Factors Influencing Long-Term Outcomes of Single-Session Gamma Knife Radiosurgery in Large-Volume Meningiomas >10 cc.

INTRODUCTION: Meningiomas are the most common primary intracranial tumour. Gamma knife radiosurgery (GKRS) is a frequently employed non-invasive method of treatment, with good remission rates and low morbidity in literature. However, the role of GKRS in the management of "large" meningiomas is unclear, with reported outcomes that vary by centre. We aimed to assess the factors that influence long-term outcomes following GKRS in meningiomas >10 cc in volume. METHODS: A retrospectively analysed all patients with meningiomas exceeding 10 cc in volume who underwent GKRS between January 2006 and December 2021 at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Demographic, clinical, radiological, and follow-up data were acquired, and factors associated with progression following GKRS were assessed. RESULTS: The cohort comprised 76 patients 29 males (38.2%) and 47 females (61.8%) with a mean age of 46.3 ± 11.02 years. Thirty-nine patients had been previously operated (51.3%). Meningiomas were most frequently located in the parasagittal region (26 tumours, 34.2%) and sphenopetroclival region (23 tumours, 30.3%), with mean lesion volume of 12.55 ± 5.22 cc, ranging 10.3 cc-25 cc. The mean dose administered to the tumour margin was 12.5 Gy ± 1.2 Gy (range 6-15 Gy). The median duration of clinical follow-up was 48 months, over which period radiological progression occurred in 14 cases (20%), with unchanged tumour volume in 20 cases (28.6%) and reduction in size of the tumour in 36 cases (51.4%). Progression-free survival after GKRS was 72% at 5 years, was significantly poorer among meningiomas with tumour volume >14 cc (log-rank test p = 0.045), tumours presenting with limb motor deficits (log-rank test p = 0.012), and tumours that underwent prior Simpson grade 3 or 4 excision (log-rank test p = 0.032). CONCLUSIONS: Meningiomas >10 cc in volume appear to display a high rate of progression and subsequent need for surgery following GKRS. Primary surgical resection, when not contraindicated, may be considered with GKRS serving an adjuvant role, especially in tumours exceeding 14 cc in volume, and presenting with limb motor deficits. Long-term clinical and radiological follow-up is essential following GKRS as the response of large meningiomas may be unpredictable.

Surgical outcomes of trigonal intraventricular meningiomas: a single-centre study.

Trigonal meningiomas are rare intraventricular tumours that present a surgical challenge. There is no consensus on the optimal surgical approach to these lesions, though the transtemporal and transparietal approaches are most frequently employed. We aimed to examine the approach-related morbidity and surgical nuances in treating trigonal meningiomas. This retrospective review assimilated data from 64 trigonal meningiomas operated over 15 years. Details of clinicoradiological presentation, surgical approach and intraoperative impression, pathology and incidence of various postoperative deficits were recorded. In our study, Trigonal meningiomas most frequently presented with headache and visual deterioration. The median volume of tumours was 63.6cc. Thirty-one meningiomas each (48.4%) were WHO Grade 1 and WHO Grade 2, while 2 were WHO Grade 3. The most frequent approach employed was transtemporal (38 patients, 59.4%), followed by transparietal (22 patients, 34.4%). After surgery features of raised ICP and altered mental status resolved in all patients, while contralateral limb weakness resolved in 80%, aphasia in 60%, seizures in 70%, and vision loss in 46.2%. Eighteen patients (28.13%) developed transient postoperative neurological deficits, with one patient (1.5%) developing permanent morbidity. Surgery for IVMs results in rapid improvement of neurological status, though visual outcomes are poorer in patients with low vision prior to surgery, longer duration of complaints and optic atrophy. The new postoperative deficits in some patients tend to improve on follow up. Transtemporal and transparietal approaches may be employed, based on multiple factors like tumour extension, loculation of temporal horn, size of lesion with no significant difference in their safety profile.

Xanthogranulomatous Colloid Cyst in a 13-Year-Old Boy: A Case Report and Surgical Implications.

