Sarcoidosis Mimicking Skull Base Meningioma

Sarcoidosis is a systemic disease characterized by granulomatous inflammation. Pulmonary and lymphatic granulomatous involvement are common.We present a rare case report of involvement of the central nervous system affecting the ocular region and mimicking optic nerve sheath meningioma. We report the case of a 79-year-old female patient with progressive visual impairment with an evolution of 4 years. Amagnetic resonance imaging scan of the cranium with gadolinium and intense homogeneous contrast enhancement revealed an expansive lesion in the right optic nerve, at the height of the optic canal. The patient was submitted to the neurosurgical approach with lesion biopsy, which showed sarcoidosis of the central nervous system. Due to the rarity of central nervous system involvement, the diagnosis of this pathologymay unfortunately be postponed. The present article aims to elucidate this pathology as a differential diagnosis of retro-orbital tumors.

Olfactory Groove Schwannoma ­ A Case Report and Literature Review

Olfactory groove schwannomas (OGSs) are rare benign tumors of the anterior skull base region. Considering the lack of Schwann cells in the optic and olfactory nerves, their origin remains enigmatic. Despite the precursor cell, total resection of the lesion is curative, as long as the histopathological features of the tumor are compatible with schwannoma. We report the case of a 32-year-old woman, addicted to crack, who was brought to the hospital presenting with cognitive dysfunction after being physically assaulted, whose neuroimaging revealed a large extra-axial mass in the subfrontal sagittal region. The presentation, immunohistochemical markers and histogenesis are discussed in the present study, along with a literature review.

Intra-nasal mass presenting with Cushing's syndrome and CSF rhinorrhea: A case report

@#<p style="text-align: justify;">This  is  a  case  of  a  47  year-old  female  presenting  with  typical Cushingoid appearance and CSF rhinorrhea. MRI revealed a 4.4 cm x 2.9 cm x 4.5 cm enhancing intranasal mass with evidence of erosion of the left cribriform extending to the left anterior cranial fossa. Dexamethasone suppression  test  yielded  elevated  cortisol  level. Endoscopic nasal biopsy done showed a round cell tumor positive for  ACTH,  synaptophysin,  chromogranin  A,  and  S-100.  Patient subsequently  underwent  endoscopic  endonasal  excision  of  left intranasal mass with creation of pericranial flap for repair of CSF leak.  This  report  is  presented  to  discuss  a  rare  case  of  ACTH secreting esthesioneurblastoma including its diagnostic challenges and surgical options for repair of anterior cranial fossa defect to address CSF leak particularly by means of a vascularized pericranial flap.</p>

Meningiomas del surco olfatorio: consideraciones del abordaje endonasal endoscópico extendido transcribiforme / Olfactory groove meningiomas: considerations of the extended endoscopic endoscopic approach transcribiform

Los meningiomas del surco olfatorio representan el 10 por ciento de los meningiomas intracraneales, se originan de la lámina cribosa del etmoides, la sutura fronto-esfenoidal y el plano esfenoidal. Son tumores en su mayoría benignos y potencialmente curables, la recurrencia ocurre en grado variable siendo el grado de resección quirúrgica el predictor más importante de recurrencia. En este artículo se exponen los resultados alcanzados con el abordaje endonasal endoscópico extendido transcribiforme en pacientes con meningiomas del surco olfatorio en el servicio de neurocirugía del hospital clínico quirúrgico Hermanos Ameijeiras. La serie fue de 12 pacientes donde la cefalea, la anosmia y los trastornos neuropsicológicos fueron los síntomas predominantes. Los tumores tuvieron un tamaño ≥ a 6 cm en el 50 por ciento de los casos y con el abordaje endonasal endoscópico extendido transcribiforme se alcanzó una resección total con Simpson I en el 92 por ciento de los enfermos. Los límites del abordaje endonasal endoscópico en la fosa anterior se encuentran en constante extensión, siendo el abordaje endonasal endoscópico extendido transcribiforme la opción ideal y prometedora para los pacientes con Meningiomas del surco olfatorio.

