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Chiari I malformations are often associated with congenital craniocervical anomalies such as platybasia, basilar invagination, and retroflexion of the odontoid process. Management of ventral brain stem compression associated with Chiari I malformations remains controversial, but several authors report a significant rate of failure with suboccipital decompression alone in the presence of pronounced ventral brain stem compression (VBSC). Treatment options described in the literature for these patients involve anterior, posterior, or combined decompressions with or without concurrent arthrodesis. A combined anterior and posterior approach provides a definitive circumferential decompression but also significantly disrupts the stability of the occipitocervical junction usually necessitating occipitocervical fixation. We describe an alternative surgical treatment for Chiari I patients with significant ventral brain stem compression where a combined anterior and posterior decompression was considered necessary. We report two patients who underwent transoral odontoidectomy with preservation of the anterior arch of the atlas and suboccipital craniectomy with C1 laminectomy followed by C1-C2 arthrodesis. Preservation of the anterior arch of the atlas in conjunction with C1-C2 arthrodesis stabilizes the occipito-atlanto-axial segments while conserving more cervical mobility as compared to an occipitocervical fusion. [ABSTRACT FROM AUTHOR]

Neurological disorders pose a challenge for targeted therapy due to restricted access of therapeutic agents to the central nervous system (CNS). Current methods are limited by procedure-related risks, invasiveness, and insufficient CNS biodistribution. A novel percutaneous transvenous technology, currently in clinical trials for communicating hydrocephalus, offers a minimally invasive approach by providing endovascular access to the cerebrospinal fluid-filled cerebellopontine angle (CPA) cistern. We hypothesized that drug delivery to the CPA cistern could yield widespread CNS distribution. Using an ovine model, we compared the biodistribution of scAAV9-CB-GFP following CPA cistern infusion with previously reported cisterna magna (CM) administration. Targeting both the CPA cistern and CM in sheep, we employed a lumbar spine-inserted microcatheter under fluoroscopy. CPA delivery of AAV9 demonstrated biodistribution and transduction in the cerebral cortices, striatum, thalamus, midbrain, cerebellum, and spinal cord, with minor liver distribution comparable to CM. The favorable safety profile in humans with hydrocephalus suggests that percutaneous endovascular injection into the CPA could offer a clinically safer and minimally invasive delivery system for CNS gene and cell-based therapies., Competing Interests: Declaration of interests C.B.H. is a shareholder, consultant, investor, and co-founder of CereVasc, Inc. B.M.B. is a shareholder and employee of CereVasc, Inc. M.J.G. is a consultant on a fee-per-hour basis for Alembic LLC, Astrocyte Pharmaceuticals, BendIt Technologies, Cerenovus, Imperative Care, Jacob’s Institute, Medtronic Neurovascular, Mivi Neurosciences, phenox GMbH, Q’Apel, Route 92 Medical, Scientia, Simcerre, Stryker Neurovascular, Stryker Sustainability Solutions, Wallaby Medical; holds stock in Imperative Care, InNeuroCo, Galaxy Therapeutics, Kapto, Neurogami and Synchron and receives research support from the NIH, the United States-Israel Binational Science Foundation, Anaconda, ApicBio, Arsenal Medical, Axovant, Balt, Cerenovus, Ceretrieve, CereVasc LLC, Cook Medical, Galaxy Therapeutics, Gentuity, Gilbert Foundation, Imperative Care, InNeuroCo, Insera, Jacob’s Institute, Magneto, MicroBot, Microvention, Medtronic Neurovascular, MIVI Neurosciences, Naglreiter MDDO, Neurogami, Q’Apel, Philips Healthcare, Progressive Medical, Pulse Medical, Rapid Medical, Route 92 Medical, Scientia, Stryker Neurovascular, Syntheon, ThrombX Medical, Wallaby Medical, the Wyss Institute, and Xtract Medical. A.M.M. is a shareholder, consultant, investor, and co-founder of CereVasc, Inc., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Hyponatremia is a common complication following endoscopic endonasal resection (EER) of pituitary adenomas. We report a single-center, multisurgeon study detailing baseline clinical data, outcomes, and factors associated with postoperative hyponatremia., Methods: This was a retrospective cohort study of patients undergoing EER for pituitary adenoma at Tufts Medical Center. Most procedures were performed by the senior author (C.B.H.). Cases were included if at least 1 postoperative sodium value was available and pathology confirmed pituitary adenoma. Hyponatremia was defined as a postoperative sodium level <135 mEq/L., Results: A total of 272 patients underwent 310 EER procedures that met the study inclusion criteria. The mean patient age was 53.3 years, and mean tumor size was 18.8 mm. Postoperative hyponatremia occurred in 12.6% of cases, with 3.6% developing hyponatremia prior to discharge. Lower preoperative sodium level was associated with an increased risk of developing any postoperative hyponatremia. Older age, prolactinoma pathology, and use of selective serotonin reuptake inhibitors were associated with moderate to severe hyponatremia (≤129 mEq/L), and lower preoperative sodium was associated with mild hyponatremia (130-134 mEq/L). Hyponatremia-related readmissions within 30 days occurred in 3.9% of patients. Both African-American race and postoperative hyponatremia were associated with an increased risk of 30-day readmission. The mean nadir sodium for hyponatremic patients was 129.9 mEq/L. Growth hormone-secreting pathology was associated with lower postoperative nadir sodium, whereas higher preoperative sodium was associated with higher postoperative nadir sodium., Conclusions: Hyponatremia is a common postoperative complication of EER for pituitary lesions that can cause significant morbidity, increased readmissions, and increased healthcare costs., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cerebrospinal fluid (CSF) bathing the central nervous system is produced by brain and choroid plexus within the ventricles for re-absorption into the venous circulation through arachnoid granulations (AG). Communicating hydrocephalus results from disruption of the absorptive process, necessitating surgical catheter-based shunt placement to relieve excess pressure from CSF buildup. Adjustable valve designs and antibiotic impregnation have minimally impacted persistent failure rates and postoperative complications. To confront this challenge, we have developed an innovative endovascular shunt implant biologically inspired from AG function to restore the natural dynamics of CSF drainage while concurrently addressing the predominant factors contributing to conventional shunt malfunction., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objectives: Tuberculum sellae meningiomas are resected via an expanded endonasal (EEA) or transcranial approach (TCA). Which approach provides superior outcomes is debated. The Magill-McDermott (M-M) grading scale evaluating tumor size, optic canal invasion, and arterial involvement remains to be validated for outcome prediction. The objective of this study was to validate the M-M scale for predicting visual outcome, extent of resection (EOR), and recurrence, and to use propensity matching by M-M scale to determine whether visual outcome, EOR, or recurrence differ between EEA and TCA., Methods: Forty-site retrospective study of 947 patients undergoing tuberculum sellae meningiomas resection. Standard statistical methods and propensity matching were used., Results: The M-M scale predicted visual worsening (odds ratio [OR]/point: 1.22, 95% CI: 1.02-1.46, P = .0271) and gross total resection (GTR) (OR/point: 0.71, 95% CI: 0.62-0.81, P < .0001), but not recurrence ( P = .4695). The scale was simplified and validated in an independent cohort for predicting visual worsening (OR/point: 2.34, 95% CI: 1.33-4.14, P = .0032) and GTR (OR/point: 0.73, 95% CI: 0.57-0.93, P = .0127), but not recurrence ( P = .2572). In propensity-matched samples, there was no difference in visual worsening ( P = .8757) or recurrence ( P = .5678) between TCA and EEA, but GTR was more likely with TCA (OR: 1.49, 95% CI: 1.02-2.18, P = .0409). Matched patients with preoperative visual deficits who had an EEA were more likely to have visual improvement than those undergoing TCA (72.9% vs 58.4%, P = .0010) with equal rates of visual worsening (EEA 8.0% vs TCA 8.6%, P = .8018)., Conclusion: The refined M-M scale predicts visual worsening and EOR preoperatively. Preoperative visual deficits are more likely to improve after EEA; however, individual tumor features must be considered during nuanced approach selection by experienced neurosurgeons., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background and Objectives: Tuberculum sellae meningiomas (TSMs) can be resected through transcranial (TCA) or expanded endonasal approach (EEA). The objective of this study was to report TSM management trends and outcomes in a large multicenter cohort., Methods: This is a 40-site retrospective study using standard statistical methods., Results: In 947 cases, TCA was used 66.4% and EEA 33.6%. The median maximum diameter was 2.5 cm for TCA and 2.1 cm for EEA ( P < .0001). The median follow-up was 26 months. Gross total resection (GTR) was achieved in 70.2% and did not differ between EEA and TCA ( P = .5395). Vision was the same or better in 87.5%. Vision improved in 73.0% of EEA patients with preoperative visual deficits compared with 57.1% of TCA patients ( P < .0001). On multivariate analysis, a TCA (odds ratio [OR] 1.78, P = .0258) was associated with vision worsening, while GTR was protective (OR 0.37, P < .0001). GTR decreased with increased diameter (OR: 0.80 per cm, P = .0036) and preoperative visual deficits (OR 0.56, P = .0075). Mortality was 0.5%. Complications occurred in 23.9%. New unilateral or bilateral blindness occurred in 3.3% and 0.4%, respectively. The cerebrospinal fluid leak rate was 17.3% for EEA and 2.2% for TCA (OR 9.1, P < .0001). The recurrence rate was 10.9% (n = 103). Longer follow-up (OR 1.01 per month, P < .0001), World Health Organization II/III (OR 2.20, P = .0262), and GTR (OR: 0.33, P < .0001) were associated with recurrence. The recurrence rate after GTR was lower after EEA compared with TCA (OR 0.33, P = .0027)., Conclusion: EEA for appropriately selected TSM may lead to better visual outcomes and decreased recurrence rates after GTR, but cerebrospinal fluid leak rates are high, and longer follow-up is needed. Tumors were smaller in the EEA group, and follow-up was shorter, reflecting selection, and observation bias. Nevertheless, EEA may be superior to TCA for appropriately selected TSM., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Background: Intracranial epidermoid cysts (ECs) are rare benign lesions of ectodermal origin that can be found in the cerebellopontine angle (CPA). If large enough, they compress surrounding structures, causing cranial neuropathies, cerebellar dysfunction, and hydrocephalus., Observations: In this case report, the authors present a patient with headaches and diplopia secondary to a CPA EC. The cyst had wrapped itself around and was strangulating the abducens nerve. This choking of the nerve was believed to have been the cause of the patient's double vision. The arachnoid band was released with a myringotomy knife., Lessons: Intracranial ECs typically cause symptoms from mass effect on surrounding structures; it is unusual for one to have choked off the nerve in the fashion presented in this case. Knowledge of the potential ways that ECs can affect nervous structures is critical for resecting them without injuring normal tissue.