INTRODUCTION: Colloid cysts are relatively uncommon lesions in the pediatric population. The xanthogranulomatous (XG) variant is very rare with less than 30 reported cases. CASE REPORT: In this report, the patient was a 13-year-old boy who presented with transient episodes of headache with blurring of vision. His MRI brain showed a T2 hyperintense well-defined cystic lesion, with an eccentrically located T2 hypointense partially enhancing nodule, at the foramen of Monro. He underwent middle frontal gyrus transcortical, transchoroidal gross total excision of the cyst. The histopathology of the lesion revealed an XG colloid cyst. The patient recovered well from the procedure and was relieved of the symptoms. CONCLUSION: XG colloid cyst may present with altered radiological features compared to the normal variant. This can pose a diagnostic dilemma, and it is important to differentiate it from a craniopharyngioma or a parasitic cyst, as in our case. When considered preoperatively, surgeons should be conscious to review their surgical strategies. Stereotactic aspiration of the XG cyst should be avoided as contents are thicker and heterogeneous than the usual. The spillage of cyst contents should be prevented. Also, the XG cysts are likely to have a poor cyst-fornix or -choroid plexus interface due to inflammation limiting complete resection.

Management of a Persistent Oblique Occipital Sinus with Staged Ligation in a Case of Medulloblastoma: A Case Report.

INTRODUCTION: A patent persistent occipital sinus (OS) can be seen in 10% of adults. The presence of such a dominant draining OS can present as a challenge for posterior fossa surgeries. Occlusion or division of the sinus can cause venous hypertension, causing a cerebellar bulge or increased intra-op bleeding. CASE REPORT: A 3-and-a-half-year-old female child presented with a vermian medulloblastoma with hydrocephalus. MR venography (MRV) revealed a large patent OS draining from the torcula to the right sigmoid sinus. She underwent a left Frazier's point VP shunt followed by a midline suboccipital craniotomy for the lesion. The OS was divided during a "Y"-shaped durotomy. Following the sinus ligation, there was a significant cerebellar bulge and excessive bleeding from the lesion. We released cisternal CSF and punctured the tumor cysts to allow the brain bulge to settle. Hemostasis was secured, and surgery was deferred, an augmented duroplasty was done, and bone flap was removed to allow for intracranial pressure decompression. The patient was electively ventilated for 24 h and weaned off gradually. A repeat MRV at 7 days showed the reorganization of the venous outflow at the torcula. Reexploration with tumor resection was done on post-op day 10. The patient recovered well from the surgery and was referred for adjuvant therapy. CONCLUSION: Surgeons should carefully analyze venous anatomy before posterior fossa surgeries. The persistent dominant OS, when present, should be taken care of while planning the durotomy. A hypoplastic but persistent transverse sinus allowed us to ligate and divide the OS. By doing a staged division of the sinus, reorganization of the venous outflow from the torcula can be allowed to occur, and the lesion can be resected.

Conventional and Advanced Magnetic Resonance Imaging Features of Supratentorial Extraventricular Ependymomas.

OBJECTIVE: To describe the magnetic resonance imaging characteristics of supratentorial ependymomas. METHODS: The magnetic resonance imaging and computed tomography imaging characteristics of 49 cases of supratentorial ependymomas were analyzed retrospectively. The location, size, degree of perilesional edema, gross appearance, computed tomography attenuation characteristics, T1 and T2 signal intensity characteristics, degree of diffusion restriction, presence of calcification, and hemorrhage were documented for each lesion. The intratumoral susceptibility scores (ITSS), apparent diffusion coefficient (ADC) values, relative cerebral blood volume, and choline/N-acetyl aspartate ratios were documented where available. RESULTS: The frontal lobe was the most common location with a mean size of 6.37 × 4.8 cm. Severe perilesional edema was evident in 30%. Heterogenous, solid-cystic appearance was present in 96% lesions, with 95% of extraventricular lesions extending from pial surface to the ventricular margin. Calcification was seen in 55% of cases. The ITSS was 3 in 85.7% of lesions. The mean ADC value calculated was 600 × 10 mm/s. The mean relative cerebral blood volume on dynamic susceptibility contrast perfusion was 4.83. The mean choline/N-acetyl aspartate ratio was 5.87. Leptomeningeal dissemination was demonstrable in 5 lesions. Four lesions were abutting the dura with frank dural invasion in one. One patient presented with disseminated disease without evidence of a primary lesion. CONCLUSIONS: A large lesion with relatively well-defined margins, heterogeneous solid cystic appearance, extending from the pial surface to the ventricular margin, presence of calcification, and ADC values approaching those of white matter should raise a suspicion of supratentorial ependymoma. High ITSS, MR perfusion parameters, and magnetic resonance spectroscopy characteristics are similar to those of other high-grade gliomas.

