Cranio-Orbital and Orbitocranial Approaches to Orbital and Intracranial Disease: Eye-Opening Approaches for Neurosurgeons.

Orbital approaches for targeting intracranial, orbital, and infratemporal disease have evolved over the years in an effort to discover safe, reliable, effective, and cosmetically satisfying surgical corridors. The surgical goals of these approaches balance important factors such as proximity of the lesion to the optic nerve, the degree of anticipated manipulation and required space for surgical maneuverability, and the type of disease. The authors provide a comprehensive review of the most commonly used periorbital approaches in the management of intra- and extracranial disease, with emphasis on the advantages and limitations of each approach.

Malignant carotid body tumor presenting with myelopathy: case report.

Malignant carotid body tumors are rare, with spread of the tumor mostly noted in regional lymph nodes. Vertebral metastases are an exceedingly rare presentation, only reported in isolated case reports, and present a diagnostic and management challenge. A case of widespread vertebral metastasis, presenting with myelopathy, from a carotid body tumor is discussed in this paper, along with management strategies.

Malignant fungal infection of the cavernous sinus: case report.

Intracranial spread of fungal infection is a life-threatening condition that usually affects immunocompromised patients. Here the authors present a case of biopsy-proven Aspergillus fumigatus infection of the paranasal sinuses in an immunocompetent patient with documented spread to the orbit, cavernous sinus, and petrous apex despite medical antifungal treatment. As a life-saving treatment, cavernous sinus resection with external carotid artery-middle cerebral artery bypass was performed. The authors discuss the literature regarding the intracranial spread of paranasal sinus fungal infections in immunocompetent patients and management strategies.

Rescue microsurgery with bypass and stent removal following Pipeline treatment of a giant internal carotid artery terminus aneurysm.

We report the microsurgical rescue and removal of a Pipeline stent embolization of a giant internal carotid artery terminus aneurysm. After the initial placement of a Pipeline Embolization Device (PED), it migrated proximally to the cavernous carotid with the distal end free in the middle of the aneurysm, resulting in only partial aneurysm neck coverage. The patient underwent microsurgical rescue with trapping, bypass, and opening of the aneurysm with PED removal. The vessel remained patent in the proximal segment previously covered by the Pipeline stent. Microsurgical rescue for definitive aneurysm treatment with PED removal can be safe and effective for aneurysms unsuccessfully treated with PED.

Surgical management of traumatic frontal sinus fractures: Case series from a single institution and literature review.

BACKGROUND: Neurosurgeons are frequently involved in the management of patients with traumatic frontal sinus injury; however, management options and operative techniques can vary significantly. In this study, the authors review the current literature and retrospectively review the clinical series at a single tertiary referral center. METHODS: After Institutional Review Board approval, the medical records and computed tomographic (CT) imaging of patients whose traumatic frontal sinus fractures were treated surgically at the University of Utah were retrospectively reviewed. Demographic information, mechanism of injury, associated injuries, operative technique, and pattern of injury on CT were analyzed. RESULTS: Between 2000 and 2012, 33 patients underwent successful cranialization of the frontal sinus following traumatic injury. The material used to obliterate the sinus varied. No patients required immediate or delayed reoperation. Nasofrontal outflow tract obstruction, the importance of which has been emphasized in the plastic surgery literature, was apparent on either initial or retrospective review of the available CT imaging in 96%. CONCLUSIONS: In this series, we successfully surgically treated 33 patients with frontal sinus fractures. The presence of cerebrospinal fluid leak, nasofrontal outflow tract injury, associated depressed skull fractures, and subsequent formation of communicating pathways and infection must be considered when constructing a treatment plan. The goals of treatment should be: (i) surgical repair of the defect and elimination of the conduit from the intracranial space to the outside and (ii) elimination of any cerebrospinal fluid pressure gradient that may develop across the surgical repair. We present a treatment algorithm focusing on the presence of nasofrontal outflow tract injury/obstruction, cosmetic deformity, and cerebrospinal fluid leak.

