23-year review of spheno-orbital meningioma: clinical, radiological, and pathological insights from 100 cases.

BACKGROUND: Spheno-orbital meningioma (SOM) represents a unique variant of sphenoid wing meningiomas, distinguished by its propensity for bone infiltration and cranio-orbital involvement. SOM exhibits a considerable incidence of misdiagnosis and recurrence. PURPOSES: To elucidate the clinical, radiological, and pathological characteristics of SOM. METHODS: Review of electronic medical records, histopathology, radiological images and follow-up information of 100 SOM patients. RESULTS: Of the 100 patients (28 males, 72 females) with SOM, mean age was 46.8 ± 12.6 years and prevalent symptoms were proptosis (99%). All the CT scans showed hyperostosis with 89.3% of the hyperostosis having an irregular edge. In MRI scans, dural tail sign was observed across all patients and the cranio-orbital tumors often penetrated temporal muscle (74.1%), extraocular muscle (74.1%) and lacrimal gland (63%). All the 100 patients underwent surgical intervention, and among them, 62 individuals received postoperative radiotherapy. Grade I resections had a lower recurrence rate(16.7%), which further decreased with the addition of radiotherapy(13.9%). In contrast, all patients with grade II or higher grade resections without radiotherapy experienced recurrence, indicating a higher risk associated with less complete tumor removal. The pathological examination revealed that intraorbital sections exhibited comparable tumor density to intraorbital SOM tumors, along with increased fibrous density but decreased vascular distribution. CONCLUSIONS: Radiological characteristics of SOM included cranio-orbital tumors, hyperostosis of the sphenoid wing with an irregular edge, and dural tail sign. Combination of gross total resection and adjuvant radiotherapy was recommended to minimize recurrence rate. Intracranial SOM tumors tended to be softer and more bleed-prone than intraorbital sections, necessitating surgical precision.

Endoscopic transorbital approach for recurrent spheno-orbital meningiomas: single center case series.

Endoscopic transorbital approaches (ETOAs) are finding wide application for skull base lesions, particularly for spheno-orbital meningiomas (SOMs). These tumors have high recurrence rates, and second surgery can often represent a challenge. In this study we analyze our experience of management of recurrent SOMs through a slightly modified eyelid crease approach. Between May 2016 and September 2023, in the Department of Neurosurgery of Fondazione IRCCS Policlinico San Matteo (Pavia, Italy), five consecutive recurrent SOMs have been treated using an endoscopic transorbital approach. Demographic data, preoperatory deficits, lesions characteristics, histology, grade of resection, eventual adjuvant treatments, complications, outcome in terms of symptoms improvement and cosmesis, and hospitalization are described. One patient maintained a right lateral rectus muscle palsy that was already present in the preoperatory, no cerebrospinal fluid (CSF) leaks were reported. All patients had postoperative periorbital edema, but no other systemic complication was found. All patients had proptosis improvement, two had visual acuity improvement, and best cosmetic outcome was obtained in all cases. Hospitalization varied between 4 and 6 days. ETOAs in the management of recurrent SOMs are safe and have good outcome. Right selection of patients is mandatory, but when feasible, endoscopic surgery can allow a virgin route to a previously operated tumor, guaranteeing a good strategic option.

Correlation of spheno-occipital synchondrosis and mandibular condylar cortication with chronological age using computed tomography in Indian population- A cross-sectional study.

BACKGROUND: Forensic age estimation is a procedure which utilises many methods to estimate the age of both living and deceased individuals, including those who have died in natural disasters or man-made catastrophes. The pattern and closure of spheno-occipital synchondrosis (SOS) fusion, along with subchondral ossification of the mandibular condyle, can be used to estimate age. AIM AND OBJECTIVES: This study aims to estimate age using computed tomographic (CT) images of spheno-occipital synchondrosis fusion (SOS) and mandibular condylar cortication (MCC), and to correlate these findings with chronological age. MATERIALS AND METHODS: The present study included 435 CT images of individuals aged 10-25 years. SOS fusion was assessed using a four-stage system, and MCC was assessed bilaterally using a three-stage system on the sagittal plane. Data on fusion stages and cortication types were entered along with chronological age, and then statistically analysed. RESULTS: SOS fusion stage 2 occurred at similar age in males (19.82 ± 2.67 years) and females (19.23 ± 2.93 years). Earlier fusion of other stages was observed in females by a mean age of 2 years. MCC was completed 1 year earlier in females, with statistically significant differences (p ≤ 0.001). When comparing cortication types and different fusion stages, only type II cortication showed statistically significant differences compared to different fusion stages (p ≤ 0.001). CONCLUSION: Mandibular condylar cortication (MCC) and spheno-occipital synchondrosis (SOS) fusion were positively correlated with chronological age, suggesting that these parameters can be used as an adjunct method for age estimation.

