Diagnosis and treatment of rare malignant temporal bone tumors / 临床耳鼻咽喉头颈外科杂志

Objective:To analyze the diagnosis, treatment and prognosis of patients with rare malignant tumors of the temporal bone. Methods:Four cases of rare temporal bone malignant tumors in our hospital between March 2014 and December 2020 were reviewed, including two cases of chondrosarcoma, one case of fibrosarcoma and one case of endolymphatic cystic papillary adenocarcinoma. There were three males and one female, ages between 28 and 56 years at the time of surgery. Common symptoms included hearing loss, facioplegia, tinnitus, and headache. All patients underwent imaging examinations to evaluate the extent of the lesions. Tumors were removed by subtotal temporal bone resection or infratemporal fossa approach, and postoperative adjuvant radiotherapy was applied if necessary. Results:One of the two chondrosarcoma patients was cured by complete resection of the tumor for 75 months, the other one recurred after the first excision of the tumor and underwent infratemporal fossa approach resection of skull base mass again with no recurrence found yet for 112 months. One patient with fibrosarcoma survived for 28 months after surgery with a positive margin and post-operative radiotherapy. One patient with endolymphatic cystic papillary adenocarcinoma recurred 12 months after subtotal lithotomy, and underwent subtotal temporal bone resection again, combined with radiotherapy. No recurrence was found for 63 months. Conclusion:The incidence of rare temporal bone malignant tumors is extremely low, the location is hidden, and the symptoms are atypical. Attention should be paid for early detection and early treatment. Surgical resection is the main treatment, and radiotherapy can be supplemented in the advanced stage or with a positive margin.

Preoperative Endovascular Embolization of Glomus Jugulare Tumors: A Retrospective Case Series of 22 Embolizations in 20 Patients and Literature Review

Objective Glomus jugulare tumors, or tympanojugular paragangliomas, are rare, highly vascularized skull base tumors originated from paraganglion cells of the neural crest. With nonabsorbable embolic agents, embolization combined with surgery has become the norm. The authors assess the profile and outcomes of patients submitted to preoperative embolization in a Brazilian tertiary care hospital. Methods The present study is a single-center, retrospective analysis; between January 2008 and December 2019, 22 embolizations were performed in 20 patients in a preoperative character, and their medical records were analyzed for the present case series. Results Hearing loss was the most common symptom, present in 50% of the patients, while 40% had tinnitus, 30% had dysphagia, 25% had facial paralysis, 20% had hoarseness, and 10% had diplopia. In 7 out of 22 embolization procedures (31%) more than a single embolic agent was used; Gelfoam (Pfizer, New York, NY, USA) was used in 18 procedures (81%), in 12 of which as the single agent, followed by Embosphere (Merit Medical, South Jordan, UT, USA) (31%), Onyx (Medtronic, Minneapolis, MN, USA) (9%), and polyvynil alcohol (PVA) and Bead Block (Boston Scientific, Marlborough, MA, USA) in 4,5% each. The most common vessel involved was the ascending pharyngeal artery, involved in 90% of the patients, followed by the posterior auricular artery in 15%, the internal maxillary artery or the occipital artery in 10% each, and the superficial temporal or the lingual arteries, with 6% each. Only one patient had involvement of the internal carotid artery. No complications from embolization were recorded. Conclusions Preoperative embolization of glomus tumors is safe and reduces surgical time and complications, due to the decrease in size and bleeding.

Pterygopalatine Fossa: Microsurgical Anatomy and its Relevance for Skull Base Surgery

Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; themaxilla, anteriorly; themedial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone,medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors.

