Spontaneous and asymptomatic rupture of an RCC with resolution of symptoms.

There is no standard of care for management of Rathke cleft cysts (RCCs), and protocol for spontaneous rupture or residual capsule fragments is not well documented.Our case involves a Caucasian man in his 80s who presented with muscle weakness, fatigue, bitemporal hemianopia and pain. Further examination demonstrated decreased thyroid and cortisol levels. MRI revealed a 1.6×1.5×1.3 cm sellar homogenous mass with extension into the suprasellar cistern. While the size of the cyst was rather large, a decision was made to follow conservatively with serial MRI. At 3 years, the mass had spontaneously regressed. The patient was asymptomatic without imaging evidence of RCC recurrence at 4-year follow-up.Classic indications for surgical intervention in suprasellar cysts were subtle in our patient and his advanced age made us take a conservative approach. Current data are lacking regarding management of RCCs presenting with endocrine dysfunction. Our case suggests that RCCs presenting with endocrine dysfunction may be managed conservatively with serial imaging-based monitoring.

IgG4-negative pituitary inflammatory pseudotumor with sphenoidal involvement resembling a macroadenoma.

BACKGROUND: Inflammatory pseudotumors (IPTs) are rare benign conditions of unknown etiology that can affect any part of the body. IPTs are most commonly associated with Immunoglobulin G4 (IgG4)-related disease. Central nervous system IPTs, especially with pituitary involvement, are even rarer entities. The presence of an IgG4-negative pituitary IPT with simultaneous extracranial involvement has not been reported. CASE REPORT: We present the case of a 41-year-old female with past medical history of rheumatoid arthritis and a diagnosis of pituitary IPT with coexisting sphenoidal (extracranial) involvement mimicking a pituitary macroadenoma at presentation. The patient underwent multiple consecutive biopsies, and an extensive workup prior to establishing the diagnosis. Laboratory work-up showed normal serum IgG4 and unremarkable liver function tests. CONCLUSION: Pituitary lesions with simultaneous sphenoidal involvement in patients with IgG4-negative systemic inflammatory disease should raise the clinical suspicion for intracranial IPTs, as these tumors can mimic aggressive counterparts causing adjacent bony erosion, and local invasion.

Long-Term Time Series Forecasting and Updates on Survival Analysis of Glioblastoma Multiforme: A 1975-2018 Population-Based Study.

OBJECTIVE: Glioblastomas multiforme (GBMs) are the most common primary CNS tumors. Epidemiologic studies have investigated the effect of demographics on patient survival, but the literature remains inconclusive. METHODS: This study included all adult patients with intracranial GBMs reported in the surveillance epidemiology and end results (SEER)-9 population database (1975-2018). The sample consisted of 32,746 unique entries. We forecast the annual GBM incidence in the US population through the year 2060 using time series analysis with autoregressive moving averages. A survival analysis of the GBM-specific time to death was also performed. Multivariate Cox proportional hazards (PH) regression revealed frank violations of the PH assumption for multiple covariates. Parametric models best described the GBM population's survival pattern; the results were compared to the semi-parametric analysis and the published literature. RESULTS: We predicted an increasing GBM incidence, which demonstrated that by the year 2060, over 1,800 cases will be reported annually in the SEER. All eight demographic variables were significant in the univariable analysis. The calendar year 2005 was the cutoff associated with an increased survival probability. A male survival benefit was eliminated in the year-adjusted Cox. Infratentorial tumors, nonmetropolitan areas, and White patient race were the factors erroneously associated with survival in the multivariate Cox analysis. Accelerated Failure Time (AFT) lognormal regression was the best model to describe the survival pattern in our patient population, identifying age >30 years old as a poor prognostic and patients >70 years old as having the worst survival. Annual income >USD 75,000 and supratentorial tumors had good prognostics, while surgical intervention provided the strongest survival benefit. CONCLUSIONS: Annual GBM incidence rates will continue to increase by almost 50% in the upcoming 30 years. Cox regression analysis should not be utilized for time-to-event predictions in GBM survival statistics. AFT lognormal distribution best describes the GBM-specific survival pattern, and as an inherent population characteristic, it should be implemented by researchers for future studies. Surgical intervention provides the strongest survival benefit, while patient age >70 years old is the worst prognostic. Based on our study, the demographics such as gender, race, and county type should not be considered as meaningful prognostics when designing future trials.

Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers.

OBJECT: Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI). METHODS: A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05. RESULTS: A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate. CONCLUSIONS: The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.

Dissemination Patterns and Short-Term Management of Multifocal Rosette-Forming Glioneuronal Tumors.

BACKGROUND: Multifocal rosette-forming glioneuronal tumors (RGNTs) are challenging to manage. Gross total resection is often impossible, and data on adjunctive therapies are limited. We reviewed cases of multifocal RGNTs in the literature with special focus on dissemination patterns and management. METHODS: A literature review was conducted using PubMed and the key words "(multifocal OR multicentric OR satellite OR dissemination) AND glioneuronal." RESULTS: There were 21 cases of multifocal RGNTs identified. Follow-up was available in 18 cases at a median of 17 months. Progression-free survival and overall survival at 1 year were 84% and 94%, respectively. Of all cases, 43% had cerebrospinal fluid (CSF) dissemination, 48% had intraparenchymal spread, and 10% had both. The presence of CSF dissemination led to palliative care and/or death in 20% of cases (n = 2). None of the cases with intraparenchymal spread progressed. Radiotherapy was used in 50% of cases with CSF dissemination, chemotherapy was used in 20%, and CSF shunting was used in 36%. No tumors with intraparenchymal spread required adjunctive therapy or shunting. CONCLUSIONS: RGNTs with CSF dissemination are more likely to behave aggressively, and early adjunctive therapies should be discussed with patients. Tumors with intraparenchymal spread grow slowly, and maximal safe resection followed by observation is likely sufficient in the short term. Long-term behavior of multifocal RGNTs is still unclear.

Symptomatic cerebral vasospasm in the setting of carmustine wafer placement for glioblastoma: A case presentation and review of literature.

BACKGROUND: Gliadel placement in glioblastoma resection, particularly with concurrent chemoradiation, has demonstrated an improvement in survival. There have been several reported adverse effects, some of which lend to significantly increased morbidity and mortality. With only two other cases described in literature, cerebral vasospasm secondary to carmustine-impregnated wafers is an extremely rare side effect. CASE DESCRIPTION: We report the case of a 51-year-old female who presented with the left lower limb paresis 8 days after high-grade glioma resection provoked by carmustine wafer placement. CONCLUSION: We urge surgeons to reconsider placement of carmustine wafers in nations where the surgical resection cavity includes exposed large cerebral vasculature. We also propose the early identification of this devastating complication in the postoperative period by maintaining a high clinical suspicion and prompt utilization of computed tomography and digital subtraction angiography in the management and treatment of these patients accordingly.

Navigable Channel-Based Trans-Sulcal Resection of Third Ventricular Colloid Cysts: A Multicenter Retrospective Case Series and Review of the Literature.

BACKGROUND: Developments in frameless neuronavigation and tubular retractors hold the potential for minimizing iatrogenic injury to the overlying cortex and subcortical tracts, with improved access to the ventricular system. The objective of the present study was to evaluate the surgical outcomes after resection of third ventricular colloid cysts using an integrated neuronavigation and channel-based approach. METHODS: We performed a multicenter retrospective analysis of surgical Outcomes after surgical resection of third ventricular colloid cysts via a transtubular trans-sulcal approach. RESULTS: A total of 16 patients were included, with a mean age of 42 years (range, 23-62 years). The mean maximum diameter of cysts was 14 mm (range, 7-28 mm), and preoperative hydrocephalous was present in 12 patients (75%). Gross total resection was achieved in all 16 cases. Of the 12 patients, 4 (25%) had undergone septum pellucidotomy, in addition to cyst resection. No case had required conversion to open craniotomy. No perioperative mortalities occurred. Three patients (18.8%) had developed transient memory deficits, 1 of whom had also developed a pulmonary thromboembolism. The median length of hospital stay was 4 days (range, 2-18 days). All the patients reported resolution of preoperative symptoms at the 1-month follow-up examination. Only 1 patient (6.25%) had required insertion of a ventriculoperitoneal shunt. The median follow-up duration was 6.5 months (range, 3-24 months), and no recurrences were observed. CONCLUSION: Use of a channel-based navigable retractor provided a minimal trans-sulcal approach to third ventricular colloid cysts with the benefit of bimanual surgical control in an air medium for definitive resection of third ventricular colloid cysts.