Pediatric cerebral proliferative angiopathy presenting infratentorial hemorrhage.

Cerebral proliferative angiopathies (CPAs) are distinct vascular malformations with varied clinical presentations and radiological findings from arteriovenous malformations (AVM) (Lasjaunias et al. in Stroke 39(3):878-85, 2008). They usually manifest with seizures if present supratentorial, headache, and progressive neurological deficits due to steal phenomenon or rarely with hemorrhage (Lasjaunias et al. in Stroke 39(3):878-85, 2008). Most of the patients are usually young females. Pediatric cases are extremely rare, with few cases reported till now. Here we report a child who presented with cerebellar bleed and diagnosed as CPA. The child was managed medically, and there was no change in caliber of the vessels after 18 months of follow-up. A short review of cases of CPA in pediatric age group presentations and management was undertaken in this case report.

Multiple-site neural tube defects: embryogenesis with complete review of existing literature.

OBJECTIVE: Multiple-site neural tube defects (MNTDs) are very uncommon, with the predominant number of cases being reported in developing countries. The classic theory of neural tube closure fails to explain the occurrence of these defects. Multisite closure theory, first proposed in 1995, explains most of the occurrences with a few modifications specific to a few defects. In this paper, the authors endeavor to explain all the defects, along with their genetic and embryological bases, and to review the available literature and discuss their own experience in the management of these complex cases. METHODS: The authors retrospectively reviewed the data of all the patients treated surgically for MNTDs over that past 14 years. All possible demographic data, clinical details, and radiological imaging data were reviewed. In addition, surgical parameters, complications, and status at follow-up of more than 12 months were evaluated. All previously reported cases of MNTD were analyzed, and comparisons with the present series were made. RESULTS: A total of 3 major series (including the present one) on MNTDs have been from India. A total of 57 such cases (including those of the present series) have been reported in the available literature. While previous series reported a higher incidence of spinal defects, the present series had a higher rate of cephalic defects (55%). Among the reported cases, insertion of a ventriculoperitoneal shunt was necessary in 12 (26%), and only 4 patients were operated on in 2 stages. Neurological status at presentation dictated outcome. CONCLUSIONS: MNTDs are extremely rare, and their embryogenesis is different from that of single neural tube defects. Simultaneous repair of 2 or even 3 defects is possible in a single-stage surgery. The requirement of a shunt is uncommon, and complications following surgery are rare. Folic acid supplementation may reduce the incidence of defects.

"Tailored" far lateral approach to anterior foramen magnum meningiomas - The importance of condylar preservation.

INTRODUCTION: Anterior and anterolaterally situated foramen magnum meningiomas are a technically complex subgroup of meningiomas. The need for an extensive exposure and bone work and their complex anatomy make them a difficult and challenging group of tumors to resect. The bone work has ranged from an extensive condylar resection to condylar preserving exposures. In this paper, we present our experience with condylar preserving or minimal condylar resection based approaches to these tumors. MATERIALS AND METHODS: All patients who underwent surgical resection of anterior and anterolaterally situated foramen magnum meningiomas were included in the analysis. The study period was more than 10 years from 2005 to 2015 at our institute; a tertiary referral centre in India. The records along with demographic profile, clinico-radiological features, surgical strategies, outcomes as well as mortality and morbidity were analysed. RESULTS: There were a total of 20 patients (9 males and 11 females) who were operated during the study period. The average age was 36.7 years. In 16 patients, gross-total or near-total resection could be achieved, four patients underwent subtotal resection. Eight patients had fresh morbidity in the form of new motor deficits, pseudomeningocele formation, worsening of the lower cranial nerve functions or post-operative adhesions leading to syrinx formation. The follow-up ranged from 6 months to 140 months. CONCLUSION: Foramen magnum meningiomas are an eminently treatable group of tumors. Condylar preservation provides a good visualization, while helping to preserve joint stability and in avoiding instrumental stabilization.

Differentiation of grade II/III and grade IV glioma by combining "T1 contrast-enhanced brain perfusion imaging" and susceptibility-weighted quantitative imaging.

