Postoperative computed tomography and MRI demonstrated excellent resection of the skull base fibrous dysplasia with placement of soft tissue and fat flap in the surgical defect, decrease of right-sided proptosis, and drainage of the right frontal parenchymal abscesses. Three months later, the patient underwent placement of a custom-made Medpor cranioplasty implant (Stryker, Kalamazoo, Michigan). At her last follow-up appointment, 14 mo after surgery, she had complete resolution of the diplopia and gaze palsy. Neuroimaging demonstrated a small residual of fibrous dysplasia on the left frontoethmoidal recess. The patient gave consent for publication.Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy027 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Bifrontal Craniotomy for Resection of Recurrent Fibrous Dysplasia: 2-Dimensional Operative Video","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_sn3qh8og"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas.

OBJECTIVE Anterior skull base meningiomas are benign lesions that cause neurological symptoms through mass effect on adjacent neurovascular structures. While traditional transcranial approaches have proven to be effective at removing these tumors, minimally invasive approaches that involve using an endoscope offer the possibility of reducing brain and nerve retraction, minimizing incision size, and speeding patient recovery; however, appropriate case selection and results in large series are lacking. METHODS The authors developed an algorithm for selecting a supraorbital keyhole minicraniotomy (SKM) for olfactory groove meningiomas or an expanded endoscopic endonasal approach (EEA) for tuberculum sella (TS) or planum sphenoidale (PS) meningiomas based on the presence or absence of olfaction and the anatomical extent of the tumor. Where neither approach is appropriate, a standard transcranial approach is utilized. The authors describe rates of gross-total resection (GTR), olfactory outcomes, and visual outcomes, as well as complications, for 7 subgroups of patients. Exceptions to the algorithm are also discussed. RESULTS The series of 57 patients harbored 57 anterior skull base meningiomas; the mean tumor volume was 14.7 ± 15.4 cm3 (range 2.2-66.1 cm3), and the mean follow-up duration was 42.2 ± 37.1 months (range 2-144 months). Of 19 patients with olfactory groove meningiomas, 10 had preserved olfaction and underwent SKM, and preservation of olfaction in was seen in 60%. Of 9 patients who presented without olfaction, 8 had cribriform plate invasion and underwent combined SKM and EEA (n = 3), bifrontal craniotomy (n = 3), or EEA (n = 2), and one patient without both olfaction and cribriform plate invasion underwent SKM. GTR was achieved in 94.7%. Of 38 TS/PS meningiomas, 36 of the lesions were treated according to the algorithm. Of these 36 meningiomas, 30 were treated by EEA and 6 by craniotomy. GTR was achieved in 97.2%, with no visual deterioration and one CSF leak that resolved by placement of a lumbar drain. Two patients with tumors that, based on the algorithm, were not amenable to an EEA underwent EEA nonetheless: one had GTR and the other had a residual tumor that was followed and removed via craniotomy 9 years later. CONCLUSIONS Utilizing a simple algorithm aimed at preserving olfaction and vision and based on maximizing use of minimally invasive approaches and selective use of transcranial approaches, the authors found that excellent outcomes can be achieved for anterior skull base meningiomas.

Value of Ventricular Intracranial Pressure Monitoring for Traumatic Bifrontal Contusions.

To investigate clinical efficacy of and optimal therapeutic strategy for ventricular intracranial pressure monitoring (V-ICPM) in patients with traumatic bifrontal contusions (TBCs). From 8760 patients with traumatic brain injury treated between January 2010 and January 2016, a retrospective analysis was performed on 105 patients with TBCs who underwent V-ICPM and 282 patients with TBCs who did not. All patients underwent treatment at the 101st Hospital of PLA, Wuxi, China. Rates of successful conservative treatment, decompressive craniectomy, and bifrontal craniotomy; incidence of neurologic dysfunction; length of stay; and medical expenses were compared between groups. Glasgow Outcome Scale was used to assess all patients during follow-up (range, 6 months to 5.5 years). There were no significant differences in prognosis between the 2 groups (P= 0.100). Compared with the patients who did not undergo V-ICPM, the V-ICPM group had a significantly better successful conservative treatment rate (64.8% vs. 47.2%, P= 0.002), decompressive craniectomy rate (8.1% vs. 22.1%, P= 0.008), and bifrontal craniotomy rate (5.7% vs. 15.6%, P= 0.01); shorter length of stay (P=0.000); and lower medical expenses (P= 0.004). Patients with TBCs should be strictly, closely, and dynamically observed by neurosurgery intensive care unit physicians and nurses. Patients should undergo ventricular intracranial pressure probe implantation in a timely manner. V-ICPM can help optimize treatment. Although V-ICPM did not significantly improve the prognosis of patients, it had many other advantages. V-ICPM warrants further clinical research and may be beneficial for patients with TBCs.

Olfactory groove meningiomas: An analysis based on surgical experience with 129 cases.

The surgical strategy and outcome for 129 patients operated for an olfactory groove meningioma is retrospectively analyzed. One hundred and twenty nine patients with an olfactory groove meningioma operated between the years 1987 and 2016 were analyzed on the basis of clinical and radiological factors that appeared to affect the conduct of surgery and its outcome. Each factor was given points, and the points were added to obtain a score. On the basis of the score, the tumors were divided into three grades. The grades determined the difficulties that could be anticipated during surgery. In the initial part of the series, a bifrontal craniotomy was done to resect the tumor in all patients. In the later half of the series, majority of the patients were operated by the use of a unifrontal craniotomy. The aim of surgery was to resect the tumor completely. Total tumor resection was achieved in 86 patients, and subtotal tumor resection with less than 10% tumor left behind was achieved in 43 patients. Seven patients died in the immediate postoperative period. All patients where a subtotal tumor resection was done and where the patient died after surgery had a higher grade tumor. The average follow-up period was 82 months. There was non-symptomatic recurrence in 11 patients. The location and size of the tumor, extent and duration of visual symptoms, extent of tumor adjoining cerebral edema, encasement of anterior cerebral artery complex and extension in the extracranial compartment were more important factors that affected the outcome of surgery.