Jugular Foramen's Paraganglioma in a Patient with Von Hippel-Lindau Disease: Case Report

Glomus jugular tumors, also known as paragangliomas (PGLs), are rare and related to several clinical syndromes described. These are located in the carotid body, the jugular glomus, the tympanic glomus and the vagal glomus. The symptoms are directly related to the site of involvement and infiltration. These lesions have slow growth, are generally benign and hypervascularized, have a peak incidence between the age of 30 to 50 years old; however, when associated with hereditary syndromes, they tend to occur a decade earlier. Several familial hereditary syndromes are associated with PGLs, including Von Hippel- Lindau disease (VHL) in< 10% of the cases. The diagnosis and staging of PGLs are based on imaging and functional exams (bone window computed tomography [CT] with a "ground moth" pattern and magnetic resonance imaging (MRI) with a "salt and pepper" pattern). The cerebral angiography is a prerequisite in patients with extremely vascularized lesions, whose preoperative embolization is necessary. The histopathological finding of cell clusters called "Zellballen" is a characteristic of PGLs. Regarding the jugular foramen, the combination of two or three surgical approaches may be necessary: (1) lateral group, approaches through themastoid; (2) posterior group, through the retrosigmoid access and its variants; and (3) anterior group, centered on the tympanic and petrous bone. In the present paper, we report a case of PGL of the jugular foramen operated on a young female patientwho underwent a surgery with a diagnosis ofVonHippel-Lindau Disease (VHL) at the Neurosurgery Service of the Hospital Heliópolis, São Paulo, state of São Paulo, Brazil in 2018, by the lateral and posterior combined route.

Clinical application of combined infratemporal fossa approaches for internal carotid artery in petrous bone reconstruction for large lateral skull base tumors / 中华耳鼻咽喉头颈外科杂志

Objective: By summarizing the technical points and therapeutic outcomes of combing infratemporal fossa approach (IFA) and internal carotid artery (ICA) reconstruction for the colossal skull base tumor invading ICA in petrous bone, the clinical application value was discussed. Methods: Five patients (2 males, 3 females,aging from 27 to 55 years old) who received surgeries between July 2015 and May 2017 for lateral skull base pathology involved petrous ICA using technique combined IFA and pre-reconstruction, were reviewed. Results: Among the five patients, three were paraganglioma of head and neck, one was carotid aneurysms, and one was recurrent adenoid cystic carcinoma (ACC). The median tumor size in the largest cross-section was 60 mm × 51 mm (range, 28 mm × 22 mm-72 mm × 58 mm). Complete excision was achieved with IFA and ICA reconstruction. The median blood loss volume was 1 000 ml (range, 600-2 500 ml). Four cases showed no new long-term neurologic sequelae, while one showed hemiplegia due to graft vessel occlusion. Except for the one with ACC having facial nerve cut, others achieved good facial nerve function of HB grade Ⅰ to Ⅱ during 3 to 12 months, follow-up. No tumor recurrence was observed over the median duration of follow-up for above 36 months (range, 36-58 months). Conclusion: For lesions involved superior part of ICA, which is unable to separate from ICA, IFA and ICA reconstruction can achieve complete excision.

Radioanatomic study on the role of Hadad-Bassagasteguy flap in skull base reconstruction in endoscopic endonasal approach / 中华耳鼻咽喉头颈外科杂志

