Temporal Fossa Research Articles

Novel Techniques to Manage Temporomandibular Disorders – A Multidisciplinary Approach

ABSTRACT Temporomandibular joint is a compound, bilateral, ginglymoarthroidal joint articulating the condyle to temporal glenoid fossa. TMDs often project a constellation of signs and symptoms. Therefore, the treatment plan for TMD’s should be more holistic. Current literature supports the interrelationship between chronic pain and behavioral, psychological, and psychosocial factors. This review elicits various treatment strategies for TMD’s and emphasizes combination of various therapies in resolution of pain and discomfort in patients with such disorders.

Primary orbital and adnexal rhabdomyosarcoma: a study of 54 Asian Indian patients

ABSTRACT Purpose To describe the clinical presentation, management, and outcomes of orbital and adnexal rhabdomyosarcoma (RMS) in an Asian-Indian cohort and analyze the factors predictive of outcomes. Methods Retrospective interventional case series of 54 patients of histopathology-proven RMS Results The mean age of presentation with RMS was 10 years (median, 7 years; range, <1–54 years). The most common tumor location was the superonasal quadrant (n = 21, 39%). Extensions beyond the orbit into the sinuses, temporal fossa, and brain were seen in 15 (28%), 3 (6%), and 8 (15%), respectively. First-line treatment modalities included a combination of surgical debulking, chemotherapy, and external beam radiotherapy in 20 (37%) patients; chemotherapy and radiation in 20 (37%); complete surgical excision and chemotherapy in 3 (6%); orbital exenteration, chemotherapy, and external beam radiotherapy in 1 (2%); chemotherapy alone in 1 (2%) patient, and 9 (17%) patients were lost to follow up. By Intergroup Rhabdomyosarcoma Study Group (IRSG) grouping, tumors belonged to groups I (n = 2,4%), II (n = 13, 29%), and III (n = 30, 67%). Kaplan-Meier survival estimates for tumor recurrence, lymph node metastasis, systemic metastasis, and death (n = 45) were 84%, 82%, 95%, and 95% at 1 year, 69%, 76%, 81%, and 77% at 5 years, 69%, 76%, 81%, and 77% at 10 years, respectively. On multivariate regression, age >18 years was found to have a significantly increased risk of locoregional LN metastasis (p = 0.005). Conclusion Despite aggressive treatment modalities, the 5–year disease-specific survival rate was 77% in Asian-Indian cohort. Age > 18 years at presentation was associated with a poorer prognosis.

Modified colored three-dimensional posterior and temporal cranial fossa model with mobility of the joint between C1 and occipital condyle

BackgroundSkull base surgery requires anatomical knowledge and appropriate surgical technique in bone drilling. We developed a newly modified three-dimensional (3D) model of the posterior cranial fossa as a learning tool that improves knowledge of skull base anatomy and surgical approaches, including skull base drilling techniques. MethodsThis bone model of the posterior cranial fossa was created based on computed tomography data using a 3D printer, and incorporates artificial cranial nerves, cerebral vessels, bony structures, dura mater, and cerebellar tentorial dura. These anatomical components are differentiated with various colors. In addition, the atlanto-occipital junction can be mobilized to fully expose the surface of the cartilage between the C1 condyle and occipital condyle to allow drilling to open the hypoglossal canal under a wide surgical field. The usefulness of the model for practicing skull base surgical approaches was evaluated. ResultsExperience of bone drilling, dural dissection, and 3D positioning of important structures, including cranial nerves and blood vessels, was identical to that in actual surgery. ConclusionsThis model is designed to facilitate teaching anatomical knowledge and essential epidural procedure-related skills, and is useful for teaching the essential elements of posterior skull base surgery.