Minimally Invasive Evacuation of Severe Intraventricular Hemorrhage Using the BrainPath Endoport-Assisted Microsurgical System.

OBJECTIVE: We present the application of the BrainPath endoport-assisted microsurgical device (EAMD) as a treatment modality for patients with severe intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial intracerebral hemorrhage (sICH). METHODS: Patients with severe secondary IVH (defined as Graeb score [GS] >6) who presented to Saint Louis University Hospital, St. Louis, Missouri, United States, from 2017 to 2019 were treated with the minimally invasive approach for IVH evacuation using the atraumatic BrainPath aspiration system. RESULTS: Three patients (2 men and 1 woman) with a mean age of 54 years were included in this study. The mean preoperative GS was 10.0 with a modified GS of 23.3. The mean postoperative GS was 4.0 (P = 0.001) with a modified GS of 10.67 (P = 0.001). There were no complications related to the surgery itself in any of the reported cases. CONCLUSIONS: BrainPath EAMD evacuation of severe IVH secondary to sICH appears to be a safe and effective treatment modality that significantly increases the extent of IVH clearance, which could also lead to improved long-term patient outcomes.

The Value of White Matter Tractography by Diffusion Tensor Imaging in Altering a Neurosurgeon's Operative Plan.

OBJECTIVE: To investigate if the implementation of white matter (WM) fiber tractography by diffusion tensor imaging in presurgical planning for supratentorial tumors proximal to eloquent WM tracts can alter a neurosurgeon's operative strategy. METHODS: A retrospective review was conducted of patients with supratentorial brain tumors within eloquent WM tracts who underwent diffusion tensor imaging (DTI) tractography as part of their preoperative assessment. These patients were classified into 3 different DTI groups per the radiology reports: group 1, intact WM tracts; group 2, deviated and/or displaced WM bundles; and group 3, patients with an established WM injury (interrupted and/or destroyed tracts). A blinded prospective behavioral study followed, in which 4 neurosurgeons reviewed the preoperative images at 2 different times (magnetic resonance imaging without DTI, followed by a review of the DTI). They provided estimations about the DTI group of each individual eloquent WM category in every patient, and their planned surgical approach. RESULTS: Fifteen patients (mean age, 58.3 years) were included in the study. The neurosurgeons provided a correct DTI group estimation in 53%, 60%, and 57% of the cases that involved motor/sensory pathway tracts, optic tracts, and language tracts, respectively. The neurosurgeons underestimated DTI group 3 in the motor category and in the optic category 75% of the time. DTI did not alter the planned surgical approach. CONCLUSIONS: DTI WM tractography helped neurosurgeons to correctly identify patients with interrupted motor and optic pathway tracts so they could be more aggressive with the extent of tumor resection, despite its inability to alter the operative approach.

Intraosseous Orbital Cavernous Hemangioma with Frontal Extension and Dural Involvement.

Primary intraosseous cavernous hemangiomas are rare skull lesions that are not typically known to involve the orbital bones or the dura. We describe a rare case of a fronto-orbital bone cavernous hemangioma with extension into the dura. A 68-year-old female presented with a one-year history of diplopia with discomfort around her left orbit. Magnetic resonance images demonstrated a mass in the left frontal skull extending into the orbital rim. The patient underwent a craniotomy for tumor resection. Dural invasion was found intraoperatively. Gross total resection and reconstruction were achieved. On the postoperative follow-up, the patient was asymptomatic.  Primary calvarial intraosseous cavernous hemangiomas are most commonly located in the frontal and parietal bones. These lesions typically involve only the outer table of the skull. In lesions involving the orbit and dura, excision with cranioplasty can provide symptomatic relief with good cosmetic outcomes.

Melanoma Mimicking Malignant Peripheral Nerve Sheath Tumor with Spread to the Cerebellopontine Angle: Utility of Next-Generation Sequencing in Diagnosis.