Olfactory groove meningiomas represent 10 percent of intracranial meningiomas, originate from cribriform plate of ethmoid, frontal and sphenoid suture and the sphenoid plane. They are mostly benign and potentially curable tumors, the recurrence occurs in varying degree and the extent of surgical resection is the most important predictor of this recurrence. This article presents the results achieved with the transcribiform extended endoscopic endonasal approach in patients with meningiomas of olfactorygroove in neurosurgery department of the “Hermanos Ameijeiras” hospital. The series was of 12 patients where headache, anosmia, and neuropsychological disorders were the predominant symptoms. The tumors had a size ≥ 6 cm on 50 percent of the cases and with transcribiform extended endoscopic endonasal approach was reached total removal in 92 percent (Simpson I) of the patients. The limits of endoscopic endonasal approach for anterior fossa are in constant expansion, being the transcribiform extended endoscopic endonasal approach the ideal and promising option for patients with olfactory groove meningiomas.

The extended pterional approach allows excellent results for removal of anterior cranial fossa meningiomas / O acesso pterional extendido permite excelente resultado para a ressecção dos meningiomas da fossa craniana anterior

ABSTRACT Objective To describe a unique operative strategy, instead the classical pterional approach, and to analyses it safety and effectiveness for removal of anterior cranial fossa meningiomas. Method We identify 38 patients with tuberculum sellae and olphactory groove meningiomas operated between 1986 and 2013. Medical charts, operative reports, imaging studies and clinical follow-up evaluations were reviewed and analyzed retrospectively. The pterional craniotomy is extended toward the frontal bone providing access through the subfrontal route, besides the usual anterolateral view provided by the classical pterional approach. Results Surgical mortality occurred in one patient (2.6%). Gross total resection was achieved in 27 patients (86.8%). Median time of follow-up was 69.4 months. Conclusion The extended pterional approach allows excellent results. Total removal of meningiomas of the anterior cranial fossa was obtained in 86.8 % of patients, with low morbidity and mortality.

RESUMO Objetivo Descrever a craniotomia pterional estendida, ao invés da abordagem pterional clássica, e analisar sua segurança e eficácia para a remoção dos meningiomas da fossa anterior. Método Identificamos 38 pacientes com meningiomas do tubérculo da sela e da goteira olfatória operados entre 1986 e 2013. Os prontuários, relatórios cirúrgicos, exames de imagem e acompanhamento pós-operatório foram analisados retrospectivamente. A craniotomia pterional com extensão para o osso frontal permite acesso pela via subfrontal além da via anterolateral do acesso pterional clássico. Resultados A mortalidade cirúrgica foi de 2,6% (um paciente). A remoção total foi alcançada em 86,8% (27 pacientes) com um tempo médio de seguimento de 69,4 meses. Conclusão A abordagem pterional estendida permite excelentes resultados. A remoção total dos meningiomas da fossa craniana anterior foi obtida em 86,8% dos pacientes, com baixa morbi-mortalidade.

Secondary Reconstruction of Frontal Sinus Fracture

Fractures of frontal sinus account for 5%–12% of all fractures of facial skeleton. Inadequately treated frontal sinus injuries may result in malposition of sinus structures, as well as subsequent distortion of the overlying soft tissue. Such inappropriate treatment can result in aesthetic complaints (contour deformity) as well as medical complications (recurrent sinusitis, mucocele or mucopyocele, osteomyelitis of the frontal bone, meningitis, encephalitis, brain abscess or thrombosis of the cavernous sinus) with potentially fatal outcomes. Frontal contour deformity warrants surgical intervention. Although deformities should be corrected by the deficiency in tissue type, skin and soft tissue correction is considered better choice than bone surgery because of minimal invasiveness. Development of infection in the postoperative period requires all secondary operations to be delayed, pending the resolution of infectious symptoms. The anterior cranial fossa must be isolated from the nasal cavity to prevent infectious complications. Because most of the complications are related to infection, frontal sinus fractures require extensive surgical debridement and adequate restructuring of the anatomy. The authors suggest surgeons to be familiar with various methods of treatment available in the prevention and management of complications following frontal sinus fractures, which is helpful in making the proper decision for secondary frontal sinus fracture surgery.