Anatomie de la région frontale

The forehead is an anatomic region located between the frontal hairline cranially, the eyebrow and the glabella caudally, and the anterior border of the temporal fossa laterally on both sides. Its vertical situation, due to the telencephalon growth, is specific of the human species. From surface to deep planes, the skin and sub-cutaneous fat pads are described first. The muscular plane is constituted of the frontal muscles elevators of the forehead and the eyebrow, and the depressors which are the procerus and orbicularis oculi muscles superficially, the depressor supercilii muscle, and the corrugator supercilii in a deep plane. The galea aponeurotica, located deep to the frontal muscles, is a fibrous lamina on which the muscles of the skull insert. There is a sexual dimorphism of the frontal bone. The male forehead has extensive supraorbital bossing, and above this there is often a flat area, in teh femalethe supraorbital bossing is often nonexistent and above, there is a continous mild curvature. Blood supply to the forehead is given by an anterior pedicle constituted by the supraorbital and supratrochlear vessels and a lateral pedicle made of the anterior branches from the superficial temporal vessels. The sensory innervation of the forehead is given by the ophtalmic nerve which divides in frontal, nasociliar and lacrymal nerves. The motor innervation is given by the temporal ramus of the facial nerve which passes laterally to the zygomatic arch, and gives the innervation of the frontal, corrugator supercilii and procerus muscles.

Carbon-ion radiotherapy for clear cell odontogenic carcinomas

BackgroundClear cell odontogenic carcinoma (CCOC) is a rare odontogenic malignant tumor. The standard treatment for CCOC is surgical resection and adjuvant radiotherapy (RT). Radiotherapy is generally considered in inoperable cases. However, there are no reports on definitive RT for CCOC, and the role of RT in patients with inoperable CCOC remains unknown. Therefore, in this report, we present two cases of carbon-ion (C-ion) RT for CCOC.Case presentationIn case 1, a 73-year-old man with mandibular CCOC presented with recurrence in the inferior temporal fossa after two tumor resections. The tumor was considered inoperable, and C-ion RT (57.6 Gy in 16 fractions) was administered. The tumor remained controlled even after 20 months of C-ion RT; however, the patient died of other causes. In case 2, a 34-year-old man with maxillary CCOC presented with recurrence in the left sinonasal region after two tumor resections. The tumor was considered inoperable, and C-ion RT (64 Gy in 16 fractions) was administered. However, recurrence was observed in the irradiated field 19 months after the treatment. Subsequently, C-ion RT (64 Gy in 16 fractions) was repeated for the recurrent tumors. Seven years and 6 months after the initial irradiation, the tumor remains controlled, and the patient is alive without any unexpected serious adverse events.ConclusionC-ion RT may be an effective treatment option for patients with inoperable CCOC.

Aesthetic Temporal Augmentation with the Pedicled Temporoparietal Fascia Flap.

The contour of the temple area can significantly influence the overall facial shape and proportions. To date, various methods and techniques have been used to augment the deficient temporal fossa; however, each of these approaches has certain inherent limitations. The present study aimed to transfer the temporoparietal fascia flap (TPFF) to the frontotemporal regions for aesthetic temporal augmentation. This was a retrospective study of 13 cases with temporal depression who underwent a TPFF procedure for aesthetic temporal augmentation. These cases were operated for three years, from January 1, 2020, to December 1, 2023, at Nanjing Second Hospital, Nanjing, China. The data of bilateral temple width showed a measurement of 12.20 ± 0.53cm (preoperative) and 14.36 ± 0.41cm (postoperative), with a statistically significant difference (p < 0.001). There were no postoperative complications, including hematomas, infection, or facial nerve injuries. All patients were followed for 6 to 48 months (mean: 18 months) and exhibited cosmetic improvement. Overall, 10 patients were satisfied with the aesthetic results, while 3 were unsatisfied due to undercorrected depression. During the follow-up period, the temple volume was maintained. The frontal temple exhibited a smooth contour, and scalp baldness at the incision site was inconspicuous. Compared with other methods, the pedicled TPFF flap transfer is a safe and effective technique for correcting depressions in the frontotemporal regions. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Finds of Skulls of Juvenile Kurdalagonus maicopicus (Cetacea, Cetotheriidae) in the Upper Miocene of the Republic of Adygea.