Objective: To evaluate the value of Hadad-Bassagasteguy flap (HBF) in endoscopic endonasal approaches (EEA) skull base reconstruction by radioanatomic measurements on CT of the skull base of Chinese adults. The following data in terms of anterior skull base defect and reconstruction, sphenoid platform area and middle skull base defect and reconstruction including sphenoid platform and sella area, clivus area defect and reconstruction, and HBF were collected and assessed. Methods: CT image data of 42 Chinese adults were selected to obtain radioanatomic measurement data related to HBF, anterior skull base defect and reconstruction, middle skull base defect and reconstruction, and defect and reconstruction of clivus area. SPSS 26.0 software was used to analyze the data. Results: The radioanatomic measurement data about HBF and skull base of 42 Chinese adults were obtained. The width of the leading edge of HBF [(37.49±2.86) mm] was 6 mm more than the anterior skull base width at the level of the anterior ethmoidal artery [(30.87±8.61) mm], and the width of the trailing edge of HBF [(42.61±3.95) mm] was also 6 mm more than the anterior skull base width at the level of the sphenoethmoidal junction [(26.79±2.79) mm]. The total length of HBF including the pedicle [(79.68±4.96) mm] was 6 mm more than the length of the anterior skull base reconstruction [(54.06±8.67) mm], and the length of HBF without pedicle [(46.27±3.14)] mm was 6 mm more than the length of anterior skull base defect [(30.87±8.61) mm]. The trailing edge width was 6 mm more than the planum sphenoidal width at the level of the optic strut [(30.87±8.61) mm]. The total length of HBF including the pedicle was 6 mm more than the length of the planum sphenoidal, and the sella reconstruction [(64.44±10.25) mm], also was 6 mm more than the length of the planum sphenoidal reconstruction [(73.61±8.28) mm]. The length of HBF without pedicle was 6 mm more than the length of the planum sphenoidal, and the sella defect [(27.88±3.74) mm], also was 6 mm more than the length of the planum sphenoidal defect [(15.50±3.38) mm]. The width of the leading edge of HBF and the width of the trailing edge were both 6 mm more than the width of clivus reconstruction at the level of the foramen lacerum [(21.68±2.30) mm]. The total length of HBF including pedicles was 6 mm more than the clivus reconstruction length [(67.09±5.44) mm], while the length of HBF without pedicles was also 6 mm more than the clivus defect length [(37.19±3.80) mm]. Conclusions: In this study, the radiosanatomic measurements ensured that HBF could provide sufficient tissue flap for the reconstruction of the anterior skull base and sphenoid plateau and extend the reconstruction area to sella and clivus. Preoperative radiosanatomic measurement can be used to predict the size of HBF required for skull base reconstruction, which provides important guidance for flap harvest.

Analysis on endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach under the microscope for skull base tumor with intra and extra-cranial involvement / 中华耳鼻咽喉头颈外科杂志

Objective: To evaluate the application of combination use of endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically in skull base tumor with intra and extra-cranial involvement. Methods: A total of 7 patients (4 males and 3 females, aging from 27 to 65 years old, with a medium age of 48) undergone complicated skull base surgeries via endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically from May 2016 to January 2018 were reviewed respectively. The patients included 2 cases of recurrent invasive pituitary adenoma, 3 cases of basal skull meningiomas, 1 case of clivus chondrosarcoma, and 1 case of recurrent nasopharyngeal carcinoma. The lesion extensively infiltrated nasal cavity, extending to the paranasal sinus, bilateral cavernous sinus, sellar region, suprasellar, superior clivus, temporal lobe, pterygopalatine fossa, infratemporal fossa and important intracranial vessels. All the 7 patients were treated under general anesthesia by endoscopic endonasal approach combined with frontotemporal orbitozygomatic approach under the microscope. Total excision rate, intraoperative and postoperative complications and postoperative curative effect were observed. All of them were followed up for 6 to 12 months. The Glasgow Outcome Scale (GOS) was used to evaluate the prognosis. Result: Total tumor removal was performed in 5 cases, subtotal removel in 2 cases. There was no complication during the operation. Postoperative severe complications occurred in 2 cases, including 1 case of cerebrospinal fluid rhinorrhea and intracranial infection, which was cured by lumbar cistern drainage and intrathecal injection; 1 case occurred oculomotor nerve paralysis, which recovered during follow-up. Postoperative complications occurred in 1 case of trochlear nerve dysfunction, 2 cases of facial numbness, and 1 case of tinnitus. During follow-up, all patients recovered to varying degrees. There was no bleeding and death after the operation. No tumor recurred during the follow-up period. All patients were recovered well with GOS grade Ⅳ-Ⅴ. Conclusions: Endoscopic transnasal approach combined with microscopic frontotemporal orbitozygomatic approach can remove tumors in one stage, reduce surgical complications and improve surgical effect. It has good application prospects and is suitable for excising complex intracranial and extracranial communicating tumors of widely involving sellar, clivus and petrous apex area.