Cutaneous spindle cell malignancy is associated with a broad differential diagnosis, particularly in the absence of a known primary melanocytic lesion. We present an unusually challenging patient who presented with clinical symptoms involving cranial nerves VII and VIII and a parotid-region mass, which was S100-positive while lacking in melanocytic pigment and markers. Over a year after resection of the parotid mass, both a cutaneous primary lentigo maligna melanoma and a metastatic CP angle melanoma were diagnosed in the same patient, prompting reconsideration of the diagnosis in the original parotid-region mass. Next-generation sequencing of a panel of cancer-associated genes demonstrated 19 identical, clinically significant mutations as well as a high tumor mutation burden in both the parotid-region and CP angle tumors, indicating a metastatic relationship between the two and a melanocytic identity of the parotid-region tumor.

Trans-Sulcal Endoport-Assisted Evacuation of Supratentorial Intracerebral Hemorrhage: Initial Single-Institution Experience Compared to Matched Medically Managed Patients and Effect on 30-Day Mortality.

BACKGROUND: The surgical management of supratentorial intracerebral hemorrhages (ICH) remains controversial due to large trials failing to show clear benefits. Several minimally invasive techniques have emerged as an alternative to a conventional craniotomy with promising results. OBJECTIVE: To report our experience with endoport-assisted surgery in the evacuation of supratentorial ICH and its effects on outcome compared to matched medical controls. METHODS: Retrospective data were gathered of patients who underwent endoport-assisted evacuation between January 2014 and October 2016 by a single surgeon. Patients who were managed medically during the same period were matched to the surgical cohort. Previously published cohorts investigating the same technique were analyzed against the present cohort. RESULTS: Sixteen patients were identified and matched to 16 patients treated medically. Location, hemorrhage volume, and initial Glasgow Coma Scale (GCS) score did not differ significantly between the 2 cohorts. The mean volume reduction in the surgical cohort was 92.05% ± 7.05%. The improvement in GCS in the surgical cohort was statistically significant (7-13, P = .006). Compared to the medical cohort, endoport-assisted surgery resulted in a statistically significant difference in in-hospital mortality (6.25% vs 75.0%, P < .001) and 30-d mortality (6.25% vs 81.25%, P < .001). Compared to previously published cohorts, the present cohort had lower median preoperative GCS (7 vs 10, P = .02), but postoperative GCS did not differ significantly (13 vs 14, P = .28). CONCLUSION: Endoport-assisted surgery is associated with high clot evacuation and decreases 30-d mortality compared to a similar medical group.

Staged Trapping of Traumatic Basilar Trunk Pseudoaneurysm: Case Report and Review of Literature.

BACKGROUND: Traumatic intracranial aneurysms (TICAs) of the posterior circulation in the pediatric populations are rare. Only a few reports in the literature document basilar artery TICA in the pediatric population. These cases were typically associated with a clival fracture and commonly diagnosed weeks to months after trauma. We present a case of a patient with a basilar TICA diagnosed after a motor vehicle collision treated with staged trapping and review of the literature. CASE DESCRIPTION: We present a case of a 14-year-old boy who sustained a high-speed motor vehicle collision and developed a basilar trunk TICA identified on admission. Initially, the patient underwent craniotomy for proximal sacrifice of the basilar artery in hope for spontaneous thrombosis of the aneurysm through flow reversal. Endovascular options were reviewed and felt to be less feasible than surgical trapping. Due to continued filling through the right posterior communicating artery, the second surgery was performed to distally trap the aneurysm. The aneurysm was opened, showing some thrombosis and the absence of flow. Repeat magnetic resonance imaging did not reveal any new infarction, and the patient was discharged with neurologic improvement over time. At 1 year, he was able to ambulate unassisted and had a modified Rankin Scale score of 3. CONCLUSION: Development of a TICA may be more acute than literature previously suggested. Treatment consists of a wide range of options and should be considered, especially in the pediatric population, to prevent rupture. Trapping can be performed safely if adequate collateral flow is present in the setting of a large basilar artery aneurysm.

Recurrent hemorrhage in hemangioblastoma involving the posterior fossa: Case report.