Role of Craniofacial Resection for Malignant Tumors Involving the Anterior Skull Base: Surgical Experience in a Single Institution

BACKGROUND: Craniofacial resection (CFR) has been regarded as a standard treatment for various tumors involving the anterior skull base. The purpose of this study was to evaluate the results of CFR for the patients with anterior skull base malignancies in our hospital. METHODS: We retrospectively analyzed 17 patients with anterior skull base malignancies treated with CFR between 2001 and 2012. Mean follow-up duration was 41 months (range, 2-103 months). RESULTS: Intracranial involvement was found in 11 patients (65%) and orbital extension in 6 patients (35%). Classical bifrontal craniotomy was combined with endoscopic endonasal approach in 14 patients and external approach in 3 patients. Vascularized flap was used for reconstruction of the anterior fossa floor in 16 patients (94%). The most common pathological type was squamous cell carcinoma (6 patients). Gross total resection was achieved in all cases. Postoperative complications developed in 4 patients (24%) and included local wound problem and brain abscess. One patient with liver cirrhosis died from unexpected varix bleeding after the operation. Although postoperative treatment, such as radiotherapy or chemotherapy, was performed in 14 patients, local recurrence was seen in 6 patients. The mean overall survival time after the operation was 69.0 months (95% confidence interval: 47.5-90.5 months) with a 1-, 2-, and 5-year survival rate of 82.3%, 76.5%, and 64.7%, respectively. Postoperative radiotherapy was found to be the powerful prognostic factor for favorable survival. CONCLUSION: Considering the higher local control rate and acceptable complication or mortality rate, CFR with adjuvant radiotherapy is a gold standard treatment option for malignant tumors involving anterior skull base, especially with extensive intracranial involvement.

Endoscopic Frontal Sinus Surgery / 대한이비인후과학회지

Surgery on the frontal sinus or frontal recess remains a challenge for rhinologist because of its variability and complex anatomy. Its location, relatively complex and narrow frontal recess also make visualization difficult and predispose it to stenosis. Significantly, serious complications are possible due to the anterior ethmoidal artery, orbit and anterior cranial fossa. An understanding of frontal sinus and frontal recess anatomy is essential to perform endoscopic frontal sinus surgery. This paper examines frontal sinus anatomy and then variable procedures of endoscopic frontal sinus surgery. The selection of less invasive procedure as possible after assessment of the patient's history, diagnostic endoscopy, and the CT scan makes successful endoscopic treatment of frontal sinus diseases.

Two Cases of Cerebrospinal Fluid Rhinorrhea Caused by Closed Nasal Reduction / 대한이비인후과학회지

Cerebrospinal fluid (CSF) rhinorrhea usually occurs after a traumatic or non-traumatic head injury, as more than 80% of all cases of CSF rhinorrhea are caused by traumatic head injuries. In fact, CSF rhionorrhea is observed in 2 to 3% of traumatic head injuries, with 50% of the CSF found in the anterior cranial fossa, but mostly of them in the cribriform plate. CSF rhionorrhea can occur two days after a traumatic head injury, but it can take up to 3 months to notice the symptoms of CSF rhionorrhea in a patient with a traumatic head injury. Iatrogenic CSF rhionorrhea is usually caused by neurosurgery operation or otorhinolaryngological surgery such as sinus surgery. For example, closed reduction treating nasal bone fractures can cause CSF rhionorrhea, so patients should be watched at all times. This paper reports two cases of CSF rhionorrhea caused by closed nasal reduction.

A swelling of the maxilla: a case report and differential diagnosis

Ossifying fibromas are benign fibro-osseous tumors of mesenchymal origin. Although ossifying fibromas have principally been found in the jaw, they have also been reported in the frontal, ethmoid, sphenoid, and temporal bones, as well as the orbit and anterior cranial fossa. Ossifying fibromas affecting the jaw exhibit variable behaviors ranging from slow growth to occasionally aggressive local destruction. In the present article, we discuss a differential diagnosis considered for maxillary swellings and report a rare case of ossifying fibroma occurring in the maxilla.

