Middle Fossa Research Articles

Drainage of middle cranial fossa epidural abscess through mastoidectomy: Our experience and review of the literature

Background: Otitis media (OM) can uncommonly lead to intracranial complications. Epidural abscesses represent a large proportion of cases; however, literature regarding the optimal surgical management of otogenic epidural abscesses is sparse. Favorably located epidural abscesses may be amenable to drainage through a transmastoid approach because the tegmen mastoideum lies immediately inferior to the middle cranial fossa (MCF). Case Description: We report 3 pediatric patients with OM complicated by epidural abscesses of the MCF. The ages ranged from 3 to 6 years old, with 2 females and 1 male. All 3 patients had acute mastoiditis with an abscess of the MCF ranging from 1.6 cm to 6.3 cm at the largest dimension. All patients underwent canal wall-up mastoidectomy with the evacuation of the MCF abscess through a small window, 0.7 × 0.7 cm or less, created in the tegmen mastoideum. All patients were successfully treated through this approach and had complete resolution of their infection on follow-up imaging. There were no postoperative temporal lobe encephaloceles. Conclusion: This is one of the few descriptions of the treatment of an otogenic epidural abscess of the MCF through a transmastoid approach. Collaboration with neurosurgery is vital because their familiarity with the intracranial space helped to guide the accurate direction of dissection. This highlights the importance of a multidisciplinary approach in the treatment of epidural intracranial abscess of the MCF through this approach. The risk of postoperative temporal lobe encephalocele was minimized due to the small tegmen defect size.

Exploring the Potential Use of Virtual Reality with a Supraorbital Keyhole Craniotomy for Anterior Skull Base Meningiomas: Two Case Reports

Introduction: A supraorbital keyhole craniotomy (SOKC) is a novel alternative to frontal craniotomies for accessing the anterior fossa for resecting tumors and clipping aneurysms; however, its implementation is limited in patients at a high risk of complications. We present two cases involving the use of augmented reality (AR) and virtual reality (VR) for patient selection and preoperative planning for a supraorbital tumor resection of anterior fossa meningiomas. Methods: This is a prospective, single-center case series at a research institute. We identified patients with an anterior or middle fossa meningioma regardless of age, gender, and tumor characteristics who could undergo an SOKC and MRI. The preoperative planning was performed with the BrainLab Magic Leap AR/VR platform. The meningiomas were resected through the SOKC under neuronavigation. Results: We identified two cases: a 37-year-old male with a meningioma in the sellar region and an 84-year-old male with a right anterior fossa meningioma, both confirmed by MRI. Both patients had a complete tumor resection by a minimally invasive SOKC after preoperative planning with the AR/VR platform. Postoperatively, hyponatremia complicated the first case, while the second case developed an intracranial hemorrhage. They both recovered after the appropriate interventions. Conclusions: The use of an SOKC for anterior skull base meningiomas should be individualized after considering the lesion characteristics, vascular control needs, and the surgeon’s expertise. VR/AR-assisted preoperative evaluation and planning will optimize the patient selection and surgical outcomes. We can utilize VR/AR technologies to identify patients that will benefit from an SOKC and expand the implementation of the approach beyond its current limitations.

Intradural Repair of Temporal Bone Encephalocele and Cerebrospinal Fluid Leak: Results from a Single Institution

Abstract Background Lateral temporal bone encephaloceles incidence is increasing with obesity rates. Middle fossa (MF) craniotomy, transmastoid (TM), or combined MF + TM access can be used for repair. Methods Retrospective review of MF or MF + TM repair with an intradural graft. Sex, age, and body mass index (BMI) were collected. Pre/postoperative audiometric results were included. Postoperative complications were reported. Results A total of 49 patients (50 repairs) were included. In addition, 74% were women (p < 0.05). Ten patients had a history of chronic otitis media and surgery. Average BMI was 35.8, and average age was 59. Furthermore, 54% had multiple skull base defects; 18 (36%) patients had a MF approach. In total, 32 (64%) patients had a MF + TM approach for repair; 13 (40.1%) of these patients had a concurrent tympanoplasty. Hearing improved for 74%. Air conduction pure-tone average improved by an average of 5 dB (p 0.27). No differences in hearing outcomes were observed between the MF and MF + TM groups. Two patients (6%) had hearing decline. Eight complications were reported (1 (2%) skin infection, 4 (8%) recurrent/persistent cerebrospinal fluid [CSF] leaks requiring lumbar drain or shunt, and 3 (6%) episodes of aphasia or mental status change). Age >65 years was not associated with risk of postoperative complication. Conclusion Intradural repair of encephalocele and CSF leak is a safe and effective surgical approach. Intradural reinforcement along the entire MF floor is beneficial for multiple areas of dehiscence and thin dura. Complication rates including recurrent/persistent CSF leak and aphasia related to temporal lobe retraction were similar to previously published reports and not associated with older patient age. Hearing was stable or improved in 94% with no difference noted between MF and MF + TM repair.