The endoscopic transnasal approach in management of the sinonasal tumor invading the anterior skull base / 中华耳鼻咽喉头颈外科杂志

Objective: To evaluate the feasibility of the endoscopic transnasal approach (ETA) and to analyze the outcomes and factors of this surgical technique in the management of the tumor invading the anterior skull base. Methods: A retrospective analysis was performed on 42 patients (31 males and 11 females, with mean age of 49 years) with sinonasal tumor invading the anterior skull base, who underwent ETA from June 2015 to April 2019 in Eye, Ear, Nose and Throat Hospital of Fudan University. Pathologically, there were 15 cases of squamous carcinoma (14 patients with T4bN0M0 and 1 patient with T4bN1M0) and 27 of olfactory neuroblastomas with Kadish stage C. Anterior skull base reconstruction was performed using the vascular pedicled nasoseptal mucoperiosteal flap and fascia lata. Brain non-contrast-enhanced CT was performed on the first postoperative day to exclude massive pneumocephalus, relevant brain edema and subarachnoid hemorrhage. Sinonasal contrast-enhanced MR was performed to assess the extent of the tumor removal. Kaplan-Meier analysis was used to calculate the overall survival (OS) and Cox multivariate regression analysis was used to determine the prognostic factors. Results: The mean duration of the surgery was 452 minutes. Total resection was performed in 36 patients (85.7%), subtotal resection in 2 patients (4.8%) with orbital involvement, partial resection in one patient (2.4%) with injury of the internal carotid artery. One patient (2.4%) underwent the second resection because of the tumor residual, two patients (4.8%) with unsure tumor residual. Mean follow-up was 20 months, with 17 months of median follow-up. One-, two-and three-year overall survival was 86.5%, 76.9% and 64.5%, respectively. For squamous carcinoma, one-, two-and three-year overall survival was 86.2%, 86.2% and 57.4%, respectively. For olfactory neuroblastomas, One-, two-and three-year overall survival was 86.9%, 75.3% and 67.8%, respectively. Multivariate analysis showed that tumor residual (P=0.001) and recurrence (P<0.01) were independent prognostic factors for survival. Conclusions: The ETA is safe and feasible in selected patients with sinonasal tumor invading the anterior skull base. Tumor residual and recurrence are independent prognostic factors for survival.

5-aminolevulinic Acid and Surgical Margin Analysis in Calvarial Metastasis with Pericranium or Dural Extension: Technical Note

Metastasis to the calvarium with direct pericranium or dural infiltration may be treated with radical surgical removal in selected cases. We describe microsurgical resection of calvarial metastases with fluorescence-guided technique using 5-aminolevulinic acid (5-ALA) in two female patients with breast cancer. Fluorescence findings were positive in both cases. Margins in the scalp and dural layer were 5-ALA negative at the end of surgical removal. Intraoperative pathology was performed in all cases to confirm if oncological limits were free of disease. One case was 5-ALA positive in the outer layer of the dura-mater and another in the pericranium. At the end of the removal in both cases, the surgicalmargins were 5-ALA fluorescence-free. Intraoperative pathology confirmed oncological limits of the resection. 5-aminolevulinic acid fluorescence-guided surgery for calvarial metastases with pericranium and/or dural extension seems to be a safe and reliable method to aid the surgical margins for complete removal, possibly delaying or avoiding adjuvant irradiation for progression control.

Macroprolactinoma clival ectópico: una forma rara de presentación de adenoma hipofisario / Ectopic clival macroprolactinoma: a rare presentation of pituitary adenoma

Los adenomas pituitarios son los tumores hipofisarios más frecuentes siendo una entidad rara cuando se trata de adenomas ectópicos, es decir, sin conexión con la glándula pituitaria. Se cree que derivan de células residuales del tracto de migración embriológico desde la bolsa de Rathke. Su presentación clínica es muy variable porque depende de la producción hormonal y del efecto masa en estructuras adyacentes. Generalmente suponen un reto diagnóstico debido a su baja frecuencia, la clínica variable de presentación y que no presentan características específicas en las pruebas de imagen. Generalmente el diagnóstico se realiza de manera retrospectiva tras la resección quirúrgica. Presentamos el caso de un varón de 56 años que se presentó con unos valores de prolactina de 6647.5 ng/ml (2.2-17.7) con clínica de hipogonadismo aislada que se resolvió con tratamiento médico sin precisar resección quirúrgica, con una disminución de la densidad radiológica y estabilización del tamaño y sin clínica compresiva ni alteración visual.