Objective: Primary spinal cord astrocytomas are rare, fatal, and poorly studied., Methods: This study included a 2-center, retrospective analysis of primary spinal cord astrocytoma patients from 1997 to 2020. Patients with drop metastases or without at least one follow-up were excluded., Results: Seven World Health Organization grade I, 6 grade II, 7 grade III, and 4 grade IV astrocytoma patients were included. Older patients had higher grades (median 20 years in grade I vs. 36.5 in grade IV). The median follow-up was 15 months. Thirteen patients were discharged to rehabilitation. Eight patients demonstrated radiographic progression. Adjuvant therapy was utilized more in higher grades (5 of 13 grades III vs. all 11 grades IIIIV). Six patients died (1 death in grades III vs. 5 in grades IIIIV). Ten patients had worsened symptoms at the last follow-up. The median progression-free survival in grade I, II, III, and IV tumors was 116, 36, 8, and 8.5 months, respectively. The median overall survival in grade I, II, III, and IV tumors was 142, 69, 19, and 12 months, respectively. Thrombotic complications occurred in 2 patients, one with isocitrate dehydrogenasewild type glioblastoma., Conclusions: Outcomes worsen with higher grades and lead to difficult postoperative periods. Clinicians should be vigilant for thromboembolic complications. Further research is needed to understand these rare tumors., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The New England Neurosurgical Society (NENS) was founded in 1951 under the leadership of its first President (Dr. William Beecher Scoville) and Secretary-Treasurer (Dr. Henry Thomas Ballantine). The purpose of creating the NENS was to unite local neurosurgeons in the New England area; it was one of the first regional neurosurgical societies in America. Although regional neurosurgical societies are important supplements to national organizations, they have often been overshadowed in the available literature. Now in its 70th year, the NENS continues to serve as a platform to represent the needs of New England neurosurgeons, foster connections and networks with colleagues, and provide research and educational opportunities for trainees. Additionally, regional societies enable discussion of issues uniquely relevant to the region, improve referral patterns, and allow for easier attendance with geographic proximity. In this paper, the authors describe the history of the NENS and provide a roadmap for its future. The first section portrays the founders who led the first meetings and establishment of the NENS. The second section describes the early years of the NENS and profiles key leaders. The third section discusses subsequent neurosurgeons who steered the NENS and partnerships with other societies. In the fourth section, the modern era of the NENS and its current activities are highlighted.

