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We describe the case of a 32-year-old man from Cape Verde having headache and increasing visual loss. Clinical and radiological investigations disclosed a massive destructive lesion involving the anterior and central skull base, orbit and nasoethmoid region initially interpreted as a malignant small round cell tumour. Surgical biopsies were negative for neoplasm, showing an intense inflammatory infiltrate together with fungus, later characterised as Aspergillus flavus spp. The patient was immunocompetent with no evidence of congenital or acquired immunodeficiencies. Invasive fungal infections in immunocompetent patients are rare and can be a diagnostic challenge. The best diagnostic clues include the patient’s origin from tropical climates, imaging features and the identification of fungal hyphae on pathology specimens. Although a devastating disease in immunocompromised patients, craniocerebral aspergillosis in immunocompetent patients carries a better prognosis. Available literature supports the combined used of ‘conservative’ surgical resection and antifungal therapy as the best treatment option.

Mucormycosis is a very commonly encountered disease in the sinonasal region in patients with diabetes and immunocompromised status specially in the northern part of the Indian continent. Due to its fulminant nature and involvement in the rhino-orbital-cerebral region, prognosis is poor even after extensive debridement and amphotericin-B therapy. We present a case with diagnosis of sarcoidosis being treated with systemic steroids who developed sudden-onset ptosis and left lateral rectus palsy. On radiological evaluation with MRI, a heterogenously peripherally enhancing lesion was seen in the nasopharynx suggestive of nasopharyngeal abscess. The patient was taken up for emergency surgery; a necrotic lesion with destruction of sphenoid bone, pterygoids and clivus was seen originating in the nasopharynx. The lesion on fungal staining came out to be broad aseptate hyphae suggestive of mucormycosis.

Introduction Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition. Objective To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach. Methods A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined. Results Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 − 41 months). Conclusion Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Background The jugular foramen (JF) can be the site of several tumours. Paragangliomas, schwannomas and meningiomas are the most commonly reported. We describe a case of melanocytoma originating from the JF and presenting with an accessory nerve palsy. Illustrative case A 48-year-old woman presented with a 6-month history of cervical and left shoulder pain with wasting and weakness of the left trapezius. A Magnetic Resonance Imaging (MRI) showed a T1-hyperintense, T2-isointense, heterogeneously enhancing lesion involving the left JF and extending into the cerebello-medullary and cerebello-pontine cisterns. A retrosigmoid craniotomy was performed and a near-total removal achieved. The accessory nerve was involved by tumour and could not be preserved. Given the diagnostic uncertainty between melanotic schwannoma, metastatic melanoma and meningeal melanocytoma, next generation sequencing and genome-wide DNA methylation arrays were performed, documenting a mutation in GNA11 (c.6226A>T, p. Gln209Leu) and a methylation profile consistent with melanocytoma. The patient underwent adjuvant fractionated radiotherapy of the tumour remnant. A follow-up MRI 4 years after surgery did not show any tumour recurrence. Conclusions The differential diagnosis of skull base pigmented tumours can be challenging, particularly when they occur in unusual locations such as the JF. They can be misdiagnosed given their similar clinical, neuroradiological and pathological features if anatomy of the site of origin is not carefully considered and molecular tests are not performed, leading to erroneous treatment and follow-up planning.

Malignant tumours arising in the paranasal sinuses or maxilla usually spread to the surrounding regions. The skull base and the anterior cranial fossa are frequently affected as well. When the resection of a tumour involves an orbital exenteration, a transconjunctival-perilimbic incision can be added to a coronal approach in order to preserve the eyelids and the conjunctiva, avoiding cutaneous midfacial incisions. Patients with a diagnosis of malignant tumour affecting the orbit, upper jaw, paranasal sinuses, and/or anterior skull base were eligible for this technique. Tumoural invasion of the eyelids, conjunctiva, lacrimal system, or surrounding skin was considered a contraindication for this technique. A retrospective study of the clinical records was performed and age, type of tumour, location, and reconstructive technique were evaluated. Eight patients referred to the study department between 2015 and 2019 were selected. All patients underwent craniofacial surgery and orbital exenteration. The transconjunctival-perilimbic approach was combined with a coronal incision in all cases. In our experience, the transconjunctival-perilimbic approach to orbital exenteration proposed in this paper can be used successfully in skull base surgery. Combined with a coronal and transmandibular approach, it allows wide access to the facial skeleton/anterior skull base while avoiding skin incisions in the midface.

The purposes of this study were to describe the endoscopic-assisted orbital exenteration surgical techniques, to report preliminary outcomes and to discuss advantages, indications and limitations of this approach. All patients who underwent endoscopic-assisted orbital exenteration at a single tertiary-care center were retrospectively reviewed. A concomitant reconstruction was performed in all cases. The extent of surgical resection was tailored to the size and location of tumor and was classified into four subtypes. A total of 40 patients were included in this series. Orbital exenteration type 1 was performed in 7 cases, type 2 in 11 cases, type 3 in 19 cases, and type 4 in 3 cases. The reconstruction was performed with a pedicled temporal flap in 5 patients and with a free vascularized flap in 34 cases. A radical resection of disease was obtained in 32 cases. After a mean follow-up of 36 months, 14 patients died of disease, one patient died of other causes, 7 are alive with disease, and 18 patients are currently alive without evidence of disease. The preliminary data emerging from this case-series support the feasibility and safety of endoscopic-assisted orbital exenteration.

Posttreatment imaging evaluation of sinuses encompasses a wide gamut of procedures, ranging from endoscopic procedures for sinonasal inflammatory diseases to markedly radical surgeries for malignant neoplasms (with or without reconstructions), as well as providing access for surgeries involving the anterior and central skull base. Advances in both techniques and devices have expanded the use of endoscopic approaches in managing both benign and malignant lesions, in addition to being the primary surgical method for treating all medically refractive sinonasal inflammatory disorders. Familiarity with the complex anatomy in the sinonasal region and knowledge of the various procedures is indispensable in interpreting these imaging studies.

OBJECTIVE A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures. METHODS The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively. RESULTS Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat. CONCLUSIONS Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

The aim of this study was to better understand posterior oral cavity cancer (POCC) and its surgical treatment. This was a retrospective study of 76 patients who were diagnosed with POCC and underwent surgical treatment. Twenty-eight patients were treated with anatomical unit resection surgery (AURS) and 48 patients with conventional surgery. After initial treatment with curative intent, the patients were followed-up regularly with clinical examinations and imaging; the median duration of follow-up was 30.9 months (range 2-67 months). The 3-year overall survival was 64.3% in the experimental AURS group and 39.6% in the conventional surgery control group (hazard ratio 0.49, 95% confidence interval 0.26-0.93; P=0.031). The 3-year disease-free survival was 64.3% in the experimental group and 37.5% in the control group (hazard ratio 0.53, 95% confidence interval 0.27-1.02; P=0.114). In conclusion, AURS is an effective surgical treatment for POCC that can considerably improve patient survival rates.