Fragments of two skulls of young cetotheriid baleen whales were described from the Fortep'yanka 2 locality (Russia, Republic of Adygea, Maikop district, Fortep'yanka River valley, Upper Miocene, Upper Sarmatian, Blinovskaya Formation). The finds were attributed to Kurdalagonus maicopicus (Spasskii, 1951) based on the morphology of the posterior (mastoid) process of the petrosal bone, the structure of the posterior edge of the temporal fossa, and the S-like shape of the supraoccipital ridges. The skull proportions and the degree of suture closure made it possible to determine the individual age of the whales within a year. New finds significantly complement the data on the structure of the sutures of the lateral wall of the skull and age-related variability of cranial morphology in representatives of the genus Kurdalagonus.

Nonspecific inflammatory pseudotumor of the maxillary and temporal fossa: a study of seven cases

ObjectiveInflammatory pseudotumor (IPT) is a rare, locally aggressive, benign neoplasm of unknown etiology. Because of its aggressive clinical behavior and locally destructive or infiltrative features, it may be mistaken for a malignant tumor. Approximately 5–44% of extrapulmonary IPT occur in the head and neck, primarily affecting the orbit. Study DesignBetween 2008 and 2021, our hospital received referrals for seven patients (three men and four women, aged 42–73 years) with pain, swelling, mass, and trismus. Computed tomography, magnetic resonance imaging, and biopsy were performed on all patients to diagnose IPT. ResultsOf the seven patients, four received low-dose prednisolone (PSL), one underwent surgery, and two were left untreated. The IPT disappeared in one of the two untreated cases, whereas it improved and later deteriorated in the other. The surgical patient had no recurrence. Low-dose PSL was effective in two patients; however, high-dose PSL and immunosuppressants were required in the remaining two cases owing to infiltration into each orbit or brain region. ConclusionsLow-dose PSL treatment was applicable in IPT cases affecting the maxillary to temporal fossa region, wherein symptoms did not improve without treatment. However, when low-dose prednisolone was ineffective, high-dose prednisolone and immunosuppressants were required.

Characterizing immune microenvironment cell composition of chronic rhinosinusitis with nasal polyps based on mass cytometry technology

Objective: To analyze the cellular composition characteristics of the nasal tissue immune microenvironment in patients with control, chronic rhinosinusitis without nasal polyps (CRSsNP), non-eosinophilic chronic rhinosinusitis with nasal polyps (neCRSwNP), and eosinophilic chronic rhinosinusitis with nasal polyps (eCRSwNP) using mass cytometry flow technology. Methods: Thirteen CRS patients who underwent endoscopic nasal surgery at the Department of Otorhinolaryngology Head and Neck Surgery of Peking Union Medical College Hospital from March to December 2022 were recruited, including 8 males and 5 females, aged 22.3 to 58.3 years. Three control mucosae were obtained from normal ethmoid or sphenoid sinuses of patients with benign tumors of the temporal fossa or non-functional pituitary adenomas who underwent endoscopic surgery, excluding allergic rhinitis and sinusitis. Sixteen clinical tissue samples (3 of control, 3 of CRSsNP, 4 of neCRSwNP, and 6 of eCRSwNP) were prepared into single-cell suspensions. Mass cytometry flow detection was performed using a combination of 42 molecular markers to analyze the differences in cell subpopulations among the groups. Data were analyzed using GraphPad Prism 9. Results: Based on the mass cytometry flow results, cells from control, CRSsNP, neCRSwNP, and eCRSwNP were divided into seven main cell subgroups, with detailed subgrouping of T/NK cells and myeloid cells. In T/NK cells, compared with the control group, the number of NK CD56bright cells increased in the CRSsNP group, while NK CD56dim cells decreased; compared with the CRSsNP group, the eCRSwNP group showed a decrease in NKT cells and CD4+Tem cells; compared with the CRSsNP group, the eCRSwNP group showed a significant increase in CD25 expression within Treg cells; compared with the CRSsNP group, the eCRSwNP group showed a significant decrease in Tbet expression in CD8+Teff cells and CD8+TRM cells; in eCRSwNP, the expression of CD103 in CD8+TRM cells was significantly lower than in CRSsNP. In myeloid cells, compared with the other three groups, the eCRSwNP group showed a significant increase in macrophages and a significant decrease in cDC1 and monocytes; compared with the control group and CRSsNP, the eCRSwNP group also showed a significant decrease in resting state macrophages; compared with the CRSsNP group, the eCRSwNP group showed a significant decrease in the level of CX3CR1 within cDC2 and monocytes; the expression levels of NLRP3 in cDC2 and macrophages in the eCRSwNP group were significantly higher than in the other three groups; compared with the control group, the expression levels of Gata3 in cDC2 and macrophages in the eCRSwNP group were also significantly increased; additionally, the expression of CCR2 within monocytes in the eCRSwNP group was lower than in the CRSsNP group. In ILC, compared with the control group, the expression of CCR6 decreased in the eCRSwNP group. Conclusions: Compared with the control group, CRSsNP, and neCRSwNP, eCRSwNP shows an increase in macrophage number, a decrease in cDC1 and resting state macrophages, and depletion of protective cells CD103+CD8+TRM. Additionally, the expression levels of CCR2 and CX3CR1 in monocytes of eCRSwNP are decreased.

