Petroclival Clinoidal Folds and Arachnoidal Membranes of the Anteromedial Incisural Space: Clinical Anatomy for Neuro Critical Care.

A systematic and narrative literature review was performed, focusing attention on the anatomy of the area located at the junction of the sphenoid and the basal portion of the temporal bone (petrous bone, petrous apex, upper petro-clival region) encircled by the free edge of the tentorium, the insertion of the tentorium itself to the petrous apex and the anterior and posterior clinoid processes that give rise to three distinct dural folds or ligaments: the anterior petroclinoid ligament, the posterior petroclinoid ligament and the interclinoid ligament. These dural folds constitute the posterior portion of the roof of the cavernous sinus denominated "the oculomotor triangle". The main purpose of this review study was to describe this anatomical region, particularly in the light of the relationships between the anterior margin of the free edge of the tentorium and the above-mentioned components of the sphenoid and petrous bone.

Peri-partum respiratory management of pregnant women with neuro-muscular disorders: a prospective observational study (IT-NEUMA-Pregn study).

BACKGROUND: Pregnant women with neuromuscular diseases (NMDs) often display respiratory muscle impairment which increases the risk for pulmonary complications (PCs). The aim of this study was to identify pregnant NMDs patients with pulmonary risk factors and to apply in these women non-invasive ventilation (NIV) combined with mechanical insufflation-exsufflation (MI-E) in the peri-partum period. METHODS: We conducted a multicenter observational study on women with NMDs undergoing cesarean section or spontaneous labor in a network of 7 national hospitals. In these subjects we applied a protocol for screening and preventing PCs, and we evaluated PCs rate, maternal and neonatal outcome. RESULTS: Twenty-four patients out of the 94 enrolled pregnant women were at risk for PCs and were trained or retrained to use NIV and/or MI-E before delivery. After delivery, 17 patients required NIV with or without MI-E. Despite nine out of the 24 women at pulmonary risk developed postpartum PCs, none of them needed reintubation nor tracheostomy. In addition, the average birth weight and Apgar score were normal. Only one patient without pulmonary risk factors developed postpartum PCs. CONCLUSION: This study showed the feasibility of applying a protocol for screening and treating pregnant NMDs women with pulmonary risk. Despite a PCs rate of 37% was observed in these patients, maternal and neonatal outcome were favorable.

Tuberculum sellae meningiomas: surgical outcomes in 65 patients, review of the literature and proposal for an anatomical and radiological classification.

Tuberculum sellae meningiomas (TSM) are challenging tumors due to their proximity to vital neurovascular structures. We propose a new classification system based on anatomical and radiological parameters. All patients treated for TSM, between January 2003 and December 2016, have been retrospectively reviewed. A systematic research was performed in PubMed database to review all studies comparing the performance of transcranial (TCA) and transphenoidal (ETSA) approaches. Overall, 65 patients were included in the surgical series. Gross total removal (GTR) was achieved in 55 patients (85%) and near total resection in 10 (15%). 54 patients (83%) showed a stability or an improvement of visual functions and 11 (17%) worsened. Postoperative complications were observed in seven patients (11%): CSF leak in one patient (1.5%); diabetes insipidus in two (3%); hypopituitarism in two (3%) third cranial nerve paresis and subdural empyema in one (1.5%). For the literature review, data about 10,833 patients (TCA N.=9159; ETSA N.=1674) were recorded; GTR was achieved in 84.1% (range 68-92%) of TCA and in 79.1% (range 60-92%) of ETSA; visual improvement (VI) occurred in 59.3% of TCA (range 25-84%) and in 79.3% of ETSA (range 46-100%); visual deterioration (VD) was registered in 12.7% of TCA (0-24%) and in 4.1% of ETSA (range 0-17%); a CSF-leak was observed in 3.8% of TCA (range 0-8%) while in ETSA in 18.6% of patients (range 0-62%); vascular injuries was reported in 4% (range 0-15%) of TCA and in 1.5% (range 0-5%) of ETSA. In conclusion, TSMs represent a unique category of midline tumors. The proposed classification system provides an intuitive and reproducible method in the choice of the most suitable approach.

Chondromyxoid Fibroma of the Skull Base: Our Experience with an Elusive Disease.

Chondromyxoid fibroma (CMF) is an extremely rare lesion of the skull base. This histologic type typically predilects metaphysis of the long bones. It is locally invasive/infiltrative, and this tendency is more concerning in the skull base, where a radical resection is often technically impossible because of the presence of vital neurovascular structures. We present a case of a 19-year-old woman who presented with a sudden onset of right facial weakness, progressively worsening to a severe disfiguring motor weakness. Gadolinium-enhanced brain magnetic resonance imaging showed an osteolytic lesion located in the right mastoid involving the stylomastoid foramen and the right seventh cranial nerve. A partial mastoidectomy was performed, with an excellent rate of tumor resection and complete local control of the disease at follow-up. The analysis of current literature indicates that a radiologic diagnosis is rarely strictly convincing of CMF. Histologic diagnosis is often difficult due to the lack of a specific immunohistochemical pattern of chondrosarcoma. Surgery is currently recognized as the mainstay to manage this lesion, although a trend toward adjuvant radiation therapy (RT) currently is seen. Although a tendency of local recurrence is well recognized in the literature, the very slow and indolent behavior of this lesion plus the trend to enhance local control of the disease with high-dose RT pushed us to a reappraise the role of radical skull base surgeries burdened by the risks of major complications, cosmetic deformities, and additional neurologic deficits.