Endoscopic Endonasal Transodontoid Treatment of a Ruptured Anterior Spinal Artery Aneurysm.

Isolated spinal artery aneurysms are a rare cause of intracranial subarachnoid hemorrhage (SAH). A 49-year-old female presented with severe headache. Initial imaging showed SAH and intraventricular hemorrhage (IVH), but no clear source of bleeding was identified. One week into being observed in the intensive care unit, she reported another severe headache. Computed tomography head showed more SAH and IVH. A second angiogram revealed a ruptured small anterior spinal artery (ASA) aneurysm at the craniocervical junction. She underwent a C1-2 fusion followed by an endoscopic endonasal transodontoid approach and wrapping of the ASA aneurysm. At 2 years' follow-up, there was no sign of aneurysm growth or rerupture. This is the first reported case of an endoscopic endonasal transodontoid approach to an aneurysm.

Laryngeal Diffuse Large B-Cell Lymphoma Presenting as Laryngeal Stenosis.

BACKGROUND: Laryngeal stenosis is challenging for treatment due to uncertain etiology. Primary laryngeal lymphoma as the initial clinical manifestation of laryngeal stenosis has been rarely reported. Primary diffuse large B-cell lymphoma as an underlying etiology has not been reported. CASE REPORT: A 79-year-old male presented with dyspnea, stridor and dysphonia of 6 months' duration. Computed tomography scans and flexible laryngoscopic examination revealed vocal cord mobility with bilaterally limited abduction and a subglottic stenosis up to 50%. The laryngeal mucosa was smooth. Laryngeal biopsy showed atypical lymphoid infiltrates, predominantly large sized B-cells, in the submucosa with crush/cauterized artifacts. The tumor cells were positive for B-lymphocyte antigen CD20, paired-box 5 (PAX5), B-cell lymphoma 2 (BCL2), BCL6 and multiple myeloma oncogene 1 (MUM1). They were negative for CD10, CD30, cyclin D1 (CCND1), SRY-box 11 (SOX11), activin-receptor like kinase 1 (ALK1), CD138 and c-MYC, and negative for kappa/lambda light chain and Epstein-Barr virus-encoded small RNA by in situ hybridization. The pathologic diagnosis was diffuse large B-cell lymphoma. Fluorescent in situ hybridization (FISH) for MYC was negative. Next-generation sequencing using a 175-gene panel was performed and no pathologic mutations were identified. No lymphadenopathy elsewhere was identified. The patient was treated with chemotherapy and was doing well at the 5-month follow-up. CONCLUSION: To the best of our knowledge, this is the first documented case of primary laryngeal diffuse large B-cell lymphoma presenting as increasing laryngeal stenosis. The rarity, diagnosis and treatment of this entity are discussed.

Combined Endoscopic Transorbital and Endonasal Repair of High Flow Orbital Apex/Middle Fossa Cerebrospinal Fluid Leak with a Nasoseptal Flap.

BACKGROUND AND IMPORTANCE: High flow orbital apex or middle fossa cerebrospinal fluid (CSF) leaks can be life threatening and complex to repair. These leaks associated with large dural defects are most commonly repaired with an open temporalis muscle patch or free flaps, but these flaps do not always stop the leak. CLINICAL PRESENTATION: A 65-year-old patient presented two years after orbital exenteration and radiation for squamous cell carcinoma. He developed multi-organism meningitis and pneumocephalus secondary to a large high-flow orbital apex/middle fossa CSF leak. To repair the leak, a combined endoscopic transorbital/endonasal approach with pedicled nasospetal flap and dermis fat graft was used. We describe the unique endoscopic technique that was used to treat the life threatening high flow orbital apex/middle fossa CSF leak. The technique allowed the use of the transposed pedicled flap, which is an alternative to the free flap in controlling CSF leak. Cisternogram post-operatively and clinical exam confirmed resolution of CSF leak. Although a critically ill patient at admission with a modified Rankin scale (MRS) of 5, he was discharged home on continued IV antibiotic therapy with a MRS of 3. Endoscopic evaluation at three months after treatment showed the effectiveness of the flap and he continued to improve clinically. CONCLUSION: This is the first case to describe a combined endoscopic transorbital and endonasal repair of high flow orbital apex/middle fossa CSF leak with a pedicled nasoseptal flap. These techniques can be utilized during initial reconstruction after orbital exenteration or as a salvage flap.

Paramedian Forehead Flap for Repair of Refractory High-Flow Anterior Skull Base CSF Leak.

AIM: The paramedian forehead flap (PMFF) has been well described for nasal reconstruction. However, it has never been reported for use in the repair of high flow anterior skull base cerebral spinal fluid (CSF) leaks. MATERIAL AND METHODS: The patient is a 55 yo African American male cocaine abuser who initially presented with a high flow anterior skull base CSF leak, extensive pneumocephalus, and intra-cerebral and intra-ventricular abscesses with an oro-nasal-cerebral fistula. The patent initially underwent bi-frontal craniotomy, exenteration of the frontal sinus, abdominal fat graft, resection of intra-cerebral abscesses, and repair of high flow anterior skull base CSF leak with a pedicled pericranial flap (PF). 18 months after the patient's surgery he had resumed his use of cocaine and suffered necrosis of his PF. This caused his high flow CSF leak to recur. After extensive psychiatric treatment, he stopped cocaine use and was subsequently repaired with a pedicled de-epithelialized PMFF originating off the bilateral supratrochlear arteries. RESULTS: The patient has had no CSF leak for 3 years, and primary closure of the forehead was achieved with good cosmetic outcome. CONCLUSION: This case highlights the use of PMFF for the treatment of recurrent high flow anterior skull base CSF leak. It also highlights the importance of treatment of the patient's underlying medical disorder, in this case, the patient's addiction to cocaine. We provide a detailed discussion for the use of the de-epithelialized PMFF and how it can be utilized as a vascularized reconstructive technique to repair complex refractory cerebral spinal fluid leaks.