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

Objectives Sigmoid sinus (SS) compression and injury is associated with postoperative SS occlusion and corresponding morbidity. Leaving the SS skeletonized with a thin boney protection during surgery might be favorable. This study quantifies the effect of the SS position on the operative exposure in the translabyrinthine approach and assesses the feasibility of retracting a skeletonized SS.

Methods Twelve translabyrinthine approaches were performed on cadaveric heads with varying SS retraction: skeletonized stationary (TL-S), skeletonized posterior retraction (TL-R), and deskeletonized collapsing of the sinus (TL-C). High-definition three-dimensional reconstruction of the resection cavity was obtained. The primary outcome, “surgical freedom” (mm²), was the area at the level of the craniotomy from which the internal acoustic porus could be reached in an unobstructed straight line. Secondary outcomes include the “exposure angle,” “angle of attack,” and presigmoid depth.

Results During TL-R, surgical freedom increased by a mean of 41% (range: 9–92%, standard deviation [SD]: 28) when compared to no retraction (TL-S). Collapsing the SS in TL-C provided a mean increase of 52% (range: 19–95%, SD: 22) compared to TL-S. In most cases, the exposure is the greatest when the SS is collapsed. In 40% of the specimens, the provided exposure while retracting (TL-R) instead of collapsing (TL-S) the sinus is equal or greater than 50% of other specimens in which the sinus is collapsed.

Conclusion In cases with favorable anatomy, a translabyrinthine resection in which the skeletonized SS is retracted provides comparably sufficient exposure for adequate and safe tumor resection.

Objective Eagle syndrome, categorized into classical styloid syndrome and stylocarotid syndrome, presents challenges in determining the optimal surgical approach for styloid process (SP) resection. While intraoral resection suffices for many cases, especially classical styloid syndrome cases, stylocarotid syndrome sometimes demands a transcervical resection due to its intricate spatial dynamics. We describe a step-by-step procedure for modified transcervical resection using a supra digastric muscle approach (SDMA) for SP, emphasizing anatomical precision.

Methods and Results The approach is described in the case of a 60-year-old woman with acute cerebral infarction from left internal carotid artery dissection. Employing carotid artery stenting, we identified SP elongation as the underlying cause requiring transcervical resection to avoid stent damage. The operative procedure involves meticulous dissection via a linear skin incision, exposing key anatomical structures such as the sternocleidomastoid muscles, digastric muscles (DMs), and the transverse process of the atlas. Surgical corridor via supra DM space is an invaluable technique, offering the shortest distance to the SP without compromising nearby nerves. The SP, covered by muscles and ligaments, is carefully stripped off, enabling its amputation near the temporal skull base. The entire procedure is performed under a microscope to preserve surrounding nerves.

Conclusion The SDMA is a simple and safe technique, offering enhanced anatomical precision and minimizing the risk of nerve damage.

Introduction Fellowship training has become increasingly sought after by neurosurgeons aiming for academic careers over the last two decades. This study assesses American Board of Neurological Surgeons board-certified neurosurgeons specializing in skull base or open cerebrovascular surgery between 2013 and 2023, focusing on identifying academic career predictors through demographic and academic outputs.

Methods The study utilized the American Association of Neurological Surgeons Neurosurgical Fellowship Training Program Directory to identify neurosurgeons certified from 2013 to 2023, gathering demographic details and academic productivity from Scopus.

Results Among 173 neurosurgeons, 87.86% were male, 36.36% were graduates from top 40 National Institutes of Health-funded medical schools, and 49.42% completed their residency in highly ranked departments. In univariate analysis, predictors for an academic career included publishing in the field before residency (p = 0.03054), a higher h-index before and after residency (p = 0.03976 and 0.0003101), and increased publication volume during and up to 3 years post-fellowship (2.284e-06). Multivariate analysis found that publication volume during and up to 3 years post-fellowship (odds ratio [OR] = 4.98, 95% confidence interval [CI]: 2.07–11.9, p = 0.0003) and basic science publications (OR = 2.4, 95% CI: 1.05–5.49, p = 0.038) were the most significant predictors of academic career placement.

