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craniotomy for anterior skull base lesions Miguel A. Sánchez-Vázquez Pablo Barrera-Calatayud Manuel Mejia-Villela Julio F. Palma-Silva Isidro Juan-Carachure Jose M. Gomez-Aguilar Federico Sanchez-Herrera November 1999 91 5 892 896 10.3171/jns.1999.91.5.0892 J Neurosurg Journal of Neurosurgery 0022-3085 Journal of Neurosurgery Publishing Group 1 11 1999 November 1999 91 5 10.3171/jns.1999.91.issue-5

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Garnette R. Sutherland, Taro Kaibara, Deon Louw, David I. Hoult, Boguslaw Tomanek and John Saunders

and skull base lesions. In total, 158 MR imaging studies were performed in the 46 patients ( Table 2 ). The studies included 67 T 1 -, 62 T 1 - (after gadolinium administration), and 29 T 2 -weighted sequences. In all studies, the signal-to-noise ratio was sufficient to provide high-quality images that enhanced the surgical procedure. Surgical-planning intraoperative imaging was performed prior to surgical preparation and draping, interdissection images were made at various stages of the operative procedure, and quality assurance imaging followed wound closure

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Miguel A. Sánchez-Vázquez, Pablo Barrera-Calatayud, Manuel Mejia-Villela, Julio F. Palma-Silva, Isidro Juan-Carachure, Jose M. Gomez-Aguilar and Federico Sanchez-Herrera

futility of conventional approaches. 4, 11 Although radical cranial base approaches are well established and their features are widely recognized, the extent of surgical invasion can be reduced as a result of better illumination and magnification, thus diminishing risk to the patients. In 1981, at the Seventh International Congress of Neurological Surgery in Munich, Sanchez-Vazquez 14 described the transciliary subfrontal approach for tumors of the sellar region. Since that time, more than 260 consecutive patients with a variety of skull base lesions—tumors, vascular

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Marc S. Schwartz, Gregory J. Anderson, Michael A. Horgan, Jordi X. Kellogg, Sean O. McMenomey and Johnny B. Delashaw Jr.

osteotomy; however, the decision to use these techniques should still be made on a case-by-case basis, depending on the pathological condition to be treated. Acknowledgment We wish to thank Lynn Kitagawa for illustrations. References 1. Al-Mefty O : Supraorbital-pterional approach to skull base lesions. Neurosurgery 21 : 474 – 477 , 1987 Al-Mefty O: Supraorbital-pterional approach to skull base lesions. Neurosurgery 21: 474–477, 1987 2. Al-Mefty O , Anand VK : Zygomatic approach to skull-base lesions. J Neurosurg 73 : 668 – 673 , 1990 Al-Mefty O, Anand

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Johann Romstöck, Christian Strauss and Rudolf Fahlbusch

T he surgical management of large posterior fossa lesions aims at complete removal of the tumor with functional preservation of cranial nerves. 2, 16 In cases of extended skull base lesions, avoidance of disfiguring facial nerve weakness is desirable; however, the integrity of the ninth, 10th, and 12th cranial nerves is essential to life if the patient suffers from the postoperative disorders of swallowing and aspiration. Intraoperative electrophysiological monitoring was developed to reduce the incidence of postoperative morbidity. 1, 3, 5, 6, 21, 23, 27 In

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Frederick F. Lang, O. Kenneth Macdonald, Gregory N. Fuller and Franco DeMonte

Object. Primary meningiomas arising outside the intracranial compartment (primary extradural meningiomas [PEMs]) are rare tumors. To develop a better understanding of these tumors and to establish a comprehensive classification scheme for them, the authors analyzed a series of patients treated at the M. D. Anderson Cancer Center (MDACC) and reviewed all cases reported in the English-language literature since the inception of the use of computerized tomography (CT) scanning.

Methods. Clinical records, results of radiographic studies, and histological slides were reviewed for all cases of PEM at MDACC. Demographic features, symptoms, tumor location, histological grade, and patient outcome were assessed in all cases. A comprehensive literature search identified 168 PEMs in 142 patients reported during the CT era. These reports were also analyzed for common features. Tumors for both data sets were classified as purely extracalvarial (Type I), purely calvarial (Type II), and calvarial with extracalvarial extension (Type III). Type II and Type III tumors were further categorized as convexity (C) or skull base (B) lesions.

The incidence of PEMs at MDACC was 1.6%, which was consistent with the rate reported in the literature. In both data sets, the male/female ratio was nearly 1:1. The most common presenting symptom was a gradually expanding mass. The age of patients at diagnosis of PEM was bimodal, peaking during the second decade and during the fifth to seventh decades. In all MDACC cases and in 90% of those reported in the literature the PEMs were located in the head and neck. The majority of tumors originated in the skull (70%).

