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Daniel C. Rohrer, Kim J. Burchiel, and David P. Gruber

✓ A diverse collection of unverified theories as to the etiology of extradural meningeal cysts have been previously proposed. One case of intraspinal extradural meningeal cyst of the thoracolumbar region is presented in which a ball-valve mechanism involving an idiopathic dural rent and a herniated segment of an underlying dorsal rootlet was suggested by the operative findings. Closure of the dural rent with marsupialization of the meningeal cyst obliterated this extradural lesion. The ball-valve mechanism of formation and other previously proposed theories are discussed.

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Erin M. Kennedy, David P. Gruber, David A. Billmire, and Kerry R. Crone

✓ The surgical treatment of transsphenoidal cephaloceles in children is controversial. Reduction and repair via a transcranial approach are associated with high postoperative rates of morbidity, mortality, and hypothalamic dysfunction. In this study, four patients, aged 3 to 35 months at surgery, underwent successful transpalatal repair of two encephaloceles and two meningoceles. Two patients presented with nasal obstruction in infancy, one presented with unexplained meningitis, and in one patient the lesion was found incidentally during evaluation for seizures. Two children had median cleft face syndrome, another had an associated Arnold—Chiari type I malformation, and the fourth had no other cranial abnormalities. All patients underwent preoperative evaluation including magnetic resonance (MR) imaging. Auditory, ophthalmological, genetic, endocrinological, or other evaluation was undertaken as indicated. Lesions were approached through the median raphe of the hard and soft palates. All cephaloceles were easily visualized and dissected after division of the nasal palatal mucosa. The dural sac and its contents were reduced by surface coagulation after division and dissection of the overlying mucosa. Once reduced, the bone defect was obliterated in three of four patients. The dura was not opened and anomalous neural elements were not resected. At follow-up evaluation, all patients demonstrated resolution of preoperative symptoms without evidence of infection or lasting morbidity. Follow-up MR imaging showed reduction in all cases. The authors conclude that this transpalatal approach is safe and reliable for the treatment of transsphenoidal cephaloceles in young children.

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David P. Gruber, Gary A. Zimmerman, Thomas A. Tomsick, Harry R. van Loveren, Michael J. Link, and John M. Tew Jr.

Object. The goal of this retrospective study was to evaluate endovascular treatment by means of Guglielmi detachable coils (GDCs) compared with surgical management for basilar artery (BA) apex aneurysms.

Methods. Forty-one patients presented with saccular BA apex aneurysms with angiographically definable necks that were judged suitable for either treatment. Of 20 patients who underwent surgery and 21 who underwent GDC embolization, 15 (75%) and 11 (52%), respectively, were treated in the acute phase after subarachnoid hemorrhage (SAH). Twenty-four (92%) of the 26 patients presenting with an SAH had a Hunt and Hess Grade III or better. Fifteen patients with unruptured or ruptured aneurysms more than 14 days post-SAH were treated electively. Patients in the endovascular and surgical treatment groups had aneurysms with comparable dimensions and configurations. Overall, 15 (75%) of the surgical patients and 20 (95%) of the patients in whom GDC embolization was performed had a good outcome (Glasgow Outcome Scale score of 4 or 5). Among those patients treated in the acute stage post-SAH, 11 (73%) of the surgical group and 10 (91%) of the endovascular group did well. Fourteen patients treated electively (93%) had good outcomes. There were two deaths (10%) in the surgical group and none in the endovascular group. Patients treated surgically were hospitalized twice as long and incurred twice the expenses of patients who underwent endovascular treatment (p < 0.001).

Conclusions. Endovascular GDC embolization of select BA apex aneurysms may be a competitive alternative to direct surgical clipping. Long-term follow up is needed to better define the natural history of the endovascularly treated aneurysm and to further evaluate the accuracy of these preliminary results.

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Andrew L. Ko, Patrik Gabikian, Jonathan A. Perkins, David P. Gruber, and Anthony M. Avellino

Anatomical variants of the basiocciput are uncommon and usually clinically benign. While the majority remain undetected, these anomalies rarely manifest as CSF rhinorrhea or recurrent meningitis associated with meningocele. Compromise of the leptomeninges provides an avenue of ingress for pathological organisms and can lead to recurrent meningitis, necessitating operative repair of the defect to prevent infection. A review of the literature reveals only 3 cases in which a congenital basioccipital defect has been associated with a meningocele requiring surgical repair.

The authors present a case of recurrent meningitis in an infant with a congenital basioccipital meningocele treated with a minimally invasive endoscopic technique. At the 2-year follow-up the repair remained successful, with no evidence of recurrence of the meningocele or CSF infection. The literature regarding the etiology and treatment of these lesions was reviewed, with an emphasis on the safety and efficacy of the endoscopic approach. Note that recurrent meningitis in the setting of a skull base defect may indicate the presence of other congenital anomalies that will necessitate multidisciplinary care for a patient's long-term well-being.

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Ashwatha Narayana, Patrick Kelly, John Golfinos, Erik Parker, Glyn Johnson, Edmond Knopp, David Zagzag, Ingeborg Fischer, Shahzad Raza, Praveen Medabalmi, Patricia Eagan, and Michael L. Gruber

Object

Antiangiogenic agents have recently shown impressive radiological responses in high-grade glioma. However, it is not clear if the responses are related to vascular changes or due to antitumoral effects. The authors report the mature results of a clinical study of bevacizumab-based treatment of recurrent high-grade gliomas.

Methods

Sixty-one patients with recurrent high-grade gliomas received treatment with bevacizumab at 10 mg/ kg every 2 weeks for 4 doses in an 8-week cycle along with either irinotecan or carboplatin. The choice of concomitant chemotherapeutic agent was based on the number of recurrences and prior chemotherapy.

Results

At a median follow-up of 7.5 months (range 1–19 months), 50 (82%) of 61 patients relapsed and 42 patients (70%) died of the disease. The median number of administered bevacizumab cycles was 2 (range 1–7 cycles). The median progression-free survival (PFS) and overall survival (OS) were 5 (95% confidence interval [CI] 2.3–7.7) and 9 (95% CI 7.6–10.4) months, respectively, as calculated from the initiation of the bevacizumab-based therapy. Radiologically demonstrated responses following therapy were noted in 73.6% of cases. Neither the choice of chemotherapeutic agent nor the performance of a resection prior to therapy had an impact on patient survival. Although the predominant pattern of relapse was local, 15 patients (30%) had diffuse disease.

Conclusions

Antiangiogenic therapy using bevacizumab appears to improve survival in patients with recurrent high-grade glioma. A possible change in the invasiveness of the tumor following therapy is worrisome and must be closely monitored.