Delayed presentation of an arteriovenous malformation after cerebellar hemangioblastoma resection—Case report

AbstractIntroductionHaemangioblastoma has been uncommonly reported to occur in coexistence either temporally or spatially with the development of an arteriovenous malformations (AVM). We present a case of a delayed AVM following haemangioblastoma resection.Presentation of case44 year old female initially presented with a several week history of headaches, vertigo and nausea and emesis and was found to have a cystic lesion with a solid enhancing component on Magnetic Resonance Imaging (MRI) in the superior aspect of the vermis. She underwent gross total resection and final pathology was consistent with WHO grade I haemangioblastoma. One year later, patient re-presented with headaches, dizziness and left trochlear nerve palsy with rotary nystagmus. Imaging revealed a left posterior tentorial paramedian cerebellar vascular nidus with venous drainage into the left transverses sinus suspicious for arteriovenous malformation. She underwent gross total resection of the lesion. Final pathology confirmed the diagnosis of an arteriovenous malformation.DiscussionRecent research supports both haemangioblastoma and AVM are of embryologic origin but require later genetic alterations to develop into symptomatic lesions. It is unclear in our case if the AVM was present at the time of the initial haemangioblastoma resection or developed de novo after tumor resection. However, given the short time between tumor resection and presentation of AVM, de novo AVM although possible, appears less likely.ConclusionAVM and haemangioblastoma rarely presents together either temporally or spatially. We present a case of a delayed AVM following haemangioblastoma resection. More research is needed to elucidate the rare intermixture of these lesions

Antibiotic prophylaxis in anterior skull‐base surgery: a survey of the North American Skull Base Society

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151867/1/alr22396.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151867/2/alr22396_am.pd

Endonasal Vascularized Flaps For Cranial Base Reconstruction

Since the introduction of extended endoscopic cranial base surgery, postoperative cerebrospinal fluid (CSF) leak has been a formidable and troublesome issue resulting in complications such meningitis, pneumocephalus, and the need for additional surgical interventions. Establishment of a watertight cranial base reconstruction is the most critical step in preventing postoperative CSF leakage. Historically, various free grafts, both synthetic and autologous, were utilized as repair materials for reconstruction of the cranial base defect often in combination with temporary CSF diversion. Free grafts are often sufficient for repair of small low flow, low pressure dural defects. High postoperative CSF leak rates reported in the initial endoscopic skull base literature are evidence that free grafts do not provide a reliably competent repair for large defects or direct high-flow CSF leaks. The introduction of the Hadad-Bassagasteguy vascularized nasoseptal flap has significantly reduced the reported CSF leak rate with a recent meta-analysis reporting that use of the vascularized flap is associated with a 7% rate of postoperative CSF leakage compared to 16% with free grafts alone for large dural defects.6 Since the initial description of the vascularized pedicled nasoseptal flap in 2006, many surgeons have developed a variety of alternative vascularized flaps for endonasal cranial base reconstruction. In this article, we summarize and compare several of the most clinically useful vascularized flaps including their harvest technique, indications and limitations, and potential complications. Pages: 28-3

The Current State of Visualization Techniques in Endoscopic Skull Base Surgery

Skull base surgery has undergone significant progress following key technological developments. From early candle-lit devices to the modern endoscope, refinements in visualization techniques have made endoscopic skull base surgery (ESBS) a standard practice for treating a variety of conditions. The endoscope has also been integrated with other technologies to enhance visualization, including fluorescence agents, intraoperative neuronavigation with augmented reality, and the exoscope. Endoscopic approaches have allowed neurosurgeons to reevaluate skull base neuroanatomy from new perspectives. These advances now serve as the foundation for future developments in ESBS. In this narrative review, we discuss the history and development of ESBS, current visualization techniques, and future innovations

Evaluation of Non-Watertight Dural Reconstruction with Collagen Matrix Onlay Graft in Posterior Fossa Surgery

Objective : Many surgeons advocate for watertight dural reconstruction after posterior fossa surgery given the significant risk of cerebrospinal fluid (CSF) leak. Little evidence exists for posterior fossa dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Our objective was to report the results of using collagen matrix in a non-watertight fashion for posterior fossa dural reconstruction

Surgical Management of Giant Prolactinomas: A Descriptive Study

Introduction. Giant prolactinoma (GP) is a rare pituitary lactotropic cell tumor larger than 4 cm in its widest dimension, and is less likely than a smaller prolactinoma to achieve prolactin normalization on dopamine agonist (DA) monotherapy. There is a paucity of data on the circumstances and outcomes of second-line management of GP with surgery. Herein, our institution’s experience with the surgical management of GPs is described. Methods. A single-center retrospective analysis was conducted of patients who underwent surgery for giant prolactinoma from 2003 to 2018. A chart review was conducted for demographic data, clinical features, laboratory and radiographic findings, operative and pathology reports, perioperative management, and clinical outcomes in follow-up. Descriptive statistics were used. Results. Of 79 prolactinoma cases, 8 patients had GP with a median age of 38 years (range 20–53), 75% (6/8) were male, with a median largest tumor dimension of 6 cm (range 4.6–7.7), and a median prolactin level of 2,500 μg/L (range 100–>13,000). Six patients had transsphenoidal surgery for dopamine agonist (DA) resistance or intolerance. Two patients had a craniotomy for a missed diagnosis; one was due to the hook effect. No tumor resections were complete by either surgical approach; all had persistent hyperprolactinemia requiring postoperative DA therapy, and two patients had an additional craniotomy procedure for further tumor debulking. There was no recovery of pituitary axes and postoperative deficits were common. Remission as defined by prolactin normalization occurred in 63% (5/8) at a median time of 36 months (range 14–63 months) on DA therapy after surgery with a follow-up of 3–13 years. Conclusions. GPs infrequently require surgical resection, which is generally incomplete and requires adjuvant therapy. Given the rarity of surgery for GPs, multi-institutional or registry studies would yield clearer guidance on optimal management

Cholesterol granulomas presenting as sellar masses: a similar, but clinically distinct entity from craniopharyngioma and Rathke\u27s cleft cyst.

