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

Objective: The inferior temporal arteries (ITAs), branches of the posterior cerebral artery (PCA), are critical vascular structures encountered during subtemporal surgical approaches. Anatomical data based on multiphase postmortem computed tomography angiography (MPMCTA) are provided as a tool for preoperative surgical planning to lower the risk of ITA injury.

Methods: Adult (≥18 years) cases that underwent MPMCTA during 2015 to 2023 and whose cause of death did not involve the cerebral circulation were included in the study. Standardized measurements on four predefined coronal slices in relation to the posterior clinoid process (PCP) were established with references to projections in axial and sagittal planes. The main aim was to assess the presence, width, and course of anterior ITA (AITA), middle ITA (MITA), and posterior (PITA) particularly within the individual established quadrants of the middle cranial fossa.

Results: A total of 74 hemispheres were studied among 37 patients with the mean age of 52 ± 20.2 years. PITA was present in 98.7% of studied hemispheres, followed by MITA in 90.7% and AITA in 89.2%. The course of PITA was straight (65.8%) or oblique (34.3%), with significant difference in mean width ( p  = 0.050), branching angle ( p  < 0.001), distance to tentorial hiatus ( p  < 0.001), and superior petrosal sinus ( p  < 0.001). A pattern of PITA loop was defined as a twisting of its course within the collateral sulcus. Significant relationship between the presence of AITA and MITA ( p  < 0.001) along with the co-presence of AITA and PITA ( p  = 0.029) was found.

Conclusion: Knowledge of ITA characteristics and their relationship to surrounding anatomical structures is vital in subtemporal neurosurgical interventions. Preoperative inspection of the collateral sulcus and its relation to the surgical trajectory is critical to prevent PITA injury.

Background: Advances in endoscopic orbital surgery have sparked discussion regarding reconstructive procedures for medial orbital wall defects following tumor removal. This study describes an innovative orbital periosteal suturing technique that addresses the functional and aesthetic concerns created by orbital surgery.

Objective: Comprehensive clinical evaluation of a novel orbital periosteal suturing technique for endoscopic medial orbital wall reconstruction.

Methods: A retrospective chart review identified five patients who underwent endoscopic transnasal resection and subsequent orbital periosteal suturing for reconstruction. The surgical approach involved a binostril transseptal technique to create a broad surgical corridor. The postoperative follow-up was 13.4 ± 1.8 months.

Results: In the five patients, the mean age was 47.6 ± 13.0 years and the lesions were predominantly distributed on the left side (60%). Reconstruction time with the orbital periosteal suture procedure averaged 47.2 ± 6.6 minutes, employing four to five stitches. No patients experienced short-term complications such as visual acuity defect, new or exacerbated diplopia, or cranial nerve palsy within 2 weeks, and no long-term complications such as enophthalmos or prolonged diplopia were observed.

Conclusion: Orbital periosteal suturing is an effective and resource-efficient technique for endoscopic reconstruction of the medial orbital wall. Surgeons may consider this method among the available options for orbital reconstruction, representing a novel advancement in the field.

Introduction: Rigid endoscopes have allowed surgeons to safely perform endoscopic sinus surgery. However, their rigid nature creates inherent visualization limitations. The study herein looks to assess the visualization potential of a novel articulating rigid-flexible endoscope when compared with traditional rigid and flexible nasal endoscopes.

Methods: A new articulating endoscope capable of bending its distal tip and extending beyond the point of angulation was compared with 0- and 30-degree 4.0-mm rigid endoscopes, and a 3.7-mm flexible nasopharyngoscope in their ability to visualize predefined anatomic landmarks within the maxillary, sphenoid, and frontal sinuses. Visible markers were placed at applicable landmarks using image guidance in a total of five cadaveric heads. The ability to visualize these intrasinus anatomic landmarks was recorded for each scope.

Results: When inspecting the surgically naive anatomy of all sinus ostia and predefined anatomic landmarks, the articulating endoscope had superior visualization ( p  < 0.01) compared with the 0-degree, 30-degree, and flexible endoscopes throughout all sinuses (maxillary sinus: 62.5, 0, 5, and 0%, respectively; sphenoidal sinus: 92.5, 27.5, 37.5, and 40%, respectively; frontal sinus: 51.4, 5.7, 20, and 37.1%, respectively). After performing a Draf IIa, the articulating endoscope was able to visualize 100% of the predefined frontal sinus landmarks compared with 22.9, 45.7, and 65.7% for the 0-degree, 30-degree, and flexible endoscopes, respectively ( p  < 0.001).

Conclusion: The articulating rigid-flexible endoscope is superior in reaching and visualizing anatomic landmarks within the paranasal sinuses, compared with standard endoscopes.

Objectives: The aims of this study were to analyze the clinical characteristics of patients with recurrent and metastatic sinonasal undifferentiated carcinoma (SNUC) and evaluate the current treatment strategies to help guide future management.

Design: This is a retrospective cohort study.

Setting: The study was conducted at six international tertiary treatment centers.

Participants: Patients with documented diagnoses of recurrent or metastatic SNUC since 1983 were included in the study.

Main outcome measures: Patient demographics and clinical characteristics were collected. Primary outcome measures included disease-specific survival (DSS), overall survival (OS), and time to recurrence (TTR) following initial treatment. Further univariable and multivariable analyses were performed to assess for prognostic factors.

