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.

Identificación prequirúrgica de pares craneales en tumores de la base del cráneo mediante la técnica de tensor de difusión / Diffusion tensor technique as a preoperative identification of cranial nerves in skull base tumors

Objetivo: El objetivo de este trabajo es demostrar la utilidad de las técnicas de tensor de difusión de alta densidad (DTI 32 direcciones) para visualizar el trayecto de los pares craneales antes de la cirugía en pacientes con patología tumoral de la base del cráneo. Materiales y métodos: Se estudiaron 26 pacientes con patología tumoral de la base del cráneo con secuencias de tensor de difusión de alta densidad. Los resultados imagenológicos fueron correlacionados con los hallazgos intraoperatorios. Resultados: En todos los pacientes estudiados fue posible la identificación prequirúrgica del recorrido de los nervios involucrados por las lesiones de la base del cráneo y también hubo una correlación entre los datos obtenidos mediante las imágenes y los hallazgos intraoperatorios. Conclusión: La visualización del recorrido de los nervios craneales mediante la difusión de alta densidad demostró ser segura y reproducible para identificar los pares y su recorrido...

Objective: The objective of this work is to demonstrate the usefulness of high density diffusion tensor imaging techniques (HD-DTI 32 directions), to visualize the course of the cranial nerves prior to surgery in patients with skull base tumor disease.Materials and methods: Twenty-six patients with skull base tumor disease were studied with sequences of high density diffusion tensor imaging. The imaging results were correlated with the intra-operative fi ndings.Results: Pre-surgical identifi cation of the course of the nerves affected by the injuries of the skull base was possible in all the studied patients, with the imaging results correlating with the intraoperative fi ndings.Conclusion: The visualization of the course of the cranial nerves with high density diffusion tensor imaging was shown to be safe and reproducible for the identifi cation of cranial nerves and their course...

Endovascular treatment of iatrogenic pseudoaneurysm and delayed carotid-cavernous fistula following trans-sphenoidal surgery / Tratamiento endovascular de pseudoaneurisma y fístula carótida-cavernosa iatrogénica después de la cirugía trans-esfenoidal

Lesiones accidentales de la arteria carótida son complicaciones poco frecuentes de diversos procedimientos diagnósticos y terapéuticos. Representan una condición grave y potencialmente mortal si el tratamiento no se realiza adecuadamente. Un paciente de sexo femenino, 45 años de edad, que ingresó en el servicio de Otorrinolaringología con queja de la disminución de la agudeza auditiva y acúfenos en el oído izquierdo. La resonancia magnética encefálica mostro una formación expansiva / infiltrativa a comprometer desde la nasofaringe izquierda hasta la base del cráneo, con la participación de la arteria carótida interna (ACI) en el mismo lado en su segmento petroso. Durante el procedimiento de biopsia, se produjo una laceración en la carótida derecha intracavernosa con sangrado abundante. Se realizó un taponamiento local y el paciente fue remitido a la angiografía cerebral que mostró un seudoaneurisma en la arteria carótida interna derecha en su segmento cavernoso. Después de una prueba de oclusión, la ACI derecha fue ocluida por 2 globos. Tres semanas después, el estado del paciente mostró empeoramiento progresivo de la agudeza visual, proptosis ocular, hiperemia conjuntival y la restricción del movimiento ocular en el ojo derecho. Una nueva angiografía fue realizada y mostró la persistencia de la oclusión de la ACI en su origen y un seudoaneurisma asociado con fístula carótido-cavernosa derecha, que se opacificado después de la inyección de contraste en la ACI izquierda, a través de la arteria comunicante anterior. El paciente fue sometido a un nuevo tratamiento endovascular con resolución de la lesión. Laceración de ACI durante la cirugía transesfenoidal es una complicación rara y potencialmente fatal. La prevención es el mejor tratamiento para cualquier lesión accidental. La utilización de técnicas endovasculares ha permitido para el tratamiento satisfactorio de esta condición.

