Search

Background: The external opening of the carotid canal (EOCC), the entry point of the internal carotid artery into the skull, varies across populations. This study characterized the EOCC with the mastoid process (shortest distance from the EOCC to the tip of the mastoid process [SDTCC]), the foramen magnum (shortest distance from the EOCC to the foramen magnum [SDFM]), and the midline of the skull base (shortest distance from the EOCC to the midline of the base of the skull [SDMCC]) in the Nigerian population. Materials and Methods: Fifty skull base pictures were taken in the plumed position with a digital camera. Measurements were taken using Image J software, and Euclidean distances were calculated. The shapes of the EOCC were noted. Paleontological Statistics (PAST 3.0) was used to perform descriptive statistics. Paired t-test and Pearson correlation were used to compare bilateral values and the relationship between the parameters, respectively. Results: The length (right, 0.53 [standard deviation (SD)=2.5] mm; left, 10.99 [SD=2.84] mm) and width (right, 13.96 [SD=2.43] mm; left, 14.16 [SD=2.09] mm) of the EOCC were recorded. In contrast to the populations in South Africa, Serbia, and India, the length of the EOCC obtained from this study is shorter than the breadth. The length of SDFM (right, 41.04 mm; left, 44.13 mm), SDMCC (right, 58.4 mm; left, 57.97 mm), and SDTCC (right, 57.29 mm; left, 55.61 mm) was established among Nigerians. Conclusion: The Nigerian population showed EOCC of shorter length than the breadth compared to other populations, and the size of the skull is independent of the foramina size. These dimensions may provide information for procedures that affect the skull base.

Parapharyngeal abscess in an infant is a very rare condition. We present the case of a 4-month-old girl with large masses on the neck's left side. Computed tomography showed an extensive parapharyngeal abscess. Left tonsillectomy was performed under general anesthesia from a transoral approach, followed by an incision and evacuation of the abscess from the parapharyngeal space. Microbiological analysis identified a massive occurrence of Streptococcus intermedius. [ABSTRACT FROM AUTHOR]

Solitary fibrous tumors (SFTs) and haemangiopericytomas (HPCs) are rare mesenchymal tumors in central nervous system (CNS). Although progressed recognition to the diagnosis and treatment of SFT/HPCs, it still remains many confusions regarding on its occurrence, aggressive evolution, malignant transformation, dedifferentiation phenomenon, distant metastasis and unpredictable propensity. Seventeen cases of CNS SFT/HPCs who underwent surgical treatment from January 2010 to December 2020 were collected in the authors' institute. Clinical, radiological, pathological data and followup details were reviewed in all cases. The age of this series was 41-73 years old. Seven cases located subtentorially, five cases originated from middle skull base and four in supratentorial. MRI shows iso-signal intensity on T1WI, and heterogeneous slightly long/short signal on T2WI. There is significant contrast after gadolinium-enhancement. It is easy to be misdiagnosed before surgery. The positive rate of nuclear STAT6 is 94.12%, higher than CD34 (87.5%). Eight patients were grade I, eight grade II and one in grade III. Five cases developed tumor relapse, in which two cases had local intracranial recurrence combined with dissemination and metastasis of cerebrospinal fluid in the spinal canal, accompanied by pathological malignant transformation, and another one occurred blood metastasis. CNS SFT/HPCs are rare intracranial tumors with unpredictable propensity. Gross total resection is critical to its overall clinical prognosis. Given its potential recurrence and malignant transition, adjuvant radiotherapies are recommended when necessary, and long-term follow-up is indispensable. The underlying molecular biological mechanisms are still needed to be further exploration. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to assess degree of audiovestibular handicap in patients with vestibular schwannoma. Methods: Audiovestibular handicap was assessed using the Hearing Handicap Inventory, Tinnitus Handicap Inventory and Dizziness Handicap Inventory. Patients completed questionnaires at presentation and at least one year following treatment with microsurgery, stereotactic radiosurgery or observation. Changes in audiovestibular handicap and factors affecting audiovestibular handicap were assessed. Results: All handicap scores increased at follow up, but not significantly. The Tinnitus Handicap Inventory and Dizziness Handicap Inventory scores predicted tinnitus and dizziness respectively. The Hearing Handicap Inventory was not predictive of hearing loss. Age predicted Tinnitus Handicap Inventory score and microsurgery was associated with a deterioration in Dizziness Handicap Inventory score. Conclusion: Audiovestibular handicap is common in patients with vestibular schwannoma, with 75 per cent having some degree of handicap in at least one inventory. The overall burden of handicap was, however, low. The increased audiovestibular handicap over time was not statistically significant, irrespective of treatment modality. [ABSTRACT FROM AUTHOR]

Background: Subtotal petrosectomy (STP) has attracted massive interest over last two decades. The aim is to present our experience of this uncommon surgery. The indications, outcomes, and our variation in surgical technique would be presented and literature reviewed. Methods: A retrospective observational study of all patients who underwent STP at a tertiary care center in India was analyzed. Results: A total of 9 ears (in 8 patients) underwent STP over last 5 years at our center. The pathological conditions for which STP was done included chronic otitis media squamous (four ears), middle ear tumors (three ears), petrous apicitis (one ear), and traumatic cerebrospinal fluid (CSF) otorhinorrhea (one ear). The indication of STP included disease clearance (eight ears), unserviceable hearing (seven ears), hearing rehabilitation with otological implants (six ears), and intraoperative CSF gusher (one ear). Intraoperative indications included CSF gusher, large tegmen defect with erosion of apical turn of cochlea, and erosion of anterior bony wall of external auditory canal. The mean follow-up period was 36 months (range of 6 months to 60 months). None of the patients had any dehiscence of blind sac closure or secondary acquired cholesteatoma on imaging. Conclusions: STP facilitates disease clearance by providing unmatchable exposure in difficult otological scenarios and additionally isolates middle ear cleft from external environment, thereby eliminating problems of mastoid cavity. Furthermore, it also prepares ear for second stage otological implants. It is a safe surgery with minimal complications. [ABSTRACT FROM AUTHOR]

Introduction Pituitary tumors account for 25% of all primary brain tumors and for 15% of overall intracranial expansive masses. Pituitary metastases, in contrast, are a rare condition, estimated as 1.8% of all resected sellar lesions. We present here a rare case of clear cell renal carcinoma metastasis to the pituitary gland.

