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Susumu Oikawa, Kazuhiko Kyoshima and Shigeaki Kobayashi

Object

The authors report on the surgical anatomy of the juxtadural ring area of the internal carotid artery to add to the information available about this important structure.

Methods

Twenty sides of cadaver specimens were used in this study. The plane of the dural ring was found to incline in the posteromedial direction. Medial inclination was measured at 21.8š on average against the horizontal line in the anteroposterior view on radiographic studies. Posterior inclination was measured at 20.3š against the planum sphenoidale in the lateral projection, and the medial edge of the dural ring was located 0.4 mm above the tuberculum sellae in the same projection. The lateral edge of the tuberculum sellae was located 1.4 mm below the superior border of the anterior clinoid process. The carotid cave was situated at the medial or posteromedial aspect of the dural ring; however, two of the 20 specimens showed no cave formation. The carotid cave contained the subarachnoid space in 13 sides, the arachnoid membrane only in three sides, and the extraarachnoid space in two sides. The authors propose that the marker of the medial side of the dural ring, which is more proximal than the lateral, is the tuberculum sellae in the lateral view on radiographic studies. In the medial aspect of the dural ring the intradural space can be situated below the level of the tuberculum sellae because of the existence of the carotid cave.

Conclusions

The authors found that an aneurysm arising from the medial side of the juxtadural ring area even below the tuberculum sellae is a potential cause of subarachnoid hemorrhage.

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Griff Harsh, Robert Ojemann, Mark Varvares, Brooke Swearingen, Mack Cheney and Michael Joseph

Object

Clival chordomas are frequently midline lesions whose posterior growth may breach the dura and invaginate the brainstem. This precludes safe delivery of potentially curative high-dose fractionated proton radiotherapy. To avoid this problem, the authors performed pedicled rhinotomy to resect chordomas in 10 patients.

Methods

Pedicled rhinotomy is a midface transnasal route to the intercarotid sella and clivus from the tuberculum sellae to the mid-C-2 level. It involves a lateral rhinotomy incision, osteotomies of nasal bones and cartilage, lateral rotation of the nose, removal of the nasal septum and medial maxillary walls, opening of ethmoid and sphenoid sinuses, and dissection of nasopharynx and oropharynx to expose the clivus and craniovertebral junction. Tumors involving the sella, medial cavernous sinuses, middle and lower clivus, and C-1 arch and dens can be removed even if they traverse the dura. Closure involves dural repair, grafting of fat and split-thickness skin, rotation of a vascularized mucosal pedicle, and reattachment of nasal cartilage.

Ten clival chordomas in adult patients were surgically removed via a pedicled rhinotomy approach. Seven patients had previously undergone a total of nine skull base procedures. In eight of the 10 patients, tumors compressing the brainstem were completely removed using this technique. One patient required an additional subtemporal resection of a suprasellar tumor before definitive radiotherapy could be undertaken. No patient sustained any new neurological deficit; in eight patients headache, diplopia, or hemiparesis improved. One patient developed postoperative cerebrospinal fluid leakage and meningitis that were successfully treated with antibiotic agents and shunt placement.

Conclusions

Pedicled rhinotomy provides excellent shallow-field exposure of midline clival chordomas and permits relief of brainstem compression and the postoperative administration of potentially curative proton beam irradiation.

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.14.6.5 Tuberculum sellae meningiomas John H. Chi Michael W. McDermott 6 2003 14 6 1 6 10.3171/foc.2003.14.6.6 FOC.2003.14.6.6 Surgical management of posterior petrous meningiomas James K. Liu Oren N. Gottfried William T. Couldwell 6 2003 14 6 1 7 10.3171/foc.2003.14.6.7 FOC.2003.14.6.7 Anatomy of the combined retrolabyrinthine–middle fossa craniotomy John S. Oghalai Robert K. Jackler 6 2003 14 6 1 4 10.3171/foc.2003.14.6.8 FOC.2003.14.6.8 Anatomical basis of approaches to foramen magnum and lower clival meningiomas: comparison of retrosigmoid and transcondylar

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Stephen J. Hentschel and Franco DeMonte

Object

Olfactory groove meningiomas (OGMs) arise over the cribriform plate and may reach very large sizes prior to presentation. They can be differentiated from tuberculum sellae meningiomas because OGMs arise more anterior in the skull base and displace the optic nerve and chiasm inferiorly rather than superiorly.

Methods

The authors searched the neurosurgery database at the M. D. Anderson Cancer Center for cases of OGM treated between 1993 and 2003. The records of these patients were then reviewed retrospectively for details regarding clinical presentation, imaging findings, surgical results and complications, and follow-up status.

