Journal of Neurological Surgery Part B: Skull Base最新文献

Introduction: Skull base surgery is a highly innovative, multidisciplinary field that brings together teams of neurosurgeons, otolaryngology-head and neck surgeons (OHNS), plastic surgeons, ophthalmologists, radiation oncologists, and others. However, not long ago, the nascent field was instead characterized by isolated individual brilliance.

Methods: This paper explores the contributions of several key players toward breaking silos and transforming the field into what it is today. Our analysis centers on the formation of the North American Skull Base Society (NASBS), and the instrumental role that it played in the development of skull base surgery. We interviewed 12 past presidents of the NASBS and 2 prominent figures in skull base surgery. The contents of those 20 hours and 38 minutes of interviews and documents from initial NASBS meetings were analyzed. Key moments were segmented into short video clips, which complement this manuscript and are available on the NASBS website.

Results: A compelling narrative of collaboration, mentorship, and tenacity emerged from our analysis. In the 20th century, the field of skull base surgery was characterized mainly by courageous but isolated efforts by neurosurgeons and OHNS surgeons. Through mentorship, collaboration, and incredible innovation, it has since grown into a multidisciplinary, cutting-edge specialty that utilizes the strengths of several medical specialties. This transformation was largely facilitated by the formation of the NASBS in 1989, which enabled worldwide communication and collaboration among those dedicated to advancing the field.

Conclusion: The growth of skull base surgery in North America and the instrumental role of the NASBS highlight the power of collaboration and innovation. It is important to recognize and celebrate the key players who facilitated the creation and success of the NASBS, which continues to unite young members across countless disciplines under one banner.

Introduction: Over the past several decades expanded endonasal approaches have advanced significantly, paralleling the increasing importance of skull base defect reconstruction. The nasoseptal flap (NSF) is first line for most skull base reconstruction but may fail for complex or recurrent cerebrospinal fluid (CSF) leaks in central skull base. The inferior turbinate flap (ITF) presents an alternative due to proximity and robust vascular supply. This cadaveric study compares the NSF and ITF in central skull base repairs, detailing indications, limitations, and dimensions.

Methods: We analyzed five cadaveric head specimens provided by the Medical College of Georgia Department of Anatomy. The NSF and ITF were raised bilaterally on each head, yielding 20 flaps in total. Length and width of each flap were measured, and total coverage area was calculated. SPSS (ver.20.0) was used for statistical analysis. Differences in mean width, length, and coverage area between the NSF and ITF were analyzed using Student's two-independent sample t -test, with p -values <0.05 considered statistically significant.

Results: The NSF was significantly longer (64.6 mm) than ITF (42.8 mm), but the ITF was wider (46.6 mm) than NSF (36.5 mm). NSF had a larger mean coverage area (23.6 cm ² ) than ITF (19.9 cm ² ) ( p  = 0.053).

Conclusion: While the NSF provides superior coverage, the ITF is a viable option in the reconstruction ladder for central skull base defects when NSF fails, offering advantages in terms of proximity, vascular supply, and lower morbidity over other rescue flaps. Surgical technique in harvesting this flap should be known to any skull base surgeon over other more complex reconstruction flaps.

Objective: The aim of this study was to evaluate how patients with vestibular schwannoma (VS) were prepared for facial paralysis (FP).

Study design: This study comprised an online survey of members of the Acoustic Neuroma Association of America who had FP.

Methods: A 28-question survey gathering information on the patient experience related to management of FP was created. Associations between treatment setting and presence of FP were analyzed using SAS Enterprise Guide 8.4. Significance was considered at p -values < 0.05 in a univariate and multivariable model.

Results: A total of 251 subjects with VS and FP responded. A total of 14% presented with FP, 70% were diagnosed with VS at least 6 months prior to treatment, and 61% were treated at academic centers. A total of 28% felt prepared for life with FP and 42% were confident their medical team understood management. Less than 30% of respondents received educational materials. After developing FP, speech and swallow difficulty and anxiety were common, but few respondents were referred for expert management. Subjects at academic centers were more often referred to specialists in the same location. Those with preoperative FP felt their medical teams better prepared them for it, had fewer complaints of difficulty speaking, and were happier with their recovery.

Conclusion: Significant gaps in preparation and management of FP were identified. Preoperative FP led to improved perception of care; however, the delivery was similar to those without it. Studies of surgeons who manage VS are needed to better understand how they prepare patients for the emotional and physical sequelae of FP.

Background: Elevated intracranial pressure can cause skull base defects and a spontaneous cerebrospinal fluid (CSF) leak. Venous sinus stenting (VSS) has emerged as a promising treatment option for patients with a CSF leak in the setting of idiopathic intracranial hypertension (IIH). There is a lack of literature on symptomatology and quality of life (QOL) after VSS for IIH patients with a CSF leak. This study explores the effects of VSS on symptoms and QOL in IIH patients with a CSF leak.

Methods: This is a retrospective study on patients who have IIH complicated by a CSF leak and underwent VSS. A QOL questionnaire was developed from the migraine disability assessment test and the PROMIS-PI was given to patients included in this study.