Surgical ventriculoperitoneal shunting remains standard treatment for communicating hydrocephalus, despite persistently elevated infection and revision rates. A novel minimally invasive endovascular cerebrospinal fluid (CSF) shunt was developed to mimic the function of the arachnoid granulation which passively filters CSF from the central nervous system back into the intracranial venous sinus network. The endovascular shunt is deployed via a femoral transvenous approach across the dura mater into the cerebellopontine angle cistern. An octogenarian with intractable hydrocephalus following subarachnoid hemorrhage underwent successful endovascular shunting, resulting in swift intracranial pressure reduction from 38 to <20 cmH 2 O (<90 min) and resolution of ventriculomegaly. This first successful development of a percutaneous transluminal venous access to the central nervous system offers a new pathway for non-invasive treatment of hydrocephalus and the potential for intervention against neurological disorders., Competing Interests: Competing interests: AMM and CBH are shareholders, investors, and co-founders of CereVasc Inc., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Odontoidectomy is a challenging yet effective operation for decompression of non-neoplastic craniovertebral junction disease. Though both the endoscopic endonasal approach (EEA) and the transoral approach (TOA) have been discussed in the literature, there remain few direct comparisons between the techniques., Objective: To evaluate the perioperative outcomes of EEA vs TOA odontoidectomy., Methods: A retrospective review of all cases undergoing odontoidectomy by either the EEA or TOA was performed. Attention was paid to the need for prolonged nutritional support, prolonged respiratory support, and hospitalization times., Results: During the study period between 2000 and 2018, 25 patients underwent odontoid process resection (18 TOA and 7 EEA). The most common indication for surgery was basilar invagination. Hospital length of stay, intensive care unit length of stay, and intubation days were all significantly shorter in the EEA group compared to the TOA group (P < .01, P = .01, P < .01, respectively). Prolonged nutritional support in the form of a gastrostomy tube was required in 5 patients and tracheostomy was required in 4 patients; all of these underwent odontoidectomy by the TOA. There was no statistical difference in neurological outcomes between the EEA and TOA groups (P = .17)., Conclusion: Odontoidectomy can be performed safely through both the EEA and TOA. The results of this study suggest the EEA has shorter hospitalizations and a lower probability of requiring prolonged nutritional support. These advantages are likely the results of decreased oropharyngeal mucosa disruption as compared to the TOA., (© Congress of Neurological Surgeons 2021.)

Introduction  There are many reported modifications to the retrosigmoid approach including variations in skin incisions, soft tissue dissection, bone removal/replacement, and closure. Objective  The aim of this study was to report the technical nuances developed by two senior skull base surgeons for retrosigmoid craniectomy with reconstruction and provide anatomic dissections, surgical video, and outcomes. Methods  The regional soft tissue and bony anatomy as well as the steps for our retrosigmoid craniectomy were recorded with photographs, anatomic dissections, and video. Records from 2017 to 2019 were reviewed to determine the incidence of complications after the authors began using the described approach. Results  Dissections of the relevant soft tissue, vascular, and bony structures were performed. Key surgical steps are (1) a retroauricular C-shaped skin incision, (2) developing a skin and subgaleal tissue flap of equal thickness above the fascia over the temporalis and sub-occipital muscles, (3) creation of subperiosteal soft tissue planes over the top of the mastoid and along the superior nuchal line to expose the suboccipital region, (4) closure of the craniectomy defect with in-lay titanium mesh and overlay hydroxyapatite cranioplasty, and (5) reapproximation of the soft tissue edges during closure. Complications in 40 cases were pseudomeningocele requiring shunt ( n  = 3, 7.5%), wound infection ( n  = 1, 2.5%), and aseptic meningitis ( n  = 1, 2.5%). There were no incisional cerebrospinal fluid leaks. Conclusion  The relevant regional anatomy and a revised technique for retrosigmoid craniectomy with reconstruction have been presented with acceptable results. Readers can consider this technique when using the retrosigmoid approach for pathology in the cerebellopontine angle., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objectives: Initially treating vestibular schwannomas (VSs) with subtotal resection (STR) followed by Gamma Knife radiosurgery (GKRS) for progression of tumor residual is a strategy that balances maximal tumor resection with preservation of neurological function. The effect of timing of GKRS for residual and recurrent VSs remains poorly defined. We developed a simple and practical treatment algorithm for the timing of GKRS after STR of VSs and reviewed our follow-up results to determine outcomes between patients treated with early vs. late GKRS., Patients and Methods: Patients that underwent STR between 1999 and 2017 for a VS at Tufts Medical Center were identified and included in the study cohort. Patients who received GKRS ≤ 12 months after STR were included in the early intervention group. Patients who received GKRS > 12 months after STR or did not have tumor progression on follow-up thus not requiring GKRS were included in the observation/delayed intervention group., Results: STR of VSs was performed on 23 patients. Mean patient age at the time of STR was 53.0 years (range: 20-86.2). The mean follow-up was 4.2 years (range: 1 month-15.5 years). Patients most frequently presented with hearing loss. There were 5 patients (21.7 %) in the early intervention group and 18 (78.3 %) patients in the observation/delayed intervention group. Ten of 23 patients (43.5 %) required GKRS. Thirteen (56.5 %) did not receive GKRS. None of the patients in the early intervention group or the observation/delayed intervention group had changes in House-Brackmann (HB) Grade either after GKRS or at the end of the study period., Conclusions: GKRS of residual or recurrent tumor is safe following STR of VS and appears to carry a low risk of worsening facial nerve function when performed for progressive tumor growth., (Copyright © 2020. Published by Elsevier B.V.)