The genetic basis of intradural spinal tumors and its impact on clinical treatment.

Genetic alterations in the cells of intradural spinal tumors can have a significant impact on the treatment options, counseling, and prognosis for patients. Although surgery is the primary therapy for most intradural tumors, radiochemothera-peutic modalities and targeted interventions play an ever-evolving role in treating aggressive cancers and in addressing cancer recurrence in long-term survivors. Recent studies have helped delineate specific genetic and molecular differences between intradural spinal tumors and their intracranial counterparts and have also identified significant variation in therapeutic effects on these tumors. This review discusses the genetic and molecular alterations in the most common intradural spinal tumors in both adult and pediatrie patients, including nerve sheath tumors (that is, neurofibroma and schwannoma), meningioma, ependymoma, astrocytoma (that is, low-grade glioma, anaplastic astrocytoma, and glioblastoma), hemangioblastoma, and medulloblastoma. It also examines the genetics of metastatic tumors to the spinal cord, arising either from the CNS or from systemic sources. Importantly, the impact of this knowledge on therapeutic options and its application to clinical practice are discussed.

Retrograde cysto-myelogram: Case Report.

BACKGROUND: In the scenario of blunt trauma with suspected bladder injury, conventional retrograde cystography is the gold standard for accurate diagnosis. CASE DESCRIPTION: The authors report the case of a 54-year-old patient who presented with pelvic and sacral fractures and a ruptured bladder after being hit by a vehicle. A retrograde computed tomography cystogram demonstrated extraperitoneal extravasation of the contrast agent, which traversed violated sacral nerve roots, resulting in contrast entering the subarachnoid space at the left sacral ala predominantly through the left L5 and S1 nerve roots. CONCLUSIONS: This is the first known report of an accidental myelogram imaging performed through a retrograde cystogram.

Motion-related vascular abnormalities at the craniocervical junction: illustrative case series and literature review.

The craniocervical junction (CCJ) functions within a complicated regional anatomy necessary to protect and support vital neurovascular structures. In select instances, vascular pathology can be attributed to this complicated interplay of motion and structure found within this narrow space. The authors report 3 cases of complex vascular pathology related to motion at the CCJ and detail the management of these cases. Two cases involved posterior circulation vascular compression syndromes, and one case involved a vascular anomaly and its relation to aneurysm formation and rupture. The patient in Case 1 was a 66-year-old man with a history of syncopal episodes resulting from the bilateral vertebral artery becoming occluded when he rotated his head. Successful microsurgical decompression at the skull base resulted in patent bilateral vertebral artery V3 segments upon head movement in all directions. The patient in Case 2 was a 53-year-old woman who underwent elective resection of a right temporal meningioma and who experienced postoperative drowsiness, dysphagia, and mild right-arm ataxia. Subsequent MRI demonstrated bilateral posterior inferior cerebel-lar artery (PICA) strokes. Cerebral angiography showed a single PICA, of extradural origin, supplying both cerebellar hemispheres. The PICA exhibited dynamic extradural compression when the patient rotated her head; the bilateral PICA strokes were due to head rotation during surgical positioning. In Case 3, a 37-year-old woman found unconscious in her home had diffuse subarachnoid hemorrhage and evidence of a right PICA aneurysm. A right far-lateral craniectomy was performed for aneurysm clipping, and she was found to have a dissecting aneurysm with an associated PICA originating extradurally. There was a shearing phenomenon of the extradural PICA along the dura of the foramen magnum, and this microtraumatic stress imposed on the vessel resulted in a dissecting aneurysm. This series of complex and unusual cases highlights the authors' understanding of vascular pathology of the CCJ and its management.

Surgical management of a transosseous meningioma with invasion of torcula, superior sagittal sinus, transverse sinus, calvaria, and scalp.