PURPOSE: MRI is a useful method for discriminating low- and high-grade glioma using perfusion MRI and susceptibility-weighted imaging (SWI). The purpose of this study is to evaluate the usefulness of T1-perfusion MRI and SWI in discriminating among grade II, III, and IV gliomas. METHODS: T1-perfusion MRI was used to measure relative cerebral blood volume (rCBV) in 129 patients with glioma (70 grade IV, 33 grade III, and 26 grade II tumors). SWI was also used to measure the intratumoral susceptibility signal intensity (ITSS) scores for each tumor in these patients. rCBV and ITSS values were compared to seek differences between grade II vs. grade III, grade III vs. grade IV, and grade III+II vs. grade IV tumors. RESULTS: Significant differences in rCBV values of the three grades of the tumors were noted and pairwise comparisons showed significantly higher rCBV values in grade IV tumors as compared to grade III tumors, and similarly increased rCBV was seen in the grade III tumors as compared to grade II tumors (p < 0.001). Grade IV gliomas showed significantly higher ITSS scores on SWI as compared to grade III tumors (p < 0.001) whereas insignificant difference was seen on comparing ITSS scores of grade III with grade II tumors. Combining the rCBV and ITSS resulted in significant improvement in the discrimination of grade III from grade IV tumors. CONCLUSION: The combination of rCBV values derived from T1-perfusion MRI and SWI derived ITSS scores improves the diagnostic accuracy for discrimination of grade III from grade IV gliomas.

Role of Dynamic Contrast-Enhanced Perfusion Magnetic Resonance Imaging in Grading of Pediatric Brain Tumors on 3T.

BACKGROUND/AIMS: Perfusion magnetic resonance imaging (MRI) is useful for preoperative assessment of brain tumors. Dynamic susceptibility contrast perfusion MRI is commonly used for evaluation of brain tumors. Dynamic contrast-enhanced (DCE) MRI is an alternative method that has mainly been used in adult brain tumors. In this preliminary study, we report our initial experience with the DCE perfusion MRI in pediatric brain tumors. METHODS: Sixty-four newly diagnosed pediatric brain tumor patients underwent DCE perfusion MRI on a 3-T scanner. Hemodynamic and kinetic parametric maps were generated and the regions with the highest values were measured on each map. Statistical differences were sought to differentiate between low-grade tumors, high-grade tumors, and medulloblastomas. The perfusion metrics of common posterior fossa tumors were also compared. RESULTS: Relative corrected cerebral blood volume (rCBV) and fractional plasma volume measures differed significantly between high- and low-grade tumors (p < 0.05). High-grade tumors could be differentiated from low-grade tumors, with an rCBV cutoff value of 2.41 and 88.6% sensitivity and 65% specificity. There was no significant difference in Ktrans, Kep, Ve, or λtr between these 2 groups of tumors. rCBV, relative quantification of the cerebral blood flow, and permeability indices were found to be significantly different in various posterior fossa tumors, i.e., pilocytic astrocytoma, ependymoma, and medulloblastoma (p < 0.05). CONCLUSION: DCE-derived perfusion metrics are useful in differentiating high-grade tumors from low-grade ones and discriminating among various posterior fossa tumors in the pediatric age group.

Management of Perforator Plunge in the Transverse Sinus.

Plunging is rare with the use of automatic-release perforators. We describe the management of a case of plunging in the transverse sinus in a child who underwent suboccipital craniotomy. The perforator got stuck in the bone and transverse sinus. The perforator-bone complex was removed in one piece with suturing of the transverse sinus.

Surgical management of petroclival meningiomas: Factors affecting early post-operative outcome.

INTRODUCTION: Petroclival meningiomas pose a major challenge to the treating neurosurgeon. The philosophy of treatment has changed over the decades from a nihilistic attitude to that of aggressive total excision to now a more tempered, maximal safe excision preventing morbidity followed by adjuvant treatment. Despite the advances in neurosurgery, surgical management of these tumours is still associated with sizable morbidity and mortality. MATERIAL AND METHODS: This is a retrospective study of surgically managed petroclival meningiomas at our institute. Clinical status, radiological features and surgical outcome were analysed. RESULTS: Between January 2003 and August 2013, we have operated on 30 patients. The most common presenting complaints were varying degrees of cranial nerve involvement and cerebellar dysfunction. Surgery was done using one of the skull base approaches with the retrosigmoid approach being used maximally (22 cases). Total or near-total excision was possible in 11 cases. There was a post-operative deterioration in cranial nerve functions in all patients and deterioration in Karnofsky Performance Score in seven patients at discharge. Three improved to independent status on follow-up. There was mortality in two cases. Overall 23 of the 30 patients (76.6%) had favourable outcomes. CONCLUSIONS: These are challenging tumours to treat and are associated with sizable morbidity and mortality. On statistical analysis, we found that if the tumour has a size of 3-5 cm and petroclival in location with no sphenoid extension and the lesion is homogenous on T2-weighted images, then there was a trend towards gross total resection and favourable outcome.