In the MDACC series and in the literature review, the majority (67% and 89%, respectively) of tumors were histologically benign. Although fewer PEMs were malignant or atypical (33% at MDACC and 11% in the literature), their incidence was higher than that observed for primary intracranial meningiomas. Distant metastasis was not a common feature reported for patients with PEMs (6% in the literature).

Outcome data were available in 96 of the cases culled from the CT-era literature. The combination of the MDACC data and the data obtained from the literature demonstrated that patients with benign Type IIB or Type IIIB lesions were more likely to experience recurrence than patients with benign Type IIC or Type IIIC tumors (26% compared with 0%, p < 0.05). The more aggressive atypical and malignant tumors were associated with a statistically significant higher death rate (29%) relative to benign tumors (4.8% death rate, p < 0.004).

Conclusions. Defining a tumor as a PEM is dependent on the tumor's relation to the dura mater and the extent and direction of its growth. Classification of PEMs as calvarial or extracalvarial and as convexity or skull base lesions correlates well with clinical outcome.

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Jean Régis, Philippe Metellus, Henry Dufour, Pierre-Hughes Roche, Xavier Muracciole, William Pellet, Francois Grisoli and Jean-Claude Peragut

, Meckel cave, petrous apex, pontocerebellar angle, and petroclivus, whether benign or malignant, are likely to cause TN. 4–7, 23, 27, 30, 34, 56 The region of the skull base was long considered to be a surgical barrier because of its complex anatomy. Improvements in skull-base microsurgical techniques and the anatomical knowledge of this region 1–3, 44–51 have facilitated more aggressive attempts to remove skull base lesions, while still maintaining acceptable rates of mortality and morbidity. Despite these treatments, total tumor removal with minimal incidences of

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Amos O. Dare, Michael K. Landi, Demetrius K. Lopes and Walter Grand

, 1999 Perneczky A, Muller-Forell W, van Lindert E, et al: Keyhole Concept in Neurosurgery: With Endoscope-Assisted Microneurosurgery and Case Studies. New York: Thieme, 1999 7. Sanchez-Vazquez MA , Barrera-Calatayud P , Mejia-Villela M , et al : Transciliary subfrontal craniotomy for anterior skull base lesions. Technical note. J Neurosurg 91 : 892 – 896 , 1999 Sanchez-Vazquez MA, Barrera-Calatayud P, Mejia-Villela M, et al: Transciliary subfrontal craniotomy for anterior skull base lesions. Technical note. J

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James T. Kryzanski, Donald J. Annino Jr. and Carl B. Heilman

The treatment of malignant skull base tumors has improved with the development of skull base surgical approaches that allow en bloc resection of a lesion and increase the efficacy of adjuvant therapies. The anatomical complexity of these lesions and their surroundings has led to a relatively high complication rate. Infection and cerebrospinal fluid fistulas are the most common serious procedure-related complications. They result from the frequent necessity of working in a contaminated space such as the paranasal sinuses as well as from the creation of large dural and skull base defects. The authors have reviewed the literature regarding complications of surgery for malignant skull base lesions and present several techniques and strategies for minimizing their incidence by performing the craniofacial approach to anterior skull base lesions.

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Eve C. Tsai, Stephen Santoreneos and James T. Rutka

Although many treatment strategies for skull base tumors in adults have been reported, relatively little has been reported regarding such therapies in the pediatric population. Skull base tumors in children present a therapeutic challenge because of their unique pathological composition, the constraints of the maturing skull and brain, and the small size of the patients. In this review, the authors examine the pediatric skull base lesions that occur in the anterior, middle, and posterior cranial base, focusing on unique pediatric tumors such as encepahalocele, fibrous dysplasia, esthesioneuroblastoma, craniopharyngioma, juvenile nasopharyngeal angiofibroma, cholesteatoma, chordoma, chondrosarcoma, and Ewing sarcoma. They review management strategies that include radio- and chemotherapy, as well as surgical approaches with emphasis on the modifications and complications associated with the procedures as they apply in children. Evidence for the advantages and limitations of radiotherapy, chemotherapy, and surgery as it pertains to the pediatric population will be examined. With a working knowledge of skull base anatomy and special considerations of the developing craniofacial skeleton, neurosurgeons can treat skull base lesions in children with acceptable morbidity and mortality rates. Outcomes in this population may be better than those in adults, in part because of the benign histopathology that frequently affects the pediatric skull base, as well as the plasticity of the maturing nervous system.