Spinal cord atrophy as a primary outcome measure in phase II trials of progressive multiple sclerosis.

OBJECTIVES: To measure the development of spinal cord (SC) atrophy over 1 year in patients with progressive multiple sclerosis (PMS) and determine the sample sizes required to demonstrate a reduction in spinal cord cross-sectional area (SC-CSA) as an outcome measure in clinical trials. METHODS: In total, 44 PMS patients (26 primary progressive multiple sclerosis (PPMS), 18 secondary progressive multiple sclerosis (SPMS)) and 29 healthy controls (HCs) were studied at baseline and 12 months. SC-CSA was measured using the three-dimensional (3D) fast field echo sequences acquired at 3T and the active surface model. Multiple linear regressions were used to investigate changes in imaging measurements. RESULTS: PPMS patients had shorter disease duration, lower Expanded Disability Status Scale (EDSS) and larger SC-CSA than SPMS patients. All patients together showed a significantly greater decrease in percentage SC-CSA change than HCs, which was driven by the PPMS. All patients deteriorated over 1 year, but no association was found between percentage SC-CSA change and clinical changes. The sample size per arm required to detect a 50% treatment effect over 1 year, at 80% power, was 57 for PPMS and 546 for SPMS. CONCLUSION: SC-CSA may become an outcome measure in trials of PPMS patients, when they are at an early stage of the disease, have moderate disability and modest SC atrophy.

Evidence for early neurodegeneration in the cervical cord of patients with primary progressive multiple sclerosis.

Spinal neurodegeneration is an important determinant of disability progression in patients with primary progressive multiple sclerosis. Advanced imaging techniques, such as single-voxel (1)H-magnetic resonance spectroscopy and q-space imaging, have increased pathological specificity for neurodegeneration, but are challenging to implement in the spinal cord and have yet to be applied in early primary progressive multiple sclerosis. By combining these imaging techniques with new clinical measures, which reflect spinal cord pathology more closely than conventional clinical tests, we explored the potential for spinal magnetic resonance spectroscopy and q-space imaging to detect early spinal neurodegeneration that may be responsible for clinical disability. Data from 21 patients with primary progressive multiple sclerosis within 6 years of disease onset, and 24 control subjects were analysed. Patients were clinically assessed on grip strength, vibration perception thresholds and postural stability, in addition to the Expanded Disability Status Scale, Nine Hole Peg Test, Timed 25-Foot Walk Test, Multiple Sclerosis Walking Scale-12, and Modified Ashworth Scale. All subjects underwent magnetic resonance spectroscopy and q-space imaging of the cervical cord and conventional brain and spinal magnetic resonance imaging at 3 T. Multivariate analyses and multiple regression models were used to assess the differences in imaging measures between groups and the relationship between magnetic resonance imaging measures and clinical scores, correcting for age, gender, spinal cord cross-sectional area, brain T2 lesion volume, and brain white matter and grey matter volume fractions. Although patients did not show significant cord atrophy when compared with healthy controls, they had significantly lower total N-acetyl-aspartate (mean 4.01 versus 5.31 mmol/l, P = 0.020) and glutamate-glutamine (mean 4.65 versus 5.93 mmol/l, P = 0.043) than controls. Patients showed an increase in q-space imaging-derived indices of perpendicular diffusivity in both the whole cord and major columns compared with controls (P < 0.05 for all indices). Lower total N-acetyl-aspartate was associated with higher disability, as assessed by the Expanded Disability Status Scale (coefficient = -0.41, 0.01 < P < 0.05), Modified Ashworth Scale (coefficient = -3.78, 0.01 < P < 0.05), vibration perception thresholds (coefficient = -4.37, P = 0.021) and postural sway (P < 0.001). Lower glutamate-glutamine predicted increased postural sway (P = 0.017). Increased perpendicular diffusivity in the whole cord and columns was associated with increased scores on the Modified Ashworth Scale, vibration perception thresholds and postural sway (P < 0.05 in all cases). These imaging findings indicate reduced structural integrity of neurons, demyelination, and abnormalities in the glutamatergic pathways in the cervical cord of early primary progressive multiple sclerosis, in the absence of extensive spinal cord atrophy. The observed relationship between imaging measures and disability suggests that early spinal neurodegeneration may underlie clinical impairment, and should be targeted in future clinical trials with neuroprotective agents to prevent the development of progressive disability.