Key points: Virtual reality (VR) and Fitbit devices are well tolerated by patients after skull base surgery.Postoperative recovery protocols may benefit from incorporation of these devices.However, challenges including patient compliance may impact optimal device utilization. [ABSTRACT FROM AUTHOR]

AbstractBackground and ImportanceClinical PresentationConclusionCalcifying pseudoneoplasms of the neuraxis (CAPNON) is an extremely rare tumor, with nearly 150 cases have been reported in the literature. We present a case of CAPNON at foramen magnum (cervicomedullary junction). We also discuss the histological and radiological features of this rare pathology.A 35-year-old male patient presented to our center complaining of neck pain for the last 6 months and for the last 3 months has had headaches associated with nausea, blurred vision and papilledema. The patient’s magnetic resonance imaging showed the presence of right craniocervical junction intra-dural extramedullary tumor. Neuro examination showed no neurological deficits. He underwent midline suboccipital craniotomy with C1 laminectomy. The mass was completely resected, and histopathology confirmed it to be a CAPNON.We presented a new case of CAPNON at cervicomedullary junction. The tumor was radically resected, without any complications. Resection of this kind of tumor is curative, and the need for post-operative chemo or radiotherapy is unnecessary, which depends on the outcome of future research and the long-term follow ups. [ABSTRACT FROM AUTHOR]

Oncocytoma arising from the parotid gland and extending into the parapharyngeal space (PPS) has not been previously reported. A 64-year-old woman presented with a large slowly growing mass extending from the parotid to the submandibular area, expanding medially to displace the pharynx across the midline. Core-needle biopsy revealed an oncocytoma in the PPS measuring 120 × 88 × 60 mm in size. Although the tumor was of an unprecedentedly large size and extended into multiple spaces, it could be removed via a cervical–parotid approach without osteotomy. The resected tumor was again diagnosed as oncocytoma. A postoperative complication was weakness of the ipsilateral facial nerve, which almost completely resolved in 6 months. No recurrence has been noted on 1 y follow-up. We were able to resect an extremely large oncocytoma arising from the parotid gland without osteotomy. [ABSTRACT FROM AUTHOR]

Background: The anatomical characteristics of the anterior ethmoidal artery (AEA) exhibit a high degree of variability, especially regarding its topography. Methods: PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Google Scholar were searched to identify all studies that included information regarding the morphometric and topographical characteristics of the AEA. Results: Ultimately, a compilation of 38 studies meeting the predetermined criteria, and possessing comprehensive and pertinent data, were incorporated into the current meta-analysis. In the overall analysis, reports of the AEA being embedded within the skull base or at the level of the skull base producing a bony protrusion were found in 56.91% of cases (95% CI: 43.55–69.80%). The mean diameters of the AEA in the intraorbital and intracranial areas were 0.94 mm and 0.76 mm, respectively. Moreover, the artery coursed most commonly between the second and third lamellae, with a prevalence of 65.82% (95% CI: 55.39–75.56%). Conclusions: The AEA may be at a high risk of iatrogenic injury during various sinus and skull base surgeries, especially if the surgeon performing these procedures is unfamiliar with the vast number of variations this vessel may exhibit. The spatial relationship between this vessel and the skull base is especially variable, and understanding this variability goes hand in hand with intraoperative safety. [ABSTRACT FROM AUTHOR]

Simple Summary: Currently, there is no global consensus regarding the treatment of skull-base chondrosarcoma. Some believe surgery is sufficient, while others administer adjuvant radiotherapy regardless of the extent of surgical resection. This review aims to gather the latest available evidence regarding the treatment of skull-base chondrosarcoma and to analyze the long-term prognosis to ascertain the potential added value of adjuvant radiotherapy and its application. Surgery and radiotherapy are key elements to the treatment of skull-base chondrosarcomas; however, there is currently no consensus regarding whether or not adjuvant radiotherapy has to be administered. This study searched the EMBASE, Cochrane, and PubMed databases for clinical studies evaluating the long-term prognosis of surgery with or without adjuvant radiotherapy. After reviewing the search results, a total of 22 articles were selected for this review. A total of 1388 patients were included in this cohort, of which 186 received surgery only. With mean follow-up periods ranging from 39.1 to 86 months, surgical treatment provided progression-free survival (PFS) rates ranging from 83.7 to 92.9% at 3 years, 60.0 to 92.9% at 5 years, and 58.2 to 64.0% at 10 years. Postoperative radiotherapy provides PFS rates ranging between 87 and 96.2% at 3 years, 57.1 and 100% at 5 years, and 67 and 100% at 10 years. Recurrence rates varied from 5.3% to 39.0% in the surgery-only approach and between 1.5% and 42.90% for the postoperative radiotherapy group. When considering prognostic variables, higher age, brainstem/optic apparatus compression, and larger tumor volume prior to radiotherapy were found to be significant factors for local recurrence. [ABSTRACT FROM AUTHOR]

Role of 3-D models in the identification of the site and extent of bone defects in the skull base for the treatment of CSF rhinorrhea is analyzed. Such models were used successfully in the management of two patients who failed previous attempts at basal reconstruction. The principal advantage of the models was in exact delineation of the size and site of bone defect and deciphering of its relationship with adjoining critical regions of the brain. [ABSTRACT FROM AUTHOR]

This article examines the factors that predict academic career paths among neurosurgery residents who completed a skull-base (SB) fellowship. The study collected data on 81 neurosurgery residents who pursued a SB fellowship from 2018 to 2023. The results showed that academic SB neurosurgeons tended to publish more papers, resulting in a higher h-index, than their nonacademic colleagues before and during their residency. Academic surgeons also typically began publishing on topics within SB surgery earlier in their training compared to nonacademic surgeons. This suggests the importance of early mentoring from a SB neurosurgeon during residency. [Extracted from the article]

