Extent of resection and survival outcomes in World Health Organization grade II meningiomas.

PURPOSE: WHO grade II meningiomas behave aggressively, with recurrence rates as high as 60%. Although complete resection in low-grade meningiomas is associated with a relatively low recurrence rate, the impact of complete resection for WHO grade II meningiomas is less clear. We studied the association of extent of resection with overall and progression-free survivals in patients with WHO grade II meningiomas. METHODS: A retrospective database review was performed to identify all patients who underwent surgical resection for intracranial WHO grade II meningiomas at our institution between 1995 and 2019. Kaplan-Meier analysis was used to compare overall and progression-free survivals between patients who underwent gross total resection (GTR) and those who underwent subtotal resection (STR). Multivariable Cox proportional-hazards analysis was used to identify independent predictors of tumor recurrence and mortality. RESULTS: Of 214 patients who underwent surgical resection for WHO grade II meningiomas (median follow-up 53.4 months), 158 had GTR and 56 had STR. In Kaplan-Meier analysis, patients who underwent GTR had significantly longer progression-free (p = 0.002) and overall (p = 0.006) survivals than those who underwent STR. In multivariable Cox proportional-hazards analysis, GTR independently predicted prolonged progression-free (HR 0.57, p = 0.038) and overall (HR 0.44, p = 0.017) survivals when controlling for age, tumor location, and adjuvant radiation. CONCLUSIONS: Extent of resection independently predicts progression-free and overall survivals in patients with WHO grade II meningiomas. In an era of increasing support for adjuvant treatment modalities in the management of meningiomas, our data support maximal safe resection as the primary goal in treatment of these patients.

The influence of age on the histological grading of meningiomas.

This study was undertaken to assess the relationship between the age of patients at the time of their surgery and histological grading of meningiomas. A retrospective review was conducted for 1,083 consecutive patients with meningiomas who had surgical removal between January 1991 and December 2006. Histological grading for each tumor was done utilizing the WHO classification for meningiomas. The incidence of WHO grade II or III tumors between the elderly and the non-elderly groups was compared. The mean age at diagnosis for the WHO grade I, II, and III tumors was 55.1 (±14.79), 59.0 (±15.54), and 64.3 years (±13.28) (p value = 0.007), respectively. We found that 11.9 % of meningiomas diagnosed after the age of 60 years was WHO grade II or III, while this value was only 6.9 % for patients 60 years or younger (p = 0.0006). Our study showed that the combined incidence of WHO grade II and III meningiomas increases as age advances. We believe that this constitutes an important piece of information requiring neurosurgeons to carefully and continuously observe the elderly patients harboring meningiomas.

The Dorello canal: historical development, controversies in microsurgical anatomy, and clinical implications.

Interest in studying the anatomy of the abducent nerve arose from early clinical experience with abducent palsy seen in middle ear infection. Primo Dorello, an Italian anatomist working in Rome in the early 1900s, studied the anatomy of the petroclival region to formulate his own explanation of this pathological entity. His work led to his being credited with the discovery of the canal that bears his name, although this structure had been described 50 years previously by Wenzel Leopold Gruber. Renewed interest in the anatomy of this region arose due to advances in surgical approaches to tumors of the petroclival region and the need to explain the abducent palsies seen in trauma, intracranial hypotension, and aneurysms. The advent of the surgical microscope has allowed more detailed anatomical studies, and numerous articles have been published in the last 2 decades. The current article highlights the historical development of the study of the Dorello canal. A review of the anatomical studies of this structure is provided, followed by a brief overview of clinical considerations.

Spontaneous cerebrospinal fluid rhinorrhea as the initial presentation of growth hormone-secreting pituitary adenoma.