Functional correlates of cognitive dysfunction in multiple sclerosis: A multicenter fMRI Study.

In this multicenter study, we applied functional magnetic resonance imaging (fMRI) to define the functional correlates of cognitive dysfunction in patients with multiple sclerosis (MS). fMRI scans during the performance of the N-back task were acquired from 42 right-handed relapsing remitting (RR) MS patients and 52 sex-matched right-handed healthy controls, studied at six European sites using 3.0 Tesla scanners. Patients with at least two abnormal (<2 standard deviations from the normative values) neuropsychological tests at a standardized evaluation were considered cognitively impaired (CI). FMRI data were analyzed using the SPM8 software, modeling regions showing load-dependent activations/deactivations with increasing task difficulty. Twenty (47%) MS patients were CI. During the N-back load condition, compared to controls and CI patients, cognitively preserved (CP) patients had increased recruitment of the right dorsolateral prefrontal cortex. As a function of increasing task difficulty, CI MS patients had reduced activations of several areas located in the fronto-parieto-temporal lobes as well as reduced deactivations of regions which are part of the default mode network compared to the other two groups. Significant correlations were found between abnormal fMRI patterns of activations and deactivations and behavioral measures, cognitive performance, and brain T2 and T1 lesion volumes. This multicenter study supports the theory that a preserved fMRI activity of the frontal lobe is associated with a better cognitive profile in MS patients. It also indicates the feasibility of fMRI to monitor disease evolution and treatment effects in future studies.

Improved MRI quantification of spinal cord atrophy in multiple sclerosis.

PURPOSE: To identify an improved method for measuring spinal cord cross-sectional area (CSA) using magnetic resonance imaging (MRI) in multiple sclerosis (MS). MATERIALS AND METHODS: MRI was performed on 15 controls and 15 MS patients and repeated in nine controls and nine patients after 6 months. At this timepoint, an additional scan was acquired to evaluate scan-rescan reproducibility. Two sequences were acquired in the cervical cord: 3D phase sensitive inversion recovery (PSIR) and 3D magnetization prepared rapid acquisition T1-weighted gradient echo. CSA was outlined at C2-C3 using two methods: a semiautomated edge detection method and active surface model (ASM). We evaluated reproducibility for all combinations of sequences and analysis methods using coefficient of variation (COV) and intraclass correlation coefficient and performed sample size calculations for clinical trials to reduce longitudinal cord atrophy. RESULTS: PSIR/ASM combination provided the lowest values of COV for intrarater, interrater, scan-rescan reproducibility (0.002%, 0.03%, and 0.1% respectively). At 6-month follow-up no significant changes were seen in CSA of controls, and a trend towards significance was observed in patients. CONCLUSION: PSIR/ASM proved more reproducible than established methods of evaluating CSA in MS and also provides the lowest number of subjects per arm for 6-month and 1-year clinical trials.

Movement disorder Deep brain stimulation Hybridization: Patient and caregiver outcomes.

Background and Objectives: Deep brain stimulation (DBS) is a well-established surgical treatment for certain movement disorders and involves the implantation of brain electrodes connected to implantable pulse generators (IPGs). As more device manufacturers have entered the market, some IPG technology has been designed to be compatible with brain electrodes from other manufacturers, which has facilitated the hybridization of implant technology. The aim of this study was to assess the benefits of hybridization of non-rechargeable, constant voltage IPGs to rechargeable, constant current IPGs. Methods: A list of DBS movement disorder patients who had their non-rechargeable, constant voltage IPGs replaced with rechargeable, constant current IPGs from a different manufacturer was compiled. Structured surveys of these patients, and their caregivers when applicable, were undertaken to determine both patient and caregiver satisfaction in this DBS hybridization strategy. Results: Eighteen patients met inclusion criteria and twelve patients or their caregivers completed the structured survey (67% response rate). Nine patients had Parkinson's disease (75%), three had essential tremor (25%). Nine (75%) were converted from bilateral single-channel IPGs, and three (25%) were converted from a unilateral dual-channel IPGs. Overall, 92% of patients and caregivers surveyed reported improvement or no change in their symptoms, 92% reported a decrease or no change in their medication requirements, and 92% report they are satisfied or very satisfied with their IPG hybridization and would recommend the surgery to similar patients. There were no immediate surgical complications. Conclusion: In this series of movement disorder DBS patients, surgery was safe and patient and caregiver satisfaction were high with a hybridization of non-rechargeable, constant voltage IPGs to rechargeable, constant current IPGs.