The American Board of Neurological Surgery (ABNS) was incorporated in 1940 in recognition of the need for detailed training in and special qualifications for the practice of neurological surgery and for self-regulation of quality and safety in the field. The ABNS believes it is the duty of neurosurgeons to place a patient's welfare and rights above all other considerations and to provide care with compassion, respect for human dignity, honesty, and integrity. At its inception, the ABNS was the 13th member board of the American Board of Medical Specialties (ABMS), which itself was founded in 1933. Today, the ABNS is one of the 24 member boards of the ABMS. To better serve public health and safety in a rapidly changing healthcare environment, the ABNS continues to evolve in order to elevate standards for the practice of neurological surgery. In connection with its activities, including initial certification, recognition of focused practice, and continuous certification, the ABNS actively seeks and incorporates input from the public and the physicians it serves. The ABNS board certification processes are designed to evaluate both real-life subspecialty neurosurgical practice and overall neurosurgical knowledge, since most neurosurgeons provide call coverage for hospitals and thus must be competent to care for the full spectrum of neurosurgery. The purpose of this report is to describe the history, current state, and anticipated future direction of ABNS certification in the US.

Background: Optimal management of third ventricular colloid cysts remains debated. While microsurgery offers greater resection rates and lower recurrences, endoscopy offers a perceived less invasive option., Objective: To describe the evolution of our practice to favor microsurgery and determine the optimal management of recurrent colloid cysts., Methods: Any patient having undergone surgery for a colloid cyst by the senior author was identified and included in the study cohort. Clinical, radiographic, and operative records were reviewed, with attention paid to those patients requiring recurrent surgery., Results: Thirty-three patients were treated for intracranial colloid cysts between 1995 and 2017. Two patients had initial surgical treatment at an outside institution prior to presentation at our institution. Microsurgery was used in 15/31 initial cases, endoscopy in 13 cases, and ventriculoperitoneal shunting in 3 cases. Between 1995 and 2005, 89% of colloid cysts (8/9 cases) were resected endoscopically, whereas 74% of colloid cysts (14/19 cases) were resected by microsurgery after 2005. Of the 13 patients treated endoscopically, 6 (46%) required surgery for recurrent cysts. Incomplete cyst wall resection at the initial operation increased the recurrence rate to 55%. There were no recurrences in the microsurgery cohort., Conclusion: Surgical resection of recurrent colloid cysts should focus on complete removal of the cyst wall to minimize the chance of recurrence. Microsurgery has been shown to provide the highest success rates for cyst wall resection and lowest rates of recurrence and is therefore recommended for patients undergoing surgery for primary and recurrent colloid cysts., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Childhood cancer survivors are at risk for ongoing health risks related to their initial treatment. One potential long-term complication following radiation is the development of secondary tumors, including peripheral nerve tumors, such as schwannomas. We present three adolescent and young adult (AYA)-aged survivors of pediatric cancer (22-40 years), followed in our AYA survivorship clinic. Each was found to have a schwannoma many years following total body irradiation for a childhood primary malignancy. We highlight a late effect of low-dose total body irradiation as well as the importance of long-term monitoring in this population.

Background: Intracranial metastasis is a common complication of systemic malignancy. A rare subset of intracranial masses constitutes tumor-to-tumor metastasis, in which an extracranial neoplasm hematogenously spreads to an existing intracranial lesion., Case Description: Here we present the unique case of a 59-year-old man with known hepatocellular carcinoma who presented with acute headaches, double vision, vertigo, and gait instability in the context of 2 years of right-sided hearing loss. Head imaging showed a heterogeneous right cerebellopontine angle mass extending into the porus acousticus with adjacent cerebellar edema. Histopathologic analysis after resection found coexisting hepatocellular carcinoma within a vestibular schwannoma., Conclusions: Tumor-to-tumor metastasis is an important consideration in the diagnostic work-up and treatment of patients with known systemic malignancy who present with a new intracranial lesion. This pathologic entity could be missed if this patient were treated with single-fraction radiosurgery such as Gamma Knife., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective  Solitary fibrous tumors (SFT) and hemangiopericytomas (HPC) are now classified along a single spectrum of fibroblastic mesenchymal tumors with NAB2-STAT6 fusion. This fusion acts as a driver mutation that constitutively activates EGR1, which is known to be involved in the p16 pathway. Overexpression of p16 is associated with malignancy and worse prognosis in multiple mesenchymal tumors. The authors sought to investigate p16 immunoexpression in association with malignancy and prognosis of SFT/HPC tumors. Design  Twenty-three SFT/HPC tumors (central nervous system [CNS]: 12, non CNS: 11) diagnosed at our institution from 2002 to 2016 were assigned into 3 grades. Data from microarray immunohistochemistry for STAT6, synaptophysin, CD56, chromogranin, SST2A, EGR1, Ki67, and p16, grade and survival were analyzed. Results  CNS SFT/HPCs tend to be malignant (grade 3; 67 vs. 18%, p  = 0.036) and more likely to express synaptophysin (33 vs. 0%, p  = 0.035) than non CNS tumors. Overexpression of p16 (immunopositivity ≥ 50% tumor cells) was associated with malignant (grade 3) tumors, and has a sensitivity of 70% (7/10), and a specificity of 77% (10/13), as a predictive marker for malignancy. SFT/HPC patients with low p16 expression demonstrated significantly longer disease-free survival time (median survival > 113 months) than those with high p16 expression (median survival = 30 months, p  = 0.045). Conclusions  SFT/HPCs in the CNS are more likely to be malignant than the tumors in other sites. High p16 expression is also associated with malignancy and shorter disease-free survival time in SFT/HPC tumors in our study cohort. Clinically, p16 overexpression can be used as predictive marker for malignancy and prognosis and a possible therapeutic target.

