Spinal cord stimulation for complex regional pain syndrome type I with spinal myoclonus - a case report and review of literature.

BACKGROUND: Complex regional pain syndrome (CRPS) is a chronic neuropathic painful condition, sometimes associated with spinal myoclonus. For intractable cases spinal cord stimulation is an important modality of treatment but the response of specifically myoclonus to this treatment is not well described. CASE DESCRIPTION: A 40-year old male, had a history of trauma 12 years back since when he had intractable neuropathic pain in his both upper limbs with superimposed severely disabling myoclonic jerks. He had been through multiple treatment failures. We inserted a cervical spinal cord stimulator which led to immediate cessation of myoclonic jerks, with significant improvement in visual analogue score and Oswestry disability index. CONCLUSION: In patients of chronic intractable cervico-brachial pain disorder with superimposed myoclonus, cervical spinal cord stimulation may be effective against the myoclonus as well as the pain.

Conservative treatment of exposed implant following anterior cervical instrumentation surgery - A case report and review of literature.

We report a case of traumatic C3-C4 disc prolapse in a 58 years old male, who underwent ACDF at our centre. On the third post-operative day, a hypopharyngeal rent with implant exposure was discovered. The patient suffered aspiration pneumonitis. He was tracheostomised and percutaneous endoscopic gastrostomy (PEG) feeding was started. He was managed conservatively with appropriate antibiotics and physiotherapy. He recovered and after 6 months the PEG was removed and oral feeding resumed. He was doing well 42 months after the initial surgery.

Pediatric Langerhans Cell Histiocytosis with BRAF Mutation Affecting Sacral Vertebra: A Case Report and Disease Review.

BACKGROUND: Histiocytoses are rare diseases affecting mainly children and can occur in any organ of the body. They are divided into Langerhans type and non-Langerhans type. Langerhans cell histiocytosis (LCH) mainly affects skin, bones, and lymph nodes but can also affect the hematopoietic system. Bone lesions can be critical when they involve skull base, orbit, or vertebrae and can cause permanent neurological sequelae or death. Histopathological diagnosis and molecular markers are the mainstay for accurate diagnosis. Sixty percent of LCH cases show mutation in the BRAF oncogene. They are treated with multimodality treatment which includes surgery, chemotherapy, and BRAF inhibitor therapy. Owing to the rarity of the disease and paucity of cases, the understanding and standardization of treatment is still evolving. CASE REPORT: A 14-year-old boy presented with backache, and his imaging showed erosion of first sacral vertebral body with soft tissue component impinging and compressing the spinal canal. Histopathology and molecular diagnosis showed LCH which was positive for BRAF gene mutation. Adequate canal decompression and near-total removal of the disease load with fixation of weight-bearing axis resulted in symptomatic relief and good outcome. Systemic chemotherapy was given for the small residual disease due to fear of recurrence and impending neurological complications. He responded well to first-line therapy with vinblastine and prednisolone with complete resolution of disease on a follow-up scan. CONCLUSION: Accurate diagnosis with molecular markers is essential for a good outcome of LCH. Treatment of lesions at critical locations like skull base, orbit, or vertebral axis needs to be tailored to prevent permanent neurological deficits. Newer therapies in the form of BRAF inhibitors are on the way, but the efficacy and benefit need to be tested.

Rare Presentation: A Report of 2 Identical Cases with Thoracic Compressive Myelopathy in Down Syndrome.

BACKGROUND: Atlantoaxial instability, a common finding in patients with Down syndrome (DS), is attributed to laxity of ligamentous structures. Cervical spondylosis identified in these patients has a pathogenesis of ligament laxity and early degeneration compared with the normal population. No cases have been reported showing affection of thoracic or lower levels. CASE DESCRIPTION: Two adults with DS presented with progressive spastic paraparesis with hypertrophy of ligamentum flavum at the lower thoracic level, causing canal stenosis and myelopathy. Degenerative changes were seen in the entire spine. Both patients improved with canal decompression. CONCLUSIONS: Degenerative changes of the spine occur earlier in DS, probably due to increased movements across the vertebrae owing to laxity in the ligaments. Routine workup of patients with DS presenting in their adult lives should keep in mind the affection of lower spinal levels. Early identification of thoracic myelopathy and lumbar canal stenosis gives a chance of cure.