Patients with acromegaly usually present with characteristic clinical features or comorbidities associated with excess insulinlike growth factor 1 (IGF-1)/growth hormone (GH) or may come to medical attention secondary to mass effects causing visual field distortions. Herein, we report a case of spontaneous cerebrospinal fluid (CSF) rhinorrhea as the presenting symptom of acromegaly. A 68-year-old man presented to an outside facility with a 2-day history of headache associated with nausea, vomiting, dizziness, and clear nasal discharge and underwent 2 attempted repairs of a sphenoid sinus CSF leak. Examination on admission to our hospital was significant for fluctuating level of consciousness. Subsequently, subtle coarse facial features were appreciated. Pituitary function testing showed thyrotropin and gonadotropin deficiencies along with an elevated age- and sex-matched IGF-1 of 285 (normal level, 59-225 ng/mL). Nadir GH during oral glucose tolerance test was 5.5 ng/mL and confirmed the diagnosis of acromegaly. Magnetic resonance imaging showed pneumocephalus, an enlarged sella with an elongated pituitary stalk, and partial erosion of the anterior wall of the sphenoid sinus. A distinct adenoma could not be identified. An endoscopic, transnasal, transsphenoidal exploration and biopsy with multilayered skull base reconstruction were performed. Histologic examination of the biopsy contents was consistent with a GH-producing adenoma. Postoperatively, the patient's fluctuating level of consciousness improved and returned to baseline after his successful skull base repair. During the follow-up period, he had an IGF-1 of 713 ng/mL and started treatment with a somatostatin analogue. To our knowledge, this is the first reported case of a GH-producing pituitary adenoma presenting with spontaneous CSF rhinorrhea. Pituitary adenomas should be considered in the differential diagnosis of patients presenting with spontaneous CSF rhinorrhea with abnormal sellar image, and these patients should undergo a thorough hormonal evaluation.

High incidence of optic canal involvement in clinoidal meningiomas: rationale for aggressive skull base approach.

INTRODUCTION: Literature specifically focusing on clinoidal meningiomas is scant, particularly with regards to the postoperative visual outcome. In this study, we aimed to document the incidence of optic canal involvement (OCI) by the tumor, its management using a skull base technique, and its significance with relation to the visual outcome. MATERIALS AND METHODS: Fifty-two patients with clinoidal meningiomas were retrospectively analyzed. In 47 patients, skull base technique consisting of extradural anterior clinoidectomy with falciform ligament and optic nerve sheath opening was performed. Pre-operative visual status and post-operative outcome were analyzed with respect to OCI. RESULTS: The incidences of OCI was present in 19 (36%) and pre-operative visual deficit (VD) in 24 (46%) patients. With regard to pre-operative visual status, OCI was seen in 14 (58%) of 24 patients with VD, as compared to five (18%) in 28 patients without (p = 0.004). Among the 22 patients with VD and detailed postoperative neuro-ophthalmological evaluation, 17 (77%) had visual improvement, and in five patients (23%), vision was unchanged. In the presence of OCI in 11 patients, vision improved in seven (64%), and remained unchanged in four patients (36%), whereas all but one of the 11 patients (91%) without OCI improved and in the remaining one (9%), remained unchanged. Simpson Grade I and II resection was achieved in 71%. CONCLUSION: OCI is observed in 36% of clinoidal meningiomas, and it correlates well with pre-operative visual status. With the use of the skull base technique, without which the tumor in the optic canal could not have been removed completely and safely, visual improvement of 77% and stability of 23% was achieved.

Recovery of low-frequency sensorineural hearing loss following resection of a greater superficial petrosal nerve schwannoma. Case report.

Facial nerve schwannomas can occur anywhere from the internal auditory canal to the parotid gland. Schwannomas arising from the greater superficial petrosal nerve are exceedingly rare. The authors report the case of a 63-year-old woman who presented with a selective low-frequency hearing loss of 3 weeks' duration. Neurological examination demonstrated a House-Brackmann Grade II facial paresis and asymmetrical hearing loss on the left side. Audiometric evaluation showed a significant loss of low-frequency hearing with a speech reception threshold (SRT) of 30 dB and a speech discrimination score (SDS) of 88% on the left side. Magnetic resonance imaging revealed a 2.4-cm enhancing left middle fossa mass. Near-complete resection was performed via a left temporal craniotomy. The tumor was located in the Glasscock triangle and had invaded the petrous bone overlying the cochlea. A very small piece of the tumor over the cochlea was left in order to preserve hearing. A postoperative audiogram showed significant improvement in the patient's hearing, with an SRT of 20 dB and an SDS of 100%. The histological findings were consistent with schwannoma. The patient experienced postoperative improvement of hearing function despite cochlear involvement, which has previously been reported as an unfavorable factor for postoperative hearing outcome in facial nerve schwannomas.

Significance of the tentorial alignment in approaching the trigeminal nerve and the ventral petrous region through the suboccipital retrosigmoid technique.