Surgical Outcome of Torcula Herophili Meningioma: An Institutional Experience.

INTRODUCTION: Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation. METHODS: We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence. RESULTS: A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases. CONCLUSIONS: Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection.

Role of Optical Coherence Tomography in Predicting Visual Outcome after Surgery for Sellar and Supra-Sellar Tumors.

BACKGROUND: Almost one-fifth of patients undergoing surgery for sellar/supra-sellar tumors do not gain a significant improvement in their vision. Various methods have been described to predict prospective visual outcomes in them, although they lack uniformity. OBJECTIVE: The study was conducted to predict visual outcomes following surgery for sellar and supra-sellar tumors compressing the anterior optic pathway based on pre-operative optical coherence tomography (OCT) parameters. METHODS AND MATERIALS: This was a record-based observational descriptive longitudinal study done in a tertiary care center in India. Thirty-seven patients (74 eyes) diagnosed with sellar supra-sellar lesions were included in the study. Patients' ophthalmic evaluations, done pre-operatively and 3 months post-operatively, were reviewed. Spectral-domain OCT and segmentation were done using the automated segmentation technology of Spectralis software. The thickness of the respective layers was measured. RESULTS AND CONCLUSIONS: The mean age of the study population was 42.68 years. Eyes with a pre-operative visual acuity component of VIS (visual impairment score) ≤61, pre-operative ganglion cell layer thickness ≥26.31 um, a pre-operative inner plexiform layer thickness of ≥25.69 um, a pre-operative ganglion cell inner plexiform layer thickness of 52.00 um, pre-operative ganglion cell complex thickness ≥84.47 µm, and a pre-operative inner retinal layer thickness of ≥205.25 µm were more likely to have an improved visual outcome. Eyes with a pre-operative duration of visual symptoms of ≥15 months, VIS ≥126.50, a pre-operative decimal visual acuity of <0.035, a pre-operative visual field index of ≤8%, a pre-operative macular thickness of ≤287.06 um, a pre-operative macular RNFL (retinal nerve fiber layer) thickness ≤66.00 µm, and a pre-operative peri-papillary RNFL thickness ≤64.62 µm were unlikely to have visual improvement.

Usefulness of Opening the Diaphragma Sellae Before Transecting Interclinoidal Ligament for Endoscopic Endonasal Transoculomotor Triangle Approach: Technical Nuances and Surgical Outcomes.

OBJECTIVE: Opening the oculomotor triangle (OT) and removing the posterior fossa lesion by endoscopic endonasal approach (EEA) is challenging for even an experienced endoscopic neurosurgeon. We summarize the treatment experience and technical nuances with EEA for resection of pituitary neuroendocrine tumors and cavernous sinus (CS) meningiomas invading through the OT. METHODS: Between 2018 and 2022, 8 patients, comprising 5 with pituitary neuroendocrine tumors (3 with nonfunctioning and 2 with somatotroph tumors with increased levels of growth hormone) and 3 CS meningiomas, were treated using an endoscopic endonasal transoculomotor triangle approach. The critical surgical technique is continuously opening the diaphragma sellae from medial to lateral toward the interclinoidal ligament and transecting it to enlarge the OT. We evaluated preoperative tumor size, previous surgical history, preoperative symptoms, extent of tumor resection, histopathology, and postoperative complications for all patients. RESULTS: The gross total resection (defined as complete removal) in 3 patients (38%), near-total resection (defined as >95% removal) in 4 patients (50%), and subtotal resection (defined as ≤90% removal) in 1 patient (12%) and gross total resection of tumor invading through the OT was achieved in all patients through pure EEA. Two of 3 patients with visual deficits in nonfunctioning pituitary neuroendocrine tumors improved, and the other remained stable postoperatively. One patient showed transient oculomotor nerve palsy. The growth hormone level of the 2 patients with somatotroph tumors declined to normal. For 3 patients with CS meningiomas, cranial nerve palsy improved in 2 patients, whereas the other patient developed increased facial numbness after surgery. CONCLUSIONS: The endoscopic endonasal transoculomotor triangle approach is an efficient surgical option for tumors with CS invasion and OT penetration.