Paediatric Moyamoya Disease and Tourette's Syndrome: An Unusual Association Responding Favourably to Direct and Indirect Cerebral Revascularisation Surgery.

BACKGROUND: Moyamoya disease, an uncommon chronic intra-cerebral arteriopathy asymmetrically affecting the proximal vasculature, is rarely associated with clinical features pertaining to movement disorders. CASE DESCRIPTION: A 5-year-and-9-month-old boy developed repetitive episodic involuntary winking of the right eye along with ipsilateral shoulder shrugging movements in an absolutely conscious state, associated with paroxysmal shouts and loud laughs and punctuated with abusive verbal expressions (coprolalia). These episodic features, over the course of the next 1.5 years, got progressively accentuated by situations which evoked stress. In addition, there was progressive regression of verbal and cognitive milestones, emotional lability and aspects of attention deficit hyperkinetic disorder. The child was evaluated by a neurologist with magnetic resonance imaging of the brain, which showed characteristic ischaemic areas involving the basal ganglia and fronto-parietal cortical areas along the middle cerebral artery territory, predominantly on the left side. Subsequent cerebral angiography revealed extensive stenosis of bilateral (predominantly left-sided) internal cerebral arteries and middle cerebral arteries with evidence of diffuse leptomeningeal collaterals. The electroencephalography was reported to be normal. He was eventually diagnosed to be suffering from Moyamoya disease with associated Tourette's syndrome. Subsequently, the child underwent left-sided superficial temporal artery to middle cerebral artery anastomosis along with encephalo-duro-arterio-myo-synangiosis. Significant clinico-radiological improvement was noted after 3 months. The clinical deficiencies had dramatically resolved. There was evidence of excellent development of both direct and indirect surgical collaterals along the left middle cerebral artery territory. He could go back to school. CONCLUSION: Ours is probably the first case reporting an association of paediatric Moyamoya disease with Tourette's syndrome, which significantly resolved after cerebral revascularisation surgery.

Coexisting Vestibular Schwannoma with Fibrous Dysplasia: A Rare Occurrence.

Coexisting vestibular schwannoma (VS) with fibrous dysplasia is extremely rare. Here, we represent the case of a 48-year-old female with coexisting VS and fibrous dysplasia of overlying occipital bone. After proper evaluation, the patient underwent surgery and microscopic total excision of the right cerebellopontine angle lesion was achieved. However, during surgery, bone work was extremely tedious and exposure to reach up to lesion was difficult. To the best of our knowledge, this is the first reported case of coexisting fibrous dysplasia of overlying bone and VS as histopathological diagnosis.

Microsurgical management of giant intracranial aneurysms: a single surgeon experience from Louisiana State University, Shreveport.

BACKGROUND: Surgical management of giant aneurysms is challenging because of multiple factors: aneurysm size, wide neck, thrombosis, and calcification. The risk of ischemic complications is higher when compared with smaller aneurysms. We present our surgical experience of clipping these difficult aneurysms. METHODS: A total of 59 giant intracranial aneurysms underwent surgical clipping by a single surgeon over the last 2 decades. The case records of these patients were retrospectively reviewed to evaluate the operative outcome. The study was approved by the Institutional Review Board of the Louisiana State University Health Sciences Center, Shreveport, in compliance with Health Insurance Portability and Accountability Act regulations. RESULTS: The mean age in our series was 50.57 years (range 19 to 77 years). There was a female preponderance (female-male ratio 2.47:1). Headache was the most common form of presentation (62.7%, n = 37), followed by cranial nerve deficits (32.2%, n = 19) and seizures (13.5%, n = 8). Subarachnoid hemorrhage was seen in 38.9% (n = 23). Eleven patients had posterior circulation aneurysm. At admission, 47.8% (n = 11) of the patients were in good grade (grade I and II). Multiple aneurysms were noted in 18.64% (n = 11) of cases, but none of the patients harbored more than 1 giant aneurysm. Mortality rate was 10.1% (n = 6). The majority of patients (71.9%) experienced a good outcome (Glasgow Outcome Scale score [GOS] 4 and 5) at the last follow-up. Binary logistic regression analysis was performed to find predictors of poor outcome. Poor clinical grade, ruptured aneurysm, and posterior location predicted independently for poor outcome. CONCLUSIONS: Giant aneurysms impose a relatively higher risk of mortality and morbidity to patients. With proper case selection and appropriate surgical strategy, it is possible to achieve a favorable outcome in most cases.