OBJECT: In this study, the authors aimed to identify the factors that would predict the operative distance between the trigeminal nerve (fifth cranial nerve) and the acousticofacial nerve complex (seventh-eighth cranial nerves) preoperatively when approaching the cerebellopontine angle (CPA) through the suboccipital retrosigmoid approach. METHODS: In 40 consecutive patients who underwent microvascular decompression of the trigeminal nerve via a suboccipital retrosigmoid approach for trigeminal neuralgia, the following three parameters were assessed on preoperative magnetic resonance images: 1) the angle between the tentorium and the line drawn from the hard palate (tentorial angle); 2) the angle between the lines drawn along the petrous bones ventral to the internal auditory canals (petrous angle); and 3) the angle between the tentorium and the line connecting the opisthion to the inion (occipital angle). The distance between the trigeminal nerve and the acousticofacial nerve complex (referred to as "distance") was measured intraoperatively. Statistical analysis was performed using the Pearson correlation test. RESULTS: The mean values were 50.9 +/- 11.5 degrees for the tentorial angle, 102.5 +/- 13.1 degrees for the petrous angle, 83.4 +/- 9.7 degrees for the occipital angle, and 3.1 +/- 1.5 mm for distance. There was a strong inverse correlation between the tentorial angle and distance (r = -0.228, p = 0.08). The mean distance was 3.5 +/- 1.9 mm for a tentorial angle less than 51 degrees and 2.7 +/- 1.1 mm for a tentorial angle of at least 51 degrees. No correlation existed between either the petrous or occipital angles and distance. CONCLUSIONS: The distance between the trigeminal nerve and acousticofacial nerve complex decreases in the presence of a steep tentorial angle. This limits the operating field between these cranial nerves when reaching the petroclival or the superior CPA regions through the retrosigmoid approach. Awareness of such anatomical features at the time of preoperative planning is of paramount importance in selecting the optimum surgical approach and minimizing operative complications.

Dominant Occipital Sinus Complicating Surgery of a Fourth Ventricular Mass.

BACKGROUND: We describe a case of a fourth ventricular mass requiring a modified approach to its management owing to a rare variation of the occipital sinus (OS). CASE DESCRIPTION: A 32-year-old female presented with persistent headache and nausea. Magnetic resonance imaging revealed a fourth ventricular mass and hydrocephalus. Venous sinus anatomy appeared unusual, and thus magnetic resonance venography was performed, which identified the OS as the main drainage pathway for the entire brain, providing the sole drainage between the superior sagittal sinus and the jugular veins through the marginal sinus. Both the transverse and sigmoid sinuses were hypoplastic, and flow through the straight sinus was diminished. Thus, endoscopic third ventriculostomy and biopsy were performed as the first step. Postoperatively, the patient's nausea persisted and biopsy results were inconclusive, and thus a second surgery was planned. The dural opening was tailored so as not to damage the OS and marginal sinus, and the tumor was resected subtotally through the limited dural opening. Histopathological analysis identified a low-grade glioma. CONCLUSIONS: Rare variations of the venous/sinus anatomy may fundamentally change the surgical management plan, and recognizing such variations is crucial to minimizing the risk of potentially fatal complications.

Gliosarcoma with infratemporal fossa extension. Case report.

Gliosarcomas are bimorphic intraaxial tumors. Involvement of the skull base is highly unexpected. The authors present the case of a temporal lobe gliosarcoma with significant infratemporal fossa extension. This 55-year-old man presented with a 1-month history of severe progressive headache. Neurological examination was unremarkable except for bilateral papilledema. Magnetic resonance imaging revealed a 6-cm right temporal mass with extension into the infratemporal fossa. The patient underwent a right frontotemporal craniotomy together with drilling of the sphenoid ridge and middle fossa floor. The tumor consisted of intraaxial, intracranial as well as extradural, and extracranial components with extension to the posterolateral wall of the sphenoid sinus. It had a relatively well-circumscribed dissection plane. Gross-total resection was achieved, and the middle fossa floor was reconstructed using a rotated temporalis muscle flap. The postoperative course was uneventful except for hypesthesia in the distribution of the maxillary division of the right trigeminal nerve. The histopathological diagnosis was consistent with gliosarcoma. Radiotherapy and chemotherapy consisting of temozolomide were administered subsequently, and the patient was recurrence free 12 months after his initial diagnosis. In the presence of a mass lesion with both intraaxial and extracranial involvement, gliosarcoma should be considered among the differential diagnoses. Aggressive resection should be attempted, including the use of skull base surgical techniques to ensure an optimal outcome. The effect of skull base involvement to the overall treatment and outcome of patients with gliosarcomas would be difficult to determine given the rare occurrence of these lesions in such locations.