Simultaneous combined keyhole mini-transcranial approach and endoscopic transsphenoidal approach to remove multi-lobulated pituitary neuroendocrine tumor with suprasellar extension.

BACKGROUND: Transsphenoidal surgery (TSS) is the main method to remove pituitary neuroendocrine tumor (PitNET), but large or multi-lobulated one is still challenging. OBJECTIVE: The less invasive simultaneous combined keyhole mini-transcranial approach and standard transsphenoidal approach was used to remove multi-lobulated or hourglass-shaped non-functioning PitNET to avoid the specific complications related to extended TSS. METHODS: Twenty-one patients of large multi-lobulated or hourglass-shaped PitNET (6 patients were recurrent cases after TSS or transcranial approach) were treated by this simultaneous combined approach. The supraorbital or midline keyhole approach was performed under the operating microscope so that the fine arteries feeding optic apparatus were dissected from the tumor capsule safely and securely and the suprasellar part of the tumor was removed in the extra-capsular fashion in combination with transsphenoidal approach. RESULTS: Visual function improved after the surgery in 14 (74 %) of 19 patients with preoperative disturbance of the visual fields. Four patients (19 %) developed postoperative deterioration of pituitary endocrine functions requiring permanent hormonal replacement. One patient (4.2 %) suffered cortical laminar necrosis without permanent disorders and another patient (4.2 %) suffered cerebrospinal fluid rhinorrhea but neither was permanent. Postoperative computed tomography detected no subarachnoid hemorrhage in any patient. Gross total removal was achieved in 15 patients (71 %). Five patients (24 %) with subtotal removal and one patient (4.2 %) with partial removal had lateral tumor extension with Knosp classification 3 or 4. CONCLUSION: The combined method is an effective treatment option to remove complex PitNET safely and securely with dissecting fine arteries on the tumor capsule.

Combined open surgery and endovascular embolization for a ruptured sphenoid wing dural arteriovenous fistula.

BACKGROUND: The sphenoid wing dural arteriovenous fistula (AVF) is rare, and can manifest with severe symptoms, particularly in cases classified as greater sphenoid wing type. Endovascular therapy is generally employed, however, open surgical intervention could be warranted in cases with complex fistula. METHOD: We present a case with ruptured greater sphenoid wing dural AVF (Cognard type IV), in which endovascular embolization using liquid material was performed, followed by open surgery to concurrently disconnect the fistula and evacuate the hematoma. CONCLUSION: The sphenoid wing dural AVFs may be effectively cured by open surgery for fistula disconnection in conjunction with endovascular embolization.

Vidian Canal in Chiari Type I Malformation: A Computed Tomography Study.

OBJECTIVE: To evaluate the position and dimension of the Vidian canal (VC) in Chiari type I malformation (CIM). MATERIALS AND METHODS: Radiologic views of 49 CIM (mean age: 23.58±15.62 y, sex: 23 males/26 females) and 51 healthy subjects (mean age: 42.50±20.12 y, sex: 21 males/30 females) were included in this computed tomography study. RESULTS: In comparison with controls, the VC angle and the distance of the round foramen to VC were greater in CIM, but VC length and the distances of the superior wall of the bony sphenoidal sinus, midsagittal plane, and vomerine crest to VC were smaller in CIM. Relative to the sphenoid bone, the position of VC in CIM was determined as type 1 (59.2%) >type 2 (28.6%) >type 3 (12.2%), whereas in controls as type 1 (54.9%) >type 3 (25.5%) >type 2 (19.6%). Relative to the medial pterygoid plate, the position of VC in CIM was determined as type A (63.3%) >type B (20.4%) >type C (16.3%), while in controls as type B (43.1%) >type A (40.2%) >type C (16.7%). CONCLUSION: VC size and position correlated with CIM. Compared with controls, CIM patients had more partially protruded VC into the bony sphenoidal sinus and more medially located VC according to the medial pterygoid plate.

