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Tyler J. Kenning, Thomas O. Willcox, Gregory J. Artz, Paul Schiffmacher, Christopher J. Farrell and James J. Evans

Object

Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors.

Methods

The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect.

Results

The average body mass index (BMI) among all patients was 33.2 ± 7.2 kg/m2. Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m2). Preoperative intracranial pressures (ICPs) averaged 21.8 ± 6.0 cm H2O, with 10 patients (43%) demonstrating an ICP > 20 cm H2O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months).

Conclusions

Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H2O, BMI > 30 kg/m2, preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth).

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Tyler J. Kenning, D. David Beahm, Christopher J. Farrell, Madeleine R. Schaberg, Marc R. Rosen and James J. Evans

The authors present the case of a 21-year-old female with a progressive bitemporal hemianopsia. Cranial MR imaging revealed a large cystic suprasellar, retrochiasmatic lesion consistent with craniopharyngioma. The lesion was fully resected through an endoscopic endonasal transsphenoidal and transplanum approach. Closure of the resultant dural defect was performed with a bilayer fascia lata button and autologous mucoperichondrial nasoseptal flap. Each portion of this procedure was recorded and is presented in an edited high-definition format.

The video can be found here: http://youtu.be/i3-qieLlbVk.

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Marc R. Rosen, Mindy R. Rabinowitz, Christopher J. Farrell, Madeleine R. Schaberg, M.P.H. and James J. Evans

Endonasal resection of olfactory groove meningiomas allows for several advantages over transcranial routes, including a direct approach to the bilateral anterior cranial base and dura mater, early tumor devascularization, and avoidance of brain retraction. Although considered minimally invasive, the endoscopicapproach to the cribriform plate typically requires resection of the superior nasal septum, resulting in a large superior septal perforation. The septal transposition technique improves preservation of sinonasal anatomy through the elimination of a septal perforation while allowing for wide exposure to the midline anterior cranial base and harvest of a nasal septal flap. Herein, the authors describe a 39-year-old female who presented with a progressively enlarging olfactory groove meningioma. An endoscopic endonasal resection with a septal transposition technique was performed. On follow-up, the nasal cavity had completely normal anatomy with preservation of the turbinatesand nasal septum.

The authors conclude that septal transposition is a useful technique that allows wide exposure of the anterior cranial base with maximal preservation of normal nasal anatomy and avoidance of a large septal perforation.

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Varun R. Kshettry, Hyunwoo Do, Khaled Elshazly, Christopher J. Farrell, Gurston Nyquist, Marc Rosen and James J. Evans

OBJECTIVE

There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas.

METHODS

A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005–2009, n = 20) and a late cohort (2010–2015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively.

RESULTS

Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001).

CONCLUSIONS

High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.

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Christian Hoelscher, Ahmad Sweid, Ritam Ghosh, Fadi Al Saiegh, Kavantissa M. Keppetipola, Christopher J. Farrell, Jack Jallo, Pascal Jabbour, Stavropoula Tjoumakaris, M. Reid Gooch, Robert H. Rosenwasser and Syed O. Shah

Herein, the authors present the case of a 54-year-old male diagnosed with coronavirus disease 2019 (COVID-19) during a screening test. The patient was asked to self-isolate at home and report with any exacerbations of symptoms. He presented later with pneumonia complicated by encephalopathy at days 14 and 15 from initial diagnosis, respectively. MRI of the brain showed bithalamic and gangliocapsular FLAIR signal abnormality with mild right-sided thalamic and periventricular diffusion restriction. A CT venogram was obtained given the distribution of edema and demonstrated deep venous thrombosis involving the bilateral internal cerebral veins and the vein of Galen. CSF workup was negative for encephalitis, as the COVID-19 polymerase chain reaction (PCR) test and bacterial cultures were negative. A complete hypercoagulable workup was negative, and the venous thrombosis was attributed to a hypercoagulable state induced by COVID-19. The mental decline was attributed to bithalamic and gangliocapsular venous infarction secondary to deep venous thrombosis. Unfortunately, the patient’s condition continued to decline, and care was withdrawn.