BACKGROUND: Hemangioblastomas (HGBs) are the most common primary intra-axial posterior fossa tumor in adults. Although spontaneous hemorrhage of these tumors is exceedingly rare, despite their vascular nature, we describe a case of recurrent hemorrhage with associated tonsillar herniation, and demonstrate that a surgical approach can provide a suitable outcome. CASE DESCRIPTION: A 54-year-old female with von Hippel-Lindau (VHL) syndrome presented with acute loss of consciousness and Glasgow Coma Scale (GCS) was 4. Computed tomographic (CT) images demonstrated large volume subarachnoid hemorrhage of the posterior fossa with intraventricular extension and intraparenchymal hemorrhage involving the right cerebellar tonsil. Magnetic resonance imaging (MRI) displayed three lesions in the posterior fossa, two near the hemorrhage site. Patient underwent suboccipital craniectomy with a decent recovery followed by radiosurgery as she refused resection. A second hemorrhage occurred ultimately prompting surgical resection of the three posterior fossa lesions, with a reasonable postoperative course. CONCLUSION: Hemorrhage of HGBs of the posterior fossa can present in conjunction of tonsillar herniation. Re-hemorrhage appears to be likely if prior acute hemorrhage has occurred. A stepwise approach of surgical decompression and resection may provide the best outcome.

The Role of Catheter Angiography in the Diagnosis of Central Nervous System Vasculitis.

BACKGROUND: Central nervous system vasculitis (CNSV) is a rare disorder, the pathophysiology of which is not fully understood. It involves a combination of inflammation and thrombosis. CNSV is most commonly associated with headache, gradual changes in mental status, and focal neurological symptoms. Diagnosis requires the effective use of history, laboratory testing, imaging, and biopsy. Catheter angiography can be a powerful tool in the diagnosis when common and low-frequency angiographic manifestations of CNSV are considered. We review these manifestations and their place in the diagnostic algorithm of CNSV. SUMMARY: We reviewed the PubMed database for case series of CNSV that included 5 or more patients. Demographic and angiographic findings were collected. Angiographic findings were dichotomized between common and low-frequency findings. A system for incorporating these findings into clinical decision-making is proposed. KEY MESSAGE: CNSV is a diagnostic challenge due to the absence of a true gold standard test. In the absence of such a test, catheter angiography remains a central piece of the diagnostic puzzle when appropriately employed and interpreted.

Proposed clinical internal carotid artery classification system.

INTRODUCTION: Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. MATERIALS AND METHODS: We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. RESULTS: The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%]; P < 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%]; P < 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%]; P < 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%; P < 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%]; P < 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. CONCLUSIONS: The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.

Multifocal melanocytoma of the posterior fossa and subcutaneous scalp in the absence of neurocutaneous melanosis.

BACKGROUND: Primary leptomeningeal melanocytic neoplasms of the central nervous system are rare. Multifocal lesions typically occur in the setting of cutaneous melanosis. We present the first report of a posterior fossa melanocytoma and subcutaneous melanocytoma of intermediate grade in the absence of cutaneous melanosis. CASE DESCRIPTION: We present the case of a 22-year-old male with decreased hearing on the right side, ataxia, nausea, vomiting and a scalp mass. Magnetic resonance imaging (MRI) demonstrated occipital and cerebellopontine (CP) angle masses. The patient underwent gross total resection of the scalp mass and subtotal resection of the CP angle mass. Pathologic examination revealed melanocytoma with intermediate grade. The patient underwent stereotactic radiosurgery to the residual CP angle tumor. This case represents, to the author's knowledge, the first report associating a posterior fossa melanocytoma with a subcutaneous melanocytoma of intermediate grade in the absence of cutaneous melanosis. CONCLUSION: This case introduces the first report of a new variant of multifocal melanocytoma which is not confined to the central nervous system.

Subcutaneous melanocytoma mimicking a lipoma: a rare presentation of a rare neoplasm with histological, immunohistochemical, cytogenetic and molecular characterization.