The article discusses the versatility of the SPIWAY, an endonasal access guide (EAG) used in surgery. The SPIWAY is a stent that can be placed in the nasal cavity to provide access during endoscopic endonasal surgery. The study includes a retrospective review of cases, a cadaveric model, and a literature review to demonstrate the various uses of the SPIWAY. The article highlights the advantages of the SPIWAY, such as reducing aerosol spread, improving efficiency, and preventing tumor spillage. Overall, the SPIWAY is a useful tool in facilitating access in different surgical approaches within the head and neck. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, explores the role of transcranial motor evoked potentials (t-MEPs) in the surgical resection of skull base meningiomas. The study examines whether t-MEPs monitoring affects postoperative motor function and identifies specific tumor features that may predict intraoperative t-MEPs alteration and postoperative motor deficits. The results show that using t-MEPs monitoring can help reduce the frequency of new-onset postoperative paresis in skull base meningioma surgery, particularly for high-risk locations. The study provides valuable insights for neurosurgeons performing these surgeries. [Extracted from the article]

Objective The North American Skull Base Society (NASBS) multidisciplinary annual conference hosts skull base researchers from across the globe. We hypothesized that the work presented at the NASBS annual conference would reveal diverse authorship teams in terms of specialty and geography. Methods In this retrospective review, abstracts presented at the NASBS annual meeting and subsequently published in the Journal of Neurological Surgery Part B: Skull Base between 01/01/2011 and 12/31/2020 were collected. Variables extracted included year, type of presentation, and author names and affiliations. Statistical analyses were performed with SPSS V23.0 with p -values less than 0.05 considered significant. Geographic heat maps were created to assess author distribution, and a network analysis was performed to display authorship collaboration between geographic regions. Results Of 3,312 published abstracts, 731 (22.1%) had an author with an affiliation outside of the United States. Fifty-seven distinct countries were represented. Three-hundred twenty-four abstracts (9.8%) had authorship teams representing at least 2 different countries. The top five US states by abstract representation were Pennsylvania, California, New York, Ohio, and Minnesota. A majority of authors reported neurosurgery affiliations (56.7% first authors, 53.2% last authors), closely followed by otolaryngology (39.1% first authors, 41.5% last authors). No solo authors and very few (3.3%) of the first authors reported a departmental affiliation outside of otolaryngology or neurosurgery. Conclusions Authors from many countries disseminate their work through poster and oral presentations at the NASBS annual meeting. Ten percent of abstracts were the product of international collaboration. Most authors were affiliated with a neurosurgery or otolaryngology department. [ABSTRACT FROM AUTHOR]

Background: Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology‐based topics spanning the field. Methods: In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence‐Based Review with Recommendations, Evidence‐Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses format, and completed sections underwent a thorough and iterative consensus‐building process. The final document underwent rigorous synthesis and review prior to publication. Results: The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology‐based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention. Conclusion: As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses. [ABSTRACT FROM AUTHOR]

Objective: Frailty metrics estimate a patient's ability to tolerate physiologic stress and there are limited frailty data in patients undergoing expanded endonasal approaches (EEA) for suprasellar pathologies. Elevated frailty metrics have been associated with increased perioperative complications in patients undergoing craniotomies. We sought to examine this potential relationship in EEA. Study Design: Retrospective cohort study. Setting: Two tertiary academic skull base centers. Methods: Cases of patients undergoing EEA for suprasellar pathologies were reviewed. Demographic, treatment, survival, and postoperative outcomes data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, the modified 5‐item frailty index (mFI‐5), and the Charlson comorbidity index (CCI). Primary outcomes included 30‐day medical and surgical complications. Results: A total of 88 patients were included, with 59 (67%) female patients and a mean age of 54 ± 15 years. The most common pathologies included 53 meningiomas (60.2%) and 21 craniopharyngiomas (23.9%). Most patients were ASA class 3 (54.5%) with mean mFI‐5 0.82 ± 1.01 and CCI 4.18 ± 2.42. There was no association between increased frailty and 30‐day medical or surgical outcomes (including postoperative cerebrospinal fluid leak), prolonged length of hospital stay, or mortality (all P >.05). Higher mFI‐5 was associated with an increased risk for 30‐day readmission (odds ratio: 2.35, 95% confidence Interval: 1.10‐5.64, P =.04). Conclusion: Despite the patient population being notably frail, we only identified an increased risk for 30‐day readmission and observed no links with deteriorating surgical, medical, or mortality outcomes. This implies that conventional frailty metrics may not effectively align with EEA outcomes. [ABSTRACT FROM AUTHOR]

Recent advances in medical imaging, computer vision, 3-dimensional (3D) modeling, and artificial intelligence (AI) integrated technologies paved the way for generating patient-specific, realistic 3D visualization of pathological anatomy in neurosurgical conditions. Immersive surgical simulations through augmented reality (AR), virtual reality (VR), mixed reality (MxR), extended reality (XR), and 3D printing applications further increased their utilization in current surgical practice and training. This narrative review investigates state-of-the-art studies, the limitations of these technologies, and future directions for them in the field of skull base surgery. We begin with a methodology summary to create accurate 3D models customized for each patient by combining several imaging modalities. Then, we explore how these models are employed in surgical planning simulations and real-time navigation systems in surgical procedures involving the anterior, middle, and posterior cranial skull bases, including endoscopic and open microsurgical operations. We also evaluate their influence on surgical decision-making, performance, and education. Accumulating evidence demonstrates that these technologies can enhance the visibility of the neuroanatomical structures situated at the cranial base and assist surgeons in preoperative planning and intraoperative navigation, thus showing great potential to improve surgical results and reduce complications. Maximum effectiveness can be achieved in approach selection, patient positioning, craniotomy placement, anti-target avoidance, and comprehension of spatial interrelationships of neurovascular structures. Finally, we present the obstacles and possible future paths for the broader implementation of these groundbreaking methods in neurosurgery, highlighting the importance of ongoing technological advancements and interdisciplinary collaboration to improve the accuracy and usefulness of 3D visualization and reality technologies in skull base surgeries.