Meningothelioma as the predominant histological subtype of midline skull base and spinal meningioma.

OBJECT: This study was undertaken to test a hypothesis that meningiomas of the midline skull base and spine are predominantly of the meningothelial histological subtype. METHODS: The cases of 794 consecutive patients who underwent resection for meningioma at the Cleveland Clinic between January 1991 and March 2004 were reviewed retrospectively. The authors analyzed the relationship between the tumors' histological subtypes and sites of origin in the 731 patients from this group who harbored tumors that were determined to be benign histologically (World Health Organization Grade I). Meningothelial meningiomas (MMs) accounted for 63.5% (464/731) of the Grade I tumors. The incidence of MM according to the site of origin was as follows: 84.9% (186/219) in the midline skull base, 58.3% (35/60) in the lateral skull base, 48.5% (183/377) in a non-skull base location, and 80% (60/75) in spinal locations. The incidence of MM in the midline skull base and spinal locations were significantly higher than in non-skull base or lateral skull base locations. CONCLUSIONS: Meningiomas of the midline neuraxis are predominantly meningotheliomas. Analysis of the increasingly available data on genetic and topographic characteristics of MMs suggests that they may represent a unique entity, contrary to the prevailing belief that all benign meningiomas are identical tumors.

Wilbrand's knee: does it exist?

OBJECTIVE: In 1904, Hermann Wilbrand reported that nasal ON fibers form a loop into the contralateral ON, subsequently referred to as Wilbrand's knee. He had further theorized that a lesion affecting Wilbrand's knee would develop a distinct visual field defect characterized by an ipsilateral central scotoma with a contralateral superotemporal visual field defect. We present clinical evidence that disputes the existence of Wilbrand's knee. METHODS: A retrospective analysis of 3 patients whose ONs were divided at the ON-chiasm junction is presented. Two patients had an ONS meningioma and the other patient had sarcoidosis of the ON. Resection of the lesion and the ON up to the nerve-chiasm junction was done to prevent the disease from extending into the OC and the contralateral ON. The patients had detailed neuro-ophthalmologic evaluations preoperatively and postoperatively. RESULTS: After the resection of the ON at the ON-chiasm junction in the 3 patients, junctional scotoma could not be detected by visual perimetry. CONCLUSION: No clinical perimetric evidence was found to support the existence of Wilbrand's knee in the anterior visual pathway.

Major depression with psychosis after resection of a giant middle fossa hemangiopericytoma.

BACKGROUND: Postoperative onset of acute major depression in a patient with no previous history of psychiatric disorder is highly unexpected after skull base surgery. CASE DESCRIPTION: A 38-year-old woman with no previous physical or mental illness presented with a 3-month history of left ear pain, short-term memory disturbance, and motor dysphasia. Magnetic resonance imaging revealed a large extraaxial tumor in the left middle fossa. Left temporal craniotomy was performed, achieving complete tumor resection. The patient showed signs of confusion, disorientation, and severe depression 3 days after the surgery. She developed insomnia and auditory hallucinations along with expressed suicidal ideation, then deteriorated rapidly, necessitating a transfer to a psychiatric unit. In spite of the intensive treatment with antidepressive and antipsychotic medications, she continued to have prolonged psychotic symptoms and depression for several months after surgery. CONCLUSION: Although the incidence is rare, psychiatric complications should be anticipated in patients undergoing resection of a large skull base tumor affecting the temporal lobe. The exact mechanism in this process is not clear; however, it is important to clinically differentiate treatable etiologies such as steroid-induced psychosis and postoperative delirium.

Evaluation of Non-Watertight Dural Reconstruction with Collagen Matrix Onlay Graft in Posterior Fossa Surgery.