Introduction Endoscopic transnasal access to the skull base, both for treatment and reconstruction, can cause olfactory morbidity. Knowing the main consequences of this intervention is essential to have objective criteria for decision-making regarding the appropriate surgical technique. Objectives The aim of this study is to determine the impact on olfactory function of the endonasal endoscopic access to the skull base with the creation of the nasoseptal flap. Methods A prospective research was carried out in which 22 patients who underwent endoscopic transnasal surgery at the skull base, with the creation of a nasoseptal flap. The Connecticut Chemosensory Clinical Research Center test was applied before and at the 1st, 3rd and 6th postoperative months. Results The results showed that only in the first month of follow-up the mean patient classification was statistically worse than at the other evaluation moments (p < 0.05), but there was no mean difference in the Connecticut score classification between the other moments (p > 0.05); that is, patients showed worsening in the 1st month and returned to the preoperative mean after the 3rd month of follow-up. Conclusion The present study showed that the postoperative decrease in olfaction is transient, since the patient's sense of smell returns to pre-surgical values in the 3rd postoperative month. Resumo Introdução O acesso transnasal endoscópico à base do crânio, tanto no tratamento quanto na reconstrução, pode ocasionar morbidade olfatória. Conhecer as principais consequências dessa intervenção é fundamental para se dispor de elementos objetivos para a decisão da técnica cirúrgica adequada. Objetivo Determinar o impacto na função olfatória do acesso endoscópico endonasal à base do crânio com confecção do retalho nasosseptal. Método Foi feita pesquisa prospectiva na qual foram incluídos 22 pacientes submetidos à cirurgia endoscópica transnasal à base do crânio com confecção de retalho nasosseptal. Foi aplicado o teste Connecticut chemosensory clinical research center antes e após o 1°, 3° e 6° meses da cirurgia. Resultados Os resultados evidenciaram que apenas no 1° mês de seguimento a classificação média dos pacientes foi estatisticamente pior do que nos demais momentos de avaliação (p < 0,05), mas entre os demais momentos não houve diferença média na classificação do escore de Connecticut (p >0,05), ou seja, os pacientes pioraram no 1° mês e voltaram à média pré-operatória a partir do 3° mês de seguimento. Conclusão No presente estudo, demonstramos que a diminuição do olfato pós-operatória é transitória, já que, no 3° mês depois da cirurgia, o olfato do paciente retorna aos valores pré-cirúrgicos.

A 42-year-old woman presented with fever, left ear pain, restricted mouth opening, difficulty in swallowing and inability to open her left eyelid for a period of 10 days. She was treated with antibiotics for the same at a local medical facility; however, a sudden decrease in her left eye vision prompted her to visit our tertiary centre. Her history was insignificant except for having multiple left ear syringing for an insect removal 10 days before onset of her current symptoms. On examination, she had ptosis of the left eye with chemosis, dilated pupil with only perception of light and restricted ocular mobility. Oral examination revealed trismus and bulge in the left peritonsillar region. Left ear examination revealed a large central perforation with mucopurulent discharge. CT of the neck with contrast demonstrated a collection in the left peritonsillar space with left internal carotid artery thrombosis. MRI of the brain with gadolinium revealed left cavernous sinus thrombosis with acute infarcts in the left frontal lobe. An emergency incision and drainage of the left peritonsillar abscess was performed. Culture grew broad aseptate fungal hyphae. Despite starting on antifungal therapy, she succumbed to her illness.

The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.

BACKGROUND: Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations. METHODS: A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the third of a three-part series describing non-vestibular schwannomas (IX, X, XI, XII). RESULTS: A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to preoperative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management. CONCLUSION: This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management paradigm is shifting towards the compromise between function preservation and progression free survival.

Purpose of review The aim of this study was to present the evaluation and current management of congenital paediatric nasal dermoid. Recent findings There has been a trend towards less invasive surgical excision techniques, including purely endoscopic excision, endoscopic-assisted approaches and midline excision with nasal bone osteotomies and bone flap. These approaches allow adequate access for both total resection and nasal contour and skull base reconstruction. Following resection, if nasal bone osteotomies are insufficient for restoring nasal appearance, free temporoparietal fascial graft and/or conchal cartilage can be considered. For nasal tip deformities, interdomal sutures and free fat grafting are a suitable option. Summary Complete surgical excision remains the treatment of choice for nasal dermoid lesions. The surgical approach taken and reconstruction depends on the type of lesion (cyst versus sinus or fistula), location (intranasal versus extranasal), whether or not there is intracranial extension, and experience of the surgical team.

Knowledge of anatomy and its variations is the key to safe and efficient surgery. The endoscopic endonasal route to the sella has evolved to become the preferred route to access a wide variety of diseases. We describe the skeletal, vascular, and neural anatomic variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided.

Intraoperative internal carotid artery (ICA) injury during open skull base surgery is a catastrophic complication. Multiple techniques and management strategies have been reported for endoscopic skull base surgery; however, the literature on managing this complication in open skull base surgery is limited. To perform a systematic review and give an overview of the different techniques described to manage this complication intraoperatively, a systematic review was conducted in PubMed, Ovid Medline, Ovid Embase and Scopus for literature published until July 2021. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full. PRISMA guidelines were strictly adhered to. Out of 4492 articles, only 12 articles could be included, reflecting an underreporting of open skull base ICA injuries. Multiple techniques can be used depending on the location and size of the injury as well as the surgeon's experience. Described techniques include the following: a primary repair via a micro-suture or nonpenetrating clips; wrapping or plugging; coating; occlusion of the parent artery with or without a bypass; packing with further endovascular management. A treatment algorithm is proposed.

Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.

Neurodiagnostic and neurointerventional radiology (NIR) play a central role in the diagnosis and treatment of skull base disorders. Noninvasive imaging modalities, including computed tomography and magnetic resonance imaging, are important in lesion localization, evaluation of lesion extent, and diagnosis, but cannot always be definitive. Image-guided skull base biopsy and percutaneous and endovascular treatment options are important tools in the diagnosis and treatment of head, neck, and skull base disorders. NIR plays an important role in the treatment of vascular disorders of the skull base. This article summarizes the imaging evaluation and interventional therapies pertinent to the skull base.

Skull base infections are uncommon but can be life threatening without timely recognition. Imaging plays a crucial role because symptoms can be vague and nonlocalizing. Necrotizing otitis externa in diabetic or immunocompromised patients is the commonest cause of skull base osteomyelitis (SBO), followed by sinogenic infections and idiopathic central SBO. Multiparametric magnetic resonance (MR) and high-resolution CT are the mainstays for establishing a diagnosis and estimating disease extent, with MR being superior in ascertaining marrow and soft tissue involvement. Monitoring treatment response, of which imaging is a fundamental part, is challenging, with emerging promising imaging tools.