Background: Meningiomas are extra-axial tumors that arise from meningothelial cells, accounting for about one-third of primary central nervous system malignancies. While they are often classified by location and histology, the role of the molecular profile in their development and progression is significant. The topographic distribution of meningiomas has not been extensively studied, and it is unclear whether specific histological subtypes have predilection sites. Therefore, this study analyzes the preferred locations of meningiomas according to different biological characteristics and their association with different gradings. Methods: This is a retrospective chart review of patients in tertiary institutes over 14 years. The data were retrieved from medical and pathological record archives. An association between the biological nature of tumors and the location of meningiomas was analyzed. SPSS version 25 was used to analyze the data. Results: Out of 272 patients, the predominant location for meningioma distribution was convexity (33.5%), followed by parafalcine (12.5%). WHO Grade I meningiomas were the most common, accounting for 84.2% of all meningiomas. The transitional histological subtype is the common variant (34.6%). The distribution of the histological subtype of meningioma in relation to tentorium was statistically significant. However, that was not the case with the skull base. Conclusion: The spatial distribution of meningiomas within the brain is not uniform. The most frequent locations for meningiomas were found to be convexity and parafalcine. Transitional and fibroblastic meningiomas were the predominant subtypes.

Background and objective: Gross total resection of skull base meningioma is so challenging due to its relevant high morbidity. Gamma knife radiosurgery is concerned by providing a favorable therapeutic option in the management of SBM. This study aims to evaluate the neurological outcome after GKRS as an adjuvant or primary treatment for SBM according to their locations. Methods: This retrospective cross-sectional study consisted of 108 patients with SBM who underwent GKRS as an adjuvant or primary treatment. We found 40 patients with cavernous sinus meningioma (CSM), 36 patients with petroclival meningioma (PCM), and 22 patients with cerebellopontine angle meningioma (CPM). 81.1% of whom were female (n = 90) with a median age of 52.68 years. The mean tumor volume was 4.5 cm3 and the mean marginal dose was 13 Gy. Results: Tumor control was achieved in 96.4 % of patients at a median follow-up of 38.4 months. Over all 17 of 108 patients (15.6%) report improvement in their neurological symptoms. Patients with CPM demonstrated lower rates of neurological symptoms improvement compared to patients with PCM and CSM. Deterioration of neurological symptoms after GKRS developed in 11 patients (10.1%) which was more reported by patients with CSM than the others. The most improvement in cranial nerve deficit was in CN Ⅵ, Ⅴ, VIII among patients with CSM, PCM, and CPM respectively. Conclusion: GKRS is acceptable as a primary or adjuvant treatment for SBM by providing an appreciable rate of improvement in neurological symptoms.

IntroductionChordomas are aggressive tumors that are thought to arise from remnants of the embryological notochord. They can arise along the ventromedial aspect of the sacrum, mobile spine, and clivus—with most cases occurring in the sacrum or skull base. Despite surgery and radiation, chordomas often progress and become refractory to further treatment. The high recurrence rate of chordomas has created an urgent need to develop new systemic treatment options. Recent case reports and clinical trials have highlighted the use of immunotherapy for refractory chordomas. In this review, we summarize the results of these studies and discuss the potential role of immunotherapy for chordomas.MethodsThe PUBMED database was queried for studies mentioning both “Chordoma” and “Immunotherapy.” All case series and case reports that involved administration of an immunotherapy for chordoma were included. Additional studies that were found during literature review were added. ClinicalTrials.Gov was queried for studies mentioning both “Chordoma” and “Immunotherapy.” The final cohort consisted of all clinical trials that utilized immunotherapy for chordomas of any location.ResultsEight case reports and series detailing the use of immunotherapy for treatment refractory chordoma were identified. Most patients received immunotherapy targeting the PD-1/PD-L1 interaction, and two patients received therapy targeting this interaction along with the tyrosine kinase inhibitor pazopanib. One patient received a vaccine derived from autologous tumor cells, and one patient received a viral vector that downregulated the effect of TGF-beta. One clinical trial utilized a brachyury vaccine in conjunction with standard of care radiotherapy.ConclusionsImmunotherapy for chordoma is a promising area of investigation with increasing, but small, numbers of case series and clinical trials. Despite challenges in patient accrual, future directions in chordoma immunotherapy may lie in vaccine-based therapies and immune checkpoint inhibitors. Understanding chordoma heterogeneity and microenvironment will likely elucidate important chordoma features that will inform future clinical trial design.

Cystic degeneration of the fibrous dysplasia is a very rare clinical condition and may present with loss of vision when it involved the skull base. A 12-year-old female child presented with an enlargement of the skull. She was diagnosed as large skull base and skull vault tumor. She underwent partial removal of the tumor, and custom-made titanium implant was inserted. The diagnosis was fibrous dysplasia. Two years after the initial diagnosis, she presented with total loss of vision at her right eye. Radiological imaging confirmed the cystic degeneration within the tumor. She re-operated and the cyst fluid was evacuated in association with the removal of cyst wall. The diagnosis was the cystic degeneration of the fibrous dysplasia. Her vision was improved a few days after the surgery. Fibrous dysplasia of the skull base should be closely followed-up in order to prevent severe visual complications. [ABSTRACT FROM AUTHOR]

Parapharyngeal lipoma with skull base extension is rare tumor found in head and neck region. We report a case of 66 years old female patient with left side face swelling extending to neck. On clinical examination, it was found soft, non-tender, mobile swelling present over left side pre-auricular region. It was extending from pretragal area superiorly to left submandibular region inferiorly. CECT neck and fine needle aspiration cytology was done to know the benign nature of disease. It suggest tumor extending from skull base to C6 vertebral level in parapharyngeal space. Tumor was excised via Trans parotid-transcervical approach. Parapharyngeal lipomas are confined to either the prestyloid or post styloid compartments. We report an unusual parapharyngeal lipoma involving both the compartments of the parapharyngeal space. [ABSTRACT FROM AUTHOR]