OBJECTIVE: Many surgeons advocate for watertight dural reconstruction after posterior fossa surgery given the significant risk of cerebrospinal fluid (CSF) leak. Little evidence exists for posterior fossa dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Our objective was to report the results of using collagen matrix in a non-watertight fashion for posterior fossa dural reconstruction. METHODS: We conducted a retrospective review of operations performed by the senior author from 2004-2011 identified collagen matrix (DuraGen) use in 84 posterior fossa operations. Wound complications such as CSF leak, infection, pseudomeningocele, and aseptic meningitis were noted. Fisher's exact test was performed to assess risk factor association with specific complications. RESULTS: Incisional CSF leak rate was 8.3% and non-incisional CSF leak rate was 3.6%. Incidence of aseptic meningitis was 7.1% and all cases resolved with steroids alone. Incidence of palpable and symptomatic pseudomeningocele in follow-up was 10.7% and 3.6% respectively. Postoperative infection rate was 4.8%. Previous surgery was associated with pseudomeningocele development (p<0.05). CONCLUSION: When primary dural closure after posterior fossa surgery is undesirable or not feasible, non-watertight dural reconstruction with collagen matrix resulted in incisional CSF leak in 8.3%. Incidence of pseudomeningocele, aseptic meningitis, and wound infection were within acceptable range. Data from this study may be used to compare alternative methods of dural reconstruction in posterior fossa surgery.

Enhanced exposure of carotico-oculomotor triangle following extradural anterior clinoidectomy: a comparative anatomical study.

OBJECTIVE: To quantify and compare the carotico-oculomotor triangle (COT) area before and after extradural anterior clinoidectomy (AC). METHODS: Ten cadaveric heads were dissected bilaterally. Before and after an extradural AC, the following points were measured: (1) the internal carotid artery (ICA) bifurcation to the tip of the anterior clinoid process (ACP) (A) and to the distal dural ring (A'), (2) the ICA bifurcation to the point where the oculomotor nerve becomes obscured by the tentorial fold (B) and to the porus oculomotoris after incision of the tentorial fold (B'), and (3) the tip of the ACP to the point where the oculomotor nerve becomes obscured by the tentorial incisura (C) and from the distal dural ring to the porus oculomotoris (C'). The area of the COT was calculated before and after AC (DeltaABC and DeltaA'B'C', respectively). RESULTS: The mean values were as follows: A: 9.15 +/- 0.93 mm, A': 13.45 +/- 0.82 mm; B: 7.80 +/- 1.24 mm, B': 9.90 +/- 1.21 mm; C: 7.15 +/- 0.99 mm, C': 9.3 +/- 1.26 mm; DeltaABC: 26.26 +/- 6.05 mm, DeltaA'B'C': 45.06 +/- 8.92 mm. CONCLUSIONS: Extradural AC enhances the exposure of the COT almost twofold. This increased exposure can be of significant help during resection of lesions of the parasellar and basilar apex regions.

Recurrent head-and-neck chemodectomas: a comparison of surgical and radiotherapeutic results.

PURPOSE: To compare the outcome of salvage radiotherapy (RT) and surgery for recurrent head-and-neck chemodectomas. MATERIALS AND METHODS: We retrospectively studied 70 patients with benign chemodectomas of the head and neck treated with surgery at the Cleveland Clinic between July 1969 and August 1999; 29 of these patients were diagnosed with recurrent tumors. Salvage RT was used in 12 patients (gamma knife radiosurgery for 7, conventional external beam RT for 4, and intensity-modulated RT for 1 patient). The median follow-up was 55 months for the entire group of 70 patients. RESULTS: The median time to recurrence was 36 months. Of the recurrences, 16 were glomus jugulare, 7 were carotid body tumors, 5 were glomus tympanicum, and 1 was thyroid paraganglioma. RT was used in 12 patients (9 patients with glomus jugulare, 2 with glomus tympanicum, and 1 with thyroid paraganglioma). Surgery was performed in 17 patients (7 patients with glomus jugulare, 7 with carotid body, and 3 with glomus tympanicum). For patients with glomus jugulare and glomus tympanicum tumors, the 5-year freedom from disease progression was 100% for patients treated with RT vs. 62% for those treated with surgery (p = 0.0124). Seven patients with carotid body tumors and 1 patient with thyroid paraganglioma were treated successfully with surgery and RT, respectively. No significant side effects were associated with RT; however, postoperative complications occurred in 8 of the 17 surgery patients (new cranial nerve palsies, meningitis, infection, and cerebrospinal fluid leak). CONCLUSION: Salvage RT appears superior to surgery and should be considered the treatment of choice for patients with recurrent glomus jugulare and glomus tympanicum tumors. For recurrent carotid body tumors, surgery produced excellent local control, most likely because of the easier resectability in this location.