Pituitary adenomas are the most common hypophyseal tumors being a rare entity when they are ectopic, without connection to the pituitary gland. They are thought to arise from residual cells in the migration tract from Rathke´s pouch. Its clinical presentation is variable depending on the hormonal production and the pressure effect on adjacent structures. They usually are a diagnostic challenge due to their low frequency, wide range of clinical presentation and not showing specific features on imaging techniques. The diagnosis is made usually retrospectively after surgical resection. We report the case of a 56 years old male that presented with a prolactine value of 6647.5 ng/ml (2.2-17.7) and isolated hypogonadism symptoms that resolved with medical treatment without surgery, diminishing the radiological density and stabilizing the size without having compresive symptoms nor visual disturbances.

Radiocirugía cerebral estereotáctica en el tratamiento de tumores de base de cráneo / Stereotactic brain radiosurgery in the treatment of skull base tumors

La radiocirugía estereotáctica ha demostrado efectividad en el tratamiento multimodal de los tumores de base de cráneo, de todas maneras se sugiere que en áreas radiobioló;gicamente sensibles (ej. nervios ó;pticos y tronco cerebral) la dosis radiante debería reducirse por los efectos radiotó;xicos. Para evitar la ineficacia terapó;©utica, una alternativa recientemente implementada es la radiocirugía multisesió;n (RCH). Se analizó; en forma retrospectiva una serie de tumores de base de cráneo, con el fin de evaluar el tratamiento con RCH a travó;©s del control tumoral en las imágenes post-tratamiento. Se evaluó; tambín edad, sexo, histología tumoral, volumen tumoral, protocolo radiante, Karnofsky performance status (KPS) pre-tratamiento y neurocirugía y tratamiento radiante previos. Fueron tratados 84 pacientes entre enero 2009 y enero 2017. La mediana de edad fue 51.5 aó;±os; sexo femenino: 53.6%. Hubo un 92.7% de no-progresió;n luego del tratamiento, con una mediana de tiempo de seguimiento de 36 meses. Los tumores tratados fueron principalmente adenomas hipofisarios, neurinomas del acó;ºstico, y meningiomas de base de cráneo. La mayoría de los pacientes recibió; un esquema de tratamiento fraccionado de 5 días, con una dosis total de 25 Gy. No se observó; radiotoxicidad tardía clínicamente manifiesta. En el análisis multivariado, un KPS alto pre-tratamiento fue significativamente asociado a la no-progresió;n tumoral. En esta serie, la alta incidencia de no-progresió;n tumoral indicaría que el tratamiento con RCH podría ser una opció;n terapó;©utica en algunos casos de tumores de base de cráneo, principalmente recurrencias o remanencias tumorales de adenomas hipofisarios, neurinomas y meningiomas.

Stereotactic radiosurgery has shown effectiveness in the multimodal treatment of skull base tumors, however it is suggested that in radiobiologically sensitive areas (eg. optic nerves and brainstem) the radiation dose should be reduced due to radiotoxic effects. To avoid the consequent therapeutic ineffectiveness, a recently implemented alternative is multisession radiosurgery (RCH). We retrospectively analyzed a series of patients with skull base tumors, in order to evaluate the treatment with RCH through tumor control in the post-treatment images. Age, sex, tumor histology, tumor volume, radiation protocol, pre-treatment Karnofsky performance status (KPS) previous neurosurgery and radiant treatment were also evaluated. Eighty-four patients were treated between January 2009 and January 2017. The median age was 51.5 years; females: 53.6%. There was a 92.7% non-progression after treatment, with a median follow-up time of 36 months. Treated tumors were mainly pituitary adenomas, acoustic schwannomas, and skull base meningiomas. Most of the patients received a 5-day fractionated treatment scheme, with a total dose of 25 Gy. No clinically manifest late radiotoxicity was observed. In the multivariate analysis, a high pre-treatment KPS was significantly associated with tumor non-progression. In our series, the high incidence of tumor non-progression would indicate that treatment with RCH could be a therapeutic option in some cases of skull-base tumors, mainly recurrences or tumor residuals of pituitary adenomas, neurinomas and meningiomas.

