Suprasellar Meningioma Classification: Endoscopic Transnasal Perspective.

Objectives Midline suprasellar meningiomas include planum sphenoidale, tuberculum sellae, and diaphragma sellae meningiomas. Multiple classifications have been previously documented; however, they come with controversies and limitations, including those with surgical implications. The aim of this study was to classify suprasellar meningiomas based on their behavior toward the underlying bone and neurovascular structures. Methods Patients with newly diagnosed suprasellar meningiomas that underwent extended endoscopic transnasal approach between 2015 and 2021 were included in this study. The following parameters were evaluated: chiasmatic sulcus length, location of the optic chiasm and nerves, optic canal involvement, and vascular displacement. Results We identified 40 cases of midline suprasellar meningiomas, 1 diaphragma sellae meningioma (type A), 10 tuberculum sellae meningiomas (type B), 9 chiasmatic sulcus meningiomas (type C), and 10 planum sphenoidale meningiomas (type D). Asymmetrical visual complaints were most common in chiasmatic sulcus meningiomas, followed by tuberculum sellae meningiomas (66 and 50%, respectively). Chiasmatic sulcus meningiomas showed increased separation between the optic chiasm and the A1/A2 complex (8.9 mm) compared with tuberculum sellae (2.7 mm) and planum sphenoidale (1.9 mm) meningiomas. Compared with other types, increased chiasmatic sulcus length was observed in chiasmatic sulcus meningiomas. Conclusion Preoperative evaluation of bone involvement and tumor relation to neurovascular structures can be used to classify suprasellar meningiomas. Chiasmatic sulcus meningioma is a distinct subtype of suprasellar meningiomas. Its unique behavior toward nearby neurovascular structures could be of surgical value during tumor resection.

Atypical meningiomas compared to other WHO Grade 2 meningiomas: Histological features and prognosis.

OBJECTIVES: To study each atypical feature in atypical meningioma versus other grade 2 meningiomas and its possible relation to recurrence. METHODS: This is a retrospective study of patients with WHO grade 2 meningioma operated in our institution between 01/2008 and 12/2020. The rate of recurrence, reoperation and readmission were recorded during the follow-up period. A statistical analysis was done to determine the significance of each pathological feature in regard to recurrence. RESULTS: A total of 74 patients were included as WHO grade 2 meningioma with 60 (81%) patients having an AM and 14 (19%) patients with chordoid or clear cell meningioma. The mean age was 51 years±14. The most common location was meningioma abutting the frontal lobe (convexity). Major atypical features were more noted in the AM, however, there was no significant difference between AM and other types of meningioma. Increased Nuclear cytoplasmic ratio and cellularity were found significantly more in AM. The recurrence rate was 16.2%. No specific pathology feature (major or minor) nor the type of Grade 2 meningioma was significantly related to recurrence. CONCLUSION: The types of WHO grade 2 meningiomas have similar prognosis and recurrence rates. There is no significant difference between the atypical features in indicating a more aggressive nature or risk of recurrence in grade 2 meningiomas.

A Prospective Comparison Between Soft Tissue Dissection Techniques in Pterional Craniotomy: Functional, Radiological, and Aesthetic Outcomes.

BACKGROUND AND OBJECTIVES: Given the complex anatomy of the operative region and individual surgeon preferences, some techniques for soft tissue dissection before pterional craniotomy have gained more popularity than others. This prospective study used subjective and objective measurements to compare the functional, radiological, and aesthetic outcomes of 3 such dissection techniques. METHODS: This multicenter prospective cohort study included all patients who underwent elective pterional craniotomy between 2018 and 2020 at 3 centers in Riyadh, Saudi Arabia. All patients underwent 1 of 3 soft tissue dissection techniques: myocutaneous flap, interfascial, and subfascial dissection techniques. Clinical and radiological assessments were performed upon discharge and at the 3- and 6-month follow-ups. RESULTS: We included 78 patients, with a mean age of 44.9 ± 16.3 years. Myocutaneous flap, interfascial, and subfascial dissections were performed in 34 (43%), 24 (30%), and 20 patients (25%), respectively. The myocutaneous flap method had the shortest opening ( P = .001) and closure ( P = .005) times; tenderness was more evident in this group than in the others ( P = .05). The frontalis muscle was most affected in the interfascial dissection group ( P = .05). The frontalis nerve function was similar in all groups after 6 months ( P = .54). The incidence of temporomandibular joint dysfunction was highest in the myocutaneous flap group (29%). Decreased temporalis muscle thickness at the 6-month postoperative follow-up was most severe in the subfascial dissection group (12.6%), followed by the myocutaneous flap (11.9%) and interfascial dissection (9.9%) groups, with no significant difference ( P = .85). Temporal hollowing was more prominent in the myocutaneous flap group ( P = .03). Cosmetic satisfaction was highest in the interfascial dissection group, with no significant difference ( P = .4). CONCLUSION: This study provides important information for neurosurgeons in weighing the benefits and risks of each technique for their patients.