Neglected Spheno-orbital Meningioma Presenting with Unilateral Blindness

Sphenoorbital meningiomas (SOM) constitutes 9% of all intracranial meningiomas and are originated from sphenoid wing dura. They are also called en plaque meningioma. They cause hyperostosis of involved bone and their soft tissue growth may spread the orbit, the infratemporal fossa, and the temporal fossa. Most patients with SOM are middle- aged women and most commonly presents with unilateral, nonpulsating, progressive proptosis. Recently a woman with unilateral progressive proptosis from a remote area of Bangladesh presented to us with blindness of her left eye due to diagnostic delay. After thorough evaluation and imaging studies, she was diagnosed with a large spheno-orbital meningioma with extensive bony involvement of skull base and orbit. Objective: This report highlights the necessity of creating awareness among optometrists, undergraduate medical students as well as and ophthalmologists who are practicing in remote areas of Bangladesh about clinical presentation of sphenoorbital meningiomas which is a benign lesion but may be a cause of unilateral blindness if remain undiagnosed for long Bang. J Neurosurgery 2023; 13(1): 51-54

Lateral rectus pulley concerning the orbital wall. Area of a stereotyped bony insertion

PurposeTo examine the lateral rectus muscle pulley and its bony insertion concerning the orbital rim and periorbita. DesignProspective. An observational anatomic study. MethodsStudy population: Twenty postmortem orbits (10 right, 10 left) of 10 Caucasian cadavers (8 females, 2 males; age range at death, 57–100 years; median age, 79.5 years) fixed by the Thiel method.Intervention: The floor of the temporal fossa was exposed, and a bone window on the lateral wall of the orbit, posterior to the sphenozygomatic suture, was created, keeping the periorbita intact. The lateral canthus and lateral palpebral ligament were isolated and opened, and the eyelids were folded back. The frontozygomatic suture was identified, and the orbital septum opened adjacent to the orbital rim. The conjunctiva was opened at the limbus, and the lateral rectus insertion was isolated. The bone pillar containing the frontozygomatic suture and the insertion of the periorbita and the pulley was isolated and removed en bloc. The lateral rectus muscle was isolated and excised.Main outcome measures: Position of the pulley ring on the lateral rectus muscle belly and its bony attachment area in the lateral wall of the orbit. ResultsThe pulley bony attachment was roughly quadrilateral with an approximate area of 90 mm2, 3 mm (mean, range 1–5 mm) posteroinferior to the frontozygomatic suture and 1 mm posterior to the orbital rim. The anterior margin of the pulley sleeve was found at 21.0 mm (median, p25-75 20.0–22.8) from the scleral insertion. ConclusionsThe lateral rectus pulley is stereotyped in its position in the muscle belly and its bony insertion, coinciding with the point of greatest adhesion of the periorbita to the anterior part of the lateral wall of the orbit.