In vivo magnetic resonance spectroscopy detection of combined glutamate-glutamine in healthy upper cervical cord at 3 T.

The possibility of quantifying the superimposed signal of glutamate and glutamine (Glx) and its components by ¹H magnetic resonance spectroscopy (MRS) in the spinal cord is an exciting challenge with important clinical applications in neurological conditions. The spinal cord is a particularly difficult region of interest due to its small volume, magnetic field inhomogeneities and physiological motion. In this study, we investigated for the first time the feasibility of obtaining quantitative measurements of Glx in healthy cervical spinal cord by ¹H MRS at 3 T. The aim of this study was to compare two commercially available MRS sequences by spectral simulations and in vivo. A short echo time (TE) point resolved spectroscopy (PRESS) with TE = 30 ms and a stimulated echo acquisition mode (STEAM) with TE = 11 ms and mixing time (TM) = 17 ms were compared for reliability of Glx fit. Data allowed us to determine sample size estimates for future clinical studies for the first time. Results showed that PRESS provided a reliable fit for Glx in all cases (Cramér Rao lower bounds < 20%) whereas no reliable Glx fits were achieved using STEAM. Neither protocol provided reliable Glu quantification. The power calculations showed that a minimum sample size of 17 subjects per group was needed to detect Glx changes of > 20% using the PRESS sequence. This study proposed a clinically feasible MRS method for Glx detection in the human cervical cord in vivo including sample sizes needed for conclusive clinical studies.

Complicated Management of Left-Sided Loculated Empyema Secondary to Streptococcus intermedius and Prevotella in a 53-Year-Old Male.

We present the case of a 53-year-old male with complicated left-sided parapneumonic effusion due to Streptococcus intermedius and Prevotella buccae. Management required video-assisted thoracoscopic surgery and partial decortication of the left lung. Complications during the hospital stay were extensive, including sepsis, acute hypoxic respiratory failure, alcohol withdrawal, and transient ischemic attack.

Temporal lobe perceptual predictions for speech are instantiated in motor cortex and reconciled by inferior frontal cortex.

Humans use predictions to improve speech perception, especially in noisy environments. Here we use 7-T functional MRI (fMRI) to decode brain representations of written phonological predictions and degraded speech signals in healthy humans and people with selective frontal neurodegeneration (non-fluent variant primary progressive aphasia [nfvPPA]). Multivariate analyses of item-specific patterns of neural activation indicate dissimilar representations of verified and violated predictions in left inferior frontal gyrus, suggestive of processing by distinct neural populations. In contrast, precentral gyrus represents a combination of phonological information and weighted prediction error. In the presence of intact temporal cortex, frontal neurodegeneration results in inflexible predictions. This manifests neurally as a failure to suppress incorrect predictions in anterior superior temporal gyrus and reduced stability of phonological representations in precentral gyrus. We propose a tripartite speech perception network in which inferior frontal gyrus supports prediction reconciliation in echoic memory, and precentral gyrus invokes a motor model to instantiate and refine perceptual predictions for speech.

A Rare Third Ventricular Dermoid Cyst in an Adult With Imaging Characteristics Consistent With a Colloid Cyst.

A 64-year-old male presented with spontaneous intracerebral hemorrhage and obstructive hydrocephalus without evidence of a third ventricular mass in 2019. The patient was lost to follow-up and re-admitted one year later for hydrocephalus secondary to a third ventricular mass. Imaging characteristics were consistent with a colloid cyst, which was the presumptive diagnosis. A transcallosal transchoroidal approach was utilized for cyst resection. The cyst wall was carefully incised, releasing flakey, partially solid contents which were grossly inconsistent with a colloid cyst. Due to the concern of iatrogenic cyst rupture in the setting of unknown diagnosis, the patient was placed on steroids post-operatively. Surgical specimens sent at the time of surgery were consistent with dermoid cyst. We present the first reported case of a third ventricular dermoid cyst in an adult initially misdiagnosed as a colloid cyst based on imaging characteristics.

Microvascular decompression in patients with isolated maxillary division trigeminal neuralgia, with particular attention to venous pathology.