Intracranial arachnoid cyst in a 28-year-old man. A clinical case with a fatal outcome

Most intracranial arachnoid cysts are thought to be non-tumorous, congenital, intra-arachnoid cerebrospinal fluid collections that account for about 1% of all intracranial space-occupying lesions. In children, the prevalence of this pathology is 2.6%; in adults, it reaches 1.4%. The disease is more often registered in men. Most often arachnoid cysts are supratentorial. Their most common locations are in the middle cranial fossa and the retrocerebellar cistern. Less often they can be detected on the convexity of the brain hemispheres; however, cases of arachnoid cysts at more unusual sites have also been described, including in newborns. The pathology is often characterized by an asymptomatic course, while certain symptoms may have an acute onset, which is due to compression of brain structures caused by the large cyst size.This article describes a clinical case of a large intracranial arachnoid cyst in a 28-year-old man. It was not verified in the antemortem diagnosis, but was revealed according to the autopsy findings (macroscopic features of the cyst, histologic presentation with specific morphological changes, and findings of computed tomography of the cerebral hemispheres).

Radiographic Estimation of Superior Canal Dehiscence Area in a Prediction Model of Surgical Outcome.

Computed tomography (CT) imaging of the temporal bone constitutes an integral element in the diagnostic workup of superior canal dehiscence (SCD). This study explores the utility of a clinically efficient method of manually estimating SCD size on CT imaging in predicting surgical outcomes. Cohort study. Tertiary center. Consecutive middle fossa repairs of SCD between 2011 and 2022 were included. Measurements of approximate dehiscence area (ADA), a previously established estimation method, on temporal bone CT imaging were performed by trained raters blind to clinical information. Surgical outcomes, evaluated with symptom resolution and audiometric improvement following repair, were assessed in multivariable regression models with ADA as the primary predictor and patient demographics and other history factors as covariates. Among 311 cases included, mean ADA was 2.68 mm2, and 71% of cases achieved overall symptom improvement (OSI). Every 1 mm2 rise in ADA predicted on average 3 dB greater narrowing of low-frequency air-bone gap (β 95% confidence interval, CI [-5.4, -0.7]) but 50% lower odds of OSI (adjusted odds ratio: 95% CI [0.32, 0.78]) among unilateral SCD cases. A model incorporating ADA, patient demographics, and history factors predicted OSI with a sensitivity, specificity combination as high as 85%, 73% and a positive predictive value, negative predictive value combination as high as 85%, 82% (area under the curve: 95% CI: 0.76-0.93). Increased ADA predicts more pronounced audiometric improvement but poorer symptomatic response among unilateral SCD cases. ADA is an efficient and practical method of estimating SCD size and demonstrated clinical utility in accurately predicting surgical outcomes.

Cerebral convexity arachnoid cysts: A focused systematic review with defining characteristics

