that the best chance for cure comes through radical total removal, most authors, both pioneer and modern, have been content with subtotal removal to avoid the devastating sequelae of injury to the encased cerebral vessels; 6, 9, 17, 22, 31, 43, 51, 56 hence, repeated surgery and radiation therapy are frequently required. However, unless total removal is achieved, detrimental regrowth is expected in the majority of patients. 1, 15, 17, 37, 47 Recent advances in cranial-base and cavernous sinus surgery have facilitated total removal, allowing respectable mortality
Ossama Al-Mefty and Luis A. B. Borba
mortality rates. 25 High-dose radiation therapy, especially proton beam or combined proton—photon beam therapy, has been shown to provide good results in tumor control and acceptable rates of complications; 7, 8, 28 radiation therapy appears to be more effective when administered after surgery than when given after tumor recurrence, 4 and its effectiveness has been related to the volume of residual tumor. 11 Hence, we have used combined radical surgical removal and postoperative proton—photon beam therapy, which appears to be the most efficacious treatment for these
Emad Aboud, Ossama Al-Mefty and M. Gazi Yaşargil
M any sources are available for training in neurosurgery, but none of them reliably mimics the anatomy and characteristics of the vascular tree in the human brain during live surgery, in particular, during hemorrhage. Cadaver models injected with colored silicone, gelatin, or any other congealed material lack pulsation and vascular filling, which allow manipulation of vessels, hemostasis, clipping, and suturing. On the other hand, live anesthetized animals do not represent true human anatomy. We have developed a new model in which vessels in a cadaveric head
Franco DeMonte and Ossama Al-Mefty
. Postoperative Course Immediately after surgery the patient was neurologically normal and had undisturbed eye movement. Thirty hours later, however, she was noted to be restless and agitated. She became lethargic, showed decreased responsiveness, and lapsed into a coma over the next 12 hours. During this progressive neurological decline, she became profoundly hypoxemic. An increasing fraction of inspired oxygen and, ultimately, mechanical ventilation were required. A perfusion lung scan showed a low probability of a pulmonary embolus. The patient's chest x-ray study was
Kenan I. Arnautović and Ossama Al-Mefty
controls the tumor locally. The surgical route, however, is outside the region of the primary tumor and outside the irradiated area and is therefore vulnerable to tumor seeding by surgical implantation. Surgical seeding of tumor cells along the operative route or at distant locations where fat tissue is harvested is an underrecognized surgery-related complication in cases of chordomas. We found six patients in whom surgical seeding of the tumor cells had occurred in tissues separate from the primary tumor. In this article we draw attention to this underrecognized
Kenan I. Arnautović and Ossama Al-Mefty
introduced 4 years ago and was used in five patients. Postoperative imaging included a CT scan obtained 24 hours after surgery and MR images obtained during the early postoperative period, followed by MR imaging performed at 3 months and 6 months, and thereafter on an annual basis. Perioperative multidisciplinary evaluations included audiological evaluation both before and after surgery, speech pathology and otolaryngological evaluations, and pre- and postoperative swallowing studies. Patients were placed on a nothing per mouth regimen postoperatively with parenteral
Kenan I. Arnautoviæ and Ossama Al-Mefty
Chordomas have a high propensity for local recurrence and progression, as well as for systemic and cerebrospinal fluid metastasis. The authors identified and analyzed a series of patients with chordomas, focusing on an underrecognized entity—surgical seeding.
In a retrospective analysis of 82 patients with chordomas treated over a 10-year period (1990–2000) the authors found six patients (7.3%) in whom surgical seeding had occurred. In five (83%) of these patients the primary tumor was located at the clivus. In one (17%) the tumor was present in the cervical region. There were two male (33%) and four female patients (67%) with a mean age of 34 years. The seeding sites, which were separate from the primary tumor, were located along the operative route or in the abdomen where fat was removed. The seeding was diagnosed 5 to 15 months after surgery (mean 12 months). One seeding site was present in five patients and 17 seeding sites were present in one patient. The involved tissues included mucosa, bone, dura, muscle, and fat. After resection, all seedings were documented histologically.
Seeding of chordomas occurs along the operative route and at distant locations where fat is harvested. Early diagnosis and aggressive surgical treatment are recommended. Based on the results of this study, it is suggested that surgical techniques, postoperative irradiation, the neuroradiological follow-up protocol, and even research on chordomas should be reevaluated.
Paulo A. S. Kadri and Ossama Al-Mefty
Schwannomas of the jugular foramen are rare, comprising between 2 and 4% of intracranial schwannomas. The authors retrospectively analyzed their surgical experience with schwannomas of the lower cranial nerves that presented with intra- and extracranial extensions through an enlarged jugular foramen. The transcondylar suprajugular approach was used without sacrificing the labyrinth or the integrity of the jugular bulb. In this report the clinical and radiological features are discussed and complications are analyzed.
This retrospective study includes six patients (three women and three men, mean age 31.6 years) with dumbbell-shaped jugular foramen schwannomas that were surgically treated by the senior author during a 5.5-year period. One patient had undergone previous surgery elsewhere. Glossopharyngeal and vagal nerve deficits were the most common signs (appearing in all patients), followed by hypoglossal and accessory nerve deficits (66.6%). Two or more signs or symptoms were present in every patient. Three tumors presented with cystic degeneration. In four patients the jugular bulb was not patent on neuroimaging studies. The suprajugular approach was used in five patients; the origin of the tumor from the 10th cranial nerve could be defined in three of them. All lesions were completely resected. No death or additional postoperative cranial nerve deficits occurred in this series. Aspiration pneumonia developed in one patient. Preoperative deficits of the ninth and 10th cranial nerves improved in one third of the patients and half recovered mobility of the tongue. No recurrence was discovered during the mean follow-up period of 32.8 months.
With careful, extensive preoperative evaluation and appropriate planning of the surgical approach, dumbbell-shaped jugular foramen schwannomas can be radically and safely resected without creating additional neurological deficits. Furthermore, recovery of function in the affected cranial nerves can be expected.
Ossama Al-Mefty and Aramis Teixeira
reviewed. Twenty-eight patients underwent surgical treatment. The remaining patients either declined surgery and received radiation therapy at other institutions or were followed up conservatively. Patients were evaluated through detailed neurological, neuroophthalmological, and neurootological examinations. High-resolution CT scans of the temporal bone with a bone algorithm were obtained. Multiplanar MR images were obtained both with and without contrast enhancement (nine patients were treated before MR imaging was available). In each patient the serum catecholamine
Benedicto O. Colli and Ossama Al-Mefty
techniques and our ability to diagnose these lesions, treatment of patients with skull base chordomas and chondrosarcomas is still a challenge for neurosurgeons. Because the tumor originates from the bone at the base of the skull, the recurrence rate of these lesions, even after exceptionally complete resection, remains high. 31 Several factors, such as patient age at onset of symptoms, the pathological patterns of the tumor, history of surgery or radiotherapy, extent of resection, adjuvant radiotherapy, and cytogenetic abnormalities, are thought to influence the