Accidental carotid artery lesions are uncommon complications from diverse diagnostic and therapeutic procedures. It represents a grave and potentially lethal condition if treatment is not adequately performed. A female patient, 45 years old, who was admitted to the Otolaryngology service complaining of diminished auditory acuity and tinnitus in the left ear. The encephalic magnetic resonance imaging (MRI) showed an expansive/infiltrative formation compromising the left nasopharynx to the skull base, involving the ipsilateral internal carotid artery (ICA) in its petrous segment. During the biopsy procedure, there was a right intracavernous ICA laceration with copious bleeding. A local tamponade was performed and the patient was referred to cerebral angiography (CAG), which showed a right ICA pseudoaneurysm in its intracavernous segment. After a balloon occlusion test, the right ICA was occluded by 2 balloons. Three weeks after, the patient’s condition showed progressive worsening of visual acuity, occular proptosis, conjuctival hyperemia and occular movement restriction in the right eye. A new CAG was performed and showed persistence in the right ICA occlusion in its origin and an intracavernous pseudoaneurysm associated with ipsilateral carotidcavernous fistula, which became opacified after contrast injection in left ICA, through the anterior communicating artery. The patient was submitted to a new endovascular treatment with lesion resolution. ICA laceration during transsphenoidal surgery is a rare and potentially fatal complication. The prevention is the best treatment for any accidental lesion. Utilization of endovascular techniques has allowed for satisfactory treatment of this condition.

Maffucci' s syndrome complicated by intracranial chondrosarcoma: two new illustrative cases

Maffucci's syndrome is a rare congenital condition, sometimes misdiagnosed as Ollier's disease, characterized by multiple enchondromas combined with hemangiomas and phlebectasia. Coexisting primary malignancies have been described sporadically. We report two cases of Maffucci's syndrome associated with cranial base chondrosarcoma, emphasizing pathophysiological features and the challenging management of intracranial chondrosarcomas. To the best of our knowledge, only twelve similar cases have been reported in the literature.

Síndrome de Maffucci é uma condição congênita rara, às vezes confundida com a doença de Ollier, caracterizada por encondromas múltiplos associados com hemangiomas e flebectasia. A concomitância com neoplasias primárias tem sido relatada esporadicamente. Nós relatamos dois casos de síndrome de Maffucci associada a condrossarcoma da base do crânio, enfatizando aspectos fisiopatológicos e o manejo desafiador dos condrossarcomas intracranianos. Em revisão da literatura, podemos encontrar o relato de apenas doze casos similares.

Crohn's disease associated to chordoma: a case report

Crohn's disease is an inflammatory bowel disease characterized by remissions and exacerbations. Immunosuppressants are frequently used to induce and maintain remission in these patients. The use of the immunomodulator azathioprine has been associated to malignancies. Chordomas are rare, locally aggressive tumors arising from remnants of the notochord. A specific trigger for this tumor has not been identified and association to any medication has not been reported. The purpose of this report is to present the first case reported in the literature of Crohn's disease associated to a chordoma. The patient to be presented was on azathioprine therapy, among other medications. A review of literature revealed that Crohn's disease and chordoma have abnormalities in chromosomes 1 and 10. Inflammatory bowel disease and chordoma also have abnormalities in chromosomal regions 1p, 3p, and 7q. Despite these findings, a direct genetic relationship between these diseases is speculative.

Torcicolo secundário a tumor na fossa posterior: relato de caso / Torticollis secondary to a posterior fossa tumor: case report

Os autores relatam um caso de torcicolo, em paciente com 40 anos de idade, sexo masculino, portador de lesao expansiva infratentorial. Após revisao da literatura a respeito do assunto, chamam atençao para hipótese diagnóstica de tumor na fossa posterior como causa rara de torcicolo. A literatura médica nacional a respeito do assunto é escassa, justificando esta publicaçao.