IntroductionArachnoid cysts are non-neoplastic accumulations of cerebrospinal fluid formed within partitioned layers of the arachnoid mater. They represent about 1% of all intracranial masses in humans. Most arachnoid cysts present in the middle cranial fossa, but few occur along the cerebral convexity. Gross imaging of cerebral convexity arachnoid cysts (CCACs) is extremely scarce. The purpose of this study is to conduct a focused systematic review of CCACs and report their defining clinical characteristics. MethodsA systematic literature review was conducted to compile and summarize primary sources of anatomical and clinical information about CCACs. A large CCAC was discovered and dissected in a human cadaver. The CCAC was photographed in situ, and its impacts on contiguous gyri and sulci were documented and presented as a representative example of a CCAC. ResultsCCAC formation is attributed to congenital (primary) or trauma-related (secondary) etiologies. While they are often asymptomatic, CCAC location and size can influence symptomology. The anticipated increase in intracranial pressure can elicit mild (e.g., headache) to severe (e.g., seizure, hydrocephalus) sequelae. The present study exhibits a remarkably large CCAC that developed within the left central sulcus, displacing the precentral and postcentral gyri. The central sulcus artery and vein were present and appeared unaffected. ConclusionsManagement of CCACs can range from close observation with no intervention in asymptomatic cases to surgical intervention. Typical surgical options include microsurgical fenestration via craniotomy, neuroendoscopic fenestration, and various forms of shunting. The efficacy of one surgical approach over another remains highly debated. As CCACs are mostly diagnosed with CT and/or MRI, gross imaging of CCACs is extremely rare. This study provides clinical anatomists, neurologists, and neurosurgeons with visual insight and perspective into the physical and clinical characteristics of CCACs.

Temporal lobe evolution in Hominidae and the origin of human lobe proportions.

Objectives Evolutionary changes in hominin social complexity have been associated with increases in absolute brain size. The temporal lobes are nestled in the middle cranial fossae (MCF) of the skull, the dimensions of which allow estimation of temporal lobe volume (TLV) in extant and fossil taxa. Materials and Methods The main aim of this study is to determine where along the hominid phylogeny, major temporal lobe size transitions occurred. We used computed tomography (CT) scans of crania, 3D photogrammetry data, and laser surface scans of endocranial casts to measure seven MCF metrics in 11 extant anthropoid taxa using multiple regressions to estimate TLV in 5 extant hominids and 10 fossil hominins. Phylogenetic comparative methods mapped temporal lobe size, brain size, and temporal lobe proportions onto phylogenetic trees broadly for Hominidae and specifically for Hominini. Results Extant Homo sapiens were not an outlier in relative brain size, temporal lobe size, or proportions of the temporal lobes, but some proportions within the lobe were uniquely altered. The most notable changes in relative temporal lobe size and proportions saw a decrease in relative temporal lobe size and proportions in the genus Pan compared to other extant great apes and fossil hominins while there was a relative increase in the temporal lobe width and length in Australopithecus-Paranthropus clade compared to the genus Homo and other extant great apes including modern humans. Discussion We do not find support for the social brain, environmental or functional craniology hypotheses alone but think it prudent to consider the implications of cerebral reorganization between the temporal lobes and other regions of the brain within the context of these hypotheses and with future investigation is warranted.

A Case of Bilateral Idiopathic Temporal Cerebrospinal Fluid Leakage With Multiple Fistulas in the Middle and Posterior Cranial Fossae Closed Using the Transmastoid Approach

A Case of Bilateral Idiopathic Temporal Cerebrospinal Fluid Leakage With Multiple Fistulas in the Middle and Posterior Cranial Fossae Closed Using the Transmastoid Approach

Medicare Reimbursement and Utilization Trends Within Skull Base Surgery

Medicare reimbursements for otolaryngology and neurosurgery procedures have generally declined since 2000. We explore Medicare reimbursement trends for anterior cranial fossa, middle cranial fossa, posterior cranial fossa, pituitary surgery, and skull base reconstruction surgery from 2000-2022. Cross-sectional analysis of the Centers for Medicare and Medicaid Services Physician Fee Schedule was performed from 2000-2022 on approach, resection, and repair of the skull base (Current Procedural Terminology codes 31290-31291, 61546, 61548, 61575-61619, and 62165). Reimbursement data were adjusted for inflation to 2022 U.S. dollars, and annual and total changes calculated. The Centers for Medicare and Medicaid Services Part B National Summary Data File was analyzed for trends in Medicare procedure volume and total payment. Adjusted for inflation since 2000, reimbursements for anterior cranial fossa, middle cranial fossa, posterior cranial fossa, pituitary surgery, and skull base reconstruction codes had an overall decrease of 22.85%, 32.43%, 28.09%, 44.22%, and 38.65%, respectively. Simultaneously, procedure volume increased at an average annual rate of 63.99%, 128.57%, 19.75%, 36.11%, and 12.79%, respectively. While nominal per-service Medicare reimbursement has increased for skull base surgery codes, there has been a downward trend in inflation-adjusted procedural reimbursement. This parallels findings in other otolaryngology and neurosurgery procedures. Despite this, surgical volume in all skull base surgery subfields has increased, indicating increased utility and adoption of these techniques.

