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This report is a retrospective analysis of the surgical outcome of 15 patients (8 females, 7 males; mean age, 37.8 years) with residual or recurrent vestibular schwannomas operated on between 1987 and 2005. These 15 patients were part of a larger series of 252 consecutive vestibular schwannoma excisions. Tumors were classified as large (10) when their diameter exceeded 3.5 cm and giant (5) when their diameter exceeded 4.5 cm. All patients had previously undergone surgery. Hearing was lost in all cases, 8 had complete facial nerve palsy, 6 had trigeminal nerve deficits, 5 had cranial nerve IX and X palsy, and 10 had ataxic gait. Twelve patients had hydrocephalus. The tumors were reoperated through the retrosigmoid-transmeatal approach. The mean postoperative follow-up was 4.9 years. Complete resection was achieved in all patients. The facial nerve was preserved in 6 of the 7 patients with preoperative facial function. Transient worsening of bulbar cranial nerves palsy occurred in 2 cases. Cerebrospinal fluid leakage occurred in 3 patients. There were no deaths, and the tumors were histologically benign. Surgical removal is the only treatment for these lesions. Total resection associated with a low morbidity rate is possible. Preservation of the facial nerve is difficult due to severe scar tissue.

Introduction: A transclival spontaneous fistula is a rare event. It usually becomes symptomatic and is detected by means of either CSF rhinorrhea or intracranial complications such as meningitis. Different skull base variants of normality have been described in anatomic and radiological literature. Of special interest to surgeons is the possibility that some of such bone variants occur in the embryological formation of the anterior skull base, resulting in a local bone defect or persistence of a vascular canal in the clivus that might become symptomatic after a precipitating factor such as skull base approaches. Case Report: We present a case of a CSF fistula due to a clival bone defect manifesting after transsphenoidal surgery for a pituitary microadenoma. We did not consider it a postsurgical complication because no extended approach was employed and the clival bone was not drilled by surgical maneuvers. The case is illustrated with pre-, intra-, and postoperative images, and the pathophysiology of spontaneous transclival fistula, as well as its possible complications and management, is discussed with basis in current literature. Conclusion: The authors suggest that the patient harbored an embryological remnant, previously described as “canalis basilaris medianus,” which, after resection of clival mucosal layer, communicated the CSF space around the clival area with the retropharynx. The possibility of detecting such embryological remnants preoperatively and its consequences of alerting to the possibility of early postoperative fistulas make this report of value for skull base surgeons.

Objective: With the advent of modern neurosurgical techniques and multidisciplinary “skull base groups,” surgery has become the treatment of choice for jugular foramen lesions. Tumors with large intracranial extension represent, however, a considerable challenge to the skull base surgeon. With the availability of new diagnostic procedures these tumors have been more precisely studied and questions arise of whether, when, and how these lesions should be treated. Data from 110 consecutive patients, surgically treated in the past 18 years, were retrospectively analyzed to identify surgical outcomes. Methods: Between 1987 and 2006, 110 patients with jugular foramen tumors presenting with intracranial-intradural extension were operated upon at the Neurological Institute of Curitiba and State University of Campinas, Brazil. A multidisciplinary craniocervical approach was the standard method of treatment. The same surgical technique was used to resect all tumors. Preoperative embolization was performed in cases of paragangliomas and well-vascularized meningiomas. Saphenous graft bypass was carried out in 2 patients before removal of the lesions due to infiltration of the ICA. A new muscle-fascia flap was developed by our group and was used to cover the surgical defect. When necessary, the facial nerve was reconstructed with nerve grafts (great auricular nerve) or XII/VII anastomosis. Results: Paragangliomas were the most frequent lesions, followed by schwannomas and meningiomas. There were 62 paragangliomas, 18 schwannomas, and 11 meningiomas. The most common signs and symptoms were hearing loss and dysfunction of cranial nerves IX, X, and XI. Complete tumor removal was achieved in 89% of benign tumors and 80% of paragangliomas. Lower cranial nerves deficit was the most frequent complication (10 patients, 9.4%); it was transient in 4 cases. Facial and cochlear nerve paralysis occurred in 8 patients (7.5%). The function of facial nerve recovered spontaneously in 3. CSF leak was observed in 4 patients (3.7%). Four patients (3.7%) died after surgery. Conclusion: Radical removal of benign jugular foramen tumors is the treatment of choice and may be curative. Single-stage removal of complex cases of jugular foramen tumors may be performed safely with acceptable morbidity. Postoperative lower cranial nerves deficit is the most serious surgical complication. The possible causes of complications in these large tumors and the strategies used to avoid them will be presented.