OBJECT: The authors have the clinical impression that patients with isolated V2, or maxillary division, trigeminal neuralgia (TN) are most often women of a younger age with atypical pain features and a predominance of venous compression as the pathology. The aim of this study was to evaluate a specific subgroup of patients with V2 TN. METHODS: Among 120 patients who underwent microvascular decompression (MVD) for TN in 2007, data were available for 114; 6 patients were lost to follow-up. Patients were stratified according to typical (Burchiel Type 1), mixed (Burchiel Type 2a), or atypical (Burchiel Type 2b) TN. A pain-free status without medication was used to determine the efficacy of MVD. All patients were contacted in June 2008 and again in January 2009 at 12-24 months after surgery (median 18.4 months) and asked to rate their response to MVD as excellent (complete pain relief without medication), fair (complete pain relief with medication or some relief with or without medication), or poor (continued pain despite medication; that is, no change from their preoperative baseline pain status. RESULTS: Of 114 patients, 14 (12%) had isolated V2 TN. Among these 14 were 2 typical (14%), 1 mixed (7%), and 11 atypical cases (79%) of TN. Among the remaining 100 cases were 37 typical (37%), 14 mixed (14%), and 49 atypical cases (49%) of TN. In the isolated V2 TN group, all patients were women as compared with 72% of women in the larger group of 100 patients (p = 0.05, chi-square test). The average age in the isolated V2 TN group was 51.2 years (median 48.1 years) versus 54.2 years (median 54.0 years) in the remainder of the group (p = NS, unpaired Student t-test). In the isolated V2 TN group, there was a predominance of atypical pain cases (79%) versus 49% in the remainder of the group, and this finding trended toward statistical significance (p = 0.07, chi-square test). Venous contact or compression (partly or wholly) was noted in 93% of the patients with isolated V2 versus 69% of the remainder of the group (p = 0.13, chi-square test). The likelihood of excellent outcomes in the patients with V2 TN (71%) was compared with that in typical pain cases (79%) among patients in the rest of the group (that is, the bestoutcome group), and no difference was found between the 2 groups (p = 0.8, chi-square test). CONCLUSIONS: The authors confirmed that patients with isolated V2 TN were more likely to be female, tended toward an atypical pain classification with venous pathology at surgery, and fared just as well as those presenting with typical pain.

Lesson of the month 2: A rare presentation of stroke: diagnosis made on magnetic resonance imaging.

Bilateral thalamic infarcts are uncommon posterior circulation strokes. The artery of Percheron (AOP) is a rare anatomical variant involving a singular arterial supply to both thalami and occlusion leads to bilateral thalamic infarction.We report the case of a 71-year-old man who presented with decreased consciousness (fluctuating Glasgow Coma Scale score of 5-7). He had a background of atrial fibrillation and was anticoagulated with dabigatran, a novel oral anticoagulant. Computed tomography (CT) scan showed a mildly reduced attenuation in the region of the left thamalus.Subsequent diffusion-weighted magnetic resonance imaging (MRI) showed acute brainstem infarction, extending into the thalamus bilaterally, likely due to AOP occlusion. Bilateral thalamic infarcts due to AOP occlusion may not be recognised on initial CT scan and are more readily seen using diffusion-weighted MRI, which is the most beneficial imaging modality to aid in early diagnosis and treatment.

Value of the central vein sign at 3T to differentiate MS from seropositive NMOSD.

OBJECTIVE: To assess the value of the central vein sign (CVS) on a clinical 3T scanner to distinguish between multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD). METHODS: Eighteen aquaporin-4-antibody-positive patients with NMOSD, 18 patients with relapsing-remitting MS, and 25 healthy controls underwent 3T MRI. The presence of a central vein in white matter lesions on susceptibility-weighted imaging, defined as a thin hypointense line or a small dot, was recorded. RESULTS: The proportion of lesions with the CVS was higher in MS than NMOSD (80% vs 32%, p < 0.001). A greater proportion of lesions with the CVS predicted the diagnosis of MS, rather than NMOSD (odds ratio 1.10, 95% confidence interval [CI] 1.04 to 1.16, p = 0.001), suggesting that each percent unit increase in the proportion of lesions with the CVS in an individual patient was associated with a 10% increase in the risk of the same patient having MS. If more than 54% of the lesions on any given scan show the CVS, then the patient can be given a diagnosis of MS with an accuracy of 94% (95% CIs 81.34, 99.32, p < 0.001, sensitivity/specificity 90%/100%). CONCLUSION: The clinical value of the CVS in the context of the differential diagnosis between MS and NMOSD, previously suggested using 7T scanners, is now extended to clinical 3T scanners, thereby making a step towards the use of CVS in clinical practice. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that the CVS on 3T MRI accurately distinguishes patients with MS from those with seropositive NMOSD.