Inhibition of ras-mediated activator protein 1 activity and cell growth by merlin.

The neurofibromatosis type2 (NF2) gene encodes an intracellular-associated protein that is referred to as either merlin or schwannomin. Merlin/Schwannomin is a tumor suppressor protein that has been reported to block the Ras-mediated cell proliferation and -anchorage-independent cell growth. However, its inhibitory mechanism is uncertain. In this report, merlin was demonstrated to be effective in suppressing Ras-induced foci-formation and its associated AP-1 activity in NIH3T3cells. In addition, merlin blocked Ras-induced Rb phosphorylation, and inhibited the increase of cyclin D1 levels. It also blocked E2F-1-dependent transcription. These results suggest that merlin inhibits abnormal cell proliferation which is activated via Ras by repressing Rb phosphorylation, blocking the increase of the cyclin D1 protein level, and inhibiting the activation of AP-1- and E2F-1-dependent transcription in NIH3T3 cells.

Necrotizing neurosarcoidosis of the cranial base resembling an en plaque sphenoid wing meningioma: case report.

OBJECTIVE AND IMPORTANCE: Necrotizing sarcoid granuloma (NSG) has been recognized as a histological variant of sarcoidosis. Two cases of neurosarcoidosis (NS) with NSG with concomitant systemic disease have been described previously. We present an unusual case of primary NS-NSG that resembled an en plaque cranial base meningioma. CLINICAL PRESENTATION: A 51-year-old man presented with a 3-month history of progressive left visual deterioration and proptosis. Brain magnetic resonance imaging demonstrated a large cranial base lesion occupying the left anterior clinoid process and sphenoid wing, extending to the left frontotemporal convexity. A second dura-based lesion was observed in the right parietal convexity. Both lesions enhanced homogeneously after administration of intravenous contrast medium. Magnetic resonance imaging characteristics were consistent with a typical clinoidal meningioma with an en plaque extension laterally. INTERVENTION: A left frontotemporal craniotomy with extradural removal of the anterior clinoid process was performed. When the dura was opened, a red fibrous mass was identified. Intraoperative histological analysis revealed the presence of necrotizing and noncaseating granulomas. Postoperatively, cerebrospinal fluid, erythrocyte sedimentation rate, C-reactive protein, and serum and cerebrospinal fluid angiotensin-converting enzyme values were normal. The search for acid-fast bacilli or fungi was negative. A diagnosis of primary NS-NSG was made. The patient began long-term high-dose corticosteroid therapy. One and a half years after surgery, his vision had improved significantly and the lesions were stable as revealed by magnetic resonance imaging. CONCLUSION: The first case of primary NS-NSG in the absence of systemic sarcoidosis is reported. NS should be included in the differential diagnosis of dura-based lesions resembling meningioma.

Rare Actinobacillus infection of the cavernous sinus causing painful ophthalmoplegia: case report.

OBJECTIVE AND IMPORTANCE: Actinobacillus actinomycetemcomitans is a gram-negative coccobacillus that is known to cause a wide array of clinical infections in debilitated patients, including periodontal disease, soft tissue abscess, pleural empyema, endocarditis, cerebral abscess, and meningitis. We report a rare A. actinomycetemcomitans cavernous sinus abscess that caused painful ophthalmoplegia in a healthy man. CLINICAL PRESENTATION: A 34-year-old man presented with a 3-month history of acute onset of left-sided retro-orbital pain that progressed to a complete left Cranial Nerve VI palsy and Cranial Nerve V1 and V2 hypesthesia. Magnetic resonance imaging revealed the presence of an enhancing lesion in the left cavernous sinus, which encased and narrowed the ipsilateral intracavernous segment of the internal carotid artery. Routine blood and cerebrospinal fluid analyses were normal. Tolosa-Hunt syndrome was suspected, and the patient was treated with high-dose corticosteroids. An open biopsy was performed after failed prolonged corticosteroid therapy. INTERVENTION: A left frontotemporal craniotomy and cavernous sinus exploration through an interdural approach were performed. A soft reddish mass was found in the cavernous sinus around Cranial Nerve V1 and V2. Multiple biopsies were obtained. Pathological analysis revealed a purulent infection containing multiple gram-negative coccobacilli. The patient's pain improved immediately, and cranial neuropathy resolved during the next several weeks. After cultures demonstrated growth of A. actinomycetemcomitans, a regimen of orally administered amoxicillin and metronidazole was initiated. Eight months after surgery, the patient was free of symptoms and a repeat magnetic resonance imaging scan was normal. CONCLUSION: We present a rare bacterial abscess of the cavernous sinus causing painful ophthalmoplegia. In patients who present with presumed Tolosa-Hunt syndrome and do not improve with prolonged high-dose corticosteroid therapy, an open biopsy is recommended to exclude a bacterial infection.