Current approaches to facial nerve schwannoma surgery.

Facial nerve schwannomas (FNSs) are exceedingly rare benign tumors. This study aims to report on a series of excised FNSs, providing clinical information and details on their surgical management, including novel approaches. We retrospectively reviewed patients who underwent surgical excision of FNSs in a private otology clinic and public tertiary referral center. The main outcome measures were facial nerve function, complete tumor removal, postoperative complications, tumor recurrence, and hearing. Seventeen patients (10 men and 7 women) with a mean age of 44.23 years (SD, 12.21) underwent surgery during the study period. The most common symptom was facial nerve dysfunction (58.8%). Facial and otoneurologic symptoms (hearing loss, tinnitus, and vertigo) were observed in 88.8% and 77.7% of patients, respectively. The middle cranial fossa (MCF) was the most common approach (six patients, 35.2%), followed by translabyrinthine (TL), transmastoid (TM), and combined TM-MCF (three patients, 17.6% each). Exclusive endoscopic transcanal suprageniculate (ETS) and mastoid combined with cervical approaches were applied once in two patients, 5.8% each. Total tumor removal was achieved in all cases. No significant postoperative complications were observed. The mean follow-up period was 193.2 months (SD, 119.5) and no tumor recurrence was observed. This study provides further evidence for the safety and efficacy of various surgical approaches for FNS, and incorporates the endoscopic transcanal approach. 4.

Surgical Technique for Repair of Tegmen Dehiscence with Encephalocele: A Retrospective Study

Tegmen dehiscence with encephalocele presents certain surgical challenges, necessitating innovative approaches to improve patient outcomes and minimize complications. Here we aim to evaluate the safety and efficacy of a novel middle cranial fossa craniotomy technique. Nineteen adult patients with radiographically confirmed tegmen dehiscence with encephalocele were included. Patients underwent a middle cranial fossa craniotomy technique for tegmen dehiscence repair, utilizing a split thickness bone graft, pedicled pericranial flap, and hydroxyapatite for extradural repair and with an inlay graft for the intradural repair. The primary outcome measured was major perioperative complications or need for revision surgery while secondary outcome measured was the resolution or improvement of preoperative symptoms associated with tegmen dehiscence. Our series encompassed tegmen dehiscence repairs in 19 patients, with an average age at surgery of 51 years (range 24 to 82). The average follow-up time was 8.80 months (range 0.43 to 27.62 months). Patients commonly presented with symptoms such as hearing loss (n=8), otorrhea (n=8), fullness or ear pressure (n=6), dizziness or imbalance (n=6), or a history of meningitis (n=4), among others. Postoperatively, symptoms resolved completely in 42% of patients (n=8) and partially in 58% of patients (n=11). Notably, no patients required revision surgery or developed new dehiscences in the follow-up period. Our middle cranial fossa craniotomy technique for tegmen dehiscence with encephalocele repair demonstrated promising postoperative outcomes, with complete or partial symptom resolution in all patients and no major complications. Our findings suggest that this technique is a safe and effective approach for tegmen dehiscence repair.

Assessing the Feasibility of Selective Piezoelectric Osteotomy in Transorbital Approach to the Middle Cranial Fossa: Anatomical and Quantitative Study and Surgical Implications

ObjectivesTo verify the feasibility and to discuss advantages and disadvantages of a piezoelectric orbitotomy (PO) during Superior Eyelid Endoscopic Transorbital Approach (SETOA). MethodsFive adult specimens underwent exoscopic/endoscopic SETOA to middle cranial fossa. The surgical corridor was created via piezoelectric orbitotomy by performing three selective and safe micrometric bone cuts providing a one-piece trapezoid bone flap which was repositioned and secured at the end of procedure. A 3D scan of the bone flap allowed us to reconstruct a 3D model and calculate its volume. An illustrative case demonstrating the application of this novel technique was also presented. ResultsAnatomical-morphometric quantitative analysis showed a mean bony-volume gain of 1,574.26 mm3 by using PO.PO yielded concrete surgical advantages and theoretical benefits in terms of functional and esthetic outcomes. All osteotomies were micrometric clear-cut and precise, resulting in a very thin bony gap; a complete sparing of soft tissues and neurovascular structures in- and around the orbit was observed. Lateral orbital wall reconstruction by replacing the bone flap aims to mitigate the risk of enophthalmos, proptosis, CSF leakage, pseudomeningocele and pulsatile headache, which represent significant challenges in the relevant literature. ConclusionPO may offer a viable, selective, effective, safe alternative to high-speed drilling during SETOA, especially for patients affected by intra-axial pathologies in which a watertight closure is mandatory. This procedure could prevent/decrease the risk of some of the main postoperative complications associated to the standard SETOA, resulting potentially in better functional and esthetic outcome.