The arcuate eminence (AE) is an anatomically consistent bony protrusion located on the upper surface of the petrous bone that has been previously studied as a reference for lateral skull base approaches. There is a paucity of information in the neurosurgical literature seeking to improve the safety of the extended middle cranial fossa (MCF) approach using detailed morphometric analysis of the AE. To evaluate the use of the AE as an anatomical landmark to help with early identification of the internal acoustic canal (IAC) in MCF approaches by means of a cadaveric study, using a new morphometric reference termed the "M-point." A total of 40 dry temporal bones and 2 formalin-preserved, latex-injected cadaveric heads were used. The M-point was established as a new anatomic reference by identifying the intersection of a line perpendicular to the alignment of the petrous ridge (PR), originating from the midpoint of the AE, with the PR itself. Subsequent anatomical measurements were performed to measure the distance between M-point and IAC. Additional distances, including PR length and the anteroposterior and lateral AE surfaces, were also measured. The mean distance between the M-point and the center of the IAC was 14.9 mm (SD ± 2.09), offering a safe drilling area during an MCF approach. This study provides novel information on identification of a new anatomic reference point known as the M-point that that can be used to improve early surgical identification of the IAC. [ABSTRACT FROM AUTHOR]

Introduction. Juvenile nasopharyngeal angiofibroma is a rare type of benign vascular tumour that affects only young males, especially those between the ages of 9 and 19. Therapeutic management depends on the extent of the lesion, being conditioned by the complexity of the anatomy of the skull base and the risk of massive bleeding due to the abundant vascular supply. The purpose of this article is to describe the modern approach to juvenile nasopharyngeal angiofibroma, starting from the general knowledge on this topic and presenting the experience of our clinic. Materials and Methods. A retrospective study was conducted on 10 male patients with juvenile angiofibroma, with clinical and imaging diagnoses, confirmed by post-ablative histopathological examination. From the 10 juvenile angiofibroma case treated in our clinic, 4 of them were less extensive, 2 with invasion to the pterygopalatine fossa, 3 involving the infratemporal fossa and 1 with minimal intracranial extension. Results. Combined approach (endoscopic trans-nasal approach and Caldwell Luc approach) was necessary in the treatment of a IIC case. Follow-up after surgery was done using MRI scans every 6 months. Recurrence was encountered in one case (9 months from the first surgery), and needed reintervention to remove the residual tumour. Conclusions. Even if it is a rare condition, the development of specific materials and techniques (endoscopic, embolization) has been considerable, allowing the reduction of intraoperative bleeding and residual tumour tissue, in conditions of minimal interference with the facial anatomy of such young patients [ABSTRACT FROM AUTHOR]

Background: The variant morphometry of the optic canal is important to neurosurgeons, radiologists and ophthalmologists in the diagnosis and management of skull base and intracanalicular lesions. Aim and Objectives: This study delved into the anatomical details of the optic canal morphometry, emphasizing its importance in neurosurgical and radiological practices. Materials and methods: Utilizing Computed Tomography (CT) images from a Nigerian Teaching Hospital, we retrospectively assessed the dimensions of the optic canal in 300 adult patients (160 males and 140 females). Rigorous ethical clearance was obtained, and image analysis included measurements of height, width, length of medial and lateral walls, and aperture diameters. Statistical analyses were conducted using SPSS software, examining variations based on age, gender, and side. Results: The left canal demonstrated a wider width, while the right exhibited a longer lateral wall (p < 0.05). Gender differences were noted in orbital and cranial aperture sizes. Agegroup comparisons revealed significant differences in wall lengths and aperture diameters. The optic canal dimensions showed weak positive correlations with age (p < 0.05). Conclusion: This study contributes vital CT measurements of the optic canal, serving as a foundational reference for ophthalmologists, neurosurgeons, and radiologists. The population-specific findings emphasize the optic canal's significance in clinical practice, particularly in the context of surgical interventions and diagnostic precision. [ABSTRACT FROM AUTHOR]

In the field of minimally invasive neurosurgery, microscopic transsphenoidal surgery (MTS) and endoscopic transsphenoidal surgery (ETS) have been widely accepted as a safe approach for pituitary lesions and, more recently, their indications have been extended to lesions at various skull base regions. It is mandatory during transsphenoidal surgery (TS) to identify key anatomical landmarks in the sphenoid sinus and distinguish them from the lesion. Over the years, many intraoperative tools have been introduced to improve the neuronavigation systems aiming to achieve safer and more accurate neurosurgical interventions. However, traditional neuronavigation systems may lose the accuracy of real-time location due to the discrepancy between the actual surgical field and the preoperative 2D images. To deal with this, augmented reality (AR)—a new sophisticated 3D technology that superimposes computer-generated virtual objects onto the user's view of the real world—has been considered a promising tool. Particularly, in the field of TS, AR can minimize the anatomic challenges of traditional endoscopic or microscopic surgery, aiding in surgical training, preoperative planning and intra-operative orientation. The aim of this systematic review is to analyze the potential future role of augmented reality, both in endoscopic and microscopic transsphenoidal surgeries. [ABSTRACT FROM AUTHOR]

Ganglioneuroma is a rare benign tumor originating in the sympathetic ganglia, composed of differentiated ganglion cells, nerve sheath cells, and nerve fibers, which tend to occur in the posterior mediastinum, adrenal gland, retroperitoneal, and other locations, occurring in the head and neck is relatively rare, and parapharyngeal space involvement is extremely rare. In our report, we present 2 adult male patients whose preoperative imaging and fine needle cytology did not confirm the diagnosis of a parapharyngeal space mass and who completely resected the tumor through a combined cervical and oral approach. Finally, pathology confirmed ganglioneuroma; we also reviewed the English articles on parapharyngeal ganglioneuroma over the past 40 years, and summarized the diagnostic and treatment characteristics of parapharyngeal ganglioneuroma in combination with our cases to improve understanding of the disease. [ABSTRACT FROM AUTHOR]