Objective The aim of this study was to describe progestin-associated meningiomas’ characteristics, outcome and management. Material and methods We included 53 patients operated on and/or followed in the department for meningioma with progestin intake longer than one year and with recent drug discontinuation. Results Cyproterone acetate (CPA), nomegestrol acetate (NomA), and chlormadinone acetate (ChlA) were involved in most cases. Mean duration of progestin drugs intake was 17.5 years. Tumors were multiple in 66% of cases and were located in the anterior and the medial skull base in 71% of cases. Transitional subtype represented 16/25 tumors; 19 meningiomas were WHO grade I and 6 were grade II. The rate of transitional subtype and skull base location was significantly higher compared to matched operated meningioma general population. No difference was observed given WHO classification. But Ki67 proliferation index tends to be lower and 5/6 of the WHO grade II meningiomas were classified as WHO grade II because of brain invasion. Strong progesterone receptors expression was observed in most cases. After progestin discontinuation, a spontaneous visual recovery was observed in 6/10 patients. Under CPA (n = 24) and ChlA/NomA (n = 11), tumor volume decreased in 71% and 18% of patients, was stabilized in 25% and 64% of patients, and increased in 4% and 18% of patients, respectively. Volume outcome was related to meningioma location. Conclusions Outcome at progestins discontinuation is favorable but different comparing CPA versus ChlA-NomA and comparing tumor location. Long-term follow-up is required. In most cases, simple observation is recommended and surgery should be avoided.

The reconstruction of anterior skull base defects after carcinologic surgery is challenging. Large defects can require the use of autologous free tissue transfer. Currently, most reconstructions use soft-tissue flaps. We describe the use of an osteocutaneous radial forearm free flap to reconstruct a large defect secondary to a malignant paraganglioma extending into the anterior cranial fossa and both orbits. The surgical resection required endonasal and transcranial approaches. We reconstructed the defect with a free osteocutaneous radial forearm flap. We laid the bone flap across the defect, resting on the orbital roof on each side, and sutured the soft component to the edge of the dura. The pedicle was funnelled from the craniotomy to a prepared cervicotomy and the micro-anastomoses were performed onto the facial artery and two satellite veins. Potential indications and major drawbacks of this technique are briefly discussed. Osteocutaneous radial forearm free flaps can be a valuable reconstructive option for patients with a large defect of the anterior skull base, needing both rigid support and a watertight closure.

Background Endoscopic transnasal transclival intradural surgery is limited by a high postoperative cerebrospinal fluid leak rate. The aim of this study was to investigate the role of three-dimensional printing to create a personalized, rigid scaffold for clival reconstruction. Methods Two different types of clivectomy were performed in 5 specimens with the aid of neuronavigation, and 11 clival reconstructions were simulated. They were repaired with polylactide, three-dimensional–printed scaffolds that were manually designed in a computer-aided environment based either on the real or on the predicted defect. Scaffolds were printed with a fused filament fabrication technique and different offsets. They were positioned and fixed either following the gasket seal technique or with screws. Postdissection radiological evaluation of scaffold position was performed in all cases. In 3 specimens, the cerebrospinal fluid leak pressure point was measured immediately after reconstruction. Results The production process took approximately 30 hours. The designed scaffolds were satisfactory when no offset was added. Wings were added during the design to allow for screw positioning, but broke in 30% of cases. Radiological assessment documented maximal accuracy of scaffold positioning when the scaffold was created on the real defect; accuracy was satisfactory when the predicted clivectomy was performed under neuronavigation guidance. The cerebrospinal fluid leak pressure point was significantly higher when the scaffold was fixed with screws compared with the gasket technique. Conclusions In this preclinical setting, additive manufacturing allows the creation of customized scaffolds that are effective in reconstructing even large and geometrically complex clival defects.

The petrous apex may be affected by a range of lesions, commonly encountered as incidental and asymptomatic findings on imaging performed for other clinical reasons. Symptoms associated with petrous apex lesions commonly relate to mass effect and/or direct involvement of closely adjacent structures. Petrous apex lesions are optimally assessed using a combination of high-resolution CT and MRI of the skull base. Management of petrous apex lesions varies widely, reflecting the range of possible pathologies, with imaging playing a key role, including lesion characterization, surveillance, surgical planning, and oncological contouring.

Introduction: Endoscopic access to the sellar region by videoendoscopy shows a low rate of surgical complications, with findings that indicate risk factors for reducing morbidities during and after the postoperative period. Objective: To evaluate, over a nine-year period, the acquisition of skills by the anterior skull base surgical team, according to the time of elimination of nasal crusts and/or the presence of morbidities in the postoperative follow-up of individuals treated in a tertiary public hospital. Methods: After confirming the diagnosis of skull base pathologies, the individuals in this study underwent endoscopic surgery according to the rostrocaudal or coronal axis. For the skull base reconstruction, the nasoseptal flap (associated or not with fascia lata with thigh fat) or free graft was used; clinical follow-up of individuals occurred for a minimum period of 12 months. To assess the impact of the surgical approach on patient clinical evolution, qualitative data related to smoking, post-nasal discharge, nasal flow, smell, taste, clinical symptoms of headache, cranial paresthesia, comorbidities and postoperative morbidities were obtained. Results: The most frequent diagnosis was pituitary macroadenoma (84.14%). The mean absence of crusts in this cohort was 124.45 days (confidence interval 95% = 119.50-129.39). There was a low cerebrospinal fluid fistula rate (3%). Reconstruction with the nasoseptal flap with a fat graft was an independent variable that recorded the highest mean time for the elimination of nasal crusts (=145 days, confidence interval 95% = 127.32-162.68). Allergic rhinitis and smoking were shown to be the most important and independent variables that increased the mean time to eliminate nasal crusts. Conclusion: The mean time to eliminate nasal crusts did not change over the years during which the procedures were performed, demonstrating the adequate training of the surgical team. Debridement and nasal irrigation with saline solutions should be performed more frequently and effectively in patients with allergic rhinitis, smokers and those who received the nasoseptal flap and fascia lata graft with autologous fat. Resumo Introdução: O acesso endoscópico à região selar por videoendoscopia demonstra baixo índice de complicações cirúrgicas, com achados que apontam fatores risco para reduzir as morbidades durante e após o período pósoperatório. Objetivo: Avaliar fatores morbidades no seguimento pós-operatório de indivíduos atendidos em um hospital público terciário. Método: Depois de confirmado o diagnóstico de doenças da base do crânio, os indivíduos deste estudo foram submetidos a cirurgia endoscópica conforme o eixo rostrocaudal ou coronal. Para a reconstrução da base do crânio usava-se o retalho nasoseptal (associado ou não à fáscia lata com gordura de coxa) ou enxerto livre; o seguimento clínico dos indivíduos ocorreu por um período mínimo de 12 meses. Para avaliar o impacto da abordagem cirúrgica na evolução clínica dos pacientes foram obtidos os dados qualitativos relativos ao tabagismo, descarga pós-nasal, fluxo nasal, olfato, paladar, sintomas clínicos de dor de cabeça, parestesia craniana, comorbidades e morbidades pós-operatórias. Resultados: O diagnóstico mais frequente foi o macroadenoma hipofisário (84,14%). A média da ausência de crostas nesta coorte foi de 124,45 dias (intervalo de confiança [95% CI] 119,50-129,39). Baixo índice de fístula liquórica (3%). A reconstrução com o retalho nasoseptal com enxerto de gordura apresentou-se com variável independente que necessitou de maior tempo médio para a eliminação de crostas nasais (=145 dias, 95% CI 127,32-162,68). A rinite alérgica e o tabagismo se demonstraram como as variáveis mais importantes e independentes para aumentar o tempo médio de eliminação de crostas nasais. Conclusão: O tempo médio de eliminação de crostas nasais não se alterou ao longo dos anos em que os procedimentos foram feitos. Deve-se fazer com maior frequência e eficácia o debridamento e as irrigações nasais com soluções salinas nos pacientes com rinite alérgica, tabagistas e os que usaram o retalho nasoseptal e enxerto de fáscia lata com gordura autóloga.