Results: A total of 97 patients with a mean (standard deviation [SD]) age of 52.4 (15.6) were identified, 15 of whom presented with metastatic SNUC and 90 of whom developed recurrence. Management in both populations was widely variable. For patients with metastatic disease, the 1-year DSS probability was 33.3% (95% confidence interval [CI], 10.8-100%). For patients with recurrent SNUC, the 1- and 5-year DSS probabilities were 45.7% (95% CI, 31.9-65.6%) and 8.6% (95% CI, 2.9-25.3%), respectively. The median (interquartile range [IQR]) TTR was 8 months (3-18.5 months). Multivariable analyses revealed a significant association between orbital involvement on initial presentation and TTR (hazard ratio [HR] = 3.28; 95% CI, 1.45-7.42; p  = 0.004).

Conclusions: To our knowledge, this is the first study addressing metastatic and recurrent SNUC based on a large patient cohort. Orbital extension of the primary SNUC may predict a higher probability of recurrence following treatment, suggesting the possible utility of a more aggressive treatment in this subgroup of patients. A heterogenous patient population and wide variability in management emphasize the challenges in standardizing care; however, dismal survival rates demonstrate the necessity for further evaluation of current approaches to improve evidence-based recommendations.

Objectives: The two histologic subtypes of craniopharyngiomas (CPs), papillary and adamantinomatous, harbor mutually exclusive mutations of BRAF V600E and CTNNB1, respectively. Studies suggest that subtotal resection (STR) plus adjuvant radiation therapy (XRT) may result in similar progression-free survival (PFS) as gross total resection (GTR). We hypothesized that STR ± XRT and GTR result in similar PFS for both BRAF and β-catenin-mutated CPs.

Design: Patients who were surgically treated for a primary CP between 2001 and 2023 at a single institution were included. Immunohistochemical studies were performed retrospectively using BRAF and β-catenin antibodies. Patients with missing immunohistochemistry (IHC) diagnosis were excluded. Differences in PFS for STR ± XRT and GTR groups were assessed with a log-rank test, stratified by BRAF and β-catenin IHC status.

Results: A total of 77 patients with CP were screened. IHC data were available for 50 patients; 20 had a BRAF mutation, and 30 had a β-catenin mutation. Among BRAF patients, 11 underwent GTR; 9 had STR, and 5 had adjuvant XRT. Among β-catenin patients, 14 underwent GTR; 16 had STR, and 6 had adjuvant XRT. For BRAF patients with GTR, the median PFS was not reached; for BRAF patients with STR ± XRT, the median PFS was 150 days ( p  < 0.01, log-rank test). For β-catenin patients with GTR, the median PFS was 1,813 days; for β-catenin patients with STR ± XRT, the median PFS was not reached ( p  = 0.80, log-tank test).

Conclusions: Both GTR and STR ± XRT seemed to offer similar PFS outcomes only for patients with β-catenin-mutated CP. For patients with BRAF-mutated CP, a greater extent of resection was significantly associated with prolonged PFS.

Objective: The study objective was to compare the length of stay (LOS) and the proportion of one-night admissions before and after the implementation of an endocrine monitoring protocol following endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma.

Methods: Patients who underwent transsphenoidal pituitary adenoma resection between July 1, 2018, and September 9, 2022, were identified, and divided into two cohorts before and after the implementation of the monitoring protocol. The overall LOS and number of nights of admission were recorded. Readmission within 30 days after surgery was also recorded. The number of outpatient laboratory tests performed and the time to the first test were also noted.

Results: Thirty patients were identified in the preprotocol group and 60 in the postprotocol group. The average admission length in the preprotocol group was significantly longer than the average admission length in the postprotocol group (2.4 vs. 1.7 days, p  = 0.004). The percentage of one-night admissions increased from 13 to 57% ( p  < 0.001). There were no significant differences in readmission rates between the two groups ( p  = 0.681). The number of laboratory encounters increased from a mean of 1.38 to 2.40 ( p  = 0.030), while the time to the first test decreased from a mean of 3.43 to 2.36 days ( p  = 0.049).

Conclusion: Patients admitted after ETSS for pituitary adenoma had shorter hospital stay and greater proportion of one-night admission with the implementation of an endocrine monitoring protocol. The all-cause readmission rate was not statistically different between the two groups. Through aggressive outpatient laboratory monitoring, one-night admission for ETSS may be feasible.

Objectives To characterize treatment and hearing outcomes for cerebellopontine angle (CPA) meningiomas with inherent risks of hearing loss and identify predictors of hearing loss for surgically treated lesions.

Design Retrospective chart review.

Setting Tertiary care medical center.

Participants Adult patients with CPA meningiomas impinging upon cranial nerve VIII and/or pretreatment hearing loss managed with microsurgery or stereotactic radiosurgery (SRS) with Gamma Knife at our center between 2012 and 2023.

Main Outcome Measures Hearing preservation rate was determined from analysis of patients with pretreatment serviceable hearing for whom hearing-preserving treatment was attempted. Surgical patients were further analyzed using multivariable Cox proportional hazards regression models to identify factors predictive of postoperative hearing loss.

Results We identified 80 patients with CPA meningiomas meeting inclusion criteria who were managed with either microsurgery (43, 54%) or radiosurgery (37, 46%). Following SRS, hearing was preserved in 88% of cases. Following microsurgery, hearing was preserved in 71% of patients—all patients who lost hearing had tumors involving the internal auditory canal (IAC). Among surgical patients only, multivariable analysis accounting for preoperative hearing, recurrence status, lesion size, and patient age, the preoperative imaging finding that the CPA meningioma surrounded the vestibulocochlear nerve was significantly associated with hearing loss (hazard ratio: 10.3, 95% confidence interval: 1.3–81.4, p = 0.02).

Conclusion Most patients with meningiomas of the CPA can experience preservation of hearing, even when there is risk of hearing loss based on pretreatment evaluation. IAC invasion and surrounding of eighth nerve by tumor may portend poorer hearing outcomes in surgically managed patients.

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.