Conclusion The study underscores the strong link between the academic career success of neurosurgeons trained in skull base and open cerebrovascular surgery and their research productivity, particularly publication volume during key career stages and involvement in basic science research. This highlight sustained research activity as a critical determinant of academic career achievement, surpassing the influence of training institution prestige.

Objectives Patients undergoing surgery for Cushing's disease may be more likely to be readmitted to the hospital than other patients with pituitary disorders. We investigated rates, causes, and predictors of unplanned readmission following transsphenoidal surgery for Cushing's disease to identify areas for clinical, financial, and administrative improvements.

Design Retrospective cohort study.

Setting Academic pituitary centers in the United States participating in a multicenter surgical outcome registry.

Participants Five hundred and nineteen patients underwent transsphenoidal surgery for treatment of Cushing's disease by 26 surgeons at nine participating institutions from 2003 to 2023.

Main Outcome Measures Unplanned 90-day readmission rates and causes of readmission.

Results Unplanned readmissions occurred in 57/519 patients (11.0%), with hyponatremia in 12/57 (21%), cerebrospinal fluid leak evaluation in 8/57 (14%), epistaxis in 6/57 (10%), deep vein thrombosis in 4/57 (7%), syncope in 3/57 (5%), and headache in 3/57 (5%). Factors including no tumor on initial magnetic resonance imaging, return to the operating room during the index admission, lack of early remission, and inpatient complications were associated with a greater probability of readmission on univariate analysis. However, none remained predictive on multivariate analysis.

Conclusion Our results show that readmission rates after transsphenoidal surgery for Cushing's disease are comparable to previously reported rates for all pituitary-related disorders, with the most common reason being hyponatremia. High-impact clinical protocols focused on preventing delayed hyponatremia may reduce the risk of readmission. Failure to identify significant predictors of readmission, even in this large clinical dataset, underscores the challenge of identifying high-risk clinical cohorts.

Objective Olfactory groove meningiomas (OGM) commonly present with olfactory deficits and compression of the frontal lobes. Given the relationship to dietary behaviors, our objective was to evaluate the relationship between OGMs and postoperative weight loss.

Methods Retrospective review of primary resection of meningiomas between 2017 and 2023 at a single institution was conducted. Neurofibromatosis type 2, pregnancy, weight loss medications, or surgeries were excluded. Data collection included preoperative body mass index (preBMI) and postoperative BMI (poBMI) at 3 to 6 and 12 months. Percent BMI change (pcBMI) was calculated by (poBMI − preBMI/preBMI × 100%). IBM SPSS Statistics (Version 27) was used for descriptive statistics and stepwise multiple linear regression.

Results Ninety-eight patients met inclusion with a mean age of 57.58 years. Three groups were stratified by location: OGM (n = 15), anterior cranial fossa excluding OGM (ACF; n = 24), and other (OTH; n = 59). Olfactory dysfunction was present in 53.8% of the OGMs. OGM presented with significantly larger lesions (57.25 ± 55.98 mm³) and a higher preBMI (34.58 ± 7.41 kg/m²) than ACF and OTH. A greater pcBMI was seen in OGM at both timepoints (−7.74%, −8.73%). OGM location, tumor volume, and preBMI were found significant on univariate analysis (p < 0.05) and included in multiple linear regression. All regression models were significant (p = 0.001). Location significantly added to the prediction at 3 to 6 and 12 months as well as preBMI at 12 months. In a subanalysis of ACF and OGM, OGM location was significantly associated with negative pcBMI at 3 to 6 and 12 months.

Conclusion OGMs are associated with higher preoperative weight and greater weight loss postoperatively compared with other locations.

Introduction Common approaches to remove skull base tumors invading the orbital apex, cavernous sinus, middle fossa, or temporal lobe include orbitozygomatic or fronto-orbital craniotomies. Recently, different types of orbital approaches have been described as alternative minimally invasive techniques.