Abordaje transciliar e interciliar para aneurismas del complejo comunicante anterior / Transient and intercervical approach for aneurysms of the anterior connecting complex

Introducción: Los abordajes trans e interciliares son utilizados para distintas patologías de la fosa craneana anterior. En algunos casos puntuales creemos que puede resultar una opción para aneurismas del complejo comunicante anterior. Objetivos: Analizar la casuística de abordajes trans e interciliares utilizados en la resolución de aneurismas del complejo carótido comunicante anterior.Material y método: Se revisó retrospectivamente los casos de aneurismas del complejo comunicante anterior abordados por vía transciliar e interciliar; se analizaron datos epidemiológicos, tamaño aneurismático, abordaje usado, la presencia de espacios subaracnoideos en neuroimágenes previas a la cirugía, Fisher, Hunt Hess, el uso de clipado transitorio, morbimortalidad, complicaciones y resultados cosméticos. Resultados: Se encontraron 6 casos de aneurismas de comunicante anterior operados por vía transciliar y 2 casos por vía interciliar. No hubo predominancia de sexos. La edad promedio fue de 54,6 años. El 62,5% fueron aneurismas chicos, 50% incidentales. Conclusiones: La utilización de este tipo de abordajes resulta útil, en algunos casos de aneurismas del complejo comunicante anterior, siendo importante la selección del caso para este tipo de abordaje. Cumple con el criterio primordial de acceder al vaso madre del aneurisma, permitiendo una exposición desde el inicio de ambas A1 y A2, es rápido su abordaje, es directo, el campo menos profundo y requiere de una familiarización con la anatomía vascular desde una visión frontal, el ser necesario un clipado transitorio los clips quedan lateral a la dirección de trabajo no obstruyendo el mismo.

Purpose: To describe and analyze the experience in the resolution of the anterior communicating aneurysms bytransciliary and interciliary approaches.Methods: Between September 1999 and March 2013, 8 patients with anterior communicating aneurysms wereoperated through transciliary and interciliary approaches.Results: 6 patients were operated through a transciliary approach and 2 patients through a interciliary approach. Therewas no gender predominance. The average age was 54,6 years old. There was a 50% of incidental aneurysms and62,5% of small aneurysms.Conclusion: These approaches can be useful in some cases of anterior communicating aneurysms in which the controlof the parent artery is possible. The corridor of dissection is direct and less deep. If necessary, temporary clipping ofthe A1 and A2 areas are accessible to the surgeon. The study of arachnoidal cistern is essential in the patient selectioncriteria for these approaches.

Haga su diagnóstico / Make your diagnosis

El diagnóstico es Quiste aracnoideo de la fosa media con extensión a la fosa anterior Galassi III

Rapidly Progressive Rhino-orbito-cerebral Mucormycosis Complicated with Unilateral Internal Carotid Artery Occlusion: A Case Report / 신경중재치료의학

Rhinocerebral mucormycosis is an acute fulminant opportunistic fungal infection usually seen in diabetic or immunocompromised patients. The fungi that cause mucormycosis inoculate the nasal mucosa and may spread to the paranasal sinuses, orbit, and brain. Our patient initially presented with mild ethmoid sinusitis. At that time, brain MRI and contrast-enhanced MR angiography were grossly normal. However, aggravation of sinusitis with extension to the right orbit and anterior cranial fossa rapidly developed within two months. Moreover, an occlusion of the right internal carotid artery was combined. We report a case of a pathologically-proven rhino-orbital-cerebral mucormycosis with serial follow-up imaging for over one year.

Modified pedicled cranial periosteum compound flap to reconstruct the defect of anterior cranial fossa complicated with cerebrospinal fluid leakage / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To explore the effect of modified pedicled cranial periosteum compound flap in reconstructing the defect of anterior cranial fossa complicated with cerebrospinal fluid leakage.@*METHOD@#Seven nasal and sinus tumor cases with defects and CSF were undertaken reconstructing surgery with the flap, of which 1 was benign and the others were malignancies. The transferred flap pedicled with the frontal branch of the superficial temporal artery and complemented with ipsilateral supraorbital and/or supratraochlear artery.@*RESULT@#All cases healed without failure, one case with adjuvant radiotherapy experienced partial free frontal bone necrosis and healed by ways of drainage through temporal incision. The inner surface of the flap in the nasal cavity was smooth.@*CONCLUSION@#Frontal cranial periosteum compound flap have some advantages, such as adequate quantity, good blood supply and easily making,so it can be choose as an important method to reconstruct the defects of anterior cranial fossa and CSF leakage.