Background and Purpose: We evaluated the inferior petrosal sinus (IPS) and adjacent cerebellopontine angle (CPA) cistern as a potential implantation site for a novel venous endovascular transdural CSF shunt concept to treat communicating hydrocephalus. We analyzed the dimensions of the IPS, CPA cistern, and distances to adjacent neurovascular structures., Materials and Methods: Gadolinium enhanced T1 weighted brain MRI datasets of 36 randomly selected patients, aged 20-80 years, were analyzed with three-dimensional multiplanar reconstruction to measure IPS diameter and length, CPA cistern depth, and IPS proximity to the vertebrobasilar arteries and brainstem. Statistical analysis was used to assess gender, sidedness, and age dependence., Results: Mean IPS diameter ranged from 2.27 mm to 3.31 mm at three axial levels, with >90% larger than 1.46 mm. CPA cistern adjacent to the IPS exhibited a mean depth of 3.86 mm to 7.39 mm between the dura and brainstem at corresponding axial levels. There was no side dependence except for a longer distance from the IPS to the basilar artery on the left compared with the right (9.72 vs 7.28, P<0.019). Linear regression analysis showed that the distance from the IPS to the brainstem was statistically significantly increased with age (P<0.0002) and was greater in men, with little side variation (P=0.524)., Conclusion: Our results demonstrate sufficient CSF CPA cisternal space adjacent to the IPS and support the feasibility of an endovascular catheter delivered transdural implantable shunt. Such a device could serve to mimic the function of the arachnoid granulation by establishing a regulated path for CSF flow from the intracranial subarachnoid space to the venous system and provide a treatment for communicating hydrocephalus., Competing Interests: Competing interests: AMM and CBH are co-founders and investors of CereVasc, LLC. AMM, CBH, and BMB are shareholders of CereVasc, LLC., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Headache is a common symptom in patients with Chiari I malformation (CMI), characterized by 5 mm or greater cerebellar tonsillar herniation below foramen magnum. Radiologists should be aware of the different types of headaches reported by CMI patients and which headache patterns are distinctive features of the diagnosis. A methodical imaging strategy is required to fully assess a CMI patient to exclude secondary causes of tonsillar herniation such as intracranial hypotension or associated conditions such as syrinx. Both anatomic and physiologic imaging can help determine if headaches are CMI associated, and assist clinicians in therapeutic decision making., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Surgical resection of sphenoid wing tumors and intraorbital pathology carries the dual goal of appropriately treating the target pathology as well as correcting proptosis. Residual proptosis following surgery can lead to cosmetic and functional disability. The authors sought to quantitatively assess the effect of orbital volume before and after reconstruction to determine the optimal strategy to achieve proptosis correction., Methods: All surgeries involving orbital wall reconstruction for orbital or intracranial pathology that preoperatively resulted in proptosis between 2007 and 2017 were reviewed. Proptosis was measured by the exophthalmos index (EI): the ratio of the distance of the anterior limit of each globe to a line drawn between the anterior limit of the frontal processes of the zygomas, comparing the pathological eye to the normal eye. Postoperative radiographic measurements were taken at least 60 days after surgery to allow surgical swelling to abate. The orbit contralateral to the pathology was used as an internal control for normal anatomical orbital volume. Cases with preoperative EI < 1.10, orbital exenteration, or enucleation were excluded., Results: Twenty-three patients (16 females and 7 males, with a mean age of 43.6 ± 22.8 years) were treated surgically for tumor-associated proptosis. Nineteen patients harbored meningiomas (11 en-plaque; 8 sphenoid wing), and one patient each harbored an orbital schwannoma, glomangioma, arteriovenous malformation, or cavernous hemangioma. Preoperative EI averaged 1.28 ± 0.10 (range 1.12-1.53). Median time to postoperative imaging was 19 months. Postoperatively, the EI decreased to a mean of 1.07 ± 0.09. Greater increases in size of the reconstructed orbit were positively correlated with greater quantitative reductions in proptosis (p < 0.01). Larger volume of soft tissue pathology was also associated with achieving greater proptosis correction (p < 0.01). Residual exophthalmos (defined as EI > 1.10) was present in 8 patients, while reconstruction in 2 patients resulted in clinically asymptomatic enophthalmos (defined as EI < 0.95). Tumor invasion into the superior orbital fissure sinus was associated with residual proptosis (p = 0.04)., Conclusions: Proptosis associated with intracranial and orbital pathology represents a surgical challenge. The EI is a reliable and quantitative assessment of proptosis. For orbital reconstruction in cases of superior orbital fissure involvement, surgeons should consider rebuilding the orbit at slightly larger than anatomical volume.

Background and Purpose: Currently no quantitative objective test exists to determine disease severity in a patient with Chiari I malformation. Our aim was to correlate disease severity in symptomatic patients with Chiari I malformation with cough-associated changes in CSF flow as measured with real-time MR imaging., Materials and Methods: Thirteen symptomatic patients with Chiari I malformation (tonsillar herniation of ≥5 mm) were prospectively studied. A real-time, flow-sensitized pencil-beam MR imaging scan was used to measure CSF stroke volume during rest and immediately following coughing and relaxation periods (total scan time, 90 seconds). Multiple posterior fossa and craniocervical anatomic measurements were also obtained. Patients were classified into 2 groups by neurosurgeons blinded to MR imaging measurements: 1) nonspecific Chiari I malformation (5/13)-Chiari I malformation with nonspecific symptoms like non-cough-related or mild occasional cough-related headache, neck pain, dizziness, paresthesias, and/or trouble swallowing; 2) specific Chiari I malformation (8/13)-patients with Chiari I malformation with specific symptoms and/or objective findings like severe cough-related headache, myelopathy, syringomyelia, and muscle atrophy. The Spearman correlation was used to determine correlations between MR imaging measurements and disease severity, and both groups were also compared using a Mann-Whitney U test., Results: There was a significant negative correlation between the percentage change in CSF stroke volume (resting to postcoughing) and Chiari I malformation disease severity ( R = 0.59; P = .03). Mann-Whitney comparisons showed the percentage change in CSF stroke volume (resting to postcoughing) to be significantly different between patient groups ( P = .04). No other CSF flow measurement or anatomic measure was significantly different between the groups., Conclusions: Our exploratory study suggests that assessment of CSF flow response to a coughing challenge has the potential to become a valuable objective noninvasive test for clinical assessment of disease severity in patients with Chiari I malformation., (© 2018 by American Journal of Neuroradiology.)

A 71-year-old female patient was referred in 2013 for evaluation of an asymptomatic nonsecreting pituitary adenoma. The adenoma, measuring 13 mm in height by 10 mm in width, was discovered incidentally on imaging in 2012. Biochemical testing demonstrated a nonfunctioning adenoma. Given the relatively small lesion size and the lack of symptoms, observation was preferred over surgical intervention. The patient was monitored with routine MRI, which until 2016 demonstrated minimal growth. In early 2016, the patient developed recurrence of metastatic breast cancer and was treated with palbociclib, a cyclin-dependent kinase (CDK) 4/6 inhibitor. This inhibitor acts on a pathway believed to be involved in pituitary adenoma tumorigenesis. One year after starting palbociclib, routine imaging demonstrated significant regression of her pituitary adenoma. The authors hypothesize that inhibition of the CDK4/6 pathway by palbociclib contributed to adenoma regression in this patient, and that palbociclib may represent a possible adjuvant therapy for the treatment of nonfunctioning pituitary adenomas.