Microsurgical management of basilar artery apex aneurysms: a single surgeon's experience from Louisiana State University, Shreveport.

OBJECTIVE: Basilar artery apex aneurysms continue to generate technical challenges and management controversy. Endovascular intervention is becoming the mainstay in the management of these formidable aneurysms, but it has limitations, especially with large/giant or wide neck basilar apex aneurysms. There is paucity of data in the available literature pertaining to the successful management of large/giant, wide neck, and calcified/thrombosed basilar apex aneurysms. We present our experience with consecutively operated complex basilar apex aneurysms so as to present the role of microneurosurgery as a viable management option for these aneurysms. METHODS: Ours is a retrospective analysis of case-records for operated cases of basilar artery aneurysms spanning 18 years. Basilar apex aneurysms >10 cm, calcified or thrombosed, neck ≥4 mm posterior direction, and retro/subsellar were considered as complex anatomy aneurysms. Basilar apex aneurysms with favorable anatomy were included in the study as a reference group for statistical analysis. Patient demographics, complex features of aneurysms, clinical grade, and outcomes were analyzed. RESULTS: A total of 33 (53.2%) patients had complex anatomy: large (>10 mm) in eight (24.2%); giant aneurysms (>25 mm) in seven (21.2%); wide-neck in 22 (66.7%); and calcified/thrombosed morphology in five (15.1%). The mean age was 48.5 years, and 22 (66.67%) were women. All aneurysms were clipped by the use of various skull base approaches. A total of 71.9% of patients harboring complex aneurysm had good outcomes. If only unruptured and good grade complex aneurysms also are considered, then 86.9% (n = 20) patients had good outcomes. Statistically there was no significant difference in the outcomes of complex and noncomplex aneurysm. CONCLUSIONS: Although concerning, the management of large/giant, wide neck, and calcified/thrombosed aneurysms with microneurosurgery is still a competitive alternative to endovascular therapy. After careful selection of appropriate skull base approaches based on the complexity of the basilar apex aneurysm, microneurosurgery can achieve acceptable results.

Rapid enlargement of aneurysmal remnant as a cause of early rebleed after coil embolization of posterior communicating artery aneurysm: a case report.

BACKGROUND: Early rebleeding of an aneurysm following endovascular coiling is a serious complication and carries a high risk of mortality and morbidity. CLINICAL PRESENTATION: A 56-year-old woman was diagnosed with subarachnoid hemorrhage (SAH) due to rupture of a saccular aneurysm arising from the communicating segment (PComm) of the right internal carotid artery. She underwent an uneventful right pterional craniotomy and clipping of the aneurysm. On postoperative day 5, she lapsed into altered sensorium. Computed tomography (CT) of the head showed fresh subarachnoid bleed and digital subtraction cerebral angiography (DSA) demonstrated a relatively small (4.9 mm × 3.5 mm × 2.6 mm) left PComm saccular aneurysm with complete obliteration of the previously clipped right PComm aneurysm. She underwent coil embolization of this aneurysm, with a small remnant at the neck (>95% occlusion was achieved). On postcoiling day 9, she again lapsed into altered sensorium. CT of the head revealed fresh SAH. CT-angiography and DSA was performed, which showed significant enlargement of the residual left PComm aneurysm with coil impaction. INTERVENTION: Patient was subjected to a standard left pterional craniotomy and clipping of the residual aneurysm. She also underwent a subsequent ventriculoperitoneal shunt for the associated hydrocephalus. She gradually recovered and was able to return to work with minimal disability. CONCLUSION: Rapid enlargement and rupture of an aneurysmal remnant following endovascular coiling is a rare cause of an early rebleed, especially associated with "small" aneurysms. A more stringent postprocedural imaging strategy along with restrained anticoagulation in such "high-risk" cases is recommended.