We herein report a 70-year-old man diagnosed with IgG4-related hypertrophic pachymeningitis with skull base involvement, who presented with isolated glossopharyngeal and vagus nerve palsy. Contrast-enhanced magnetic resonance imaging (MRI) showed enhanced dural thickening of the posterior clivus and skull base involvement. When a patient with hypertrophic pachymeningitis presents with isolated cranial neuropathy without systemic manifestations or definite MRI abnormalities, it is difficult to make a diagnosis, and the patient may be misdiagnosed. This case suggests that a detailed radiological evaluation including contrast enhancement of the skull base is very important in patients with isolated glossopharyngeal and vagus nerve palsy.

OBJECTIVES/HYPOTHESIS The objective of this study is to evaluate the impact of patient and surgical factors, including approach and reconstruction type, on postoperative nausea and vomiting episodes following endoscopic skull base surgery. STUDY DESIGN Retrospective review. METHODS We performed a retrospective chart review from July 2018 to August 2020 of 99 consecutive patients undergoing endoscopic skull base surgery at a tertiary academic skull base surgery program. All patients were treated with a standardized postoperative protocol consisting of scheduled ondansetron, along with promethazine and scopolamine for breakthrough nausea and vomiting episodes. Cumulative nausea and vomiting episodes throughout hospital stay were recorded for each patient. RESULTS Of the 99 patients identified, the mean number of nausea and vomiting episodes per patient were 0.4 ± 1.2 and 0.3 ± 0.7, respectively. Female sex (β = .65, P = .034) and extended surgical approach (β = .90, P = .027) were associated with increased risk for postoperative nausea. Furthermore, female sex (β = .44, P = .018), cavernous sinus dissection (β = .52, P = .002), and extended approach (β = .79, P = .025) significantly increased odds of postoperative vomiting episodes. There was no association between total operative time or total postoperative opioid dose and nausea and vomiting episodes (all Ps > .05). Neither increased nausea nor vomiting episodes significantly increased odds of prolonged hospitalization (P = .105 and .164, respectively). CONCLUSION This report highlights novel risk factors for patients undergoing endoscopic skull base surgery. Upfront standing antiemetic therapy may be considered when treating patients with independent predictors of postoperative nausea and vomiting, including female sex, cavernous sinus dissection, and extended surgical approach. LEVEL OF EVIDENCE IV Laryngoscope, 2021.

Information about the endonasal endoscopic approach (EEA) for the management of posttraumatic tension pneumocephalus (PTTP) remains scarce. Concomitant rhinoliquorrhea and posttraumatic hydrocephalus (PTH) can complicate the clinical course.The authors systematically reviewed pertinent articles published between 1961 and December 2020 and identified 6 patients with PTTP treated by EEA in 5 reports. Additionally, the authors share their institutional experience including a seventh patient, where an EEA resolved a recurrent PTTP without rhinoliquorrhea.Seven PTTP cases in which EEA was used as part of the treatment regime were included in this review. All cases presented with a defect in the anterior skull base, and 3 of them had concomitant rhinoliquorrhea. A transcranial approach was performed in 6/7 cases before EEA was considered to treat PTTP. In 4/7 cases, the PTTP resolved after the first intent; in 2/ 7 cases a second repair was necessary because of recurrent PTTP, 1 with and 1 without rhinoliquorrhea, and 1/7 case because of recurrent rhinoliquorrhea only. Overall, PTTP treated by EEA resolved with a mean radiological resolution time of 69 days (range 23-150 days), with no late recurrences. Only 1 patient developed a cerebrospinal fluid diversion infection probably related to a first incomplete EEA skull base defects repair. A permanent cerebrospinal fluid diversion was necessary in 3/7 cases.Endonasal endoscopic approach repair of air conduits is a safe and efficacious second-line approach after failed transcranial approaches for symptomatic PTTP. However, the strength of recommendation for EEA remains low until further evidence is presented.

OBJECTIVES Venous thromboembolism (VTE) is a major cause of morbidity and mortality for surgical patients. This article aims to determine factors that may have contributed to the development of VTE in patients undergoing lateral skull base surgery, to assess the validity of the Caprini Risk Assessment Model (RAM) score in this subset of patients, and to determine the efficacy of mechanical DVT prophylaxis alone in preventing VTE. STUDY DESIGN Retrospective chart review. METHODS A retrospective chart review was conducted of patients who underwent skull base surgery for vestibular schwannoma, and the rate of VTE was assessed. Patient demographics, comorbidities, and treatment factors were examined to determine risk factors associated with the development of a postoperative thrombotic event. Caprini RAM scores were compared for patients who developed a VTE. RESULTS Among 197 patients, the rate of VTE formation was 3.5%. No individual risk factor independently contributed to the development of a thrombotic event. The mean Caprini RAM score was 4.06 in patients who did not develop a VTE and 5.14 in the patients that did develop a VTE (P = .005). The Caprini score was significant for the risk of VTE formation, with an odds ratio of 2.8 (P = .009, 95% CI = 1.3-6.2). CONCLUSION Venous thromboembolism rates are relatively low following lateral skull base surgery. While there is no individual risk factor associated with increased VTE risk, the Caprini RAM score appears to be a useful predictor of risk. The Caprini score may be useful in identifying high-risk patients who may benefit from chemoprophylaxis for VTE prevention. LEVEL OF EVIDENCE Level III-This is a retrospective chart review study Laryngoscope, 2021.