TOPOGRAPHIC AND ANATOMICAL PECULIARITIES OF THE LATERAL REGION OF THE HEAD IN HUMAN FETUSES

HEAD IN HUMAN FETUSESAbstract. In order to clarify the topographical and anatomical peculiarities and variant anatomy of the structures of the lateral region of the head in the fetal period of human ontogenesis, 24 specimens of human fetuses aged from 4 to 10 months of intrauterine development were studied using a complex of morphological research methods (anthropometry, macroscopy, computer tomography, morphometry, reconstruction). We found anatomical variants of the masseter and temporal muscles in human fetuses. Thus, in a 5-month-old fetus, separate muscle bundles were found, which went from the right masseter to the right temporal muscle. In a 6-month-old fetus, the deep part of the left masseter muscle was fused to the left temporal muscle. In human fetuses, the temporal fascia in the direction of the zygomatic arch splits into two layers, between which there are accumulations of adipose tissue. In late fetuses, a formed sub-aponeurotic fi brous space was found. At the end of the fetal period, a deep fi brous space is observed between the periosteum and the inner edge of the temporal muscle. The cellular spaces of the temporal area in front are connected with the buccal fat pad, which creates the prerequisites for the spread of infl ammatory processes. The topographic and anatomical features of the temporal region of human fetuses are: weak development of the temporal muscle and small depth of the temporal fossa – in the middle part from 3.0 to 6.0 mm (depending on the age of the fetus); weakly developed tendinous part of the temporal muscle, which does not reach the temporal line of the parietal bone. The bony base of the temporal area is represented by the squamous part of the temporal bone, the greater wing of the sphenoid bone, part of the parietal and frontal bones, on the inner surface of which arterial grooves and impressions of cerebral gyri are hardly visible, and sometimes not at all clear or absent. Anatomical variants of the structure of the temporal and masticatory muscles, as well as the temporal fascia, can cause complications and errors during the diagnosis and surgical treatment of infl ammatory processes in the postnatal period of human ontogenesis.

Anatomy of the temporal region to guide filler injections.

Hollow temples are not typically considered aesthetically pleasing, and hollowness worsens with the aging process. When filling this region with fillers, there are several anatomical considerations, with injection techniques varying depending on the layer targeted. Specifically, injections between the superficial temporal fascia and the superficial layer of the deep temporal fascia are performed using a cannula, while periosteal layer injections involve the use of a needle to reach the bone before inserting fillers. Detailed anatomical insights encompass the boundaries of the temporal fossa and cautionary notes regarding blood vessels, supported by specific studies on veins and arteries in the temporal region. Complications, including vessel injuries, are discussed alongside an exploration of various injection techniques. This review provides a comprehensive exploration of anatomical considerations and the specific methodologies employed in temple augmentation with fillers.

Pitfall of Monobloc Advancement in Beare-Stevenson Syndrome.

Beare-Stevenson syndrome (BSS) is an extremely rare form of craniosynostosis. Half of patients with BSS died within the first year of life due to cardiorespiratory arrest or unexpected sudden death. In addition, there have only been fewer than 30 cases, which limits prognostication for clinicians. We currently have an 8-year-old patient who is being followed up. She underwent tracheostomy, cranioplasty, and shunting. After waiting for growth, for improvement of ocular herniation, monobloc advancement was performed at the age of 5 years. The temporal fossa was quite narrow due to severe midface hypoplasia. In addition, even though midface advancement, it was difficult to remove tracheostomy. This was because midfacial hypoplasia was so severe that it was hard to notice, but there was also micrognathia. We report our experience with this midface treatment.