An update on unilateral sporadic small vestibular schwannoma.

Advances in neuroimaging have increased the detection rate of small vestibular schwannomas (VSs, maximum diameter < 25 mm). Current management modalities include observation with serial imaging, stereotactic radiosurgery, and microsurgical resection. Selecting one approach over another invites speculation, and no standard management consensus has been established. Moreover, there is a distinct clinical heterogeneity among patients harboring small VSs, making standardization of management difficult. The aim of this article is to guide treating physicians toward the most plausible therapeutic option based on etiopathogenesis and the highest level of existing evidence specific to the different cohorts of hypothetical case scenarios. Hypothetical cases were created to represent 5 commonly encountered scenarios involving patients with sporadic unilateral small VSs, and the literature was reviewed with a focus on small VS. The authors extrapolated from the data to the hypothetical case scenarios, and based on the level of evidence, they discuss the most suitable patient-specific treatment strategies. They conclude that observation and imaging, stereotactic radiosurgery, and microsurgery are all important components of the management strategy. Each has unique advantages and disadvantages best suited to certain clinical scenarios. The treatment of small VS should always be tailored to the clinical, personal, and social requirements of an individual patient, and a rigid treatment protocol is not practical.

Posterior cranial fossa meningiomas.

This study evaluated the outcomes, complications, and recurrence rates of posterior cranial fossa meningiomas. We retrospectively reviewed our surgical experience with 64 posterior cranial fossa meningiomas. Mean age was 56 years with a female preponderance (67.2%). Headache was the most common symptom. Retrosigmoid approach was the commonest surgical procedure (23.4%). The incidence of cranial nerve related complications was 28%. Postoperatively facial nerve weakness was observed in 11%. The incidence of cerebrospinal fluid leak was 4.6%. Gross total resection was achieved in 37 patients (58%). Sixteen patients (25%) with residual tumors underwent Gamma knife radiosurgery. Recurrence or tumor progression was observed in 12 patients (18.7%). Operative mortality was 3.1%. At their last follow-up, 93% of the cases achieved Glasgow Outcome Scale scores 4 or 5. Total excision is the ideal goal which can be achieved with meningiomas located in certain location, such as lateral convexity, but for other posterior fossa meningiomas the close proximity of critical structures is a major obstacle in achieving this goal. In practicality, a balance between good functional outcome and extent of resection is important for posterior cranial fossa meningiomas in proximity to critical structures.

The superior transvelar approach to the fourth ventricle and brainstem.

Objective The superior transvelar approach is used to access pathologies located in the fourth ventricle and brainstem. The surgical path is below the venous structures, through the superior medullary velum. Following splitting the tentorial edge, near the tentorial apex, the superior medullary velum is split in the cerebello-mesencephalic fissure. Using the supracerebellar infratentorial, transtentorial or parietal interhemispheric routes, the superior medullary velum is approached. Splitting this velum provides a detailed view of the fourth ventricle and its floor. Materials and Methods A total of 10 formalin-fixed specimens were dissected in a stepwise manner to simulate the superior transvelar approach to the fourth ventricle. The exposure gained the distance from the craniotomy site and the ease of access was assessed for each of the routes. We also present an illustrative case, operated by the senior author (AN). Results The superior transvelar approach provides access to the entire length of the fourth ventricle floor, from the aqueduct to the obex, when using the parietal interhemispheric route. In addition, this approach provides access to the entire width of the floor of the fourth ventricle; however, this requires retracting the superior cerebellar peduncle. Using the supracerebellar infratentorial route gives a limited exposure of the superior part of the fourth ventricle. The occipital interhemispheric route is a compromise between these two. Conclusion The superior transvelar approach to the fourth ventricle provides a route for approaching the fourth ventricle from above. This approach does not require opening the posterior fossa in the traditional way, and provides a reasonable alternative for accessing the superior fourth ventricle.