Thirteen patients, (12 women and one man, mean age 56 years) harbored OGMs (mean size 5.7 cm). All patients underwent bifrontal craniotomies and biorbital osteotomies. There were 11 complete resections (including the hyperostotic bone and dura of the cribriform plate and any extension into the ethmoid sinuses) and two subtotal resections with minimal residual tumor left in patients with recurrent lesions. No complication directly due to the surgery occurred in any patient. There were no recurrences in a mean follow-up period of 2 years (range 0–5 years).

Conclusions

With current microsurgical techniques, the results of OGM resection are excellent, with a high rate of total resection and a low incidence of complications. All hyperostotic bone should be removed with the dura of the anterior skull base to minimize the risk of recurrence.

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John H. Chi and Michael W. McDermott

Tuberculum sellae meningiomas are a classic tumor of the anterior fossa that present in patients with gradual visual deterioration secondary to optic apparatus compression. If untreated, complete blindness can occur. Treatment involves tumor removal and decompression of the optic chiasm via several operative approaches. Gross-total resection (Simpson Grade I or II) is the goal of treatment and can usually be accomplished safely. Special excision-related considerations include appreciation of arachnoid planes separating the tumor from neural tissue, adequate drilling of osseous elements for optimal exposure, and intraoperative preservation of the vascular supply to the optic apparatus. The authors reviewed their experience at the University of California, San Francisco, in cases of tuberculum sellae meningiomas treated between 1992 and 2002. In most patients, improvement of vision can be achieved with minimal postoperative complications and morbidity.

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Luigi M. Cavallo, Andrea Messina, Paolo Cappabianca, Felice Esposito, Enrico de Divitiis, Paul Gardner and Manfred Tschabitscher

Object

The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens.

Methods

To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach.

Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable.

Conclusions

The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach.

Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

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Jason Rockhill, Maciej Mrugala and Marc C. Chamberlain

) parasagittal 39 (22) 4 (29) sphenoid ridge 30 (17) 3 (21) lateral ventricle 10 (5) 0 (0) tentorium 7 (4) 0 (0) cerebellar convexity 9 (5) 0 (0) tuberculum sellae 7 (3) 0 (0) intraorbital 4 (2) 0 (0) cerebellopontine angle 4 (2) 0 (0) olfactory groove 6 (3) 0 (0) foramen magnum 1 (1) 0 (0) clivus 1 (1) 0 (0) other 1 (1) 0 (0) total 179 14 TABLE 3 Clinical syndromes of intracranial meningiomas Location Syndrome parasagittal/parafalcine simple

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Deborah L. Commins, Roscoe D. Atkinson and Margaret E. Burnett

ahead of print] 2007 7 Goel A , Muzumdar D , Desai KI : Tuberculum sellae meningioma: a report on management on the basis of a surgical experience with 70 patients . Neurosurgery 51 : 1358 – 1364 , 2002 8 Goyal LK , Suh JH , Mohan DS , Prayson RA , Lee J , Barnett GH : Local control and overall survival in atypical meningioma: a retrospective study . Int J Radiat Oncol Biol Phys 46 : 57 – 61 , 2000 9 Hancq S , Salmon I , Brotchi J , De Witte O , Gabius HJ , Heizmann CW , : S100A5: a marker of recurrence in

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Christopher S. Eddleman and James K. Liu

propria of the optic nerve. 27 If there is intracranial meningioma present, such as a clinoidal or tuberculum sellae meningioma, special consideration should be taken to remove the intracranial portion in order to prevent spread to the normal contralateral optic nerve, thus sparing vision in the good eye. Visual improvement after ONSM resection has been reported in the literature, albeit rarely, and usually in association with ONSMs that were small, situated anteriorly, and close to the globe, and were not associated with significant neural invasion. In Dutton

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Enrico de Divitiis, Felice Esposito, Paolo Cappabianca, Luigi M. Cavallo, Oreste de Divitiis and Isabella Esposito

the intracavernous carotid arteries and, more superiorly, the optic nerves; between them the opticocarotid recesses, molded by the pneumatization of the optic strut of the anterior clinoid processes ( Fig. 1 ). F ig . 1. Anatomical photograph showing the landmarks on the posterior wall of the sphenoid sinus. The asterisk indicates the tuberculum sellae. C = clivus; ICA = internal carotid artery; OCR = opticocarotid recess; ON = optic nerve; S = sella; SP = sphenoid planum. Specific Modules Once a wider working space is achieved, to accommodate