Prognostic Factors and Outcomes in World Health Organization Grade 1 and Grade 2 Intracranial Meningiomas-5-Year Institutional Experience.

BACKGROUND: Meningiomas are the most frequent primary intracranial tumor. While histological grade and grade of excision are established predictors of recurrence, the predictive ability of other clinical features, such as the role of radical excision of dural attachment and postoperative radiation therapy in intermediate-risk groups, remains unknown. METHODS: Clinical and radiological features and surgical details were analyzed in 451 World Health Organization (WHO) grade 1 intracranial meningiomas and 248 WHO grade 2 meningiomas operated on between 2010 and 2015. Outcomes were assessed in 352 WHO grade 1 and 208 WHO grade 2 meningiomas, studying the effect of extent of resection and use of radiation therapy. Kaplan-Meier analysis was used to determine differences in survival by extent of resection and use of postoperative radiation therapy in the treatment of the meningiomas. RESULTS: The mean age of the cohort was 46.3 years, with a female predominance. On univariate analysis, sex, WHO grade, and Simpson grade were significant predictors of recurrence. On multivariate analysis, WHO grade and Simpson grade remained significant predictors of recurrence. Recurrence was significantly associated with poor performance status and mortality. Postoperative radiation significantly improved progression-free survival among patients with grade 2 meningiomas who underwent gross total resection, but not among patients with grade 1 and grade 2 meningiomas who underwent subtotal resection. CONCLUSIONS: WHO grade and Simpson grade are independent predictors of recurrence in meningiomas. Regardless of WHO grade, gross total resection must be performed when possible, and postoperative radiation therapy may be recommended in grade 2 meningiomas.

The impact of spheno-occipital synchondrosis exposure via extended endoscopic endonasal surgery on midface growth in pediatric patients.

OBJECTIVE: Pediatric extended endonasal procedures pose significant surgical challenges. Lesions from the suprasellar region to the lower clivus necessitate extensive exposure. This study examined whether drilling the spheno-occipital synchondrosis (SOS) to remove the posterior clinoid process and dorsum sellae (DS) for greater exposure affects pediatric midfacial growth. METHODS: From 2014 to 2020, the authors performed endoscopic endonasal surgery (EES) in 14 patients aged 12 years or younger. The lesions consisted of 11 cases of craniopharyngioma, 1 pituitary neuroendocrine tumor, 1 Rathke's cleft cyst, and 1 Langerhans cell histiocytosis. In 8 of the 14 cases, an extended EES procedure was used by exposing the SOS to remove the posterior clinoid process and DS. Measurement of the central face was based on head MRI before and after surgery. Measuring points were the sellae-nasion (SN) plane, the foremost points of the anterior maxilla (point A), and the maximum concavity point of the mandibular symphysis (point B). The authors measured and evaluated the SNA angle (angle created by the SN plane and the NA [a line connecting point A and the nasion] plane), SNB angle (angle created by the SN plane and the NB [a line connecting point B and the nasion] plane), and the ANB angle (angle created by the NA plane and the NB plane). In addition, a comparison was made with 6 pediatric cases in which transcranial surgery was performed for craniopharyngiomas. RESULTS: In the extended EES group, the average preoperative age was 7 years, and the average postoperative age was 12 years. Mean preoperative angles in this group were 84° (SNA), 80.9° (SNB), and 3.1° (ANB); mean postoperative angles were 83.5° (SNA), 83.9° (SNB), and -0.4° (ANB). In the standard EES group, the average preoperative age was 9 years, and the average postoperative age was 14.5 years. Average preoperative angles in the standard EES group were 83° (SNA), 80.3° (SNB), and 2.7° (ANB); average postoperative angles were 82.7° (SNA), 81° (SNB), and 1.6° (ANB). In the transcranial surgery group, the average preoperative age was 4.5 years, and the average postoperative age was 9.8 years. Mean preoperative angles were 83.8° (SNA), 80.3° (SNB), and 3° (ANB); mean postoperative angles were 83.8° (SNA), 82.6° (SNB), and 1.2° (ANB). The only significant difference between groups was the postoperative ANB angle, which was negative in the extended EES group compared to the standard EES group, indicating the maxilla was positioned posteriorly compared to the mandible. CONCLUSIONS: The measurement values of the EES groups and the transcranial surgery group exhibited minimal differences, except for a significant decrease in the postoperative ANB angle in the extended EES group compared with the standard EES group. These results show that extended EES may impact midface growth. Further research is required to understand the long-term impact of SOS exposure.