Objective: To review the literature and our institutional experience regarding the risk of meningitis in patients with spontaneous lateral skull base cerebrospinal fluid (sCSF) leaks awaiting surgical repair, and the roles of antibiotic prophylaxis and pneumococcal vaccination, if known. Methods: A retrospective chart review and systematic review of the literature was undertaken to identify the incidence of meningitis in patients with sCSF leaks awaiting surgical repair. Adults managed surgically for sCSF leaks at an academic tertiary care center over a 10-year period were included. Data was collected on receipt of prophylactic antibiotics and/or pneumococcal vaccines during the timeframe between diagnosis and surgical repair. Results: Institutional review identified 87 patients who underwent surgical repair of spontaneous leaks, with a 0% incidence of meningitis over a median duration of 2 months while awaiting surgery (mean 5.5 months, range 0.5-118 months). Eighty-eight percent of patients did not receive prophylactic antibiotics. No studies in the published literature demonstrated the impact of prophylactic antibiotics or pneumococcal vaccine on meningitis risk. Conclusions: There appears to be a low risk of meningitis among patients with lateral skull base sCSF leaks awaiting surgery for short durations (≤2 months), even in the absence of prophylactic antibiotics. There is a substantial gap in the published literature assessing the risk of meningitis and roles of antibiotics and vaccination in this patient population, indicating the need for large-scale study to conclusively elucidate the nature of this risk. [ABSTRACT FROM AUTHOR]

Background: Surgical removal of complex pituitary adenomas (PA) is a technically challenging procedure. To ensure safe and efficient surgery, we employ the micro-endoscopic combination technique. Method: In this study, we present our approach to the removal of a complex PA using the micro-endoscopic combination strategy. We describe our surgical setup and workflow in detail. Conclusion: Our experience with this case highlights the effectiveness of the micro-endoscopic combination technique in the management of complicated skull base surgeries with good teamwork and cooperation. [ABSTRACT FROM AUTHOR]

Despite the importance of functional outcome, only a few scoring systems exist to predict neurologic outcome in meningioma surgery. Therefore, our study aims to identify preoperative risk factors and develop the receiver operating characteristics (ROC) models estimating the risk of a new postoperative neurologic deficit and a decrease in Karnofsky performance status (KPS). A multicentric study was conducted in a cohort of 552 consecutive patients with skull base meningiomas who underwent surgical resection from 2014 to 2019. Data were gathered from clinical, surgical, and pathology records as well as radiological diagnostics. The preoperative predictive factors of functional outcome (neurologic deficit, decrease in KPS) were analyzed in univariate and multivariate stepwise selection analyses. Permanent neurologic deficits were present in 73 (13.2%) patients and a postoperative decrease in KPS in 84 (15.2%). Surgery-related mortality was 1.3%. A ROC model was developed to estimate the probability of a new neurologic deficit (area 0.74; SE 0.0284; 95% Wald confidence limits (0.69; 0.80)) based on meningioma location and diameter. Consequently, a ROC model was developed to predict the probability of a postoperative decrease in KPS (area 0.80; SE 0.0289; 95% Wald confidence limits (0.74; 0.85)) based on the patient’s age, meningioma location, diameter, presence of hyperostosis, and dural tail. To ensure an evidence-based therapeutic approach, treatment should be founded on known risk factors, scoring systems, and predictive models. We propose ROC models predicting the functional outcome of skull base meningioma resection based on the age of the patient, meningioma size, and location and the presence of hyperostosis and dural tail. [ABSTRACT FROM AUTHOR]

Background: Postoperative nausea and vomiting (PONV) are adverse effects after surgery, which may increase the risk of complications. Aprepitant is a neurokinin‐1 receptor blocker and has been shown to reduce chemotherapy‐related nausea and vomiting and PONV. However, its role in endoscopic skull base surgery remains unclear. The purpose of this study was to evaluate the effect of aprepitant in reducing PONV in endoscopic transsphenoidal (TSA) pituitary surgery. Methods: A retrospective chart review between July 2021 and January 2023 of 127 consecutive patients who underwent TSA was performed at a tertiary academic institution. Patients were divided into 2 groups based on preoperative aprepitant use. Two groups were matched based on known risk factors of PONV (age, sex, nonsmoking, and history of PONV). The primary outcome was the incidence of PONV. Secondary outcome measures included the number of anti‐emetic use, length of stay, and postoperative cererebrospinal fluid (CSF) leak. Results: After matching, 48 patients were included in each group. The aprepitant group demonstrated a significantly lower incidence of vomiting than the non‐aprepitant group (2.1% vs 22.9%, p = 0.002). The number of nausea episodes and anti‐emetic use decreased with aprepitant use (p < 0.05). There was no difference in the incidence of nausea, length of stay, or postoperative CSF leak. Multivariate analysis demonstrated that aprepitant decreased the incidence of postoperative vomiting with odds ratio of 0.107. Conclusion: Aprepitant may serve as a useful preoperative treatment to reduce PONV in patients undergoing TSA. Further studies are needed to evaluate its impact in other arenas of endoscopic skull base surgery. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to investigate potential correlations between skull density and the progression of chronic subdural hematoma (CSDH). Methods: Patients with unilateral CSDH were retrospectively enrolled between January 2018 and December 2022. Demographic and clinical characteristics, as well as hematoma and skull density (Hounsfield unit, Hu), were collected and analyzed. Results: The study enrolled 830 patients with unilateral CSDH until the resolution of the CDSH or progressed with surgical treatment. Of the total, 488 patients (58.80%) necessitated surgical treatment. The study identified a significant correlation between the progression of CSDH and three variables: minimum skull density (MiSD), maximum skull density (MaSD), and skull density difference (SDD) (p < 0.001). Additionally, in the multivariable regression analysis, MiSD, MaSD, and SDD were independent predictors of CSDH progression. The MiSD + SDD model exhibited an accuracy of 0.88, as determined by the area under the receiver operating characteristic curve, with a sensitivity of 0.77 and specificity of 0.88. The model's accuracy was validated through additional analysis. Conclusion: The findings suggest a significant correlation between skull density and the CSDH progression. [ABSTRACT FROM AUTHOR]

Due to the increase in life expectancy, the number of elderly patients suffering from a pituitary macroadenoma is expected to increase in the future. The endoscopic endonasal transsphenoidal (EET) approach tends to be the first choice for the treatment of pituitary macroadenomas in the general population. Notwithstanding, in the geriatric population, the goals of management for this condition remain unclear. The present study retrospectively evaluated and describes the cases of 6 patients >70 years of age with a pituitary macroadenoma who were treated by a skull base team, composed of one ENT surgeon and one neurosurgeon. All the patients experienced a notable improvement in their neurological deficit, while their hormonal status also improved or at least did not deteriorate after the surgery. The EET approach appears to be a safe and effective approach for the treatment of pituitary macroadenomas in the geriatric population. [ABSTRACT FROM AUTHOR]

