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Paul A. Gardner, Daniel M. Prevedello, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau and Arlan H. Mintz

. Laryngoscope 106 : 914 – 918 , 1996 6 Chakrabarti I , Amar AP , Couldwell W , Weiss MH : Long-term neurological, visual, and endocrine outcomes following transnasal resection of craniopharyngioma . J Neurosurg 102 : 650 – 657 , 2005 7 Cohen-Gadol AA , Liu JK , Laws ER Jr : Cushing's first case of transsphenoidal surgery: the launch of the pituitary surgery era . J Neurosurg 103 : 570 – 574 , 2005 8 Cook SW , Smith Z , Kelly DF : Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note . Neurosurgery

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Paul A. Gardner, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau, Arlan H. Mintz, Steven Grahovac and Susan Stefko

, optic nerves, and so on) increases the challenge of obtaining a watertight repair. Of particular interest has been our realization that despite similar size exposures for other anterior skull base and parasellar pathological entities such as pituitary adenomas and meningiomas, craniopharyngiomas have a disproportionately higher incidence of CSF leakage following surgery. 7 , 18 This increased rate may be related to a higher incidence of either transient or permanent hydrocephalus associated with craniopharyngiomas. 5 , 12 , 36 This is also reflected in the high

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Hilal A. Kanaan, Paul A. Gardner, Gabrielle Yeaney, Daniel M. Prevedello, Edward A. Monaco III, Geoffrey Murdoch, Ian F. Pollack and Amin B. Kassam

images showing GTR of the olfactory schwannoma. Discussion In an adult, the first consideration in the differential diagnosis of large, partially cystic, enhancing subfrontal lesion is a meningioma, 1 although such lesions are uncommon in childhood, and alternative possibilities are considered more likely. Olfactory schwannomas, which are exceedingly rare in children and adults, can have cystic areas like meningiomas but the key distinction is the relationship of the tumor with the adjacent bone: olfactory schwannomas tend to be erosive (see Fig. 3 ), whereas

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010

: This large prospective clinical study showed that surgical treatment for mild, moderate, and severe CSM results in objective improvement in generic and disease-specific health outcomes that are maintained at 2-year follow-up. J Neurosurg Journal of Neurosurgery JNS 0022-3085 1933-0693 American Association of Neurological Surgeons JNS.2010.113.2.1 Paper 603 Natural History of Meningiomas Soichi Oya , MD, PhD , Seon Hwan Kim , MD , Burak Sade , MD , Chong Gue Kim , MD , and Joung H. Lee

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Juan C. Fernandez-Miranda, Carlos D. Pinheiro-Neto, Paul A. Gardner and Carl H. Snyderman

The authors present the technical and anatomical nuances needed to perform an endoscopic endonasal removal of a tuberculum sellae meningioma. The patient is a 47-year-old female with headaches and an incidental finding of a small tuberculum sellae meningioma with no vascular encasement, no optic canal invasion, but mild inferior to superior compression of the cisternal segment of the left optic nerve. Neuroophthalmology assessment revealed no visual defects. Treatment options included clinical observation with imaging follow-up studies, radiosurgery, and resection. The patient elected to undergo surgical removal and an endonasal endoscopic approach was the preferred surgical option.

Preoperative radiological studies showed the presence of an osseous ring between the left middle and anterior clinoids, the so-called carotico-clinoidal ring. The surgical implications of this finding and its management are illustrated. The surgical anatomy of the suprasellar region is reviewed, including concepts such as the chiasmatic sulcus and limbus sphenoidale, medial and lateral optico-carotid recesses, and the paraclinoidal and supraclinoidal segments of the internal carotid artery. Emphasis is made in the importance of exposing the distal dural ring of the internal carotid artery and the precanalicular segment of the optic nerve for adequate intradural dissection. The endonasal route allows for early coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without any manipulation of the optic nerve. The lateral limit of dural removal is formed by the distal dural ring, which is gently coagulated after the tumor is resected. A 45° scope is used to inspect for any residual tumor, in particular at the entrance of the optic nerve into the optic canal and at the most anterior margin of the exposure (limbus sphenoidale). The steps for reconstruction are detailed and include intradural placement of dural substitute and extradural placement of the nasoseptal flap. The nuances for proper harvesting, positioning, and reinforcement of the flap are described. No lumbar drain was used.