International audience; PurposeTo report our experience of endoscopic endonasal obliteration of symptomatic sellar arachnoid cyst (SAC).MethodsFrom 2002 to 2019, we retrospectively reported the data of 17 cases of SAC operated in Timone University Hospital, Marseille, France. Preoperative clinical findings were collected including main symptoms, visual function and endocrinological assessment. Surgical procedure was homogeneous and consisted in endonasal fully endoscopic surgical obliteration of the cyst cavity with fat graft. Post-operative outcomes, complication and follow-up was reported.ResultsVisual disorders and/or headaches were the main symptoms. Our technique provided improvement for 83.3% of the patients suffering from visual disturbance and for 87.5% of those suffering from headaches. We reported 2 cases of cerebrospinal fluid (CSF) leakage (11.8%), but no meningitis. One case of definitive diabetes insipidus occurred and one case of postoperative syndrome of inappropriate antidiuretic hormone secretion was temporary. There was one case of recurrence reported. The mean follow-up was 39 months.ConclusionPatients with symptomatic SAC can be treated successfully by endoscopic endonasal obliteration of the cyst. This simple technique offers true benefits for the patients without craniotomy, but the complication rate remains high especially with the risk of CSF leakage. Special attention to skull base opening and closing could reduce this risk.

We determined the feasibility of the combined exoscopic-endoscopic technique (CEE) as an alternative to the microscope in craniofacial resection (CFR). This retrospective study was conducted at a single institution and included eight consecutive patients with head and neck tumors who underwent CFR between September 2019 and July 2021. During the transcranial approach, microsurgery was performed using an exoscope in the same manner as in traditional microscopic surgery, and an endoscope was used at the blind spot of the exoscope. The exoscope provided images of sufficient quality to perform microsurgery, while the sphenoid sinus lumen was the blind spot of the exoscope during anterior (n = 3) and anterolateral CFR (n = 2), and the medial aspect of the temporal bone was the blind spot of the exoscope during temporal bone resection (n = 2). These blind spots were visualized by the endoscope to facilitate accurate transection of the skull base. The advantages of the exoscope and endoscope include compact size, ergonomics, surgical field accessibility, and equal visual experience for neurosurgeons and head and neck surgeons, which enabled simultaneous transcranial and transfacial surgical procedures. All the surgeries were successful without any relevant complications. CEE is effective in transcranial skull base surgery, especially CFR involving simultaneous surgical procedures.

Background Nowadays, the endoscopic endonasal approach to sellar and parasellar region tumors is a common technique in neurosurgery, and surgical nuances, complications, and management strategies are shared in a multidisciplinary setting between neurosurgeons and ear, nose, and throat surgeons. Due to the heterogeneity of its variations, the role of the anterior nasal packing in endoscopic endonasal approach to the skull base surgery (EESBS) has not yet been unanimously accepted and no consensus or guidelines on its use exist. Materials and Methods A survey containing 10 questions about indications, management advantages, and pitfalls of the use of anterior nasal packing in EESBS was created by using an online open-source tool (SurveyMonkey). The questionnaire was sent to 39 Italian neurosurgical departments, which routinely adopt the endoscopic endonasal approach. Results Almost half of 39 selected centers (19; 48.7%) answered our survey. The main results can be summarized as 1) anterior nasal packing after EESBS is considered useful by 84% of participants, 2) prevention of epistaxis is the principal indication for anterior nasal packing, 3) the type of approach and skull base reconstruction influence the use of anterior nasal packing, and 4) nasal discomfort is considered the principal negative aspect of nasal packing. Conclusions Our study identified that anterior nasal packing is commonly adopted in certain conditions, namely when extensive nasal dissection is performed. Furthermore, the choice to adopt or not the anterior nasal packing should be tailored taking in account specific conditions, such as acromegaly and Cushing disease. It represents an important factor in reducing postoperative sinonasal complications of EESB.

BACKGROUND Modified orbitozygomatic craniotomy is characterized by simplicity and wide exposure. The purpose of the present study was to describe a modified orbitozygomatic approach without resecting the zygomatic arch for large parasellar tumor surgeries. METHODS Between April 2016 and December 2019, seven patients with parasellar tumor underwent surgiest with a modified orbitozygomatic approach. Surgical procedures, clinical outcomes, and complications were analyzed. RESULTS This study included 3 meningiomas, 2 pituitary adenomas, 1 chondrosarcoma, and 1 schwannoma. Modified orbitozygomatic craniotomy provides a wider surgical freedom in the opticocarotid and prechiasmatic cistern than frontotemporal craniotomy without orbitotomy, Total, subtotal, and partial resections were achieved for 3, 2, and 2 patients, respectively. Reasons for partial resections were tight adhesion to the carotid artery and encasing of the carotid artery. Permanent morbidities developed in one patient with 3rd nerve palsy and one patient with hemiparesis. CONCLUSION Modified orbitozygomatic approach can provide the shortest access to the interpeduncular cistern with a minimum brain retraction. Surgeons who experience surgical challenge during the conventional approach for parasellar tumor resection are recommended to learn the modified orbitozygomatic approach.

Objective Skull baseosteomyelitis (SBO) is a rare phenomenon that typically occurs in diabetic or immunocompromised patients, causing significant morbidity and mortality. This study aimed to analyze a single institution's treatment results in SBO patients and propose anew integrated clinicoradiological classification system. Methods The medical records of 32 SBO patients that were treated at a tertiary care center between 2006 and 2017 were retrospectively reviewed. A scoring system based on anatomical involvement according to MRI was created. Subsequently, the scoring system was integrated with cranial nerve dysfunction status and a clinical grading system (CGS) was proposed. Results Among the 32 patients, 78.1% were diabetic and 63% had cranial nerve dysfunction at presentation. Bone erosion based on CT was greater in the patients without regression (P = 0.046). The regression rate decreased from clinical grade (CG)1 to CG3 (P = 0.029). Duration of hospitalization increased as CG increased (P = 0.047). Surgery had no effect on regression status at the time of discharge (P = 0.41). The 1-year, 2-year, and 5-year overall survival rates were 82.2%, 70.8%, and 45.8%, respectively. CG was significantly correlated with overall survival but not with disease-specific survival (log-rank; P = 0.017, P = 0.362, respectively). Conclusion SBO continues to pose a challenge to clinicians, and causes significant morbidity and mortality. The proposed new classification system can be an option for grouping SBO patients according to clinical and radiological findings, helping clinicians estimate prognosis.