Recent trends in graduate medical education have emphasized the mastery of nontechnical skills, especially leadership, for neurosurgical trainees. Accordingly, we introduced leadership development and self-awareness training to interns attending the Society of Neurological Surgeons Post-Graduate Year 1 Boot Camp in the Northeast (New England/New York/New Jersey) region in 2015. Feedback about the session was collected from interns. While neurosurgical interns conveyed a desire to receive more information on improving their leadership skills, most indicated that guidance seemed to be lacking in this critical area. We discuss some of the professional development needs uncovered during this process., (Copyright © 2017 by the Congress of Neurological Surgeons.)

Background: The differential diagnosis of skull base masses is diverse and includes benign and malignant neoplasms, vascular anomalies, congenital lesions, as well as infectious and inflammatory processes. Metastatic masses of the skull base are a rare manifestation of systemic malignancies. Breast cancer is the most common cause of skull base metastases. Villaret syndrome refers to cranial nerves IX, X, XI, and XII and sympathetic chain neuropathies. It is a clinical subtype of jugular foramen syndromes., Methods and Results: A 62-year-old woman with a history of breast carcinoma presented with hoarseness dating to shortly after her mastectomy years earlier. CT angiography showed enhancing tissue just outside the right jugular foramen, and biopsy confirmed metastatic adenocarcinoma consistent with breast cancer., Conclusion: Villaret syndrome caused by breast cancer metastases has not been previously described. We present a case of Villaret syndrome caused by metastasis of invasive breast adenocarcinoma and a review of the literature of metastases of breast cancer to the skull base., (© 2015 Wiley Periodicals, Inc.)

Case: A 57year old female patient presented with a painful right-sided neck mass that on MRI was shown to be adherent to the posterior aspect of the sternocleidomastoid muscle. The mass was surgically resected en bloc without complications. Histopathologic analysis revealed the mass to be a myxoma., Review: To date, there have been several case reports of myxomas, although very few involving the head or neck. The majority of the literature available concurs that myxomas are benign neoplasms that exhibit characteristic qualities on MRI imaging. The definitive treatment by consensus is surgical excision., Conclusions: Although the incidence of head and neck myxomas is low, it is important to include in the differential of a neck mass with certain radiographic findings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives The far-lateral approach is widely used to treat pathology of the ventral foramen magnum. Numerous methods of exposure have been described, most of which utilize long skin incisions and myocutaneous flaps. Here we present our experience with gaining exposure through a small paramedian incision using a muscle-splitting technique. Design A cadaveric anatomical study was first performed to verify the feasibility of the approach. We then describe our experience with using the approach in 13 patients. A retrospective chart review was performed and data regarding pathology, imaging, and complications were collected. Results The cadaveric study confirmed that a small paramedian muscle-splitting approach allows sufficient exposure to approach many foramen magnum lesions. Our case series included 10 patients with meningioma, one brainstem glioblastoma, one posterior inferior cerebellar artery aneurysm, and one odontoid pannus. The exposure was adequate in all cases. For the meningioma patients, six had gross total resections and four had subtotal resection because of tumor adherence to neurovascular structures. Two patients experienced postoperative cardiovascular complications. There were no new neurologic deficits, cerebrospinal fluid leaks, or wound complications. Conclusions A small paramedian incision may be used to gain exposure and perform successful far-lateral approaches. The small exposure is likely to reduce the risk of local complications such as cerebrospinal fluid fistula and pseudomeningocele when compared with larger exposures.

Epidermoid cysts are rare lesions accounting for 1% of intracranial tumors with approximately 50% located within the cerebello-pontine angle (CPA). Resection is complicated by their close anatomical relation to critical neurovascular structures and their tendency to be densely adherent making complete removal a significant neurosurgical challenge. We present a 35-year-old woman with left sided tongue numbness and lower lip paresthesias with a CPA epidermoid. An endoscopic assisted retrosigmoid approach was utilized for resection. A 30-degree endoscope was used to assist in removal of unseen tumor in Meckel's cave, medial to the lower cranial nerves, and along the ventral pons. The video can be found here: http://youtu.be/bv0lMPbX7BY .

Arachnoid cysts are common, accounting for approximately 1% of intracranial mass lesions. Most are congenital, clinically silent, and remain static in size. Occasionally, they increase in size and produce symptoms due to mass effect or obstruction. The mechanism of enlargement of arachnoid cysts is controversial. One-way slit valves are often hypothesized as the mechanism for enlargement. The authors present 4 cases of suprasellar prepontine arachnoid cysts in which a slit valve was identified. The patients presented with hydrocephalus due to enlargement of the cyst. The valve was located in the arachnoid wall of the cyst directly over the basilar artery. The authors believe this slit valve was responsible for the net influx of CSF into the cyst and for its enlargement. They also present 1 case of an arachnoid cyst in the middle cranial fossa that had a small circular opening but lacked a slit valve. This cyst did not enlarge but surgery was required because of rupture and the development of a subdural hygroma. One-way slit valves exist and are a possible mechanism of enlargement of suprasellar prepontine arachnoid cysts. The valve was located directly over the basilar artery in each of these cases. Caudad-to-cephalad CSF flow during the cardiac cycle increased the opening of the valve, whereas cephalad-to-caudad CSF flow during the remainder of the cardiac cycle pushed the slit opening against the basilar artery and decreased the size of the opening. Arachnoid cysts that communicate CSF via circular, nonslit valves are probably more likely to remain stable.

Meningiomas represent the most common benign intracranial neoplasms, and may spread by direct extension into nearby venous sinuses, but gross spread to the extracranial venous system is uncommon. We report the case of a patient with extracranial intraluminal spread of meningioma within the internal jugular vein to level III of the neck. Review of the preoperative assessment and management is also presented.

The pathogenesis of Chiari malformation Type I (CM-I) and associated syringomyelia is incompletely understood. Patients often present in middle age with incidental or minimally symptomatic CM-I, whose management is controversial. One option is clinical and radiographic observation of asymptomatic and minimally symptomatic patients. The authors here present the case of a 36-year-old woman who had been monitored for 6 years for a minimally symptomatic CM-I and cervicothoracic syrinx. After 5 years of follow-up, she suffered spontaneous rupture of a cerebral cavernous malformation when she was 27 weeks pregnant. The ruptured cavernous malformation and hematoma were operatively managed via a right frontal craniotomy. Ten months after the craniotomy for resection of the ruptured cavernous malformation, follow-up MRI demonstrated resolution of the CM-I and syrinx. Few similar cases have been reported in adults. This case argues for the presence of dynamic factors in the development and maintenance of CM-I and supports the nonoperative treatment of asymptomatic and minimally symptomatic patients.