Objective With this systematic review, we analyzed the typology of intracranial tumors treated through transorbital approaches, especially through the lateral orbital (LO) wall, and analyzing the complication rates and outcomes.

Design A PubMed/Medline search was performed using the criteria: “orbitotomy,” “transorbital,” “transpalpebral,” and “lateral orbitotomy” in combination with “cavernous sinus,” “middle fossa,” and “temporal lobe.”

Main Outcome Measures From these reports, we collected diagnoses, lesion sizes and locations, approaches, outcomes, aesthetic outcomes, postoperative ptosis, postoperative cranial nerve (CN) palsies, length of CN deficits postoperatively, overall complications, and follow-up length.

Results A total of 13 papers and 3 of our own cases matched our inclusion criteria totaling 160 patients. Most patients were treated for meningiomas (135, 84.4%). The approaches included the LO approach (n = 54; 33.8%), deep transorbital (n = 5; 3.1%), mini-LO (n = 91; 56.9%), and modified LO (n = 10; 6.2%). While not all cases reported excision success, the various LO approaches achieved total (n = 42; 26.25%) resection margins. Postoperative ocular complications (including CN palsies, proptosis, or ocular disturbances) totaled 46 (28.8%) new CN palsies, 23 (14.4%) occurrences of vision loss, 1 (1.7%) with worsened proptosis, 5 (3.9%) with worsened enophthalmos, and 42 (26.3%) other complications.

Conclusion Microsurgical LO approaches, especially in the era of radiosurgery, may become a suitable alternative to other more established craniotomies.

Objectives In recent years, the transnasal endoscopic method for transsphenoidal pituitary tumor resection (eTSR), alongside the conventional sublabial microscopic transsphenoidal resection (mTSR) method, has gained popularity due to advancements in imaging and instrumentation. The current study sought to elucidate whether the trend toward eTSR was associated with changes in clinical outcomes at a single institution's multidisciplinary pituitary surgery program.

Setting and Participants The Virginia Commonwealth University (VCU) Brain Tumor Database was queried for patients who underwent either transnasal or sublabial pituitary tumor resection of pituitary tumors between 2009 and 2021.

Design Clinical outcomes were compared between the two groups.

Main Outcome Measures Surgical outcomes like estimated blood loss (EBL), cerebrospinal fluid (CSF) leak rates, hospital length of stay (LOS), and extent of resection were studied.

Results A total of 93 patients (57 mTSR, 36 eTSR) underwent review, revealing that mTSR was associated with a higher average intraoperative blood loss (310.5 ± 48.6 mL) than eTSR (160.0 ± 30.7 mL; p = 0.012). eTSR demonstrated an elevated intraoperative CSF leak incidence (36.1 vs. 15.8%; p = 0.043), but no difference in postoperative CSF leak requiring intervention. Hospital LOS and extent of resection showed no significant differences between the approaches.

Conclusion This single-institution, retrospective study suggests that, in experienced hands, both eTSR and mTSR approaches are effective with comparable risk profiles. The approach may be best determined by the surgical team's evaluation of the tumor's imaging features, paying attention to the patient's preoperative hematologic status due to the greater propensity for blood loss with the microscopic approach.

Introduction Skull base surgery has evolved from fundamental elements into a distinct multidisciplinary specialty. Using bibliometrics, we appraised the literature pertaining to skull base surgery since 1900 and studied the emergence of the specialty as a scholarly field.

Methods We queried Web of Science for all content from past presidents of the North American Skull Base Society (N = 31) and their self-identified forebears, influences, contemporaries, and trainees (N = 115). Statistical and bibliometric analyses were performed using various Python packages on article metadata.

Results Our query returned 28,167 articles. The most pertinent works (N = 15,529), identified algorithmically through an analysis of terms in titles, were published between 1900 and 2024 by 15,286 authors. The field exploded in the latter half of the 20th century, concurrently with increased interdisciplinary and international collaboration, and contemporaneously with the formation of centers of excellence and influential societies. Since 1950, prolific contributors to the field from neurosurgery, otolaryngology, radiology/radiation oncology, plastic surgery, and ophthalmology have increasingly subspecialized in skull base topics. The proportion of female authors in the corpus has grown from <1% in 1980 to 17% in 2023. We identify the articles that comprise the historical roots of modern skull base surgery, map the emergence of fundamental terminology within the corpus, and identify the authors who stand as key nodes of collaboration and influence.