Results: A total of 10 patients were included in this study. Nine patients underwent endoscopic closure of CSF prior to stent placement and one patient was treated with VSS only. There was no evidence of CSF leak recurrence in this population following VSS. Headaches improved in 5/8, tinnitus in 5/6, and visual disturbance in 4/5 patients. Diamox was discontinued in seven out of eight patients after VSS. There was an improvement in headache-specific questions ( p  = 0.0140) and overall QOL ( p  = 0.0061) on the QOL questionnaire.

Discussion: This preliminary study demonstrates that VSS is effective in alleviating many symptoms in IIH patients with a CSF leak, especially headaches. Diamox may be able to be discontinued in many patients following VSS. No CSF leak recurrence was noted in this patient population.

Objectives: We investigated the extent of access to Meckel's cave (MC) and the middle cranial fossa (MCF) protecting the internal carotid artery (ICA) using the retrosigmoid approach with endoscopic-assisted reverse anterior petrosectomy (EA-RAP).

Methods: Five specimens were dissected using the limited and extended EA-RAP. Based on the bone removal of the internal acoustic meatus (IAM) and subarcuate fossa, exposure of the MC and ICA were statistically compared.

Results: The limited and extended EA-RAP allowed access to the medial and anterior MC (4 mm posterior to the first genu of the cavernous ICA, and 20 mm posterior to foramen rotundum [FR]). The access to the lateral MC varied with distance of 12 and 8 mm medial to the foramen ovale for the limited and extended EA-RAP, respectively.In the extended EA-RAP, the exposure of the ICA was gained by drilling with the 0-degree endoscope (3 mm) versus 45-degree endoscope (9 mm). The working distances from the midpoint of the IAM to the most medial point of the exposed ICA was 24 mm. The most lateral point of the exposed ICA varied between 0- and 45-degree endoscopes with a distance of 21 and 13 mm, respectively.

Conclusion: A coronal plane from the posterior genu of the cavernous ICA and a sagittal plane to the common crus of the semicircular canals can define the area of MCF accessed by the EA-RAP. Drilling of the temporal bone should be carefully customized according to the patient and can be aided by endoscopic assistance for direct visualization to minimize the risk of injuries to ICA.

Objectives  This study aims to fill in the knowledge gap about patients with occipital condyle fractures (OCFs) and cranial nerve dysfunction (CND) and give advice about when to test the cranial nerves (CNs) and what to do when CND is diagnosed. Design  A 14-year period observational, retrospective cohort study. Setting  Level-I trauma center study. Participants  All 119 surviving cases admitted with an OCF, whereof all 40 cases with either diagnosed CND (confirmed by clinical examination) or expected CND (reported observations high suspicious for CND) were selected for detailed data collection. Early death was the only exclusion criterion because of missing data and clinical irrelevance. Main Outcome Measures  One-third of all surviving OCF patients have CND ( n  = 40/119, 33.6%), where three-quarters had more than one CN affected with a median of three CNs. Of the cases with a concomitant lateral skull base fracture ( n  = 24/40, 60%), one in three cases (36%, n  = 13/36) had facial nerve palsy and nearly two in three cases (61%, n  = 22/36) had hearing loss. Results  The facial nerve was the most commonly diagnosed CND. Solitary OCF cases often had lower CND ( n  = 11/14). Fifty-eight percent of all CND cases with follow-up data ( n  = 19/33)-corresponding to one in six of all surviving OCF cases-had chronic CND sequelae. Conclusion  Multiple and chronic CND is common in patients with an OCF. All CNs should be tested in those patients as soon as clinically possible, and testing should be repeated after 3 to 7 days and before discharge. Patients with CND should be counseled about their prognosis and be potentially referred to (e.g.) a speech and language therapist, ophthalmologist, neurologist, or otorhinolaryngologist for early treatment options.

Objective  To show the change in the anterior clinoid process (ACP) morphology in children with advancing age. Methods  Radiologic images of 180 subjects aged 1 to 18 years were included in the work. The length (ACPL), width (ACPW), and angle (ACPA) of ACP, and the distance (DisACPOS) of ACP to the optic strut (OS) were measured. ACP pneumatization and OS location types were noted. Results  ACPL, ACPW, and ACPA, and DisACPOS were measured as 12.34 ± 2.29 mm, 4.52 ± 1.03 mm, 26.26 ± 4.30°, and 5.10 ± 1.12 mm, respectively. ACP pneumatization was identified in 30 (8.3%) sides. Four types regarding its pneumatization were observed: Type 0 in 91.7% out of 360 sides, Type 1 in 2.5%, Type 2 in 3.6%, and Type 3 in 2.2%. Three configurations regarding OS location types were observed as follows: Type C in 3.6% out of 360 sides, Type D in 51.7%, and Type E in 44.7%. Linear function was calculated as y  = 9.377 + 0.312 × age for ACPL, y  = 3.716 + 0.084 × age for ACPW, and y  = 3.808 + 0.136 × age for DisACPOS. Conclusion  ACPL, ACPW, and DisACPOS increased, but ACPA did not vary with advancing ages in children. OS was located more posteriorly in children compared with adults. Most of ACP pneumatization was seen after prepubescent period.