Early Displacement of Reconstruction Material is a Predictor of Cerebrospinal Fluid Leak Post Endoscopic Skull Base Surgery.

BACKGROUND: The reconstruction technique and materials used for endoscopic skull base surgery (ESBS) are important factors in preventing cerebrospinal fluid (CSF) leak, a notable complication following this surgery. Visualizing the status of reconstruction early in the postoperative course can help determine the risk of postoperative CSF leak. Here, we aimed to determine if the radiological status of reconstruction post endonasal endoscopic surgery can predict postoperative CSF leak. METHODS: This retrospective study included patients who had undergone ESBS between 2015 and 2020. An early computed tomography (CT) scan (obtained within 24 hours of surgery) was utilized to evaluate the reconstruction and postoperative radiological changes, and its findings were correlated with the occurrence of postoperative CSF leaks. RESULTS: Our study included 11 (12.7%) out of 86 patients with CSF leaks. The type of reconstruction, construction material, and type of nasal packing were not identified as significant risk factors for CSF leaks. The location of the fat graft (placed properly vs. displaced out of the surgical cavity) was significantly associated with CSF leak (P = 0.001). All patients with a displaced solid reconstruction (n = 5), displaced septal flap (n = 6), signs of air continuation (n = 2), or significantly increased amount of air (n = 5) presented with a CSF leak (P < 0.001). CONCLUSIONS: Early postoperative CT scan is predictive of CSF leak. Displacement of the fat graft in early postoperative CT was the most important factor in predicting CSF leak. In this patient group, paying attention to radiological predictors of CSF leaks is important, supported by clinical findings.

Outcomes and complications of microscopic transcallosal colloid cyst resection: A single institution experience.

Background: Colloid cysts have always provoked the interest of neurosurgeons due to their benign histology, wide variety of clinical presentations, and differences in reported surgical outcomes. Although recent studies have reported favorable outcomes with different surgical resection approaches, the transcallosal approach remains the most popular approach to date. In this series, we report the clinical and radiological outcomes of the transcallosal approach for the resection of third ventricle colloid cysts in 12 patients. Methods: We present a case series of 12 patients who were radiologically diagnosed with a third ventricle colloid cyst who underwent transcallosal resection by a single surgeon in one center over a 6-year period. Clinical, radiological, and surgical data were collected, and surgical outcomes and complications were analyzed. Results: Of the 12 patients diagnosed with colloid cysts, 10 (83%) presented with headache, and five (41%) presented with memory disturbance. All 12 patients showed improvement or resolution of their symptoms following resection. Nine patients (75%) presented with hydrocephalus on radiology. All the patients required preoperative or intraoperative external ventricular drain insertion. Four patients (33%) experienced transient postoperative complications. None of the patients required long-term cerebrospinal fluids shunting. One (8%) of 12 patients experienced transient memory loss. No mortality was recorded during the follow-up. Conclusion: Transcallosal resection of colloid cysts has a favorable prognosis. It allows for complete resection of the cyst with minimal transient postoperative complications. Most patients with postoperative complications show complete resolution of symptoms, with no long-term morbidity.

Early Postoperative Computed Tomography Scan Air Distribution Predicts Postoperative CSF Leak in Endoscopic Skull Base Surgery.

BACKGROUND: Cerebrospinal fluid (CSF) leak remains the primary concern of endoscopic skull base surgery (ESBS). Pneumocephalus seen in postoperative images has been linked to CSF leak in some reports; however, few studies have looked at the extent to which it is indicative of CSF leak. In the current study, we aim to examine the size and location of post-ESBS pneumocephalus in the early postoperative period and determine their association with postoperative CSF leak. METHODS: Patients undergoing ESBS in a 5-year period were included. All patients underwent brain computed tomography scan within the first 24 postoperative hours. Computed tomography scans were reviewed by a neurosurgeon and a radiologist and have been classified based on the size and location of pneumocephalus. Patients were followed in the postoperative period for clinical signs of CSF leak and managed accordingly. RESULTS: Out of 120 patients, 86 patients met the inclusion criteria. Thirty-five patients (41%) had no pneumocephalus on day one postoperative imaging, while 51 patients (59%) had pneumocephalus with different sizes and distributions. Eleven of 86 patients developed CSF leak. Of the 11 patients, 5 patients (45%) had grade 4 pneumocephalus (P value = 0.02). Patients with multiple locations of pneumocephalus were more likely to develop CSF leak (P value = 0.01). CONCLUSIONS: In post-ESBS patients, both the volume and location of the pneumocephalus are potentially predictive of CSF leak. In patients with a larger volume of intra-axial air and/or multiple air locations, an impending CSF leak should be anticipated.