PURPOSE: Cholesterol granulomas in the sella are rare and can mimic the appearance of craniopharyngioma or Rathke\u27s cleft cysts. Information regarding the clinical presentation, imaging characteristics, and clinical course of sellar cholesterol granulomas can help clinicians to differentiate these lesions from other sellar cystic lesions. METHODS: We present three cases of sellar cholesterol granulomas. A literature review was performed for all cases of sellar cholesterol granulomas with individual patient data reported. RESULTS: We identified 24 previously reported cases in addition to our three cases. Mean age was 36.6 years (range 5-68). There were 16 (59%) females. The most common (74%) presenting symptom was endocrinological deficits, typically either isolated diabetes insipidus (DI) or panhypopituitarism. Location was intrasellar in 3 (11%), suprasellar in 6 (22%), and intrasellar/suprasellar in 18 (67%) patients. Lesions were most commonly (83%) T1 hyperintense. Gross total resection was achieved in 16 (64%) and subtotal resection in 9 (36%) patients. Of the seventeen (63%) patients presenting with varying degrees of bitemporal hemianopsia, all had improvement in vision postoperatively. It is worth noting that no cases of preoperative hypopituitarism or DI improved postoperatively. Even though gross total resection was only achieved in 64%, there was only one recurrence reported. CONCLUSION: Sellar cholesterol granulomas are characterized by T1 hyperintensity, younger age, and more frequent and severe endocrinological deficits on presentation. Our review demonstrates high rates of improvement of visual deficits, but poor rates of endocrine function recovery. Recurrence is uncommon even in cases of subtotal resection

Evaluation of Non-Watertight Dural Reconstruction with Collagen Matrix Onlay Graft in Posterior Fossa Surgery

OBJECTIVE: Many surgeons advocate for watertight dural reconstruction after posterior fossa surgery given the significant risk of cerebrospinal fluid (CSF) leak. Little evidence exists for posterior fossa dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Our objective was to report the results of using collagen matrix in a non-watertight fashion for posterior fossa dural reconstruction. METHODS: We conducted a retrospective review of operations performed by the senior author from 2004–2011 identified collagen matrix (DuraGen) use in 84 posterior fossa operations. Wound complications such as CSF leak, infection, pseudomeningocele, and aseptic meningitis were noted. Fisher's exact test was performed to assess risk factor association with specific complications. RESULTS: Incisional CSF leak rate was 8.3% and non-incisional CSF leak rate was 3.6%. Incidence of aseptic meningitis was 7.1% and all cases resolved with steroids alone. Incidence of palpable and symptomatic pseudomeningocele in follow-up was 10.7% and 3.6% respectively. Postoperative infection rate was 4.8%. Previous surgery was associated with pseudomeningocele development (p<0.05). CONCLUSION: When primary dural closure after posterior fossa surgery is undesirable or not feasible, non-watertight dural reconstruction with collagen matrix resulted in incisional CSF leak in 8.3%. Incidence of pseudomeningocele, aseptic meningitis, and wound infection were within acceptable range. Data from this study may be used to compare alternative methods of dural reconstruction in posterior fossa surgery

A prospective multi-center observational study of surgical versus non-surgical management for pituitary apoplexy.

OBJECTIVE: Pituitary apoplexy (PA) has been traditionally considered a neurosurgical emergency, yet retrospective single-institution studies suggest similar outcomes among patients managed medically. We established a multicenter international prospective registry to compare presentation and outcomes in PA patients treated with surgery or medical management alone. METHODS: A centralized database captured demographics, comorbidities, clinical presentation, visual findings, hormonal status, and imaging features at admission. Treatment was determined independently by each site. Key outcomes included visual, oculomotor, and hormonal recovery, complications, and hospital length of stay. Outcomes were also compared based on time from symptom onset to surgery, and from admission or transfer to the treating center. Statistical testing compared treatment groups based on two-sided hypotheses and p \u3c 0.05. RESULTS: 100 consecutive PA patients from 12 hospitals were enrolled, and 97 (67 surgical and 30 medical) were evaluable. Demographics, clinical features, presenting symptoms, hormonal deficits, and imaging findings were similar between groups. Severe temporal visual field deficit was more common in surgical patients. At 3 and 6 months, hormonal, visual, and oculomotor outcomes were similar. Stratifying based on severity of visual fields demonstrated no difference in any outcome at 3 months. Timing of surgery did not impact outcomes. CONCLUSIONS: We found that medical and surgical management of PA yield similar 3-month outcomes. Although patients undergoing surgery had more severe visual field deficits, we could not clearly demonstrate that surgery led to better outcomes. Even without surgery, apoplectic tumor volumes regress substantially within 2-3 months, indicating that surgery is not always needed to reduce mass effect