BACKGROUND The primary objective is to identify clinical predictors of internal carotid artery (ICA) blowout in radiated nasopharyngeal carcinoma (NPC). METHODS Seventeen ICA blowouts, 14 external carotid artery (ECA) bleeds, and 60 controls were identified from January 1, 2007 to July 31, 2020. Multinomial logistic regression was performed to identify features predictive of ICA blowouts. RESULTS Headache was significantly more common among ICA blowouts than ECA bleeds and controls (58.8% vs. 7.1% vs. 6.7%, p

Three-dimensional (3D) printing technology in neurosurgery has gained popularity nowadays. Skull base contains many major neurovascular structures in a confined space, along with anatomical variations making surgical approaches to this region challenging. 3D-printed model of skull base tumors consists of the patient's bony skull base, actual tumor dimensions, and surrounding major neurovascular structures. We included a total number of five patients with skull base tumors (one case of planum sphenoidale meningioma, two cases of sellar tumor with suprasellar extension, and two cases of cerebellopontine angle tumor) and 3D-printed tumor model of each of them. These models were used for preoperative simulation and served as very true to life training tool. These help in increasing the efficacy of the surgeon, improves surgical safety and ergonomics. They were also used for patient counselling, educating about the disease, the surgical procedure, and associated risks.

Background Immunoglobulin-G4-related hypophysitis is a rare inflammatory disease that can present as a tumefactive pituitary lesion mimicking hypophyseal neoplasms such as pituitary adenoma or craniopharyngioma. The literature on this entity is sparse, with fewer than 100 cases reported across 19 publications; a recent review found only 24 cases published from 2007 to 2018. Previous reports have described demographic differences, with immunoglobulin-G4-related hypophysitis in females tending to present in the second and third decades in association with other autoimmune disease, while males tend to present in the fifth and sixth decades of life without an autoimmune history. Case presentation In contrast to the reported demographic trends, here we describe a unique case of immunoglobulin-G4-related hypophysitis in a 63-year-old white female with no history of autoimmune disease who presented with a rapidly enlarging sellar and hypothalamic mass causing headaches and cranial nerve palsies, prompting biopsy for diagnosis. The patient experienced rapid response to treatment with high-dose steroids and rituximab. Conclusion The case contributes to the growing clinicopathologic description of immunoglobulin-G4-related hypophysitis and illustrates that this diagnosis should be a consideration even outside the conventional demographic setting.

This systematic review aims to clarify and comprehensively detail the sometimes variable published imaging features as well as the pathogenesis, clinical diagnostic criteria, and treatment options of IgG4-Related Diseases (IgG4-RD) in the head and neck to aid the radiologist in diagnosing relapse and new sites of disease. A literature search in PubMed and EMBASE for reported cases of IgG4-RD was performed in December 2019. Case reports or series of IgG4-RD in the head and neck in adults that included sufficient imaging and pathology findings were included. This yielded 50 reports. IgG4-RD locations included the orbits, thyroid, pituitary gland, paranasal sinuses, salivary and parotid glands, larynx, pharynx, cervical lymph nodes, meninges, and skull base. Most lesions demonstrated non-specific homogenous CT attenuation, diffuse enhancement, isointense/low T2 signal intensity, and low T1 signal intensity. 6 cases from our institution followed previously reported imaging patterns.

Introduction: As scientific knowledge has grown in biomedicine, it has also become necessary to develop tools to manage and understand the body of evidence. In that sense, bibliometrics has become a consolidated discipline for analyzing scientific activity, enabling the characterization of a particular field or area of knowledge by means of the quantification of the bibliographic characteristics of scientific publications. Objective: The objective of this study was to determine the most frequently cited articles in the field of cerebrospinal fluid rhinorrhea and otorrhea. Methods: The searches took place on the Clarivate Analytics Web of Science platform, which includes the MEDLINE database. The study period was limited to 1945–2018. Results: The 101 most cited articles in the field of cerebrospinal fluid leak were published in 36 journals, and the most important specialties contributing to the literature were neurosurgery and otorhinolaryngology. Of the 101 top-cited articles, 70% were published from 1990 to 2018, with two distinct periods of high scientific productivity: 1990–1999 and 2000–2009. In the first period, the main topic of research interest was endoscopic sinus surgery for cerebrospinal fluid fistulas, whereas from 2000 to 2009, documents focused more on surgical aspects of extended skull base approaches. The articles received 73–767 citations. The top article over the whole study period was ‘‘A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap’’ by Hadad et al., which was published 2006 in Laryngoscope. Its publication represented an inflection point in the literature on cerebrospinal fluid leak and endoscopic skull base surgery, and it gave rise to numerous other research publications. Conclusion: Different surgical innovations in the field of cerebrospinal fluid leak sparked two different periods of intense scientific activity. Otorhinolaryngology and neurosurgery were the dominant specialties. The most frequent topic studied was endoscopic surgery; others included clinical and diagnostic features, neurinoma surgery, and cerebrospinal fluid leak related to temporal bone fractures. Resumo Introdução: À medida que o conhecimento científico cresceu em biomedicina, também se tornou necessário o desenvolvimento de ferramentas para gerenciar e entender o corpo de evidências. Nesse sentido, a bibliometria tornou-se uma disciplina consolidada para a análise da atividade científica, possibilita a caracterização de um campo ou área de conhecimento específica através da quantificação das características bibliográficas das publicações científicas. Objetivo: Determinar os artigos mais citados na área de rinorreia e otorreia por líquido cefalorraquidiano. Método: As buscas foram feitas na plataforma Clarivate Analytics Web of Science, que inclui o banco de dados Medline. O período do estudo foi limitado a 1945–2018. Resultados: Os 101 artigos mais citados no campo da fístula liquórica foram publicados em 36 periódicos e as especialidades mais importantes que contribuíram para a literatura foram a neurocirurgia e a otorrinolaringologia. Dos 101 artigos mais citados, 70% foram publicados de 1990 a 2018, com dois períodos de alta produtividade científica: 1990 a 1999 e 2000 a 2009. No primeiro período, o principal tópico de interesse da pesquisa foi a cirurgia endoscópica do seio para fístulas liquóricas, enquanto de 2000 a 2009 os artigos se concentraram mais nos aspectos cirúrgicos das abordagens estendidas da base do crânio. Os artigos receberam 73 a 767 citações. O artigo principal, durante todo o período do estudo, foi ‘‘Uma nova técnica reconstrutiva após abordagens endonasais expandidas endoscópicas: retalho nasoseptal do pedículo vascular’’, de Hadad et al., publicado em 2006 no periódico Laryngoscope. Sua publicação representou um ponto de inflexão na literatura sobre fístula liquórica e cirurgia endoscópica da base do crânio e deu origem a inúmeras outras publicações de pesquisa. Conclusão: Diferentes inovações cirúrgicas no campo da fístula liquórica desencadearam dois períodos diferentes de intensa atividade científica. Otorrinolaringologia e neurocirurgia foram as especialidades dominantes. O tópico mais frequentemente estudado foi cirurgia endoscópica; outros incluíram características clínicas e de diagnóstico, cirurgia de neurinoma e fístula liquórica relacionado a fraturas do osso temporal.