Vestibular nerve sectioning for intractable vertigo: efficacy of simplified retrosigmoid approach.

OBJECTIVE: To determine the surgical efficacy of a simplified retrosigmoid approach for vestibular nerve sectioning. STUDY DESIGN: A retrospective analysis. SETTING: Tertiary academic referral center. PATIENTS: Twenty-eight consecutive patients who underwent vestibular nerve sectioning for intractable peripheral vestibular disorders. INTERVENTION: All patients had a simplified retrosigmoid approach for vestibular nerve sectioning. MAIN OUTCOME MEASURES: Functional outcome after vestibular nerve sectioning was analyzed with respect to improvement in patient disability from vertigo and reduction in the frequency of definitive vertigo attacks. Resolution of lightheadedness provided an additional outcome measure. The incidence of surgical complications, including postoperative headache, was determined, and the operative time was reviewed. RESULTS: Twenty-six patients (92.9%) had an improved functional level postoperatively, 21 (75.0%) had excellent improvement, 4 (14.3%) had significant improvement, 1 (3.6%) had limited improvement, and 2 (7.1%) had no change. No patient was worse postoperatively. Eighteen of 23 Ménière's patients (78.3%) had complete control of definitive vertigo attacks after vestibular nerve sectioning. Improvement in lightheadedness was seen in 23 patients (82.1%), 11 (39.3%) of whom reported complete resolution. Postoperative headache developed in 1 (3.6%) patient. No patients experienced infection, facial weakness, or leakage of cerebrospinal fluid. Mild hearing deterioration was seen in 2 patients (7.1%). The mean operative time was 76.3 minutes. CONCLUSION: With excellent efficacy, short operative time, and a low incidence of postoperative hearing loss or headache, this simplified retrosigmoid technique should be considered for vestibular nerve sectioning in patients with intractable peripheral vestibular disorders.

Acetyl-11-keto-beta-boswellic acid (AKBA) is cytotoxic for meningioma cells and inhibits phosphorylation of the extracellular-signal regulated kinase 1 and 2.

Acetyl-11-keto-beta-boswellic acid (AKBA) is a naturally occurring pentacyclic triterpene isolated from the gum resin exudate from the stem of the tree Boswellia serrata (frankincense). AKBA has been recently identified as a novel, orally active, non-redox and non-competitive 5-lipoxygenase inhibitor that also inhibits topisomerase I and II in vitro. Because natural pentacyclic triterpenes have an antiproliferative effect against different tumor types, we investigated the effects of AKBA on the proliferation of 11 primary cell cultures established from human surgical specimens of meningiomas, common central nervous system tumors. Treatment of meningioma cells by AKBA revealed a potent cytotoxic activity with half-maximal inhibitory concentrations in the range of 2-8 microM. At similar, physiologically achievable concentrations, AKBA rapidly (within minutes) and potently inhibited the phosphorylation of extracellular signal-regulated kinase 1 and 2 (Erk-1 and Erk-2) in meningioma cells stimulated with platelet-derived growth factor BB. High expression level of 5-LO was detected in primary meningioma cells and surgical specimens by immunoblotting analysis, suggesting the possible role of 5-LO in meningioma tumorigenesis. Considering the critical importance of the Erk-1/2 signal transduction pathway not only in meningiomas but in other human neoplasms, the interruption of signaling through this evolutionarily conserved pathway might be one of the mechanisms by which AKBA induces suppression of proliferation and apoptosis of different tumor types.