Prevalence of Asymptomatic Deep Vein Thrombosis in Preoperative State of Spine Surgeries.

BACKGROUND: Deep venous thrombosis (DVT) is considered the most common cause of preventable death among hospitalized patients. A few studies have investigated the risk of venous thromboembolic events in patients undergoing elective spine surgery and reported varying incidences. We aim to assess the incidence of preoperative lower limb DVT in patients with lumbar degenerative disease undergoing elective surgery. METHODS: This is a retrospective review of prospectively collected data on adult patients with lumbar degenerative spine diseases (lumbar stenosis [LST], lumbar spondylolisthesis [SPL], or lumbar disc herniation) who were scheduled for operative management. Each patient underwent a preoperative lower limb venous Duplex (LLVD). Incidence of DVT, risk factors, and clinical course of patients were reported. RESULTS: Forty-nine patients (32 females; 65%) were included. All patients were diagnosed clinically and radiologically with lumbar degenerative diseases; LST (44.9%), SPL (36.7%), and lumbar disc herniation (18.4%), requiring surgical management. Three patients (6.1%) were found to have positive DVT studies, leading to the cancellation or rescheduling of their procedures (P < 0.01). These included 1 patient with LST (P = 0.045) and 2 patients with SPL (P = 0.006). Among patients with LST and SPL, higher disability (modified Rankin scale ≥3) was significantly associated with positive LLVD (P = 0.035). CONCLUSION: Patients with LST or SPL with higher preoperative disability scores were at higher risk to have preoperative DVT. Further research is needed to evaluate the feasibility and value of preoperative LLVD to detect DVT in patients planned for lumbar degenerative surgery.

The 100 Most Cited Articles in Endoscopic Endonasal Skull Base Surgery: A Bibliometric Analysis.

BACKGROUND: The accelerated growth of endoscopic endonasal skull base surgery has led to an abundance of highly cited works that have helped shape the field into its current state. Highlighting these works can serve as a guide for trainees and facilitate evidence-based clinical decision making and operative techniques. METHODS: Elsevier's Scopus database was used to generate a list of the 100 most cited articles on endoscopic endonasal skull base surgery in September 2022. Results were categorized based on pathology, approach, study design, and study objective. A citation per year analysis was conducted to highlight later publications that may not have had the time to accumulate as many citations as older publications. RESULTS: The average number of citations for the 100 most cited articles was 210 per article (range 104-1285). Publication dates ranged from 1997 to 2019, with the highest number of articles among the 100 most cited being published in 2008 (15 articles). The journal with the greatest number of publications was Neurosurgery (30 articles). Of the 100 most cited articles, 77 were published between 2000 and 2010. Moreover, 40 of the 100 articles reported surgical outcomes and related complications, and the most common pathology was pituitary adenoma (25 articles). CONCLUSIONS: This article provides a list of highly influential articles in the field of endoscopic endonasal skull base surgery, highlighting its rapid evolution over the last 3 decades and demonstrating its leap from small descriptive series confined to certain pathologies to larger cohorts exploring possible boundaries and other pathologies.

Ten-year survival in glioblastoma patient with neurofibromatosis type 1: illustrative case.

BACKGROUND: Gliomas are commonly detected in patients with neurofibromatosis type 1 (NF1) at an early age. Few patients with NF1 are diagnosed with glioblastoma. The course of management, response to therapy, and prognosis of such patients are unknown. Few reports have shown longer-than-average survival rates for patients with NF1 with glioblastoma. OBSERVATIONS: A 27-year-old man with NF1 presented with symptoms of high intracranial pressure. Imaging and pathology showed left frontotemporal glioblastoma. Gross total resection was achieved, and concurrent chemoradiotherapy was administered. Recurrence of tumor was detected 48 months later, and the patient underwent tumor debulking and concurrent chemoradiotherapy. The patient received first-, second-, and third-line chemotherapy (temozolomide, bevacizumab, bevacizumab/irinotecan) with good tolerance and has survived >10 years since then with good functional status. LESSONS: This case demonstrates >10 years overall survival of glioblastoma in a patient with NF1. Reports of patients with NF1 with longer survival may be attributed to the young age at diagnosis and relatively better tolerance for therapy. It might also support the growing evidence of a unique subset of glioblastoma associated with NF1 and opens the door for a more molecular targeted therapy in the future.