BACKGROUND: Meningiomas involving both intradural and extradural structures are rare tumors. We report the complete resection of a massive complex transosseous meningioma that had invaded the torcula, superior sagittal sinus, occipital bone, and scalp. CASE DESCRIPTION: A 48-year-old male presented after 3 days of worsening headaches and blurry vision. Preoperative imaging demonstrated an 11 × 5-cm extra-axial mass that avidly enhanced with gadolinium in the region of the torcula. Angiography demonstrated occlusion of the involved portions of the superior sagittal sinus, torcula, and proximal left transverse sinus. Cortical drainage occurred via the veins of Labbι and deep drainage via an occipital sinus. Using image-guided stereotaxy, a wide-excision scalp resection and craniectomy with sinus exploration was planned for complete tumor removal. Parasitized cortical veins were preserved. Occluded portions of the superior sagittal sinus and left transverse sinus were resected along with the invaded parts of the falx and tentorium. The walls of the straight sinus, torcula, and right transverse sinus were repaired primarily to facilitate deep drainage. A latissimus dorsi free flap was used to reconstruct the scalp defect. Routine follow-up magnetic resonance imaging (MRI) at 18 months demonstrated no evidence of recurrence or regrowth. CONCLUSIONS: This case illustrates the importance of identifying aberrant venous drainage pathways when considering ligation and resection of major sinuses and discusses the management of calvarial and scalp invasion.

A practical review of prognostic correlations of molecular biomarkers in glioblastoma.

Despite extensive efforts in research and therapeutics, achieving longer survival for patients with glioblastoma (GBM) remains a formidable challenge. Furthermore, because of rapid advances in the scientific understanding of GBM, communication with patients regarding the explanations and implications of genetic and molecular markers can be difficult. Understanding the important biomarkers that play a role in GBM pathogenesis may also help clinicians in educating patients about prognosis, potential clinical trials, and monitoring response to treatments. This article aims to provide an up-to-date review that can be discussed with patients regarding common molecular markers, namely O-6-methylguanine-DNA methyltransferase (MGMT), isocitrate dehydrogenase 1 and 2 (IDH1/2), p53, epidermal growth factor receptor (EGFR), platelet-derived growth factor receptor (PDGFR), phosphatase and tensin homolog (PTEN), phosphoinositide 3-kinase (PI3K), and 1p/19q. The importance of the distinction between a prognostic and a predictive biomarker as well as clinical trials regarding these markers and their relevance to clinical practice are discussed.

Far-lateral approach for surgical treatment of fusiform PICA aneurysm.

Ruptured fusiform posterior inferior cerebellar artery (PICA) aneurysms can be technically challenging lesions. Surgeons must be ready to employ a variety of strategies in the successful treatment of these aneurysms. Strategies include complex clip techniques including clip-wrapping or trapping and revascularization. The case presented here is of a man with subarachnoid hemorrhage from a fusiform ruptured PICA aneurysm. The technique demonstrated is a far-lateral approach and a clip-wrap technique using muslin gauze. The patient was given aspirin preoperatively in preparation for possible occipital-PICA bypass if direct repair was not feasible. It is the authors' preference to perform direct vessel repair as a primary goal and use bypass techniques when this is not possible. Vessel patency was evaluated after clip-wrapping using intraoperative Doppler. Intraoperative somatosensory and motor evoked potential monitoring is used in such cases. The patient recovered well. The video can be found here: http://youtu.be/iwLqufH47Ds .

Hemorrhagic ganglioglioma of the posterior fossa: case report.

Gangliogliomas are rare tumors of the central nervous system that are usually found in the supratentorial compartment, although cases throughout the nervous system have been described. They are generally low-grade malignancies that are amenable to cure by surgical resection. Most manifest as seizures, though, based on location, they can present with focal neurological deficits. We present here a rare case of an infratentorial ganglioglioma presenting with hemorrhage. To our knowledge this is the only reported case of a hemorrhagic ganglioglioma and, as such, we examine its possible prognosis.