Background/aim Because of close relations to important anatomical structures such as cavernous sinus and optic nerve, sphenoid sinus variations must be well trained by the Otolaryngologist who has an interest in endoscopic sinus surgery. Newly defined sphenoseptal cell (SSC) is one of those variations that may lead to insufficient endoscopic sinus surgery outcomes if not defined preoperatively with imaging studies. The present study aimed to present the main characteristics of this special type of nasal cell. Materials and methods In this study 610 paranasal sinus CT scans were analyzed and reviewed retrospectively between May 2018 and December 2019. Also, endoscopic findings of SSC, that cause a surgical catastrophe in identifying skull base and sella are presented during transnasal transsphenoidal pituitary surgery. Results According to its definition and relation to the sphenoid sinus and the skull base, an SSC was seen in 21 scans of 610 patients (3.4%), 11 were women (55%) and 10 were men (45%). Conclusion Although an SCC is a rare variation of nasal air cells, preoperative diagnosis of this cell is of paramount importance in some patients during endoscopic transnasal surgery for the identification of skull base.

Bone grinding is used to remove the skull bone and access tumors through the nasal passage during cranial base neurosurgery. The generated heat of the spherical diamond tool propagates and could damage the nerves or coagulate the arteries blood. Little is known about the non-Fourier behavior of heat propagation during bone grinding. Therefore, this study develops an analytical model of the hyperbolic Pennes bioheat transfer equation (HPBTE) to calculate the three-dimensional temperature and necrosis in the grinding region. In vitro experimental investigations were carried out, and the contact zone temperature was measured using an infrared thermography system to validate the proposed thermal model. The results demonstrate that the HPBTE provides more reliable temperature evaluation and thermal damage than Fourier or parabolic heat transfer equation (PHTE). Due to the low thermal diffusivity of the bone, the lower grinding feed rate leads to higher temperature amplitude and a smaller radius of the affected zone in the surface and depth of the bone. Also, the intensity of bone necrosis decreases with the increase of the feed rate, and the shape of the damage zone becomes stretched. This analytical model can assess the potential risk of the surgery before clinical trials. Also, it could be used for comparing the different operating conditions to minimize bone necrosis and improve the control process in neurosurgeries.

Objective Surgical treatment of advanced intracranial and extracranial communicating skull base tumors is challenging, especially for the reconstruction of the large composite defect left by tumor resection. The aim of the study is to evaluate the utility of the free flap reconstruction of the defects resulting from radical resection of these tumors in a single institution. Methods The clinical data of 17 consecutive patients who underwent free flap reconstruction for defect left by salvage resection of advanced intracranial and extracranial communicating tumors from 2013 to 2019 were retrospectively collected and analyzed. Results There were 5 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 basal cell carcinomas, 2 meningiomas, 1 anaplastic hemangiopericytoma, 1 pleomorphic adenoma, 1 osteosarcoma, and 1 chondrosarcoma. All patients had recurrent neoplasms, 2 of whom had pulmonary metastasis. A modified radical cervical dissection was performed in 6 patients. The anterolateral thigh myocutaneous flap and rectus abdominis myocutaneous flap were used in 15 patients (88.2%) and 2 patients (11.8%), respectively. Complications were seen in 3 of 17 patients (17.6%) with 1 total flap loss. The median progression-free survival duration was 31 months. The 3- and 5-year progression-free survival rates were 0.47 and 0.24, respectively. The mean overall survival duration was 66 months. The 3- and 5-year overall survival rates were 0.85 and 0.68, respectively. Conclusions Free flap transfer is a safe and effective method with acceptable complications, useful for reconstruction of large composite skull base defects after salvage resection of advanced intracranial and extracranial communicating tumors. The functional and cosmetic results are satisfying.

To identify the association between skull fracture (SF) and in-hospital mortality in patients with severe traumatic brain injury (TBI).This multicenter cohort study included a retrospective analysis of data from the Japan Trauma Data Bank (JTDB). JTDB is a nationwide, prospective, observational trauma registry with data from 235 hospitals. Adult patients with severe TBI (Glasgow Coma Scale9, head Abbreviated Injury Scale (AIS) ≥ 3, and any other AIS 3) who were registered in the JTDB between January 2004 and December 2017 were included in the study. Patients who (a) were 16 years old, (b) developed cardiac arrest before or at hospital arrival, and (c) had burns and penetrating injuries were excluded from the study. In-hospital mortality was the primary outcome assessed. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (ORs) of SF and their 95% confidence intervals (CIs) for in-hospital mortality.A total of 9607 patients were enrolled [median age: 67 (interquartile range: 50-78) years] in the study. Among those patients, 3574 (37.2%) and 6033 (62.8%) were included in the SF and non-SF groups, respectively. The overall in-hospital mortality rate was 44.1% (4238/9607). A multivariate analysis of the association between SF and in-hospital mortality yielded a crude OR of 1.63 (95% CI: 1.47-1.80). A subgroup analysis of the association of skull vault fractures, skull base fractures, and both fractures together with in-hospital mortality yielded adjusted ORs of 1.60 (95% CI: 1.42-1.98), 1.40 (95% CI: 1.16-1.70), and 2.14 (95% CI: 1.74-2.64), respectively, relative to the non-SF group.This observational study showed that SF is associated with in-hospital mortality among patients with severe TBI. Furthermore, patients with both skull base and skull vault fractures were associated with higher in-hospital mortality than those with only one of these injuries.

Background The surgical treatment of giant olfactory groove meningiomas (OGMs) with marked perilesional brain oedema is still a surgical challenge. After tumour resection, increase of brain oedema may occur causing dramatic neurological deterioration and even death of the patient. The objective of this paper is to describe surgical features of a two-step staged resection of these tumours performed to counter increase of postoperative brain oedema. Methods This two-step staged resection procedure was carried out in a consecutive series of 19 patients harbouring giant OGMs. As first step, a bifrontal craniectomy was performed followed by a right-sided interhemispherical approach. About 80% of the tumour mass was resected leaving behind a shell-shaped tumour remnant. In the second step, carried out after the patients’ recovery from the first surgery and decline of oedema, the remaining part of the tumour was removed completely followed by duro- and cranioplasty. Results Ten patients recovered quickly from first surgery and the second operation was performed after a mean of 12.4 days. In eight patients, the second operation was carried out later between day 25 and 68 due to surgery-related complications, development of a trigeminal zoster, or to a persisting frontal brain oedema. Mean follow-up was 49.3 months and all but one patient had a good outcome regardless of surgery-related complications. Conclusions Our results suggest that a two-step staged resection of giant OGMs minimizes the increase of postoperative brain oedema as far as possible and translates into lower morbidity and mortality.

