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Traditional microsurgical approaches for addressing intraventricular craniopharyngioma provide limited access to the retrochiasmatic area and tumors with significant lateral or rostrocaudal extensions. Extended endoscopic endonasal approaches can effectively overcome many of limitations, yet they require a favorable working angle between the optic chiasm and pituitary gland, as well as the involvement of the third ventricle floor by the tumor. Herein, the authors describe the surgical nuances of a keyhole technique for resecting third ventricle craniopharyngiomas via a fully endoscopic minimally invasive trans-eyebrow supraorbital translaminar approach (ESOTLA). A case description detailing the key surgical steps and application of the approach is provided, along with a series of cadaveric photographs to highlight the relevant anatomy and step-by-step dissection process. The patient is a 44-year-old man who presented with polyuria, low urine specific gravity, and panhypopituitarism. Brain magnetic resonance imaging revealed a solid-cystic heterogeneous-enhanced retrochiasmatic mass within the third ventricle, consistent with craniopharyngioma. A 1-stage ESOTLA was indicated based on the narrow pituitary-chiasm angle and the high functional status of the patient. Near-total resection was achieved, and no new postoperative neurologic or endocrine change was observed. Targeted therapy was implemented based on the histologic result, and the most recent surveillance magnetic resonance imaging showed no evidence of the residual tumor. By combining a keyhole approach with variable-angle endoscopic visualization through a smaller bony and soft tissue exposure, ESOTLA can provide enhanced illumination within the third ventricle, potentially addressing cosmetic concerns and limited exposure area/angle of freedom associated with its conventional microsurgical counterpart. [ABSTRACT FROM AUTHOR]

Nervus intermedius (NI) arises from the superior salivary nucleus, solitary nucleus, and trigeminal tract. It leaves the pons as 1 to 5 roots and travels between the facial and vestibulocochlear nerves before merging with the facial nerve within the internal auditory canal. The mastoid segment of the facial nerve then gives rise to a sensory branch that supplies the posteroinferior wall of the external auditory meatus and inferior pina. This complex pathway renders the nerve susceptible to various pathologies, leading to NI neuralgia. Here, the authors present an unusual intraoperative finding of an atrophic NI in a patient with refractory NI neuralgia and a history of ipsilateral sudden-onset central facial palsy and microvascular decompression for trigeminal neuralgia. The patient underwent NI sectioning via the previous retrosigmoid window and achieved partial ear pain improvement. The gross size of the NI is compared with a cadaveric specimen through stepwise dissection. This case highlights the potential significance of subtle central ischemic events and subsequent atrophy of NI in the pathogenesis of NI neuralgia, as well as the ongoing need to investigate the therapeutic efficacy of nerve sectioning. [ABSTRACT FROM AUTHOR]

Trigeminal neuralgia (TN) is characterized by paroxysmal episodes of severe shocklike orofacial pain typically resulting from arterial compression on the trigeminal root entry zone. However, neurovascular conflict in more proximal parts of the trigeminal pathway within the pons is extremely rare. The authors present a case of microvascular decompression for TN caused by dual arterial compression on the dorsolateral pons, along with a brief literature review. Our patient was a 74-year-old man with episodic left-sided facial stabbing pain. Brain magnetic resonance imaging revealed a dual arterial compression on dorsolateral pons, the known site of the trigeminal sensory nucleus and descending trigeminal tract. Microvascular decompression was performed via a retrosigmoid approach. Complete pain relief and partial improvement of the facial hypesthesia were achieved immediately after surgery and the Barrow Neurological Institute (BNI) pain intensity score improved from V to I, and the BNI hypesthesia score decreased from III to II within a month following surgery. The literature review identified 1 case of TN secondary to an arteriovenous malformation in root entry zone with lateral pontine extension. One month following partial coagulation of the draining vein, the patient was reportedly able to reduce medication dosage by half to achieve an improvement of BNI pain intensity score from V to IIIa. Neurovascular compression in the trigeminal tract and nucleus is a rare but potential cause of TN. A thorough investigation of the trigeminal pathway should be considered during preoperative evaluation and intraoperative inspection, particularly if no clear offending vessel is identified. [ABSTRACT FROM AUTHOR]