The endoscopic endonasal approach to cranio-cervical junction: the complete panel.

We aim to establish a complete summary on the Endoscopic Endonasal Approach (EEA) to Cranio Cervical Junction (CCJ): evolution since first description, criteria to predict the feasibility and limitations, anatomical landmarks, indications and biomechanical evaluation after performing the approach. A comprehensive literature search to identify all available literature published between March 2002 and June 2015, the articles were divided into four categories according to their main purpose: 1- surgical technique, 2- anatomical landmarks and limitations, 3- literature reviews to identify main indications, 4- biomechanical studies. Thereafter, we demonstrate the approach step-by-step, using 1 fresh and 3 silicon injected embalmed cadaveric specimen heads. 61 articles and one poster were identified. The approach was first described on cadaveric study in 2002, and firstly used to perform odontoidectomy in 2005. The main indication is odontoid rheumatoid pannus and basilar invagination. The nasopalatine line (NPL), the superior nostril-hard palate Line (SN-HP), the naso-axial line (NAxL), the rhinopalatine Line (RPL) and other methods were described to predict the anatomical feasibility of the approach. The craniocervical fusion is potentially unnecessary after removal of < 75% of one occipital condyle. A recent cadaveric study stated the possibility of C1-C2 fusion via EEA. This paper reviews all available clinical and anatomical studies on the EEA to CCJ. The approach marked a significant evolution since its first description in 2002. Because of its lesser complications compared to the transoral approach, the EEA became when feasible, the approach of choice to the ventral CCJ.

The minipterional approach for ruptured and unruptured anterior circulation aneurysms: Our initial experience.

OBJECTIVE: To report our experience with the minipterional (MPT) craniotomy approach for anterior circulation aneurysms and to discuss the clinical outcomes as well as to evaluate the advantages of this unique approach. MATERIALS AND METHODS: Single-center retrospective review of 57 cases involving anterior circulation aneurysms both ruptured and unruptured aneurysms treated with the MPT. We analyzed the clinical and patient demographic data, aneurysm characteristics, surgical outcomes, and complications in these individuals. RESULTS: Between July 2008 and March 2014, of the 57 patients reviewed: 45 had middle cerebral artery (MCA), 6 had internal carotid artery terminus, and 7 had posterior communicating artery aneurysms. 20 of the 57 patients presented with a ruptured aneurysm. The average aneurysm size was 5.8 mm. The length of hospitalization for unruptured aneurysm cases ranged between 3 and 5 days. The average follow-up for all cases was 21.5 months. Successful clipping of the aneurysms was obtained in all patients. None of the cases required additional skin incisions or craniotomy extensions. The overall surgical outcomes were favorable. There was no postoperative facial nerve damage, temporalis muscle wasting, or symptoms of paresthesias around the incision line. Two patients developed a postoperative stroke manifested as symptoms of unilateral arm and facial weakness, receptive aphasia, and dysarthria. CONCLUSION: The MPT provides a reliable and less invasive alternative to the standard pterional craniotomy. Furthermore, ruptured and unruptured anterior circulation aneurysms can safely and effectively be treated with limited bone removal which provides better cosmetic outcomes and excellent postoperative temporalis muscle function.

A Pediatric Tumor Found Frequently in the Adult Population: A Case of Anaplastic Astroblastoma in an Elderly Patient and Review of the Literature.

Astroblastomas are rare, potentially curable primary brain tumors which can be difficult to diagnose. We present the case of astroblastoma in a 73-year-old male, an atypical age for this tumor, more classically found in pediatric and young adult populations. Through our case and review of the literature, we note that this tumor is frequently reported in adult populations and the presentation of this tumor in the elderly is well described. This tumor is an important consideration in the differential diagnosis when managing both pediatric and adult patients of any age who present with the imaging findings characteristic of this rare tumor.

Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors.