Endoscopic endonasal double flap technique for reconstruction of large anterior skull base defects: technical note / Técnica endoscópica endonasal utilizando duplo retalho para reconstrução de grandes defeitos da base anterior do crânio: nota técnica

Abstract Introduction: One of the main concerns in endoscopic endonasal approaches to the skull base has been the high incidence and morbidity associated with cerebrospinal fluid leaks. The introduction and routine use of vascularized flaps allowed a marked decrease in this complication followed by a great expansion in the indications and techniques used in endoscopic endonasal approaches, extending to defects from huge tumours and previously inaccessible areas of the skull base. Objective: Describe the technique of performing endoscopic double flap multi-layered reconstruction of the anterior skull base without craniotomy. Methods: Step by step description of the endoscopic double flap technique (nasoseptal and pericranial vascularized flaps and fascia lata free graft) as used and illustrated in two patients with an olfactory groove meningioma who underwent an endoscopic approach. Results: Both patients achieved a gross total resection: subsequent reconstruction of the anterior skull base was performed with the nasoseptal and pericranial flaps onlay and a fascia lata free graft inlay. Both patients showed an excellent recovery, no signs of cerebrospinal fluid leak, meningitis, flap necrosis, chronic meningeal or sinonasal inflammation or cerebral herniation having developed. Conclusion: This endoscopic double flap technique we have described is a viable, versatile and safe option for anterior skull base reconstructions, decreasing the incidence of complications in endoscopic endonasal approaches.

Resumo Introdução: Uma das principais preocupações em abordagens endoscópicas endonasais da base do crânio tem sido a alta incidência e morbidade associada a fístulas liquóricas. A introdução e o uso rotineiro de retalhos vascularizados permitiram uma acentuada redução dessa complicação, seguida por uma grande expansão nas indicações e técnicas utilizadas nas abordagens endoscópicas endonasais, incluindo grandes tumores e áreas anteriormente inacessíveis da base do crânio. Objetivo: Descrever a técnica cirúrgica realizando uma reconstrução endoscópica multicamadas da base anterior do crânio com duplo retalho, sem craniotomia. Método: Descrição passo a passo da técnica endoscópica com duplo retalho (retalhos vascularizados nasoseptal e pericraniano e enxerto livre de fascia lata), utilizados e ilustrados em dois pacientes com meningioma do sulco olfatório submetidos à cirurgia por via endoscópica endonasal. Resultados: Em ambos os pacientes procedeu-se ressecção total macroscópica seguido de reconstrução da base anterior do crânio com os retalhos nasoseptal e pericraniano onlay e enxerto livre de fáscia lata inlay. Os pacientes apresentaram uma excelente recuperação, sem sinais de fístula liquórica, meningite, necrose do retalho, inflamação meníngea crônica ou sinonasal ou hérnia cerebral. Conclusão: A técnica endoscópica de duplo retalho, como descrita, trata-se de uma opção viável, versátil e segura para as reconstruções da base anterior do crânio, diminuindo a incidência de complicações em abordagens cirúrgicas endoscópicas endonasais.

Cirugía neurológica en meningioma del tercio medio del ala del esfenoides. Presentación de un caso / Neurological surgery in meningioma of the middle third of the wing of the sphenoid. Presentation of a case

RESUMEN Se presentó un caso de una paciente de 70 años de edad, con antecedentes patológicos personales de hipertensión arterial controlada, además de un síndrome demencial instaurado hace 5 años aproximadamente. Con un diagnóstico presuntivo de una demencia tipo Alzheimer y sin estudios desde el punto de vista imagenológico. Se le realizaron diversos estudios que arrojaron una lesión extraaxial interpretada como un meningioma del tercio medio del ala del esfenoides. Se le aplicó una resección tumoral de la totalidad de la lesión, su evolución postquirúrgica fue satisfactoria.

ABSTRACT The case presented is the one of a female patient aged 70 years, with personal pathological antecedents of controlled arterial hypertension besides dementia syndrome for around five years, presumptively diagnosed as Alzheimer-kind dementia without imaging studies. She underwent several studies showing an extra axial lesion that was interpreted as meningioma of the medial third of the sphenoid wing. The tumor resection of the entire lesion was carried out; the post-surgery evaluation was satisfactory.