Metastasis to the skull base involving the sphenoid and cavernous sinus in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, among which around 18-64% metastasize, most frequently to lungs, regional lymph nodes and adrenal glands. Metastasis of HCC to the central nervous system represents a rare yet clinically significant phenomenon, often presenting diagnostic and therapeutic challenges. In this case report, we document a 35-year-old male who presented with a secondary headache and right ophthalmoplegia attributable to metastatic deposits secondary to HCC infiltrating the cavernous sinus and superior orbital fissure. Despite therapeutic interventions including local palliative radiotherapy and sorafenib, the patient succumbed to acute liver failure after 9 months. This case highlights the aggressive potential of HCC to involve the central nervous system and the importance of heightened clinical suspicion for early diagnosis and intervention in such rare but clinically impactful scenarios.

Frontotemporal Approach for Spheno-Orbital Meningioma and Orbital Compartment Resection: Technical Case Instruction: 2-Dimensional Operative Video.

BACKGROUND AND IMPORTANCE: Spheno-orbital meningiomas (SOMs) pose a challenge to the skull base neurosurgeon because of their variable presentation and involvement of critical structures within the orbit. There is no consensus on optimal management of these patients and how to achieve maximal safe resection. The authors share an illustrative case with an accompanying video to demonstrate their aggressive approach to resect SOMs and their intraorbital components. CLINICAL PRESENTATION: A 75-year-old-woman presented with progressive vision loss and proptosis. Magnetic resonance imaging was consistent with a large, left-sided sphenoid wing meningioma with extension to the orbital wall and compression of the optic nerve medially. The patient elected to undergo surgical excision and optic nerve decompression. She did well postoperatively with resolution of proptosis and good resection margins on follow-up imaging. CONCLUSION: Aggressive resection of SOMs is possible with an understanding of the underlying anatomy. Familiarity with the orbit can facilitate a maximal safe resection with optic nerve decompression.

Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases.

BACKGROUND: Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. METHODS: From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. RESULTS: Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). CONCLUSIONS: Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.

Morning Glory Disc Anomaly: Expanding the MR Phenotype.

BACKGROUND AND PURPOSE: Morning glory disc anomaly (MGDA) is a congenital malformation characterized by a funnel-shaped optic disc excavation with radiating vessels and a central glial tuft. Imaging is essential to evaluate associated cephalocele and steno-occlusive vasculopathy. The goal of this study was to assess optic nerve, chiasmatic, and sphenoid bone morphology in MGDA. MATERIALS AND METHODS: This retrospective study examined all subjects with funduscopically confirmed MGDA diagnosed and imaged with brain MR imaging between 2008 and 2023. RESULTS: Thirty-two children met inclusion criteria. Ocular involvement was unilateral in 29 subjects and bilateral in 3. Segmental optic nerve enlargement ipsilateral to the MGDA was seen in 21 subjects, with 3 also demonstrating a segmental reduction in the size of the ipsilateral optic nerve. Segmental reduction in the size of the ipsilateral optic nerve was present in 3 additional subjects, one with bilateral MGDA. The optic chiasm appeared asymmetrically thickened in 21 subjects, often with deformity. The optic nerves appeared normal in signal intensity in all subjects, with faint peripheral chiasmatic enhancement in 4 of 20 patients who received contrast. Optic nerve findings were stable in 15 subjects with multiple examinations. A persistent craniopharyngeal canal was identified in 17 subjects with sphenoid cephalocele in 1 and mild inferior pituitary gland displacement in 4. Tubular or nodular nasopharyngeal lesions were seen in 10 subjects. One subject had an off-midline sphenoid bone cleft, midbrain deformity, and abnormal thickening of and enhancement around the left oculomotor nerve; the oculomotor nerve finding was present in 1 additional patient. CONCLUSIONS: MGDA often manifests with ipsilateral optic nerve thickening, leading to a potential misdiagnosis as optic glioma. MGDA is also commonly associated with a persistent craniopharyngeal canal with variable pituitary gland and infundibular deformity, cephalocele, and tubular or nodular nasopharyngeal lesions.

Computed tomography based evaluation of the association between sphenoid sinus pneumatization patterns and variations of adjacent bony structures in relation to age and gender.