Background: In July 2009, the Accreditation Council for Graduate Medical Education (ACGME) incorporated postgraduate year 1 (PGY1 intern) level training into all U.S. neurosurgery residency programs., Objective: To provide a fundamentals curriculum for all incoming neurosurgery PGY1 residents in ACGME-accredited programs, including skills, knowledge, and attitudes that promote quality, patient safety, and professionalism., Methods: The Society of Neurological Surgeons organized 6 regional "boot camp" courses for incoming neurosurgery PGY1 residents in July 2010 that consisted of 9 lectures on clinical and nonclinical competencies plus 10 procedural and 6 surgical skills stations. Resident and faculty participants were surveyed to assess knowledge and course effectiveness., Results: A total of 186 of 197 U.S. neurosurgical PGY1 residents (94%) and 75 neurosurgical faculty from 36 of 99 programs (36%) participated in the inaugural boot camp courses. All residents and 83% of faculty participants completed course surveys. All resident and faculty respondents thought that the boot camp courses fulfilled their purpose and objectives and imparted skills and knowledge that would improve patient care. PGY1 residents' knowledge of information taught in the courses improved significantly in postcourse testing (P < .0001). Residents and faculty particularly valued simulated and other hands-on skills training., Conclusion: Regional organization facilitated an unprecedented degree of participation in a national fundamental skills program for entering neurosurgery residents. One hundred percent of resident and faculty respondents positively reviewed the courses. The boot camp courses may provide a model for enhanced learning, professionalism, and safety at the inception of training in other procedural specialties.

The aim of this study is to review and summarize the relevant literature regarding pharmacologic and non-pharmacologic methods of prophylaxis against gastrointestinal (GI) stress ulceration, and upper gastrointestinal bleeding in critically ill patients. Stress ulcers are a known complication of a variety of critical illnesses. The literature regarding epidemiology and management of stress ulcers and complications thereof, is vast and mostly encompasses patients in medical and surgical intensive care units. This article aims to extrapolate meaningful data for use with a population of critically ill neurologic and neurosurgical patients in the neurological intensive care unit setting. Studies were identified from the Cochrane Central Register of controlled trials and NLM PubMed for English articles dealing with an adult population. We also scanned bibliographies of relevant studies. The results show that H(2)A, sucralfate, and PPI all reduce the incidence of UGIB in neurocritically ill patients, but H(2)A blockers may cause encephalopathy and interact with anticonvulsant drugs, and have been associated with higher rates of nosocomial pneumonias, but causation remains unproven and controversial. For these reasons, we advocate against routine use of H(2)A for GI prophylaxis in neurocritical patients. There is a paucity of high-level evidence studies that apply to the neurocritical care population. From this study, it is concluded that stress ulcer prophylaxis among critically ill neurologic and neurosurgical patients is important in preventing ulcer-related GI hemorrhage that contributes to both morbidity and mortality. Further, prospective trials are needed to elucidate which methods of prophylaxis are most appropriate and efficacious for specific illnesses in this population.

Pneumosinus dilitans (PSD) is enlargement of the sinuses of the skull base and is frequently seen with meningiomas. Identifying PSD on imaging can assist with operative planning and preparation. Meningiomas associated with PSD are not more commonly high grade, and complete resection is frequently possible.

Object: Intracranial hemangiopericytomas are frequently located along the dural sinuses along the skull base and represent rare, aggressive CNS neoplasms that are difficult to distinguish from meningiomas based on both imaging and gross characteristics. The authors of this study describe 3 patients with these lesions and review the pertinent literature., Methods: Two men and 1 woman, whose median age at the time of the initial presentation was 37 years (range 20-53 years), constitute this series. They underwent multimodal treatment consisting of resection, embolization, radiation therapy, and in 1 case chemotherapy., Results: Two of the 3 patients treated were alive after a mean follow-up of 93 months (range 4-217 months). One patient died 217 months after the initial diagnosis. The longest tumor progression-free interval after the initial or secondary resection was 43 months (range 4-84 months)., Conclusions: Hemangiopericytomas have been reclassified as mesenchymal non-meningothelial tumors. They have an inevitable tendency to recur locally and metastasize distally. The mainstay of therapy remains an aggressive attempt to achieve gross-total resection at the initial surgery. Postoperative adjuvant radiotherapy should be offered to all patients, regardless of the degree of resection achieved. Diligent long-term follow-up is paramount as local recurrences and distal metastases can develop sometimes years after the initial treatment.

Neuroendoscopic treatment of colloid cysts is limited by the reach and flexibility of the instruments that can be passed through the working channels of the rigid neuroendoscope. The authors describe a case of a third ventricular colloid cyst where a large solid colloid fragment was recovered using a nitinol stone retrieval basket as a flexible wall-guided atraumatic salvage instrument. A flexible nitinol stone retrieval basket was successfully used through an endoscopic working channel to retrieve a large portion of the colloid cyst from the occipital horn of the lateral ventricle in a 70-year-old man who presented with progressive memory loss, urinary incontinence, and slowness of gait. A flexible nitinol stone retrieval basket can be safely and effectively maneuvered in the ventricular system, using the ventricular wall for deflection, and can be used to retrieve colloid cyst fragments as a salvage technique. Remaining free-floating large colloid cyst fragments in the ventricular system do not necessarily require a second craniotomy or bur hole for access but may be retrieved using a nitinol stone retrieval basket.

Postoperative temporalis muscle atrophy from injury to the neurovascular supply can cause significant cosmetic disfigurement, and avoidance of electrocautery use has become a common practice in minimizing this outcome. We attempted to quantify the effects of electrocautery on temporalis atrophy by retrospectively reviewing postoperative magnetic resonance images in patients having undergone an orbital frontal craniotomy. We reviewed medical records and compared volumetric measurements of the temporalis muscle in 25 patients using the contralateral temporalis muscle as an internal control. The mean size of the nonsurgical temporalis muscle was 24.6 cm(3) as compared with 23.6 cm(3) on the operated side. The difference of 1.0 cm(3) was not statistically significant (p = 0.32). The only postoperative atrophy noted visually on the magnetic resonance images developed in the posterior superior aspect of the temporalis muscle, behind the vertical incision of the temporalis muscle. In the small control group, with known injury to V3, the mean nonsurgical size was 27.7 cm(3), whereas it was 16.5 cm(3) on the contralateral surgical side. The difference of 11.2 cm(3) was statistically significant (p = 0.04). These findings suggest that the use of electrocautery to dissect the temporalis muscle does not significantly contribute to atrophy provided careful surgical technique is practiced.