Aneurysmal Bone Cyst of the Skull Base ­ Case Report

Introduction Aneurysmal bone cysts (ABCs) are pseudotumoral bone lesions of unknown etiology that are also hypervascularized, benign, and locally destructive. They are rare in the base of the skull. The present case report describes a case of aneurysmal bone cyst in the sella turcica. Case Report The present study was developed at the department of neurosurgery of the Hospital Universitário Professor Alberto Antunes of the Universidade Federal de Alagoas (HUPAA-AL, in the Portuguese acronym), Maceió, state of Alagoas, Brazil, and is accompanied by a review of the literature from the PubMed database. A 17-year-old female patient with bitemporal hemianopia and intense left hemicranial headache associated with symptoms from the cranial nerves contained in the cavernous sinus. Neuroimaging evidenced a large lesion in the suprasellar region with calcification foci, sellar erosion, and extension to the cavernous sinus. The patient was submitted to a partial lesion resection and the histopathological analysis showed an aneurysmal bone cyst. Conclusion A rare case of intracranial aneurysmal bone cyst, with the important differential diagnosis from pituitary adenoma.

Expert consensus on processes and operations of navigation-guided needle biopsy techniques for skull base tumors / 中华口腔医学杂志

Skull base surgery is an interdisciplinary subject. The anatomical structures in the skull base related to oral and maxillofacial surgery include parapharyngeal space, pterygopalatine fossa and infratemporal space. This operative area is one of the most challenging surgical areas in oral and maxillofacial surgery due to its deep site, complex anatomy and high risk. For skull base lesions, whether for preoperative biopsy or surgical treatment, there is a greater degree of difficulty and risk. Obtaining pathological information of the tumor preoperatively may help the surgeons optimize their treatment plan. Needle biopsy is one of the major minimally invasive ways to obtain the preoperative pathological results. The navigation technology, which is developing rapidly nowadays, provides a reliable assistance for deep tissue biopsy surgery. Experts from the Oral and Maxillofacial Surgery, Chinese Stomatological Association formulated an expert consensus on processes and operation of navigation-guided needle biopsy techniques for skull base tumors, so as to standardize and promote the application and operation of navigation-guided needle biopsy for skull base tumors.

Multimodal image fusion technology for diagnosis and treatment of the skull base-infratemporal tumors / 北京大学学报(医学版)

OBJECTIVE@#To explore the value of incorporated multimodal image fusion technology with computer-aided design of the skull base-infratemporal tumor treatment.@*METHODS@#A retrospective study was carried out to enroll seventeen patients with skull base-infratemporal tumors treated at Peking University Hospital of Stomatology from February 2011 to September 2018. Plain CT, enhanced CT and MRI data were imported into the iPlan 3.0 software (BrainLab navigation system), and the image fusion was performed for each patient preoperatively. Then the three-dimensional images of the tumor, vital vessels and craniofacial bones were reconstructed to prepare virtual operation design. We evaluated the application of multimodal image fusion technology that had been incorporated with computer-aided planning during the navigation-guided biopsy or surgery, through the analysis of the biopsy and operation data and regular follow-up postoperatively.@*RESULTS@#The mean age of 17 patients (7 males and 10 females) was 46 years. Primary tumors occurred in 11 cases, and recurrent tumors in 6 cases. The size of the 17 tumors ranged from 2.9 cm to 9 cm, and the mean size was 4.35 cm. There were 7 cases with skull base bone destruction and/or intracranial extension, and 10 cases with tumors adjacent to the skull base. High-quality multimodal fused images were obtained in all the 17 cases. The spatial-position relationships of the tumors, adjacent craniomaxillofacial bones and vital vessels labeled with different colors were displayed well on the generated fusion images. The multimodal image fusion technology that incorporated with computer-aided three-dimensional reconstruction and then applied in navigation-guided biopsy or surgery showed that, preoperative analysis and virtual operation design functioned with good results, especially in cases with small tumor size, recurrence or illdefined borders in the skull base-infratemporal region. Operation was carried out in 16 cases after preoperative diagnosis and assessment, and 1 case was performed by navigation-guided biopsy only. The proportions of navigation-guided surgery and biopsy were 70.6% (12/17) and 17.6% (3/17) individually. The positive rate of pathologic diagnosis using navigation-guided biopsy was 100% (3/3). All the navigation-guided biopsies or operations were carried out successfully. Complications included 1 case of cerebrospinal fluid leak from a recurred meningioma patient postoperatively, and 1 case of facial paralysis resulting from parotid-gland deep lobe tumor. Most (14/15) tumors got complete removal with safe boundary through intra-operative navigation verification and post-operative imaging confirmation, except for one case of subtotal resection to avoid the injury of cavernous sinus. The pathological results of the tumors could be classified to mesenchymal (10), adenogenous (3), neurogenic (3) or epithelial (1) resources. The follow-up time ranged from 3 to 94 months, with the median follow-up time of 9 months.@*CONCLUSION@#Taking full advantages of individualized multimodal images, could help analyze the three-dimensional spatial position relationship of tumors, vital vessels and craniofacial bones properly, and then complete the virtual operation design well. The incorporated multimodal image fusion technology with navigation technology may improve the accuracy and safety of core needle biopsy and surgical treatment of skull base-infratemporal tumors.