Background: Lateral temporal bone encephaloceles incidence is increasing with obesity rates. Middle fossa (MF) craniotomy, transmastoid (TM), or combined MF + TM access can be used for repair.

Methods: Retrospective review of MF or MF + TM repair with an intradural graft. Sex, age, and body mass index (BMI) were collected. Pre/postoperative audiometric results were included. Postoperative complications were reported.

Results: A total of 49 patients (50 repairs) were included. In addition, 74% were women ( p  < 0.05). Ten patients had a history of chronic otitis media and surgery. Average BMI was 35.8, and average age was 59. Furthermore, 54% had multiple skull base defects; 18 (36%) patients had a MF approach. In total, 32 (64%) patients had a MF + TM approach for repair; 13 (40.1%) of these patients had a concurrent tympanoplasty. Hearing improved for 74%. Air conduction pure-tone average improved by an average of 5 dB (p 0.27). No differences in hearing outcomes were observed between the MF and MF + TM groups. Two patients (6%) had hearing decline. Eight complications were reported (1 (2%) skin infection, 4 (8%) recurrent/persistent cerebrospinal fluid [CSF] leaks requiring lumbar drain or shunt, and 3 (6%) episodes of aphasia or mental status change). Age >65 years was not associated with risk of postoperative complication.

Conclusion: Intradural repair of encephalocele and CSF leak is a safe and effective surgical approach. Intradural reinforcement along the entire MF floor is beneficial for multiple areas of dehiscence and thin dura. Complication rates including recurrent/persistent CSF leak and aphasia related to temporal lobe retraction were similar to previously published reports and not associated with older patient age. Hearing was stable or improved in 94% with no difference noted between MF and MF + TM repair.

Objective: Postoperative constipation in endoscopic skull base surgery (ESBS) may provoke undesired straining, which, in theory, may create intracranial pressure shifts and impact skull base reconstruction. The purpose of this study is to assess the prevalence and contributing factors to postoperative constipation after ESBS, and whether this impacts reconstructive outcomes.

Methods: Patients undergoing ESBS between July 2018 and December 2022 at a single-center, tertiary academic skull base surgery program were retrospectively reviewed. Chart reviews were performed to identify average bowel movements per day, indication for surgery, age, sex, body mass index (BMI), history of chronic pain, length of postoperative bedrest, length of stay (LOS), and postoperative use of opioid analgesics. Additionally, use of a standing stool bowel regimen, as-needed (PRN) stool softeners/laxatives, and enemas were recorded. Constipation was defined as greater than 48 hours without a bowel movement.

Results: In total, 213 patients (115 with intradural pathologies) were identified, of which 146 (69%) patients had postoperative constipation. Postoperative constipation was associated with longer bedrest (1.86 ± 0.20 vs. 1.06 ± 0.12 days; p  = 0.011); increased morphine equivalent dose (MED) during postoperative days 2, 3, 5, and 6 (all p  < 0.05); and total postoperative MED (106.70 ± 14.01 vs. 46.88 ± 8.44 mg; p  < 0.001). Additionally, postoperative constipation was an independent predictor of LOS ( p  = 0.009). There were no differences in postoperative cerebrospinal fluid (CSF) leak between the groups ( p  = 0.622).

Conclusion: Postoperative constipation rates were high after ESBS and likely causative factors include increased immobilization and postoperative opioid use. Standing bowel regimens should be considered in ESBS patients. However, there was no increased rate of postoperative CSF leaks.

Introduction: Multiple minicraniotomies (Mct) have been proposed as alternatives to standard pterional craniotomy (Pct) for intracranial aneurysm treatment. These approaches offer limited surgical corridors and distinct working angles, posing challenges in addressing all aneurysm types with one method. We suggest a tailored Mct technique, comprising three minimally invasive approaches targeting anterior circulation aneurysm sites (middle cerebral artery, internal carotid artery, anterior communicating artery).

Methods: We conducted a retrospective, case-control study at a single center comparing Pct and Mct outcomes for ruptured and unruptured aneurysms. Parameters evaluated included conversion rates to Pct or decompressive hemicraniectomy (DHC), intraoperative rupture (IOR), surgical complications, complete aneurysm exclusion, 6-month modified Rankin Scale (mRS) scores, and aesthetic outcomes using a visual analog scale. A total of 146 patients were included, with 103 in the Mct group and 43 in the Pct group, comparable in mean age, sex, and aneurysm topography. Hunt-Hess scores and Fisher grades were lower in the Mct group initially.

Results: No cases required conversion from Mct to Pct or DHC. No significant differences were observed in IOR, surgical complications, and aneurysm exclusion rates between groups. The Mct group demonstrated better 6-month mRS scores and aesthetic outcomes.

Conclusion: Our study indicates that tailored Mct is as safe and effective as standard Pct for intracranial aneurysms, with significant cosmetic benefits. Thus, tailored Mct can be considered a valuable alternative not only to Pct but also to other minimally invasive surgical methods for these aneurysms.