Optimizing the pterional approach in medial sphenoid wing meningioma: a detailed morphometric study on anterior clinoidectomy and its effect on operability score

BackgroundMedial sphenoid wing meningiomas are best treated through pterional craniotomy, as pterional craniotomy provides wide and multidirectional exposure of the anterior and middle cranial fossa. Anterior clinoidectomy can increase the exposure potential. To delineate the role of anterior clinoidectomy (AC) in the standard pterional craniotomy approach through the evaluation of operability score measures (manoeuvrability arc, depth of surgical field, and surgical angle of attack). All patients with inner sphenoidal wing meningioma who underwent microsurgical excision between February 2022 and October 2023 were enrolled in the study. Preoperative and postoperative imaging studies (MR contrast studies and 3D thin-slice CT scans of the brain) were performed to determine the tumour size, extent, and pattern of optic canal involvement by comparing pre- and postoperative operability score parameters.ResultsTwenty-five patients met our inclusion criteria: 2 males (8%) and 23 females (92%). The mean age (SD) was 49.08 ± 6.42 years, with an age range of 39–60 years. The preoperative visual manifestations were as follows: eight patients (32%) had mild visual impairment, five patients (20%) had moderate visual impairment, six patients (24%) had severe visual impairment, and five patients (20%) had blindness. There was a significant positive correlation between the operability score and extent of resection (gross total resection was correlated with a higher operability score) (r = 0.301, n = 25, p = 0.005).ConclusionsA well-planned manoeuvrable arc allows neurosurgeons to perform surgery with precision, ultimately impacting surgical outcomes and the potential for complete tumour removal with minimal patient morbidity.

Analysis of moderate and severe traumatic brain injury associated with skull base fracture: a local tertiary center experience

BackgroundTraumatic brain injury (TBI) is a major medical and social concern in developing countries. TBI-related morbidity and mortality statistics in Egypt are lacking and do not reflect the actual magnitude of the problem.ObjectivesTo overview the incidence of moderate and severe head trauma in a heavily populated developing country and document the outcome of moderate and severe TBI associated with skull base fracture (SBF).MethodologyData of patients admitted to our center with moderate and severe TBI associated with skull base fracture (SBF) were reviewed in the period between January 2019 and March 2023.ResultsThe most common type of trauma was road traffic accidents in 54.2% of the patients; 91.2% had Single SBF (middle cranial fossa fracture was predominant 58.5%). 25.5% had an initial GCS of ≤ 8. Periorbital ecchymosis was the most common presenting sign in 36.3%. The most frequent complication (37.3%) was pneumocephalus. The presence of skull base fracture inversely affected the Glasgow outcome scale extended GOSE (P = 0.001, r = 0.674). Higher initial GCS scores were positively correlated with good GOSE (GOSE) (P = 0.001, r =− 0.222).ConclusionsRTA represents a significant cause for moderate and severe TBI in young male population. SBF is associated with poor outcome in moderate and severe TBI. Higher initial GCS score was positively correlated with good GOSE. It is important to have an overview of different types of TBI in Egypt.

Early clinico-radiological outcomes following neuroendoscopic cysto-cisternostomy for middle cranial fossa arachnoid cysts: a prospective cohort study with illustrative cases.