Efficacy and Safety Profile of Gamma Knife Radiosurgery in Classic and Idiopathic Trigeminal Neuralgia.

BACKGROUND: Trigeminal neuralgia is a debilitating disease, with severe recurrent paroxysms of shock-like facial pain. Although pharmacotherapy may suffice in the majority of cases, a proportion of patients require surgical treatment. Gamma knife radiosurgery (GKRS) represents a potential non-invasive alternative to surgery in these patients. METHODS: We retrospectively analysed all patients that underwent GKRS for classic/idiopathic TN between 2013 and 2023. Pain prior to GKRS was graded per the Barrow Neurological Institute (BNI) pain score, which was also used to define outcomes. "Complete pain relief (CPR)" was defined as a BNI pain score of I or II, while "Adequate pain relief (APR)" was defined as a BNI pain score of III, and "Failure" as a BNI score of IV or V. RESULTS: The mean age of 70 patients (50 females and 20 males) was 47.4 ± 12.4 years. The mean follow-up was 51.3 ± 16.2 months. Although initial pain relief was achieved in 64 patients (91.4%), recurrence of pain at the latest follow-up occurred in 10 patients (14.3%). Overall, 41 patients (58.6%) achieved CPR, while 13 patients (18.6%) achieved APR. Multivariate analysis revealed that multiple prior failed procedures for TN predicted failure of pain relief. CONCLUSION: GKRS is effective among patients with classic/idiopathic TN, with complete pain relief in 58.6% of patients, and adequate pain relief in 18.6% of patients. The most frequent complication is facial hypesthesia, affecting 38.6% of patients. Multiple prior failed procedures for TN significantly predict failure of pain relief at latest follow-up.

Prospective Study to Evaluate the Role of Dual Point Contrast-enhanced Magnetic Resonance Imaging in Differentiation of Brain Tumoral from Nontumoral Tissue: A Magnetic Resonance/PET Study.

Background and Purpose: Follow-up imaging of gliomas is crucial to look for residual or recurrence and to differentiate them from nontumoral tissue. Positron emission tomography (PET)-magnetic resonance imaging (MRI) is the problem-solving tool in such cases. We investigated the role of dual point contrast (DPC)-enhanced MRI to discriminate tumoral from the nontumoral tissue compared to PET-MRI taken as the gold standard. Materials and Methods: The institutional ethics committee approved the study, and consent was obtained from all the patients included in the study. We prospectively did immediate and 75-min delayed contrast MRI in glioma cases who came for follow-up as a part of PET-MRI study in our institute. Subtracted images were obtained using immediate and 75-min delayed contrast images. Color-coded subtracted images were compared with PET-MRI images. 75-min delayed contrast MRI and diffusion-weighted imaging (DWI) images with Gray Scale inversion were compared with PET attenuation-corrected images. Results: We included 23 PET MRI cases done with different radiotracers in our study. Overall, we found PET-DPC correlation in (20/20 ~ 100%) cases of enhancing tumors. In two cases (DOPA and fluorodeoxyglucose), since they were nonenhancing low-grade gliomas and the other one was melanoma with intrinsic T1 hyperintensity and the DPC technique could not be used. DWI-PET correlated in 17/19 (~89.4%) cases, and perfusion-weighted imaging (PWI)-PET dynamic susceptibility contrast (DSC)/ASL correlated in 14/18 (~77.7%) cases after cases with hemorrhage were excluded. Conclusion: DPC MRI showed a good correlation with PET MRI in discriminating tumoral from the nontumoral tissue. DPC MRI can act as a potential alternative to PET MRI in peripheral hospitals where PET is not available. However, the DPC technique is limited in low-grade nonenhancing gliomas.