Traumatic middle meningeal artery aneurysm: a case report

IntroductionTraumatic intracranial aneurysms are rare, making up about 1% of all intracranial aneurysms. They can happen due to direct injury or blunt force, with the middle cerebral artery being the most frequent site.The middle meningeal artery (MMA) is the main artery that supplies the cranial dura mater, and, because of its location, is susceptible to damage after trauma. This article reported an unusual case of giant post-traumatic MMA pseudoaneurysm. CaseA 45 year-old man was referred to our department with a history of craniectomy. He complained of non-specific headache, but neurological examination was normal. A follow-up brain CT scan identified a right temporal fossa hyperdense mass. Digital subtraction angiography diagnosed a traumatic MMA aneurysm. The patient was treated with preoperative aneurysm embolization and surgical resection. DiscussionTraumatic MMA aneurysm is a rare presentation after head trauma. It can manifest as epidural hematoma, subdural hematoma or intraparenchymal hematoma, and sometimes resembles the present case, which was discovered incidentally. ConclusionPseudoaneurysm is a rare complication of MMA trauma, with late presentation. It should be considered in patients with history of traumatic brain injury and temporal fossa extra-axial mass lesion with vascular characteristics.

Surgical Navigation Applied in Removal of Glass Located Under Zygomatic Arch.

The limited detection rate of plain radiography (as low as 75%) for glass particles within the softs renders the conventional C-arm visualization method ineffective in intraoperative scenarios. The authors report the successful use of intraoperative navigation to visualize and extract multiple small glass fragments located deep within the temporal fossa and beneath the zygomatic arch. A 25-year-old man presented with a deep facial laceration, suspected injury to the temporal branch of the facial nerve, and a 2×2cm foreign body beneath the sphenoid bone near the left zygomatic arch. The initial surgery removed most of the glass; however, two 4mm fragments remained near the skull base. Using intraoperative navigation, a 3cm incision was made, and a navigating stylet was used to locate and remove the foreign bodies. In conclusion, intraoperative navigation is a precise method for removing small, imperceptible glass fragments from challenging anatomic areas, thus reducing the need for extensive dissection compared to conventional approaches.

Long-Term Follow-Up of the Behavior of Facial Volumizing Cross-Linked Hyaluronic Acid Gels

Introduction: We present the long-term follow-up photographic and MRI data on 4 patients 42-44 months after cross-linked Hyaluronic Acid (HA) gel injection into the temple region. All injected HA gels were produced using the registered and patented “Inter Penetration Network Like®” (IPN-Like® cross-linking technology) (LABORATOIRES VIVACY, France). The initial results following injection and up to 24 months were previously reported [1,2]. Material and methods: Our study population comprised 4 Caucasian patients who were enrolled into our two previous studies that compared Stylage XL versus Stylage XL-Lido (incorporating lidocaine added at manufacturing) [1] and Stylage XL versus Stylage XXL [2]. Patients, radiologists and the independent evaluators were blinded to the type of product used. The 4 patients were each injected in both temporal fossae using the 2 different HA gels being compared (one on either side). All patients had their follow-up at month 42 after injection (M42) with the exception of one patent who her MRI and photographs taken at the same setting on month 44 (M44). Photographic assessments were undertaken by the injector and 2 independent experts using Merz-Analogic Scale® (MAS®) and the Global Aesthetic Improvement Scale (GAIS). Results: Except for participant 2 (Stylage® XL vs. Stylage® XL-Lido) on the Stylage® XL-Lido side, all the other participants were considered to have a degree of persisting improvement compared to baseline, according to experts scoring of photographs on MAS and GAIS, However, there was a gradual deterioration in the level of improvement compared to the other assessment time-points. MRI: Although the bolus of injected gel was spherical at D0, we observed a change in the shape of the implant over time on MRI, where it changed from a round to a “teardrop” shape. Slow resorption occurred from 18 months onwards. At M42-44, the gel appearance on MRI remained similar to that previously reported at M18. The MRI residual volume calculation showed persistent increased volume compared to the volume initially injected. The product location appeared stable. There were no radiological or clinical signs of inflammatory reaction in tissues adjacent to the gel. Conclusion: At long-term follow-up 42-44 months after initial injection there was still an improvement in the aesthetic appearance of the temporal fossa and the MRI images show the continued presence of the gel. We also noticed that Stylage®XL (without lidocaine) seemed to absorb more water than its counterpart with lidocaine. Likewise, Stylage® XL seemed to absorb more water than Stylage® XXL.