Background: Pneumocephalus is commonly encountered after neurosurgical procedures but can also be caused by craniofacial trauma and tumors of the skull base and rarely, can occur spontaneously. Contributing factors for the development of pneumocephalus include head position, duration of surgery, nitrous oxide (N(2)O) anesthesia, hydrocephalus, intraoperative osmotherapy, hyperventilation, spinal anesthesia, barotauma, continuous CSF drainage via lumbar drain, epidural anesthesia, infections, and neoplasms. Clinical presentation includes headaches, nausea and vomiting, seizures, dizziness, and depressed neurological status. In this article, we review the incidence, mechanisms, precipitating factors, diagnosis, and management of pneumocephalus. Search of Medline, databases, and manual review of article bibliographies. Considering four case illustrations that typify pneumocephalus in clinical practice, we discuss the common etiologies, and confirm the diagnosis with neuroimaging and management strategies. Avoidance of contributing factors, high index of suspicion, and confirmation with neuroimaging are important in attenuating mortality and morbidity. A significant amount of pneumocephalus can simulate a space-occupying lesion. Supplemental oxygen increases the rate of absorption of pneumocephalus.

We propose a surgical approach for select patients that minimizes morbidity while allowing gross total resection of lesions in the anterior portion of the infratemporal fossa. The approach we describe is an extradural approach through a subtemporal craniectomy or craniotomy with the possible addition of a zygomatic osteotomy. Lesions that have a well-defined capsule and a texture that permits manipulation are ideal for this less invasive approach. We retrospectively reviewed six cases from the primary author (C.B.H.) using a temporal craniectomy or craniotomy alone to resect lesions in the infratemporal fossa. All six cases had good clinical outcomes with no unexpected neurological deficits while achieving gross total resections. The only complication included one cerebrospinal fluid leak that was sealed endoscopically. For select lesions, a less morbid surgical approach via an extradural window through a subtemporal craniectomy or small craniotomy may be preferable to transfacial approaches. Adjuvant use of endoscopic techniques may facilitate surgical exposure and resection of large lesions.

Objective: Post-hemorrhagic hydrocephalus (PHH) secondary to germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) continues to be a common problem affecting preterm neonates. Two different devices are used to treat hydrocephalus in preterm neonates under 2.5 kg: (1) ventricular access device (VAD) and (2) ventricular to subgaleal shunt (VSGS). We aim to determine the differences between VAD and VSGS in daily patient management and shunt requirement outcome in premature infants with PHH., Method: The medical records of 32 preterm neonates diagnosed with GMH-IVH with PHH treated with a VAD or VSGS were reviewed. The grade of GMH-IVH, need for CSF taps, complications, malfunctions, and need for permanent VP shunt placement were compared between VAD and VSGS groups., Results: All (16/16) VAD patients required daily taps while 4/16 VSGS patients required daily taps. The VAD group had one complication while the VSGS group had five complications. About 28.57% of the patients treated with a VSGS did not require a permanent VP shunt. Around 6.25% of the patients treated with a VAD did not require a permanent VP shunt., Conclusion: VSGS is an effective means of providing temporary continuous drainage of CSF in PHH with an acceptable complication rate. VSGS has many advantages that make it superior to VAD as a temporizing shunt.

Objective: We present a case of syringomyelia attributed to a transverse thoracic arachnoid web at T4. The cerebrospinal fluid pressure caudal to the web was higher than the cerebrospinal fluid pressure rostral to the web, causing a syrinx in the thoracic and cervical spinal cord above the web., Clinical Presentation: A 43-year-old man presented with numbness and a burning pain in his left upper back and extremities. Magnetic resonance imaging showed a cervical-thoracic syrinx that terminated relatively abruptly at T4. Because of the abrupt termination of the syrinx at T4 and the slight ventral displacement of the spinal cord at this level, a dorsal arachnoid web was suspected., Intervention: A T4 laminectomy was performed. Intraoperative ultrasound before opening of the thecal sac showed a pulsating transverse dorsal arachnoid web. The dura was opened and the web resected, thus widely communicating the dorsal subarachnoid space. The syrinx dramatically decreased in size and the patient's pain improved but did not resolve completely., Conclusion: In patients with presumed idiopathic syringomyelia, imaging studies should be closely inspected for the presence of a transverse arachnoid web. Surgical resection of a transverse thoracic arachnoid web with syringomyelia can result in resolution of the syringomyelia and improvement in neurological function. Syrinx formation in patients with these webs may occur in the area of the spinal cord where there is lower cerebrospinal fluid pressure, which may be either rostral or caudal to the arachnoid web. We evaluate this hypothesis by comparing our case with other published cases.

Objective: Surgery is a cornerstone of treatment for a wide variety of neoplastic, congenital, traumatic, and inflammatory lesions involving the midline anterior skull base and may result in a significant anterior skull base defect requiring reconstruction. This study is a retrospective analysis of the reconstruction techniques and complications seen in a series of 58 consecutive patients with midline anterior skull base pathology treated with craniotomy or a craniofacial approach. The complication rates in this series are compared with other retrospective series and specific techniques that may reduce complications are then discussed., Design: This is a retrospective analysis of 58 consecutive patients who had surgery for a midline anterior skull base lesion between January 1994 and July 2003. Data were collected regarding pathology, surgical approach, reconstruction technique, and complications., Results: Twenty-nine patients underwent surgery for a meningioma (50%). The remainder had frontoethmoidal cancer, mucoceles/invasive nasal polyps, encephalocele, esthesioneuroblastoma, anterior falx dermoid cyst with a nasal sinus tract, or invasive pituitary adenoma. In most patients, a low and narrow two-piece biorbitofrontal craniotomy was used. When possible, the dura was repaired before entering the nasal cavity. Thirteen patients experienced a complication (22%). There was one case of postoperative cerebrospinal fluid (CSF) leak (2%), one case of meningitis (2%), two cases of bone flap infection (3%), and two cases of symptomatic pneumocephalus (3%). There were no deaths, no reoperations for CSF leak, and no patient had a new permanent neurologic deficit other than anosmia., Conclusions: Transcranial approaches for midline anterior skull base lesions can be performed safely with a low incidence of postoperative CSF leak, meningitis, bone flap infection, and symptomatic pneumocephalus. Our results, particularly with regard to CSF leakage, compare favorably with other retrospective series.