Modified retrosigmoid extended approach to jugular tubercle meningioma: A video abstract.

Background: Primary jugular fossa meningiomas are one of the rarest subgroups of meningioma, with an estimated incidence of 0.7-4.3% of all skull base meningiomas. Indeed, only 145 cases of jugular foramen meningiomas have been reported in the literature to date. While meningiomas of this region are typically referred to as "jugular foramen meningiomas," we make a distinction between meningiomas arising directly from the foramen itself, and those arising from the jugular tubercle. Jugular tubercle meningiomas, therefore, represent an even smaller subset of an already uncommon location for meningiomas. The jugular tubercle is the upper surface of the lateral parts of occipital bone presents an oval eminence, which overlies the hypoglossal canal and is sometimes crossed by an oblique groove for the glossopharyngeal, vagus, and accessory nerves. Only eight cases in the anterior foramen magnum lesions excised by a far lateral retrosigmoid approach have been described. The aim of this video article is to describe the surgical approach the senior author used to access lesion involving the jugular tubercle. Case Description: In this surgical video, we present a case of a 56-year-old female presented to our hospital with dizziness, headache, lower cranial nerves deficits, and lower limbs weakness. On exam, she was noted to have a left paraparesis, 9th, 10th, and 11th nerves palsies. An MRI scan demonstrated a mass in the region of the left jugular tubercle. Frozen section was suggestive of meningioma and our patient underwent a successful near total resection with no permanent neurologic sequelae. Conclusion: Jugular tubercle meningiomas are one of the rarest subgroups of meningioma. The described modified retrosigmoid approach provides outstanding access to the entire ventrolateral brainstem and cerebellopontine angle, with reduced approach related morbidity.

Persistence of communicating hydrocephalus post choroid plexus tumor resection: Case reports and review of literature.

BACKGROUND: Hydrocephalus is the most common presentation of choroid plexus tumors; it is thought to be caused either by mass effect obstructing the cerebrospinal fluid pathways or secretory properties of the tumor. In these case reports, we present two cases of choroid plexus tumors with persistence of communicating hydrocephalus postoperatively and review similar reports in the literature. CASE DESCRIPTION: Case 1: a 2-month-old baby girl presented with bulging fontanelle, sunsetting eyes. Magnetic resonance imaging (MRI) showed large third ventricle mass with communicating hydrocephalus. She underwent complete excision of tumor through transcortical approach with perioperative intraventricular hemorrhage. Hydrocephalus persisted postoperatively and the patient required permanent ventriculoperitoneal (VP) shunt. Case 2: a 16-year-old boy presented decreased visual acuity, papilledema, and morning headaches. MRI showed a tumor in the right ventricle and communicating hydrocephalus. He underwent transparietal resection of the tumor. In both cases, hydrocephalus persisted postoperatively and patients required permanent VP shunt. Review of similar cases showed the majority of cases required permanent shunting. CONCLUSION: Choroid plexus tumor patients can present with communicating hydrocephalus that may persist post tumor resection for different etiologies. Careful follow-up to determine the need for cerebrospinal fluid diversion through a permanent VP shunt is important.

Seizure outcome in moyamoya after indirect revascularization in pediatric patients: Retrospective study and literature review.

BACKGROUND: Moyamoya disease (MMD) is a unique cerebrovascular disorder characterized by progressive stenosis of anterior cerebral circulation. Moyamoya is not an uncommon disease in Saudi Arabia. Although a less common symptom of the disease, the incidence of seizure in MMD ranges from 6 to 30%. Indirect revascularization through Encephaloduroarteriosynangiosis technique is one of the surgical treatment options for MMD. In our cohort, we aim to evaluate seizure outcome in pediatric patients with moyamoya. METHODS: Eleven patients with seizure as primary presentation for MMD over a period of 10 years were included in the study. All patients underwent EDAS surgery. All patients underwent pre- and postoperative assessment of multiple factors contributing to seizure outcome. Patients were evaluated for surgery control clinically and radiologically. RESULTS: About 73% of MMD patients with seizures improved after EDAS surgery (P < 0.0005). Six patients out of 11 became seizure free. Patients with bilateral involvement of disease undergoing bilateral surgery had better seizure control than those undergoing unilateral surgery (P < 0.07). CONCLUSION: Patients with controlled seizure before surgery are more likely to be seizure free after intervention. Seizure outcome is favorable after indirect surgical revascularization in pediatric moyamoya patients.