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Background and Importance: Spheno-orbital meningiomas (SOMs) pose a challenge to the skull base neurosurgeon because of their variable presentation and involvement of critical structures within the orbit. There is no consensus on optimal management of these patients and how to achieve maximal safe resection. The authors share an illustrative case with an accompanying video to demonstrate their aggressive approach to resect SOMs and their intraorbital components., Clinical Presentation: A 75-year-old-woman presented with progressive vision loss and proptosis. Magnetic resonance imaging was consistent with a large, left-sided sphenoid wing meningioma with extension to the orbital wall and compression of the optic nerve medially. The patient elected to undergo surgical excision and optic nerve decompression. She did well postoperatively with resolution of proptosis and good resection margins on follow-up imaging., Conclusion: Aggressive resection of SOMs is possible with an understanding of the underlying anatomy. Familiarity with the orbit can facilitate a maximal safe resection with optic nerve decompression., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background: Trigeminal schwannomas (TSs) are intracranial tumors that can cause significant brainstem compression. TS resection can be challenging because of the risk of new neurologic and cranial nerve deficits, especially with large (≥ 3 cm) or giant (≥ 4 cm) TSs. As prior surgical series include TSs of all sizes, we herein present our clinical experience treating large and giant TSs via microsurgical resection., Methods: This was a retrospective, single-surgeon case series of adult patients with large or giant TSs treated with microsurgery in 2012-2023., Results: Seven patients underwent microsurgical resection for TSs (1 large, 6 giant; 4 males; mean age 39 ± 14 years). Tumors were classified as type M (middle fossa in the interdural space; 1 case, 14%), type ME (middle fossa with extracranial extension; 3 cases, 43%), type MP (middle and posterior fossae; 2 cases, 29%), or type MPE (middle/posterior fossae and extracranial space; 1 case, 14%). Six patients were treated with a frontotemporal approach (combined with transmastoid craniotomy in the same sitting in one patient and a delayed transmaxillary approach in another), and one patient was treated using an orbitofrontotemporal approach. Gross total resection was achieved in 5 cases (2 near-total resections). Five patients had preoperative facial numbness, and 6 had immediate postoperative facial numbness, including two with worsened or new symptoms. Two patients (28%) demonstrated new non-trigeminal cranial nerve deficits over mean follow-up of 22 months. Overall, 80% of patients with preoperative facial numbness and 83% with facial numbness at any point experienced improvement or resolution during their postoperative course. All patients with preoperative or new postoperative non-trigeminal tumor-related cranial nerve deficits (4/4) experienced improvement or resolution on follow-up. One patient experienced tumor recurrence that has been managed conservatively., Conclusions: Microsurgical resection of large or giant TSs can be performed with low morbidity and excellent long-term cranial nerve function., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Tumors of the petroclival region with multicompartment extension can be difficult to address with a single surgical approach., Method: We present the case of a patient with a large chondrosarcoma centered at the right petroclival fissure with extension into the cavernous sinus, the region beneath the cavernous sinus, cerebellopontine angle with deformation of the pons, and prevertebral space. A staged complete resection was performed using a stage 1 single-incision combined right retrosigmoid craniotomy and extended middle fossa craniotomy, followed by a stage 2 endoscopic transnasal approach., Conclusion: A combined approach to selected petroclival tumors can maximize safe resection., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: The integration of multiple approaches is sometimes needed for the safe resection of complex multicompartment skull base tumors., Method: We present the case of a spheno-orbital and deep face meningioma that required a staged resection strategy using transnasal, transoral, transfacial, and transcranial approaches for airway protection and maximal safe tumor removal., Conclusion: Limitations in individual skull base approaches for complex tumors can be anticipated and overcome by combining approaches., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Petroclival meningiomas pose significant surgical challenges because of their deep location and complex surrounding neurovasculature. The use of multiple surgical approaches can optimize safe tumor removal from multiple anatomic compartments., Method: We describe a patient with a growing superior petroclival meningioma centered at the posterior clinoid with extension into Meckel's cave that was successfully removed with a combined retrosigmoid and subtemporal middle fossa approach. This strategy avoided the need for anterior petrous bone drilling and tentorial splitting., Conclusion: A combined retrosigmoid and subtemporal middle fossa approach can provide safe access to tumors spanning the supra- and infratentorial compartments., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Defects through the skull base into the paranasal sinuses can occur during anterior skull base procedures, risking cerebrospinal fluid leak and infection if not repaired., Methods: We describe a muscle plug napkin ring technique for closure of small skull base defects, wherein a free muscle graft slightly bigger than the defect is packed tightly in the defect, half extracranially and half intracranially and sealed with fibrin glue. The technique is illustrated in the case of a 58-year-old woman with a large left medial sphenoid wing/clinoidal meningioma., Conclusions: The muscle plug napkin ring technique is a simple solution to small skull base defects., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Ruptured blister aneurysms have significant rates of morbidity and mortality, but evidence of positive results with use of flow-diverting stents such as the Pipeline embolization device (PED) is growing. The authors describe the staged endovascular treatment of a ruptured left internal carotid artery blister aneurysm in a patient with a Hunt and Hess grade IV subarachnoid hemorrhage. PED placement was done via the common femoral artery using a triaxial delivery system. The telescoping stent technique performed over 48-72 hours achieved sufficient coverage of the aneurysm neck while limiting treatment time during the acute presentation and allowing interim dual antiplatelet treatment. A staged approach allows the targeting of a second PED placement in patients whose aneurysm continues to fill on the first follow-up angiogram. The authors have not experienced increased thromboembolic complications with this approach. Complete occlusion was achieved by postbleed day 8. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2264., Competing Interests: Disclosures Dr. Couldwell: editor of Neurosurgical Focus: Video. Dr. Grandhi: personal fees from Medtronic Neurovascular, Cerenovus, Integra, and Balt Neurovascular outside the submitted work.Dr. Couldwell: editor of Neurosurgical Focus: Video. Dr. Grandhi: personal fees from Medtronic Neurovascular, Cerenovus, Integra, and Balt Neurovascular outside the submitted work., (© 2022, The Authors.)