Surgical Management of Dural Arteriovenous Fistula of The Anterior Cranial Fossa: Case Report / 대한뇌혈관외과학회지

OBJECTIVE: A dural arteriovenous fistula (DAVF) of the anterior cranial fossa is rare. We report a case of a DAVF of the anterior cranial fossa which was treated surgically, following endovascular treatment failure. METHODS & RESULTS: The subject was a 53-year-old male with a headache caused by a hematoma in the right frontal lobe. A vascular abnormality of the anterior cranial fossa was suspected on brain computed tomographic angiography. The subsequent transfemoral cerebral angiography revealed that the AVF of the anterior cranial fossa was mainly fed by the left anterior ethmoidal artery. Endovascular therapy using N-butyl cyanoacrylate was attempted. However, the procedure failed to occlude the fistula due to the existing feeding artery (the right anterior ethmoidal artery). Consequently, a surgical approach was undertaken and the lesion was successfully obliterated. CONCLUSION: We report a rare case of an intracerebral hematoma caused by a DAVF, which was successfully managed surgically following, endovascular treatment failure.

Supra-orbital keyhole removal of anterior fossa and parasellar meningiomas / Minicraniotomia supra-orbitária superciliar no tratamento de meningiomas na fossa craniana anterior e para-selares

The improvement of surgical techniques as well as the introduction of new surgical instruments promoted the use of keyhole craniotomies in neurosurgery. We evaluated the technical aspects of the supra-orbital keyhole approach considering the indications, limitations, and complications of this approach to treat anterior cranial fossa and parasellar meningiomas. Twenty-four patients (21 females; mean age, 53±8.6 years) operated on between 2002 and 2006 through a supra-orbital eyebrow approach were studied. Maximal tumor diameter ranged from 1.6 to 6 cm. Gross total resection was done in 20 (83.3 percent). All tumors were histologically benign. Two patients (8 percent) experienced CSF rinorhea and another two patients suffered transitory diabetes insipidus (8 percent). One patient experienced transitory hemiparesis. There was one case of meningitis and one mortality. Follow-up ranged between 6 to 66 months (mean 31.5±20.1 months), with no recurrence. The supra-orbital keyhole craniotomy is a useful minimally invasive approach to treat selected anterior fossa and parasellar meningiomas.

A evolução técnica e a introdução de instrumentais cirúrgicos mais delicados proporcionaram o uso de craniotomias menores no tratamento de patologias intracranianas. Avaliamos os aspectos técnicos da minicraniotomia supra-orbitária superciliar, considerando as indicações, limitações e complicações no tratamento de meningiomas na fossa craniana anterior e para-selares. Vinte e quarto pacientes (21 mulheres; idade média, 53±8,6 anos) operados entre 2002 e 2006 foram estudados. O diâmetro tumoral máximo variou de 1,6 a 6 cm. Ressecção total foi obtida em 20 (83,3 por cento). Todos os tumores eram histologicamente benignos. Dois pacientes (8 por cento) apresentaram fistula liquórica pós-operatória e outros dois diabetes insipido transitórioa (8 por cento). Um paciente evoluiu com hemiparesia transitória. Houve um caso de meningite e um de evolução fatal. O seguimento variou de 6 a 66 meses (média 31,5±20,1 meses), não houve recidiva. A minicraniotomia supra-orbitária superciliar é uma via de abordagem eficaz para o tratamento de meningiomas da fossa craniana anterior e para-selares selecionados.

Surgical management of olfactory groove meningiomas

To study the bifrontal approach to olfactory groove meningiomas [OGM], the technique, outcomes, and recurrence rates in a series of 23 cases of OGM operated on during the period between 2000 and 2009. The study included twenty three patients with OGM, 15 females and 8 males. The age ranged from 26 years to 65 years with a mean of 45.2 years. Bifrontal craniotomy and excision of tumor was done for all patients. Tumor diameter varied from 3.3 to 6.1 cm [mean 4.7 cm]. Total tumor removal [Simpson grade 1 and 2] was achieved in twenty patients [86.9%] and subtotal removal [Simpson grade 3] was achieved in three patients [13.1%], in whom the anterior cerebral artery complex was encased. The pathology in all patients was Grade I meningiomas [World Health Organization grading]. There was no operative mortality. Anosmia occurrygered in all but three patients and partial left optic injury in one patient. Three patients suffered post operative cerebrospinal fluid rhinorrhea which stopped in all after repeated lumbar drainage. Three patients suffered postoperative wound infection and responded well to appropriate antibiotic treatment. There was one recurrence in the follow up period of 6 months to 8 years with a mean of 2.6 years. A variety of surgical approaches are used for OGM resection. Bifrontal approach offers excellent exposure, and when combined with modern microsurgical cranial base techniques allows maximum safety during surgery with minimal permanent morbidity, excellent neurological outcome, and very low recurrence rates