Dorello's Canal for Laymen: A Lego-Like Presentation.

Objective Dorello's canal was first described by Gruber in 1859, and later by Dorello. Vail also described the anatomy of Dorello's canal. In the preceding century, Dorello's canal was clinically important, in understanding sixth nerve palsy and nowadays it is mostly important for skull base surgery. The understanding of the three dimensional anatomy, of this canal is very difficult to understand, and there is no simple explanation for its anatomy and its relationship with adjacent structures. We present a simple, Lego-like, presentation of Dorello's canal, in a stepwise manner. Materials and Methods Dorello's canal was dissected in five formalin-fixed cadaver specimens (10 sides). The craniotomy was performed, while preserving the neural and vascular structures associated with the canal. A 3D model was created, to explain the canal's anatomy. Results Using the petrous pyramid, the sixth nerve, the cavernous sinus, the trigeminal ganglion, the petorclival ligament and the posterior clinoid, the three-dimensional structure of Dorello's canal was defined. This simple representation aids in understanding the three dimensional relationship of Dorello's canal to its neighboring structures. Conclusion Dorello's canal with its three dimensional structure and relationship to its neighboring anatomical structures could be reconstructed using a few anatomical building blocks. This method simplifies the understanding of this complex anatomical structure, and could be used for teaching purposes for aspiring neurosurgeons, and anatomy students.

How bullet trajectory affects outcomes of civilian gunshot injury to the spine.

We analysed retrospectively the effect of missile trajectory on outcomes from civilian gunshot injury to the spine (GSIS) between 1994 and 2008. Most of the 98 patients were male (88.8%). A minority (8%) of patients had multiple column injuries and a bone or bullet fragment in the spinal canal (14%). Neurologic injury was seen in 33%; and external bracing was applied to 30% of patients. The odds of bracing among patients with multiple levels of damage were 3.4 times than for patients with a single vertebral level of damage. The odds of paralysis among black patients were 6.33 times the odds among non-black patients. The odds of paralysis among patients with a fragment in the spinal canal were 12.99 times those without. We conclude that the supero-inferior trajectory affects the number of vertebral levels involved and consequently the need for bracing. The lateral trajectory affects neurological outcomes.

Focal intradural brain infections in children: an analysis of management and outcome.

INTRODUCTION: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. MATERIALS AND METHODS: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. RESULTS: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. CONCLUSIONS: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

Reoperations after surgery for lumbar spinal stenosis.

OBJECTIVE: To study the indication for reoperations after lumbar decompression, the factors predisposing to redo operations, and the effect of prior instrumentation on developing adjacent level stenosis requiring reoperation. METHODS: Kaplan-Meier analysis was used to compare the median interval to first reoperation. Cox regression was used for multivariate analysis of time to first reoperation. RESULTS: Of 335 patients who underwent surgery for lumbar spinal stenosis, 63 (18%) underwent instrumentation in addition to decompression. There were 50 reoperations performed in 44 patients (13%). Of these 50 reoperations, 26 were at the same level, 14 were at the same level plus an adjacent level, and 10 were at an adjacent level. In 21 reoperations, the indication was adjacent level spinal stenosis; in 16, adjacent level spinal stenosis plus instability; in 9, instability alone; and in 4, disc problem. The risk of reoperation was higher among male patients (hazard ratio [HR] 1.2, 95% confidence interval [CI] 0.586-2.635) and in patients with prior instrumentation (HR 1.7, 95% CI 0.684-4.640). There was no statistical association between prior instrumentation and subsequent risk of reoperation (P = 0.12). There was no association between prior instrumentation and development of adjacent level stenosis requiring reoperation (P = 0.473). CONCLUSIONS: Many patients with spinal stenosis undergo instrumentation because of instability. Most patients in this study underwent reoperation at the same level, and the most common pathology was spinal stenosis. The risk of reoperation was lower in older patients (≥65 years old). Although there was a trend that the risk of reoperation was higher among patients with prior instrumentation, it did not reach statistical significance. In this study, there was no association between prior instrumentation and adjacent level stenosis requiring reoperation. These findings need to be evaluated further in randomized trials.