Establishing the Precise Location of Apanga Marma and defining its Structural Component through Cadaveric Study

Background: Apanga marma is a Jatrurdhwagata marma that is positioned within half angula dimension below the tail end of the eyebrow and outer to the lateral canthus of the eye. Its injury causes andhya and dristiupaghata. Sushruta classifies it as Sira structurally, however Vagbhata classifies it as Snayu marma. The precise position, radiance, and conflicts in opinion in identifying the structural entity and applied importance of this marma must be clarified. The objective of this study was to locate and ascertain the position and structural entity of Apanga marma. Materials and Methods: Study was conducted in two steps: Conceptual study by reviewing the literatures and cadaveric observational study by dissection over 4 cadavers. Results and Discussion: The Apanga marma was discovered to be positioned on the anterior section of the superior temporal fossa, near the lateral canthus of the eye. Extracranial, intracranial, and intraorbital neurovascular structures were observed within the designated area. Structures in the area include the Middle cerebral artery, the Middle meningeal artery, and the Abducent nerve, which can cause visual problems or total blindness if injured. Conclusion: Apanga marma was found to be located in the anterior section of the superficial temporal fossa, lateral to the lateral orbital edge, beneath the tail end of the eyebrow, and above the zygomatic arch. The middle meningeal and middle cerebral arteries were discovered as a specific anatomical entity in the marma area, resulting in blindness or vision impairment upon injury.

Chronic subdural hematoma associated with type II and type III Galassi arachnoid cysts: illustrative cases.

Arachnoid cysts (ACs) are congenital abnormalities that can be located anywhere within the subarachnoid space along the cerebrospinal axis, although they are most often found on the left side in the temporal fossa and sylvian fissure. ACs comprise approximately 1% of all intracranial space-occupying lesions and are considered potential risk factors for subdural hematoma (SDH) in individuals of all age groups who have experienced traumatic brain injury. Although it is uncommon for an intracystic hemorrhage of an AC to occur without evidence of head trauma, it may be more common among children and young adults. Here, the authors present three cases of spontaneous AC intracystic hemorrhage with chronic SDH. Additionally, they provide a thorough review of the existing literature. All three patients with AC were adolescent males. In all cases, AC was identified using the Galassi classification (type II or III) and associated with spontaneous intracystic hemorrhage and chronic SDH as seen on imaging. Spontaneous intracystic hemorrhage is a rare complication and occurs most commonly on the left side. Surgery is the definitive treatment, requiring either craniotomy or burr hole for hematoma evacuation and microsurgical fenestration to drain the cyst into the subarachnoid cisterns.

Immunoglobulin G4-Related Hypertrophic Pachymeningitis Presenting with Multiple Lower Cranial Nerve Palsies

Immunoglobulin G4-related disease (IgG4-RD) is a multi-organ condition that infrequently exhibits neurological involvement. Here, we describe a case of IgG4-related hypertrophic pachymeningitis with multiple lower cranial nerve palsies. A 65-year-old man presented with a 5-month history of hoarseness and dysphagia. A neurologic examination revealed multiple lower cranial nerve palsies. Brain magnetic resonance imaging indicated diffuse dural involvement along the left tentorium and temporal fossa. Serum IgG and IgG4 levels were found to be elevated. Ethmoid polyp biopsy revealed chronic inflammation with moderate lymphoplasmacytic and some eosinophilic infiltration. Up to 60 IgG4-positive cells were observed per high-power field, and the measured IgG4/IgG ratio was approximately 10% to 20%. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography indicated abnormally high FDG uptake in the left posterior fossa, tentorium, and left temporal fossa, with additional involvement of the lung, iliac artery, and renal artery. Based on these findings, we diagnosed the patient with IgG4-related hypertrophic pachymeningitis and successfully treated the condition with steroids and rituximab. IgG4-RD should be differentiated from distinct conditions presenting with multiple cranial nerve palsies accompanied by pachymeningitis.