Anterior Cranial Fossa Dural Arteriovenous Fistulae Presenting as Subdural Hematoma

Anterior cranial fossa dural arteriovenous fistulae (DAVFs) are very rare and the bleeding rate is very high, especially in the presence of leptomeningeal draining vein and aneurysmal varix formation. A 85-year-old male patient presented with subdural hematoma (SDH). Magnetic resonance image (MRI) and transfemoral carotid angiography (TFCA) disclosed DAVF at the anterior cranial fossa with bilateral arterial feeders and leptomeningeal draining vein with varix formation. The lesion was treated by simple ligation of pial connecting vein using low frontal craniotomy. In comparison with DAVFs of the other sites, the anterior cranial fossa DAVF is difficult to manage by endovascular treatment due to not only the difficulty of transvenous access but the risk of visual impairment when using transarterial route. Surgical ligation of pial connecting vein is feasible and effective treatment.

Sexual dimorphism determination by piriform aperture morphometric analysis in Brazilian human skulls / Determinación de dimorfismo sexual mediante análisis morfométrico de la apertura piriforme en cráneos humanos brasileños

The sex determination of human skeletons is important in forensic and anthropological research. It can be carried out through qualitative or quantitative analysis of morphological parameters of dimorphism. The shape of the piriform aperture is one of the classic indicators of sexual dimorphism since it describes differences between males and females according to strong population-specific behavior. The purpose of this study was to analyze the presence of sexual dimorphism in the size of the piriform aperture and its relationship with individual skin color. We used 90 human skulls from the Collection of the Federal Universidad de São Paulo (UNIFESP), with registered data on sex, age and skin color (classified as white, black and brown). The dimensions studied were: height, upper width and lower width of piriform aperture. All dimensions were greater in males than females, however, only the piriform aperture height was found to be significant with p <0.01. By analyzing differences and grouping them according skin color, the piriform aperture height was found to be significantly higher (p <0.05) in white, black and brown males. In the group of black individuals skulls, we found significant differences in the upper width (p <0.05). The main differences, related to the piriform aperture height and the low influence of skin color in the presence of sexual dimorphism in the piriform aperture size, are in contrast with what has been reported in the literature and justify the revision of the classic indicators used for diagnosis of sex in specific populations.

El diagnóstico del sexo a partir de osamentas humanas es importante en investigación antropológica y forense, éste puede ser realizado mediante análisis cualitativos o cuantitativos de parámetros morfológicos de dimorfismo. La forma de la apertura piriforme es uno de los indicadores clásicos de dimorfismo sexual, a partir de ella se han descrito diferencias entre hombres y mujeres en sus dimensiones, con un fuerte comportamiento población-específico. El propósito de este estudio fue analizar la presencia de dimorfismo sexual en las dimensiones de la apertura piriforme y su relación con el color de piel de los individuos. Se utilizaron 90 cráneos humanos de la Colección de la Universidade Federal de São Paulo (UNIFESP), con registro de sexo, edad y color de piel (clasificadas en blanco, negro y pardo). Las dimensiones analizadas fueron: altura, ancho superior e inferior de la apertura piriforme. Todas las dimensiones resultaron mayores en hombres que en mujeres, sin embargo, sólo la altura de la apertura piriforme resultó ser significativa con p<0.01. Al analizar las diferencias agrupándolas por color de piel, obtuvimos que la altura de la apertura piriforme resultó ser mayor y significativa (p<0.05) en hombres blancos, negros y pardos. En el grupo de cráneos de individuos negros, además, encontramos diferencias significativas en el ancho superior (p<0.05). Las principales diferencias encontradas, referidas a la altura de la apertura piriforme, y la baja influencia del color de piel en la presencia de dimorfismo sexual en las dimensiones de la apertura piriforme, contrastan con lo reportado en la literatura y justifican la revisión de los indicadores clásicos utilizados para el diagnóstico del sexo en poblaciones específicas.