Ambroise Paré and 16th century neurosurgery.

The luminousness of Ambroise Paré, the surgeon-statesman, has withstood the ravages of time as the mark of a man, a hero, a surgeon-par-excellence, and above all, a benevolent philosopher. A self-made individual, his tryst with the art of surgery emanated from the literally non-stop battlefields of 16th century feudal Europe. Although a maverick in the medical world of his times; he rose from the humblest origins to the highest echelons solely as a result of his own genius and diligence. Among his mammoth contributions to the renaissance of surgery, Paré did perform many procedures which we see as neurosurgical, especially in the realms of neurotrauma and paediatric neurosurgery; the present vignette is an attempt to elucidate the same.

Paraclinoid carotid aneurysms.

Paraclinoid aneurysms originate from the internal carotid artery between the distal dural ring and the posterior communicating artery. Giant, multiple and bilateral aneurysms are more frequent in this group of aneurysms. Surgical clipping of these aneurysms is technically challenging due to the adjacent bony anatomy and neurovascular structures. Operative mortality has been reduced substantially due to advances in microsurgical techniques. However, there is still no uniformity with respect to the surgical procedures used, especially regarding the use of skull-base approaches and resection of the anterior clinoid process. Due to the complexity of these aneurysms, endovascular procedures are used frequently to treat these aneurysms. We have reviewed the anatomical, radiological aspects and classification of paraclinoid aneurysms. Surgical and endovascular management options are also reviewed.

Petroclival meningiomas: study on outcomes, complications and recurrence rates.

OBJECT: Petroclival meningiomas are notoriously difficult lesions to manage surgically, given the critical neurovascular structures that are intimately associated with the tumors. In this paper, the authors' aim was to review their series of patients with petroclival meningiomas who underwent surgical treatment; emphasis was placed on evaluating modes of presentation, postoperative neurological outcome, complications, and recurrence rates. METHODS: Fifty patients underwent surgical treatment for petroclival meningiomas. The majority of the patients were women (72%). The authors retrospectively reviewed the patients' medical records, imaging studies, and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, and recurrence rates. RESULTS: Headache was the most common presentation (58%). The most commonly used approach was the transpetrous approach (in 16 patients), followed by the orbitozygomatic approach (in 13). Gross-total resection was performed in 14 patients (28%), and in the remaining patients there was residual tumor (72%). Eighteen patients with tumor remnants were treated with Gamma Knife surgery. New postoperative cranial neuropathies were noted in 22 patients (44%). The most common cranial nerve (CN) deficit following surgery was CN III dysfunction (in 11 patients) and facial weakness (in 10). In 9 patients, the CN dysfunction was transient (41%), and 7 patients had permanent dysfunction (32%). Eight patients developed hydrocephalus and all required placement of a ventriculoperitoneal shunt. A CSF leak was noted in only 2 patients (4%), and wound dehiscence was noted in 1. The CSF leaks and the wound dehiscence occurred in patients who were undergoing reoperations. Adequate radiographic follow-up (minimum 6 months) was available for 31 patients (62%). The mean follow-up was 22.1 months. In 6 patients, tumor progression or recurrences were noted. The median time to recurrence was 84 months. At the time of discharge from the hospital, 92% of the patients had good outcomes (Glasgow Outcome Scale Scores 4 and 5). Three patients died of causes not directly related to the surgery. CONCLUSIONS: Petroclival meningiomas still pose a formidable challenge to neurosurgeons. In their series, the authors used multiple skull base approaches and careful microneurosurgical technique to achieve a good functional outcome (Glasgow Outcome Scale Score 4 or 5) in 92% of patients, although the extent of gross-total resection was only 28%. The authors' primary surgical goal was to achieve maximal tumor resection while maintaining or improving neurological function. The authors favor the treatment of residual tumor or recurrent tumor with stereotactic radiosurgery.