The patient had an uneventful recovery with no CSF leak or any other complications. Imaging follow-up at 6 months showed complete removal of the tumor. The patient had no sinonasal or neurological symptoms, and olfaction was fully preserved.

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Srinivas Chivukula, Maria Koutourousiou, Carl H. Snyderman, Juan C. Fernandez-Miranda, Paul A. Gardner and Elizabeth C. Tyler-Kabara

palsies. We extended the latter group to include a single patient who presented with a chondrosarcoma. Finally, tumors in 30 patients were very heterogeneous and were broadly categorized as “other pathologies.” These included rare pathologies such as orbital meningioma, pituitary carcinoma, germinoma, and inverted papilloma. TABLE 2: Summary of the major presenting symptoms of patients with skull base tumors Presenting Symptom No. of Patients (%) Angiofibroma (n = 24) Craniopharyngioma (n = 16) RCC (n = 12) Pituitary

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Maria Koutourousiou, Paul A. Gardner, Juan C. Fernandez-Miranda, Alessandro Paluzzi, Eric W. Wang and Carl H. Snyderman

transsphenoidal approach for tuberculum sellae meningiomas . Neurosurgery 62 : 6 Suppl 3 1192 – 1201 , 2008 7 de Paiva Neto MA , Vandergrift A , Fatemi N , Gorgulho AA , Desalles AA , Cohan P , : Endonasal transsphenoidal surgery and multimodality treatment for giant pituitary adenomas . Clin Endocrinol (Oxf) 72 : 512 – 519 , 2010 8 Dehdashti AR , Ganna A , Witterick I , Gentili F : Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations . Neurosurgery 64 : 677 – 689

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Maria Koutourousiou, Juan C. Fernandez-Miranda, S. Tonya Stefko, Eric W. Wang, Carl H. Snyderman and Paul A. Gardner

D espite technological advances such as image guidance and the use of the operating microscope during the last decades, both of which have improved the surgical outcome in the management of suprasellar meningiomas, the treatment of these tumors remains challenging given the high risk of visual pathway involvement and vascular encasement of the paraclinoidal carotid artery or the anterior cerebral artery (ACA) complex. Various surgical approaches have been advocated to resect suprasellar meningiomas, with the subfrontal approach (unilateral or bilateral

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Juan C. Fernandez-Miranda, Paul A. Gardner, Milton M. Rastelli Jr., Maria Peris-Celda, Maria Koutourousiou, David Peace, Carl H. Snyderman and Albert L. Rhoton Jr.

lesions (basilar artery aneurysms) and tumoral lesions (petroclival meningiomas, chordomas) in the upper petroclival region. 8 F ig . 1. Intracranial superior view of the sellar and parasellar areas in a silicon-injected anatomical specimen. The dura mater has been removed on the left side of the specimen. The diaphragma sellae is continuous laterally with the dura forming the roof of the cavernous sinus, and it is continuous posteriorly with the dura covering the dorsum sellae and posterior clinoid processes. The interclinoid and posterior petroclinoid

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Maria Koutourousiou, Francisco Vaz Guimaraes Filho, Tina Costacou, Juan C. Fernandez-Miranda, Eric W. Wang, Carl H. Snyderman, William E. Rothfus and Paul A. Gardner

changes occurred and the progress of changes were studied on the follow-up MR images. Other than the 14 cases with posterior fossa changes that qualified for the study group (13 clival chordomas and 1 petroclival meningioma), the same morphometric parameters were evaluated in 50 patients without clival defects from the practice of the senior author as the anatomical control group; these individuals had small lesions of the pituitary fossa (pituitary microadenomas) with otherwise intact skull base bone anatomy. Potential risk factors were evaluated and compared between