Background and Importance: There is no consensus on the optimal surgical approach for managing optic nerve gliomas. For solely intraorbital tumors, a single-stage lateral orbitotomy approach for resection may be performed, but when the nerve within the optic canal is affected, two-stage cranial and orbital approaches are often used. The authors describe their technique to safely achieve aggressive nerve resection to minimize the probability of recurrence that might affect the optic tracts, optic chiasm, and contralateral optic nerve., Clinical Presentation: A 28-yr-old woman presented with painless progressive vision loss, resulting in blindness. The second of 2 transorbital biopsies was diagnostic and consistent with low-grade glioma. The lesion continued to grow on serial imaging. The patient was offered a globe-sparing operative approach, with aggressive resection of the lesion to minimize the probability of tumor recurrence, which could possibly affect vision in her contralateral eye. The patient did well postoperatively, with clean tumor margins on pathological analysis and no evidence of residual on imaging. On postoperative examination, she had a mild ptosis, which was nearly resolved at her 6-wk outpatient follow-up., Conclusion: This aggressive single-stage en bloc resection of an optic nerve glioma can achieve excellent tumor margins and preservation of extraocular muscle function., (Copyright © Congress of Neurological Surgeons 2021. All rights reserved.)

Spinal instability may arise as a consequence of decompressive lumbar surgery. An oblique lumbar interbody fusion combined with pedicle screw fixation can provide indirect decompression on neural elements, stabilization of mobile spondylolisthesis, and restoration of segmental lordosis. Minimally invasive techniques may facilitate a shorter hospitalization and faster recovery than a traditional open revision operation. The authors describe the use of an anterior interbody fusion via an oblique retroperitoneal approach and posterior pedicle screw fixation to treat a 67-year-old woman who developed L3-4 and L4-5 unstable spondylolisthesis after a lumbar laminectomy. The video can be found here: https://youtu.be/KWwGMIoDrmU., Competing Interests: Disclosures Dr. Dailey reports being a consultant for Zimmer Biomet and K2M; receiving support for non–study-related clinical or research work he oversees; and receiving an honorarium from AO North America., (© 2020, Christopher Wilkerson, Vance Mortimer, Andrew T. Dailey, and Marcus D. Mazur.)

Dural arteriovenous fistulae (dAVFs) are vascular anomalies formed by abnormal connections between branches of dural arteries and dural veins or dural venous sinus(es). These pathologic shunts constitute 10%-15% of all intracranial arteriovenous malformations. The hallmark of malignant dAVFs is the presence of cortical venous drainage, a finding that increases the likelihood of nonhemorrhagic neurologic deficit, intracranial hemorrhage, and mortality if left unaddressed. Endovascular approaches have become the primary modality for the treatment of dAVFs. The authors present a case of staged endovascular transarterial embolization of a malignant dAVF running parallel to the left transverse sinus in a patient with headaches and pulsatile tinnitus. The fistula was completely treated using Onyx and n-butyl cyanoacrylate.The video can be found here: https://youtu.be/GSAto_wlC3I.

Anterior two-thirds corpus callosotomy is a common palliative surgical intervention most commonly employed in patients with atonic or drop seizures. Recently, stereotactic laser ablation of the corpus callosum without a craniotomy has shown promise in achieving similar outcomes with fewer side effects and shorter hospitalizations. The authors demonstrate ablation of the anterior two-thirds corpus callosum in a patient with Lennox-Gastaut syndrome and drug-resistant drop seizures. Technical nuances of laser ablation with 3 laser fibers are described. Postoperatively, the patient showed a significant reduction in seizure frequency and severity over a 9-month follow-up period. The video can be found here: https://youtu.be/3-mMq5-PLiM .

Neurointerventional education relies on an apprenticeship model, with the trainee observing and participating in procedures with the guidance of a mentor. While educational videos are becoming prevalent in surgical cases, there is a dearth of comparable educational material for trainees in neurointerventional programs. We sought to create a high-quality, three-dimensional video of a routine diagnostic cerebral angiogram for use as an educational tool. A diagnostic cerebral angiogram was recorded using two GoPro HERO 3+ cameras with the Dual HERO System to capture the proceduralist's hands during the case. This video was edited with recordings from the video monitors to create a real-time three-dimensional video of both the actions of the neurointerventionalist and the resulting wire/catheter movements. The final edited video, in either two or three dimensions, can serve as another instructional tool for the training of residents and/or fellows. Additional videos can be created in a similar fashion of more complicated neurointerventional cases. The GoPro HERO 3+ camera and Dual HERO System can be used to create educational videos of neurointerventional procedures.