The dysmorphogenetic arachnoid cysts' pathomechanism is most favoured, and about 50% occur as middle cranial fossa cysts (MCFAC). Still being rare, management options are yet evolving. We described the clinico-radiological features, management and early outcomes of participants with MCFAC in our service. This prospective cohort study involved 29 pediatric participants recruited (from electronic health records, using ICD G93.0 D016080 for arachnoid cysts) between 01/01/2023 and 31/06/2023, following informed consent according to the ethical approval. All participants had neuro-imaging confirmed MCFAC. Baseline and follow-up data were retrieved and analyzed using summary (mean, standard deviation) and inferential (ANOVA, t-test) statistics. They were averagely aged 6.2 ± 4.48years and were mostly males (89.7%). 24.1% were asymptomatic. The commonest symptoms (n = 38) were headaches (23.7%), developmental delays (15.8%), eye complaints (15.8%) and cephalomegaly (7.9%). They were predominantly left-sided (89.7%). Galassi (G) 3 lesions were less (24.1%), with G2 and G1 lesions evenly sharing the rest. The average cyst volume was 58.4 ± 80.83cm3; there were significant differences (F = 4.682; p = 0.018) between the average volumes for G1 (14.4 ± 22.42cm3), G2 (61.7 ± 89.92cm3) and G3 (122.5 ± 94.37cm3) lesions. 44.8% of the participants had rigid-endoscopic cysto-cisternotomy (all between the ICA and oculomotor nerve into the interpeduncular cistern, using ventriculostomy forceps); including all G3, 50% of G2 and no G1 (had serial clinico-radiological observation) lesion. The average pre- (117.42cm3) and post-operative (53.48cm3) cyst volumes showed significant (t = - 2.797, p = 0.021) reductions. Middle cranial fossa arachnoid cysts occur predominantly amongst males, in middle childhood and left-sided. The treatment-related patient series are largely symptomatic, unlike the largely asymptomatic, screening-related series. Higher Galassi grade lesions presented with progressively, significantly larger cyst volumes and higher likelihoods of surgery. The average post-operative cyst volume at follow-up averagely showed almost 60% reduction from the pre-operative. All participants reported clinical remission.

Morphometry of the Foramen Ovale in Adult Human Skulls from a Clinical Perspective.

The foramen ovale is present in the posterior part of the greater wing of sphenoid. A trauma or space-occupying lesion in this area would result in clinical manifestations due to compression of the structures passing through it. This study was undertaken because of the clinical significance of the foramen ovale in radiological and neurological procedures. The aim is to study the morphometry of the foramen ovale and its bilateral variations. Fifty adult dry human skulls of unknown age and sex were studied. The shape of the foramen ovale (FO), presence of accessory foramina or abnormal bony outgrowths, if any, were noted. Maximum length and width of FO were measured. The foramen ovale was present bilaterally in all 50 skulls. Accessory foramen was present in 17 (34%) and 13 (26%) skulls on the right and left side, respectively. Bony out growths were present in 9 (18%) and 15 (30%) skulls on the right and the left side, respectively. Understanding the exact topography, morphometry and variations of the FO is required to enable the clinician to correctly interpret radiographs and help in planning the surgical procedures. The findings presented here should be taken into account when neurological procedures of the middle cranial fossa are performed.

Application and development of super minimally invasive surgery concept in acoustic neuroma resection

With the development of medicine, surgery has also experienced the development and evolution from traditional surgery to minimally invasive surgery, and then to super minimally invasive surgery (SMIS). Meanwhile, reducing surgical trauma and preserving and reconstructing nerve function have gradually become new goals of modern vestibular schwannoma (VS) resection surgery. The surgery of VS can be divided into hearing-preserving surgery (retrosigmoid approach and middle fossa approach) and non-hearing-preserving surgery (traditional translabyrinthine approach), according to whether the patient has practical hearing before operation. Improving the hearing preservation rate of hearing-preserving surgery and reconstructing the hearing of patients with non-hearing-preserving surgery are major challenges and hotspots. The traditional translabyrinthine approach has the highest proportion in the Department of Otolaryngology-Head and Neck Surgery, with the advantages of high facial nerve preservation rate and few intracranial complications. However, due to the resection of the cochlear nerve and labyrinth, the cochlea develops fibrosis, and patients lose the opportunity to reconstruct hearing through cochlear implantation. The new modified translabyrinthine approach can preserve the cochlear nerve and effectively reduce cochlear fibrosis, providing an opportunity for cochlear implantation to reconstruct the hearing. This is another important breakthrough in vestibular schwannoma surgery.