Background Iatrogenic internal carotid artery (ICA) injury is a catastrophic complication in open skull base surgery. There is a lack of information regarding the most appropriate techniques on how to manage this complication. Objective To highlight the difficulties encountered when an ICA injury arises intraoperatively and discuss the role and the potential pitfalls of the crushed muscle patch in the management of an ICA injury during open skull base surgery. Methods In this technical video, we demonstrate the management of intraoperative ICA injury, which occurred during the resection of a diffuse planum sphenoidale meningioma via a left pterional craniotomy. Results When isolation of the defect with temporary clips failed, we opted for a crushed muscle graft to plug the defect. Hemostasis was achieved, but because of prolonged pressure application and "overpacking," the parent vessel was occluded. Conclusion The crushed muscle patch can be easily applied; however, care must be taken not to "overpack" and occlude the ICA.

Skin cancers are the most prevalent malignant disorder affecting humans. Approximately 90% of these are nonmelanoma skin cancer (NMSC), and large tumors, especially at the 'H-zone', can invade deeply and access the skull base. The best treatment for these very advanced skin cancers is craniofacial resection followed by adjuvant treatment, but, currently, systemic therapy and neoadjuvant approaches could be considered for some patients. The current management of NMSC involving the skull base is discussed in this article.Surgical resections with negative margins followed by adjuvant treatment are the best treatment for NMSC with skull base invasion and offer the best outcomes for those patients. This approach usually requires a free flap reconstruction, followed by external beam radiation therapy. The team must keep in mind that some factors, such as gross brain invasion and extensive dura mater extension, are associated with worse outcomes.Although it occurs infrequently, very advanced NMSC can involve the skull base. In these very difficult clinical scenarios, the best therapeutic option is a multidisciplinary approach in a tertiary center.

It has been commonly accepted for a long time that the cerebrospinal fluid (CSF) drains into arachnoid granulations from the subarachnoid space to the dural venous sinus unidirectionally. However, recently, periventricular capillaries and lymphatic concepts have been introduced. The CSF moves along the perivascular space and drains into the capillary vessels or meningeal lymphatic tissues. CSF is involved in removing brain waste out of the brain. In this study, we investigated the outflow mechanism of substances in the CSF from the brain. We investigated the movement of CSF by injection of gold colloid conjugates (2, 40, and 200 nm) into the lateral ventricles of mouse fetuses and evaluated the deposition by silver stain with tissue transparency and electron microcopy. Cadaverine was also injected into the lateral ventricle to determine its movement tract. The gold particle deposition was mainly observed in the frontal skull base. Electron microscopic study showed that the gold particle deposition was observed on the choroid plexus and ependyma in the lateral ventricle and also red blood cells in the heart and liver. Two-nanometer particles were exclusively observed in the liver. Cadaverine injection study demonstrated that cadaverine was observed at the extracranial frontal skull base, choroid plexus, ependymal surface, and perivascular area in the brain white matter. The particles in the CSF were shown to move from the brain to the frontal skull base and also into the blood stream through the choroid plexus in the fetus. The outflow of particles in the CSF may be regulated by molecular size. This new information will contribute to the prevention of brain degeneration due to brain waste deposition.

CONTEXT: Little accurate information is available regarding the risk of hypopituitarism after irradiation of skull base meningiomas. DESIGN: Retrospective study in a single centre. PATIENTS: 48 patients with a skull base meningioma and normal pituitary function at diagnosis, treated with radiotherapy (RXT) between 1998 and 2017 (median follow-up of 90 months). MEASUREMENTS: The GH, TSH, LH/FSH and ACTH hormonal axes were evaluated yearly for the entire follow-up period. Mean doses delivered to the pituitary gland (PitD) and the hypothalamus (HypoD) were calculated, as well as the doses responsible for the development of deficits in 50% of patients after 5 years (TD50). RESULTS: At least one hormone deficit was observed in 38% of irradiated patients and complete hypopituitarism in 13%. The GH (35%), TSH (32%) and LH/FSH axes (28%) were the most frequently affected, while ACTH secretion axis was less altered (13%). The risk of hypopituitarism was independently related to planning target volume (PTV) and to the PitD (threshold dose 45 Gy; TD50 between 50 and 54 Gy). In this series, the risk was less influenced by the HypoD, increasing steadily between doses of 15 and 70 Gy with no clear-cut dose threshold. CONCLUSIONS: Over a median follow-up period of 7.5 years, hypopituitarism occurred in more than one third of patients irradiated for a skull base meningioma, and this prevalence was time- and dose-dependent. In this setting, the risk of developing hypopituitarism was mainly determined by the irradiated target volume and by the dose delivered to the pituitary gland.

Re-irradiation with X-rays and particle beams can be used to treat localized recurrence of unresectable head and neck cancer after initial irradiation therapy. However, re-irradiation therapy increases the risk of severe and late sequelae by 4-to 8-fold. It can also result in fatal outcomes, such as rupture of the carotid artery and cerebral necrosis or abscess. A 41-year-old woman was diagnosed with squamous cell carcinoma of the external auditory canal. The patient was initially treated with X-ray irradiation. However, the patient underwent re-irradiation with heavy particle beams and neutron rays for a recurrent tumor. The patient developed necrosis of the skull base involving the facial skin and temporal bone 2 months after the last session of re-irradiation therapy. The tissue in the parapharyngeal and masticatory regions also became completely necrotic, resulting in extensive exposure of the brain parenchyma. Although the patient underwent conservative and surgical treatment, necrosis of the tissue progressed, and a large part of the brain was exposed. Approximately 2.5 years later, although the brain is still exposed, the patient is alive without disease. Although the tumor had subsided and long-term survival was achieved, our patient developed serious osteoradionecrosis of the skull base with extensive brain exposure. For patients who are not candidates for surgery, re-irradiation alone is an option, albeit with poor prospects. This approach should be discussed with the patient while balancing the potential survival gain against the burden of treatment and the risk of complications.

Infantile myofibromatosis is a rare and nonmalignant pediatric tumor of myofibroblastic origin that may occur in solitary or multifocal forms. Soft tissue of the head and neck, trunk, and extremities, skeleton, and viscera are usually involved. Intracranial involvement is reported to be extremely rare, and its clinical picture has been poorly characterized. We present two cases of giant infantile myofibromatosis of the skull base with intracranial involvement. The first case with prenatal diagnosis involved extensively the extradural space of the occipital region and was previously treated by chemotherapy for a previous diagnosis of hemangioperycitoma. Tumor was removed at the age of 5 months and no recurrence was observed during the 3-year follow-up. The second case in a 2-year-old baby involved the anterior cranial base, the nasal cavity, the right orbit, and presented massive involvement of the anterior cranial fossa. Surgery allowed complete removal and a recurrence-free period of 7 years after surgery. Treatment options for these unusual cases are presented and details of histological diagnosis are discussed.