The caroticotympanic nerves provide postganglionic sympathetic fibres to the tympanic plexus. However, there are scant reports in the literature detailing with these nerves in great depth. As the caroticotympanic plexus lies near the often‐operated tympanic nerve, it is important for the surgeon to understand the anatomy, pathology and surgical implications of it. Here, we present a review of the available literature regarding the caroticotympanic nerves. [ABSTRACT FROM AUTHOR]

Objective: This is a case report of a dermoid cyst located in the infratemporal fossa and its surgical removal using infratemporal fossa type B approach. Case report: A 15-year-old male was referred from a local clinic after an incidental finding of a mass lesion in the skull base area on computed tomography (CT). Pre-operative magnetic resonance imaging showed a large cystic mass lesion, expanding to the foramen ovale with fat component in the right infratemporal fossa region. The lesion was completely excised using an infratemporal fossa type B approach. Conclusion: An extremely rare case of dermoid cysts of the infratemporal fossa was managed with infratemporal fossa type B approach without severe complication. [ABSTRACT FROM AUTHOR]

Abstract Objective The management of lesions involving the cavernous sinus remains a formidable challenge. To optimize care for patients with tumors extending into this skull base region a detailed understanding of the surrounding osteology as well as neural and vascular relationships is requisite. This thesis examines the gross anatomy of the region and highlights important surgical implications drawn from these as well as previously published studies. Methods A review of the historical scientific, anatomic, clinical, and surgical literature extending to the present (1992) relating to the cavernous sinus has been performed and discussed. Additionally, the author has performed and described cadaveric dissections revealing novel details about the macroscopic (dural and neurovascular anatomic relationships) and microscopic structure of the cavernous sinus. A series of cases of cavernous sinus pathologies that were addressed in an interdisciplinary surgical approach at the author's institution is also reported. Results Included in this report is a comprehensive review of the embryology of the cavernous sinus and its associated neurovascular structures. Cadaveric dissections have also revealed novel details about dural/meningeal compartments of the cavernous sinus as well as well as associated arterial, venous, and neural relationships. Microscopic observations also reveal novel fundamental insights into the components and structure of the cavernous sinus. Clinical examples from 20 patients illustrate the critical importance for clinical application of cavernous sinus anatomic knowledge to the surgical treatment of pathologies in this region. Conclusion The cavernous sinus is a tripartite venous osteomeningeal compartment intimately neighboring vital structures including the optic tracts, pituitary gland, cranial nerves III, IV, V, V, VI, and the internal carotid artery. Surgical management of cavernous sinus lesions has and continues to evolve with increasing anatomic and clinical study as well as advancements in diagnostic and surgical methodologies. Level of Evidence NA.

Purpose: To report our experience with patient specific implants for one-step orbit reconstruction following hyperostotic SWM removal and to describe the evolution of the technique through three surgical cases. Methods: Three cases of one-step SWM removal and orbit reconstruction are described. All cases are given consecutively to describe the evolution of the technique. Hyperostotic bone resection was facilitated by electromagnetic navigation and cutting guides (templates). Based on a 3D model, silicone molds were made using CAD/CAM. Then PMMA implant was fabricated from these molds. The implant was adjusted and fixed to the cranium with titanium screws after tumor removal. Results: Following steps of the procedure changed over these series: hyperostotic bone resection, implant thickness control, implant overlay features, anatomic adjustments, implant fixation. The proptosis resolved in all cases. In one patient the progressive visual acuity deterioration was recognized during the follow-up. No oculomotor disturbances and no tumor regrowth were found at the follow-up. Conclusion: CAD/CAM technologies enable creation of implants of any size and configuration, and thereby, to increase the extent of bony resection and lower the risk of tumor progression. The procedure is performed in one step which decreases the risk of postoperative morbidity.

Background: While previous studies have assessed patient reported quality of life (QOL) of various vestibular schwannoma (VS) treatment modalities, few studies have assessed QOL as related to the amount of residual tumor and need for retreatment in a large series of patients. Objective: To assess patient reported QOL outcomes following VS resection with a focus on extent of resection and retreatment. Methods: A retrospective chart review was performed using single-center institutional data of adult patients who underwent VS resection by the senior authors between 1989-2018 at Loyola University Medical Center. The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was sent to all patients via postal mail. Results: Fifty-five percent of 367 total patients were female with a mean age of 61.6 years (SD 12.63). The mean period between surgery and PANQOL response was 11.4 years (IQR: 4.74-7.37). The median tumor size was 2 cm (IQR: 1.5-2.8). The mean total PANQOL score was 70 (SD 19). Patients who required retreatment reported lower overall scores (μdiff = -10.11, 95% CI: -19.48 to -0.74; p = 0.03) and face domain scores (μdiff = -20.34, 95% CI: -29.78 to -10.91; p < .001). There was no association between extent of resection and PANQOL scores in any domain. Conclusion: In an analysis of 367 patients who underwent microsurgical resection of VS, extent of resection did not affect PANQOL scores in contrast to previous reports in the literature, while the need for retreatment and facial function had a significant impact on patient-reported outcomes.

BackgroundFacial deformities in syndromic craniosynostosis are not only functionally, psychosocially, and aesthetically impairing but also notoriously challenging to reconstruct. Whether facial suture synostosis plays a significant role in the pathogenesis of these deformities is inadequately studied in human patients.MethodsThe MEDLINE database was queried using a methodologically generated search term inventory. Article inclusion was adjudicated by 2 authors after independent review. Articles provided insight into facial suture involvement in either syndromic craniosynostosis patients or animal models of disease.ResultsComprehensive review yielded 19 relevant articles meeting inclusion criteria. Mid-20th century craniofacial biologists characterized how patent facial sutures are essential for normal postnatal facial development. They also posited that premature ossification disrupts growth vectors, causing significant dysmorphologies. Recently, facial suture synostosis was found to cause midfacial deformities independent of cranial base pathology in mouse models of syndromic craniosynostosis. Few recent studies have begun exploring facial suture involvement in patients, and although they have paved the way for future research, they bear significant limitations.ConclusionsThe hypothesis that facial suture synostosis acts in conjunction with cranial base pathology to produce the prominent, multifocal facial deformities in syndromic craniosynostosis may fundamentally alter surgical management and warrants further investigation. Methodically evaluating the literature, this review synthesizes all basic science and human clinical research thus far on the role of facial sutures in syndromic craniosynostosis and elucidates important topics for future research. We ultimately identify the need for rigorous imaging studies that longitudinally evaluate facial osteology across patients with various craniosynostosis syndromes.

