Search

Anterior approaches to the clivus must provide excellent visualization of the lesion, give adequate access for dural repair, and be cosmetically acceptable. Most current approaches enter through the nasopharynx or oropharynx, with either palatal, maxillary, or mandibular splitting for greater exposure. We have modified the transfacial approach described by others, which provides excellent access to the clivus along its rostrocaudal extent. A lateral rhinotomy incision is used and carried along the base of the right alae nasi and columella. The nasal bones are osteotomized bilaterally, and the nose is rotated on a pedicle flap, thus opening the entire nasal cavity to view. The septum and medial maxillary walls are removed. This provides excellent visualization of the ethmoid, sphenoid, posterior nasopharynx, and upper oropharynx. At the conclusion of the procedure, the nasal incision is closed, with good cosmesis. A case of recurrent chordoma of the middle and lower clivus is presented to exemplify this technique. The approach has since been used to approach clivus tumors and midline aneurysms of the vertebrobasilar system.

In a review of 68 meningiomas with good quality computed tomography (CT) scans, 40% had significant CT edema, in the sense of having low absorption around tumor. Two distinct patterns of edema could be distinguished. One was a diffuse white matter process appearing to represent active transudation of water into white matter; this occurred in 43% of tumors with edema. The second, occurring in 57% of tumors with edema, was a localized peritumoral process. This distinction has important pathophysiologic and clinical implications. The diffuse pattern did not appear to reflect tumor size: it was found in 54.6% of tumors from 2 to 4 cm in diameter and 33% of tumors over 4 cm. It appeared more often in tumors of the lateral sphenoid wing or subfrontal region and was more often associated with atypical and syncytial histological type, (p < 0.05, two-tailed t test.). It occurred disproportionately often in atypical tumors and appeared to reflect some intrinsic property of the tumor rather than compression of surrounding structures.

Over a 22-year-period (1967-1989) 80 patients 70 years of age and older underwent surgery for resection of a benign intracranial tumor. This group included 56 meningiomas and 24 acoustic neuromas. Forty-five of the tumors were completely excised, whereas 35 were partially removed. Tumor regrowth was documented in seven patients during the follow-up period, five of whom underwent additional surgery for resection of recurrent tumor. Thirty-six (64.3%) of the patients with meningiomas had only a minimal or no preoperative neurologic deficit, whereas twenty (35.7%) had a major deficit. Fifty-three (94.6%) patients who underwent surgery for resection of their meningioma made a good recovery (48 were improved or unchanged and five had minimal nonincapacitating worsening), one (1.8%) was worse, and two (3.6%) died. Fourteen (58.3%) of the patients with acoustic neuromas had only a minimal or no preoperative neurologic deficit, whereas 10 (41.7%) had a major deficit. Twenty-two (91.7%) of the patients who underwent surgery for resection of their acoustic neuroma made a good recovery (18 were improved or unchanged and four had minimal nonincapacitating worsening), two (8.3%) were worse, and none died. We conclude that, when indicated, surgery for intracranial meningiomas and schwannomas can be offered to patients 70 years of age and older with acceptable morbidity and mortality.

The management of patients with cavernous angioma continues to evolve. Our current recommendations for management are as follows. 1. Patients who are asymptomatic are observed. 2. Patients with acute severe or progressive neurological deficits are operated upon. 3. Patients presenting with a seizure are usually operated upon but some are observed, depending on the factors discussed. 4. Patients with a single hemorrhage in the cerebrum, cerebellum, or spinal cord are usually operated upon. When the hemorrhage is in the brainstem, thalamus, or basal ganglia, they are observed. 5. Patients with a recurrent hemorrhage are usually operated upon but there are exceptions when the lesion is in a deep area with high surgical risk.

A case of primary intracranial leiomyosarcoma is presented, with clinical, radiological, light microscopic, immunohistochemical, and ultrastructural data. The histogenesis is discussed and the literature on smooth-muscle tumors of the central nervous system is reviewed.

Positron scintigrams were obtained in normal subjects and in patients with intracranial tumors and cerebral vascular disease, using a multicrystal positron camera. The radiopharmaceuticals were 68Ga complexed with adenosine triphosphate (68Ga-ATP), 13N-ammonia (13NH3), and 15O2. Six clinical cases are described to illustrate the different cerebral distributions of intravenously administered 68Ga-ATP, 13NH3, and inhaled 15O2. The possible value of these agents in the study of cerebral metabolism and in differential diagnosis of intracranial disease is discussed.