Conclusion The field of skull base surgery was born from pioneering individuals with training in varied disciplines. The coalescence of skull base surgery into a distinct and diversified subspecialty has been powered by dedicated collaborative efforts on a global scale.

Objective Owing to the rarity of skull base chondrosarcomas (CS), much of its natural history and long-term impact on patient quality of life (QoL) are not well studied. This novel study demonstrates QoL among CS patients following radical treatment constituting surgery and postoperative radiotherapy over 2 decades.

Study Design Retrospective review and prospective data collection to obtain patient demographic, tumor characteristics, clinical symptoms, and patient-reported QoL outcomes using the 36-Item Short Form Health Survey (SF-36).

Setting/Participants Patients diagnosed with CS who underwent radical intent surgical resection by the senior author and adjuvant early postoperative proton beam therapy.

Results Twenty-eight skull base CS patients were identified, with 19 patients completing full treatment course. Mean long-term follow-up was 148.9 months. Diplopia symptom resolution was high. No significant deterioration in SF-36 Physical Health Component (PHC) and Mental Health Component (MHC) scores was observed at postoperative and long-term follow-up. General health was stable initially but deteriorated in long term (Δ −18.88, minimal clinically important difference [MCID]: 9.86, p = 0.04). Compared with age-matched Canadian control patients, CS patients reported similar PHC scores at baseline and follow-up. CS patients reported lower MHC scores (45.8 vs. 50.9, p = 0.13) preoperatively, which persisted at follow-up decreasing by 1.9 (43.9 vs. 53.7, p = 0.03); this difference, however, did not reach MCID threshold of Δ 5.9.

Conclusion We present the longest follow-up data on CS demonstrating stable long-term QoL with aggressive surgery. Tumor control was high and preoperative tumor size did not affect long-term QoL. Preoperative QoL was lower among CS compared with Canadian normative data. Postoperatively, only the decline in physical functioning QoL scores exceeded MCID. At long-term follow-up, the decline in physical functioning, social functioning, and general health exceeded MCID. Overall, QoL among CS patients remained lower at long-term follow-up despite absence of tumor progression and resolution of symptoms.

Introduction Skull base neuroanatomy is traditionally learned through two-dimensional anatomical atlases, which while are of unquestionable value, lack the nuanced association of three-dimensional relationships between fundamental anatomical structures relevant to surgical approaches. Surgically focused step-by-step anatomical dissections can augment trainee learning of complex skull base techniques, particularly multistep and nuanced techniques such as translabyrinthine and transcochlear approaches.

Methods Translabyrinthine and transcochlear approaches were performed on six sides of three formalin-fixed latex-injected specimens. The study objective was the completion and photo documentation of the steps involved in the approach in order to provide a comprehensive, intelligible, and anatomically oriented resource for multilevel trainees. Illustrative case examples were prepared to supplement approach dissections.

Results The translabyrinthine and transcochlear approaches offer unique lateral windows through the temporal bone into the posterior fossa, providing excellent access to pathology at the petrous apex, internal auditory canal, Meckel's cave, and anterolateral brainstem. The transcochlear approach, which is an anterior extension of the translabyrinthine, particularly provides excellent exposure of the prepontine region and clivus. Important surgical considerations include patient position, temporal bone drilling and identification of critical landmarks, dural opening and identification of neurovascular structures, and reconstruction/closure techniques.

Conclusion The translabyrinthine and transcochlear approaches are fundamental techniques for lateral skull base and posterior fossa pathologies. Both approaches are hearing-sacrificing but often require minimal to no cerebellar retraction and deliver unique visualization of prepontine neurovascular structures. This step-by-step approach guide provides a unique practical and high-yield surgically oriented learning resource for neurosurgery and otolaryngology trainees.