This video article presents a 47-year-old male patient who presented to the emergency department after a cleaver bounced off the grinding wheel and lodged between his eyebrows. The patient complained of clear nasal drainage since the trauma. Computed tomography showed a comminuted displaced fracture starting from the right frontonasal recess and extending along the right ethmoid roof. The patient underwent surgery. The skull base defect was reconstructed with a free fascia lata graft in the first operation. In the second session, the reconstruction of the skull base was reinforced with a flap that was prepared from the middle turbinate with the concha bullosa. The patient was followed for eight months. The patient's symptoms resolved completely and there was no evidence of rhinorrhoea or any other complication at the control examination. No complications were seen on control magnetic resonance imaging. [ABSTRACT FROM AUTHOR]

Abstract Objectives Current evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak. Methods A retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test. Results Analysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In patient with sCSF leaks, there was a significantly higher proportion of patients with DVS narrowing compared with published literature examining this condition in the general population (80% vs. 40%, CI 0.59–0.93, p

Summary: Angiolipomas are uncommon neoplasms of the central nervous system. They are found in the intracranial region and usually originate from the midline sellar area. In this case report, we present the clinical findings of a 69-year-old female patient who experienced progressive bilateral vision loss and headaches. Subsequent postoperative diagnosis confirmed the presence of an angiolipoma. Given the highly vascular nature of these tumors, peri-operative hemorrhagic events are a concerning complication, as was observed in this particular case. In addition to our findings, we conducted a review of previous reports on this rare condition, with a specific focus on complications.

During the last few years, the superior eyelid endoscopic transorbital approach has been proposed as a new minimally invasive pathway to access skull base lesions, mostly in ophthalmologic, otolaryngologic, and maxillofacial surgeries. However, most neurosurgeons performing minimally invasive endoscopic neurosurgery do not usually employ the orbit as a surgical corridor. The authors undertook this technical and anatomical study to contribute a neurosurgical perspective, exploring the different possibilities of this novel route. Ten dissections were performed on ten formalin-fixed specimens to further refine the transorbital technique. As part of the study, the authors also report an illustrative transorbital surgery case to further detail key surgical landmarks. Herein, we would like to discuss equipment, key anatomical landmarks, and surgical skills and stress the steps and details to ensure a safe and successful procedure. We believe it could be critical to promote and encourage the neurosurgical community to overcome difficulties and ensure a successful surgery by following these key recommendations. [ABSTRACT FROM AUTHOR]

Simple Summary: We report the experience of our institution in treating clival chordomas over 20 years and systematically review the recent literature, highlighting factors associated with outcome (age < 50 years, Ki67 ≤ 5%, and adjuvant radiotherapy are associated with better overall survival) and clues for new therapies. Recurrence in clival chordomas remains part of the disease history despite maximal treatment. Still, significant variations are evident in overall and progression-free survival, highlighting the need to develop efficient treatment strategies and recognize which factors reliably predict a more aggressive behavior of clival chordomas. Clival chordomas are rare but aggressive skull base tumors that pose significant treatment challenges and portend dismal prognosis. The aim of this study was to highlight the advantages and limitations of available treatments, to furnish prognostic indicators, and to shed light on novel therapeutic strategies. We conducted a retrospective study of clival chordomas that were surgically treated at our institution from 2003 to 2022; for comparison purposes, we provided a systematic review of published surgical series and, finally, we reviewed the most recent advancements in molecular research. A total of 42 patients underwent 85 surgeries; median follow-up was 15.8 years, overall survival rate was 49.9% at 10 years; meanwhile, progression-free survival was 26.6% at 10 years. A significantly improved survival was observed in younger patients (<50 years), in tumors with Ki67 ≤ 5% and when adjuvant radiotherapy was performed. To conclude, clival chordomas are aggressive tumors in which surgery and radiotherapy play a fundamental role while molecular targeted drugs still have an ancillary position. Recognizing risk factors for recurrence and performing a molecular characterization of more aggressive lesions may be the key to future effective treatment. [ABSTRACT FROM AUTHOR]

Transorbital neuroendoscopic surgery (TONES) comprises a group of approaches with indications expanding from orbital tumors to more complex skull base lesions. We analyzed the role of the endoscopic transorbital approach (eTOA) for spheno-orbital tumors, reporting the results of our clinical series and of a systematic review of the literature. All patients operated on from 2016 to 2022 at our institution for a spheno-orbital tumor through an eTOA were included in a clinical series, and a systematic review of the literature was performed. Our series consisted of 22 patients (16 females, mean age 57 ± 13 years). Gross tumor removal was achieved in 8 patients (36.4%) after the eTOA and in 11 (50.0%) after a multistaged strategy combining the eTOA with the endoscopic endonasal approach. Complications included 1 chronic subdural hematoma and 1 permanent extrinsic ocular muscle deficit. Patients were discharged after 2.4 ± 1.3 days. The most common histotype was meningioma (86.4%). Proptosis improved in all cases, visual deficit in 66.6%, and diplopia in 76.9%. These results were confirmed by the review of the 127 cases reported in the literature. Despite its recent introduction, a significant number of spheno-orbital lesions treated with an eTOA are being reported. Its main advantages are favorable patient outcome and optimal cosmetic results, with minimal morbidity and quick recovery. This approach can be combined with other surgical routes or adjuvant therapies for complex tumors. However, it is a technically demanding procedure, requiring specific skills in endoscopic surgery, that should be reserved to dedicated centers. [ABSTRACT FROM AUTHOR]