Estesioneuroblastoma Olfatorio: Presentacion De Un Caso / Oligatory Esthesioneuroblastoma: Presentation of a Case

Se presenta un caso de una paciente con pérdida de peso, congestión nasal epistaxis, aumento de volumen en cuello con disfagia a sólidos y líquidos de 1 mes de evolución. La tomografía de cuello muestra una masa de tejidos blandos en la base de cuello con erosión del esfenoides con extensión a la fosa craneal media, con erosión del clivus, el esfenoides y la si­lla turca. El diagnostico histopatológico es un estesioneuroblastoma.

We present a case of a patient with weight loss, nasal congestion, epistaxis, increase neck volu­ me with dysphagia to solids and liquids of 1 month of evolution. The neck tomography shows a soft tissue mass at the base of the neck with erosion of the sphe­ noid with extension to the middle cranial fossa, with erosion of the clivus, the sphenoid and the sella turcica. The histopathological diagnosis is an esthesioneuroblastoma.

Chordomas: Histopathological Study in View of Anatomical Location

BACKGROUND: Chordomas are aggressive bone tumors that have a predilection for the axial skeleton including the skull base and spinal/sacral bones. However, the histopathological and clinical differences between skull base chordoma (SBC) and sacral/spinal chordoma (SC) are unclear as previous studies have been focused on patient prognosis and treatment outcome. This study aimed to evaluate the clinicopathologic features and prognosis of chordoma according to its location. METHODS: Patients with chordomas were enrolled, and the histopathologic features were compared according to the tumor location. RESULTS: A total of 52 patients were enrolled. SBCs had more abundant chondroid matrix and diffuse growth pattern, while SCs had non-chondroid, myxoid matrix and a lobulating pattern, typical of chordoma. Old age and residual tumors were risk factors for shorter overall survival in SBCs. The chondroid matrix was an independent risk factor for shorter disease-free survival in the overall population. CONCLUSION: Chordomas have different histopathologic features depending on the anatomical location.

Endoscopic Endonasal Approach to Foramen Magnum Meningioma­Technical Note and Case Example

Foramen magnum (FM) tumors represent one of the most complex cases for the neurosurgeon, due to their location in a very anatomically complex region surrounded by the brainstem and the lower cranial nerves, by bony elements of the craniocervical junction, and by the vertebrobasilar vessels. Currently, the open approach of choice is a lateral extension of the posteriormidline approach including far lateral, and extremelateral routes. However, the transoraltranspharyngeal approach remains the treatment of choice in cases of diseases affecting the craniocervical junction. For very selective cases, the endoscopic endonasal route to this region is another option.We present a case of a ventral FM meningioma treated exclusively with the endoscopic endonasal approach.