Melanocytoma are the melanocytic tumors originating from leptomeningeal melanocytes. Melanocytomas are commonly seen in the central nervous system (CNS) and are often associated with neurocutaneous melanosis (NCM). However, simultaneous presentation of intra-axial and extracranial melanocytoma is a very rare event. Here, we report a unique case of 21-year-old male with intermediate-grade subcutaneous (SC) melanocytoma, mimicking lipoma, occurred synchronously with an intracranial melanocytoma, not associated with NCM. A 21-year-old Caucasian male presented to the emergency department (ED) with severe vertigo and vomiting. A magnetic resonance imaging (MRI) of the brain was performed at the ED, which revealed an SC mass in the right occipital scalp and a right cerebellopontine angle (CPA) mass. Excision of the SC mass revealed a well-circumscribed highly pigmented melanocytic tumor. The SC mass tumor cells were positive for melanocytic lineage markers. The histopathological features were between benign melanocytomas and malignant melanomas. The Ki67 and PHH3 IHCs confirm the intermediate grade of the tumors. An array-CGH (comparative genome hybridization) and next-generation sequencing analysis of the tumor DNA extracted from the formalin-fixed paraffin-embedded tissue reveals chromosome 6p gain and p.Q209P mutation in the GNAQ gene, respectively, consistent with the diagnosis of intermediate-grade melanocytoma.

Analysis of Decompressive Craniectomies with Subsequent Cranioplasties in the Presence of Collagen Matrix Dural Substitute and Polytetrafluoroethylene as an Adhesion Preventative Material.

OBJECTIVE: Decompressive craniectomy is an established treatment for malignant intracranial hypertension. Cranioplasty is performed once cerebral swelling has resolved. Complications include infection, postoperative fluid collections, hematoma, reoperation, and seizures. Our experience using a double layer technique during craniectomy with a collagen matrix onlay dural substitute and expanded polytetrafluoroethylene for antiadhesive properties during cranioplasty was reviewed. METHODS: This is a retrospective chart review of 39 consecutive patients who underwent craniectomy with placement of collagen matrix dural onlay and expanded polytetrafluoroethylene and subsequent cranioplasty. Demographic data, size of craniectomy defect, estimated blood loss, operative time, time between operations, presence of dural tackups, and postoperative complications were analyzed. RESULTS: Mean operative time was 132 minutes and estimated blood loss was 112 mL. Overall complication rate was 25.6% and no mortality was encountered. Nine patients had postoperative fluid collections measuring ≥ 10 mm in thickness and/or 5 mm of midline shift. Two patients required reoperation for these collections. Two patients developed infections requiring bone flap removal. Three patients developed seizures after cranioplasty. Five patients required shunt placement for hydrocephalus. CONCLUSIONS: Our dual layer closure technique at time of decompressive craniectomy carries a similar reduction in operative time and estimated blood loss when compared with cranioplasty series with other antiadhesives present. The technique described enables easy dissection of the musculocutaneous flap from the dural plane during cranioplasty and increases the safety of the operation.

Endocrinological outcome after pituitary transposition (hypophysopexy) and adjuvant radiotherapy for tumors involving the cavernous sinus.

OBJECT: Stereotactic radiosurgery and fractionated stereotactic radiotherapy are commonly used in the treatment of residual or recurrent benign tumors of the skull base and cavernous sinus. A major risk associated with radiosurgical or radiotherapy treatment of residual or recurrent tumors adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors have used a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual tumor within the cavernous sinus. Here, the authors analyze the long-term endocrinological outcomes in patients with residual and recurrent tumors who undergo hypophysopexy and adjuvant radiosurgical or conformal fractionated radiotherapy treatment. METHODS: Pituitary transposition involves placement of a fat graft between the normal pituitary gland and residual tumor in the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and the graft is interposed between the pituitary gland and the residual tumor. The residual tumor may then be treated with stereotactic radiosurgery or conformal fractionated radiation therapy. The authors evaluated endocrinological outcome, safety of the procedure, and postoperative complications in patients who underwent this procedure during a 7-year period. RESULTS: Hypophysopexy has been used in 34 patients with nonfunctioning pituitary adenomas (19), functional pituitary adenomas (8), chordomas (2), meningiomas (2), chondrosarcoma (1), hemangiopericytoma (1), or hemangioma (1) involving the sella and cavernous sinus. Follow-up (radiographic and endocrinological) has been performed yearly in all patients. Two patients experienced postoperative endocrine deficits before radiosurgery (1 transient), but none of the patients developed new hypopituitarism during the median 4-year follow-up (range 1-8 years) after radiosurgery or fractionated stereotactic radiotherapy. CONCLUSIONS: The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery or radiotherapy and effectively reduces the incidence of radiation injury to the normal pituitary gland when compared with historical controls.