Occipital condyle syndrome due to small-cell lung carcinoma: A case report.

Skull base metastases, including those from small-cell lung carcinoma (SCLC), can present with various syndromes depending on the site of involvement, such as orbital syndrome, parasellar syndrome, middle fossa syndrome, jugular foramen syndrome, and occipital condyle syndrome (OCS). One such example is OCS, which consists of unilateral occipital headache accompanied with ipsilateral hypoglossal palsy. This case report describes a 51-year-old man initially diagnosed with OCS, which led to the discovery of systemic bone metastases from SCLC. Magnetic resonance imaging showed lesions in the occipital condyle and hypoglossal canal, while positron emission tomography-computed tomography identified a lung mass and widespread metastases. SCLC is highly aggressive and metastatic, with the bone being a common site of spread. In this case, the OCS preceded the diagnosis of the underlying malignancy. Prompt diagnosis and treatment are crucial, as patients with OCS often have advanced disease. This case highlights the importance of considering SCLC as a potential etiology for OCS, given the propensity for bone metastases. Early recognition and evaluation of OCS is essential to initiate appropriate management.

Mullan's triangle or anteromedial triangle of the middle cranial fossa: a cadaveric study with its surgical importance.

Surgical approaches to the cavernous sinus (CS) and middle cranial fossa (MCF) can be challenging, particularly for young neurosurgeons. The anteromedial (Mullan's) triangle is a triangle by the side of the CS and constitutes part of the floor of the MCF. The contents include the sphenoid sinus, superior ophthalmic vein, and sixth cranial nerve. The literature contains very little research that has precisely defined and measured the anteromedial triangle while considering anatomical variances minimally. The present study was conducted on the skulls of 25 adult human cadavers which were dissected to expose the anteromedial (Mullan's) triangle on both sides. After precisely defining the triangle on each side, measurements of the three borders were taken, and using Heron's formula, the area of each triangle was calculated. On average, the length of the medial border was 12.5 (+ 3.1mm); the length of the lateral border was 9.9 (+ 3.1mm); the length of the base was 10.75 (+ 2.4mm) and the area of the anteromedial triangle was 43.9 (+ 15.06mm2). Precise anatomical knowledge of the Mullan's triangle enables the treatment of disorders in often deformed anatomy or difficult-to-access structures. That is the reason it is important to gain a thorough understanding of the surgical anatomy and to adopt a safe procedure.

Arachnoid Cysts in Athletes with Sports-Related Concussion: A Case Series and Literature Review

BackgroundArachnoid cysts (AC) are associated with a risk of rupture or haemorrhage following head impact and pose a potential predisposing factor for significant complications of sport-related concussion. Despite a recognised association between ACs and intracranial haemorrhage/cyst rupture, the risk profile of participating in contact sports with AC is not well defined. We report a retrospective case series of players presenting to the Birmingham Sports Concussion Clinic between 2017 and 2023 and underwent MRI head, with a comprehensive review of the prior literature.Results432 athletes underwent MRI of which 11 were identified to have AC (middle fossa n = 8; posterior fossa n = 2, intraventricular n = 1). Average maximal diameter was 4.1 ± 1.2 cm. 64% had a protracted recovery (≥ 3 months). 9% experienced an AC specific complication (cyst rupture, complete neurological recovery, maximal diameter 6.5 cm, Galassi II, 4 previous concussions). 91% of patients (mean maximal diameter 3.9 ± 1.0 cm) experienced no complications despite multiple previous accumulated sports-related concussions (mean 3.3, range 1–9). Case studies from the literature are summarised (n = 63), with 98% reporting complications, none of which resulted in adverse or unfavourable neurological outcomes. Across prospective and retrospective cohort studies, 1.5% had a structural injury, and (where outcome was reported) all had a favourable outcome.ConclusionsAC is an incidental finding in athletes, with the majority in our cohort having sustained serial concussions without AC complication. The single complication within this cohort occurred in the largest AC, and AC size is proposed as a tentative factor associated with increased risk of contact sports participation. Complications of AC appear to be a rare occurrence. This case series and review has not identified evidence to suggest that participation in sports with AC is of significant risk, though individualised assessment and discussion of the potential risks of contact sports participation should be offered.