Many studies revealed that the sphenoid sinus pneumatization (SSP) affects the protrusion/dehiscence of adjacent structures including optic canal (OC), foramen rotundum (FR), vidian canal (VC), and carotid canal (CC). Knowledge of this relationship bears vital importance to identify the safest surgical route during transsphenoidal procedures. Therefore, we aimed to determine the individualized prevalence of the protrusion/dehiscence of adjacent structures based on sagittal and coronal SSP (SSSP and CSSP) patterns. Computed tomography images of 300 patients were analysed to identify the SSSP and CSSP types, and the protrusion/dehiscence of adjacent structures was determined. The relationship between the variables was examined using statistical analysis in terms of age, gender, and laterality. The most prevalent SSSP type was postsellar (62.7%), followed by sellar (30%), presellar (6.6%), and conchal (0.7%). In 71.3% of patients, five types of CSSP were observed, with 23.6% and 21.7% exhibiting Type IV and V, respectively. Our results indicated that postsellar type, Type IV and V CSSP associated with the highest likelihood of protrusion/dehiscence of OC, FR, VC, and CC. Furthermore, no significant correlation was observed between these qualitative variables and gender, with the exception of the VC dehiscence, the protrusion of OC and CC. No notable differences were identified with respect to laterality. Also, the probability of having postsellar type, Type IV and V CSSP, as well as the protrusion of OC, VC, and CC, decreased with increasing age. Further detailed analysis of this association is required to predict the size of the surgical window and to prevent neurovascular injury.

[Study on the consistency between CBCT image features of sphenopalatine foramen and those seen in nasal endoscopy].

Objective:To study the clinical anatomy of the sphenopalatine foramina by dissecting the sphenopalatine foramina during Vidian nerve branch neurotomy. The anatomy and CBCT images of sphenopalatine foramen were analyzed to facilitate the navigational of clinical operation using CBCT images. Methods:From October 2017 to September 2023, 84 cases（168 sides） of Vidian nerve branch neurotomy in our department were collected. The clinical summary was made according to the anatomy of sphenopalatine foramen during the operation. Preoperative CBCT imaging findings of the sphenopalatine foramina were also studied. Results:The clinical anatomy of sphenopalatine foramen could be divided into four types: middle meatus type（1.19%）, trans-meatus type（62.29%）, superior meatus type（33.33%） and double foramen type（1.19%）. The incidence of ethmoidal ridge was 98.81%. The distance from sphenopalatine foramina to posterior nasal canal were（14.63±2.66） mm to left and（14.65±2.63） mm to right, The position Angle ∠a of lower margin of sphenopalatine foramina were（62.36±10.05）° to left and（61.51±11.82）° to right, respectively. Axial CT images can be used to divide the sphenopalatine foramen into five levels: the upper edge of the sphenopalatine foramen level, the Vidian nerve level, the basal plate interaction level, the lower edge of the sphenopalatine foramen level and the pterygopalatine canal level. The agreement between endoscopic anatomy of sphenopalatine foramen and imaging navigation was 100%. Conclusion:The sphenopalatine foramina exhibit various anatomical types. The preoperative navigational CBCT reading can effectively identify the type of sphenopalatine foramina, guide the choice of surgical method, and help avoid serious complications. This has significant clinical application value.

Clinical achievements of implantology in the pterygoid region: A systematic review and meta-analysis of the literature.

The purpose of the study is to evaluate the survival rate of pterygoid implants compared to implants placed in different maxilla area and to settle as an alternative solution for the rehabilitation of the posterior maxilla atrophy. Studies that were included for this systematic review were selected using different database of references: PubMed Medline, Lilacs and Cochrane Library. Other journal platforms were also used for the research. Five articles met the strict inclusion/exclusion criteria of the 180 articles founded. This systematic review was registered on Prospero (CRD42023409706) and followed PRISMA statement. A total of 768 implants placed presented 97.43 % with a peak of 100 % of survival rate. Follow-up period varies from a minimum of 1 year to a maximum of six years. Pterygoid implants could be a valid alternative in patients presenting a posterior maxilla atrophy, but results should be interpreted cautiously due to the difficulty of the surgical technique. Further studies in the future should be taken in consideration to confirm the success rate of pterygoid implants since there is only one prospective RCT, potentially incorporating modern technologies such as guided surgery or navigated surgery could be a solution for the success of pterygoid implants, minimizing the risk and less dependent on the operator.

Anterior clinoidectomy in low lying internal carotid artery-posterior communicating artery aneurysm.

BACKGROUND: At times, a regulation internal carotid artery-posterior communicating artery junction (ICA-P-Comm) aneurysm becomes a surgical hurdle owing to its close proximity to the anterior clinoid process, an immovable ICA and a concealed dominant P-Comm artery arising from the aneurysm neck. METHOD: A 70 year old patient with a low lying ICA-P-Comm aneurysm underwent a "tailored" intradural clinoidectomy for aneurysm clipping. CONCLUSION: A tailored anterior clinoidectomy to expose "just enough" allows a proximal ICA control in a suitable area, mobility of an atherosclerotic ICA and exposes the P-Comm artery origin which are essential in safe clipping of these aneurysms.