BACKGROUND AND PURPOSE: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) has been reported as efficacious for staging of the retroperitoneum in patients with stage I nonseminomatous germ-cell testis tumors (NSGCT). However, reports are limited to a few centers, and this procedure has yet to be widely accepted as an alternative to open retroperitoneal lymph node dissection (O-RPLND). Thus, we compared our contemporary open and laparoscopic experience with RPLND. PATIENTS AND METHODS: A retrospective chart review identified 28 patients who underwent either open (N = 6) or laparoscopic (N = 22) RPLND for clinical stage I NSGCT since 2000. Each patient received the appropriate modified template dissection. Perioperative demographic data, histologic nodal status, and recurrence data were evaluated. The mean follow-up was similar in the two groups. RESULTS: The mean operative time was not significantly different (313 minutes for L-RPLND v 284 minutes for O-RPLND). However, L-RPLND did have a significantly shorter hospitalization (1.2 v 8.5 days). Significantly more lymph nodes were removed with O-LPLND than with L-RPLND (mean 33 v 17). There was a single recurrence outside the modified template after both L-RPLND and O-RPLND and one within-the-template recurrence in the O-RPLND group. CONCLUSIONS: The L-RPLND is associated with less blood loss and a shorter hospital stay than O-RPLND, whereas the lymph-node yield of O-RPLND is greater. However, during the critical early follow-up period, the oncologic effectiveness and morbidity of L-RPLND for clinical stage I NSGCT appears similar to that of O-RPLND.

Automatic epileptic seizure detection using scalp EEG and advanced artificial intelligence techniques.

The epilepsies are a heterogeneous group of neurological disorders and syndromes characterised by recurrent, involuntary, paroxysmal seizure activity, which is often associated with a clinicoelectrical correlate on the electroencephalogram. The diagnosis of epilepsy is usually made by a neurologist but can be difficult to be made in the early stages. Supporting paraclinical evidence obtained from magnetic resonance imaging and electroencephalography may enable clinicians to make a diagnosis of epilepsy and investigate treatment earlier. However, electroencephalogram capture and interpretation are time consuming and can be expensive due to the need for trained specialists to perform the interpretation. Automated detection of correlates of seizure activity may be a solution. In this paper, we present a supervised machine learning approach that classifies seizure and nonseizure records using an open dataset containing 342 records. Our results show an improvement on existing studies by as much as 10% in most cases with a sensitivity of 93%, specificity of 94%, and area under the curve of 98% with a 6% global error using a k-class nearest neighbour classifier. We propose that such an approach could have clinical applications in the investigation of patients with suspected seizure disorders.

Large sphenoid wing meningiomas involving the cavernous sinus: conservative surgical strategies for better functional outcomes.

OBJECTIVE: The ability to resect meningiomas that involve the medial and anterior compartments of the cavernous sinus has been refuted. In this retrospective study, we determined the efficacy of total resection of meningiomas that invade the cavernous sinus but are restricted to the lateral compartment. METHODS: We reviewed the charts of 38 consecutive patients with sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous meningiomas who underwent surgical treatment. We assessed early and late cranial nerve morbidity, extent of resection, and long-term outcome (mean, 96 mo). RESULTS: In all patients, tumors exceeded 3 cm diameter. In 22 of 24 patients, total microscopic excision was achieved in tumors that involved only the lateral compartment of the cavernous sinus and touched or partially encased the cavernous internal carotid artery (i.e., modified Hirsch Grades 0 and 1, respectively). In 2 of 24 patients, remaining tumor infiltrated the superior orbital fissure. All 14 patients who had tumors that encased (with or without narrowing) the cavernous segment of the internal carotid artery (Hirsch Grades 2-4) underwent incomplete resection. Among 38 patients, mortality was 0%, late cranial nerve deficits remained in 6 (16%), and late Karnofsky Performance Scale scores exceeded 90 in 34 patients (90%). Four patients (10.5%) developed a recurrence or regrowth. Of 20 patients who were treated with either linear accelerator-based stereotactic radiosurgery or fractionated conformal radiotherapy, 11 had residual tumor and a moderate to high proliferative index, 4 had atypical tumors and 1 had angioblastic meningioma after total excision, 2 had regrowth, and 2 had recurrent tumors. In 18 (90%) of the 20 patients who underwent radiation, tumor size was reduced or controlled. CONCLUSION: On the basis of this study and a review of the literature, we demonstrate that sphenocavernous, clinoidocavernous, and sphenoclinoidocavernous meningiomas of Hirsch Grades 0 and 1 can be excised from the lateral compartment of the cavernous sinus without postoperative mortality and with acceptable rates of morbidity. Residual tumor in the medial compartment (Hirsch Grades 2-4) may be treated with some form of radiation therapy or observation.