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Cancer-associated facial pain can be caused by a variety of pathologic conditions. Here the authors describe the symptoms and incidence of facial pain secondary to three separate anatomic subcategories of cancer. The authors subsequently discuss the effectiveness and drawbacks of the most common methods of treatment.

Background The anterior skull base is an uncommon site for brain metastases. A limited number of cases have been reported where a region of the skull base is accessed through an expanded/extended transsphenoidal route. In addition, reports of overall and progression-free survival rates are lacking. Objective To report progression-free and overall survival rates for skull base metastases treated with aggressive endoscopic endonasal surgery and radiation therapy. Methods We retrospectively review a prospective database of patients at New York Presbyterian Hospital undergoing expanded endoscopic endonasal surgery from 2004 to 2014. From this database, we identified all patients whose final pathology revealed a metastatic lesion in the midline skull base. Results Seven hundred forty-nine patients underwent endonasal endoscopic surgery. Final pathology in 12 patients (1.6%) revealed metastasis to the sellar or parasellar region. Tumors were located in the sella, suprasellar cistern, clivus, ethmoid sinuses, sphenoid sinus, cavernous sinus, and craniovertebral junction. Breast and lung cancers were the most common primary diagnoses. Gross total resection was achieved in 41.6% of patients. There were no postoperative cerebrospinal fluid leaks. Adjuvant radiation therapy was used in 92% of cases. Median follow-up was 14 months (range, 1–55). Median progression-free and overall survival were 18 and 16 months, respectively. Conclusions The range of anterior skull base metastatic lesions that can be managed endonasally has increased with the advent of extended endonasal endoscopic surgical approaches. Favorable results can be obtained with this surgical approach as part of the overall management paradigm for patients with skull base metastases.

Objective To report an initial experience with a medial transorbital approach to the midline skull base performed via a transconjunctival incision. Methods The authors retrospectively reviewed their clinical experience with this approach in the management of benign cranial base pathology. Preoperative imaging, intraoperative records, hospitalization charts, and postoperative records were reviewed for relevant data. Results During the period 2009–2011, six patients underwent a transconjunctival craniotomy performed by a neurosurgeon and otolaryngologist–head and neck surgeon working together. The indications for surgery were esthesioneuroblastoma in one patient, juvenile angiofibroma in one patient, Paget disease in one patient, and recalcitrant cerebrospinal fluid leaks in three patients. Three patients had prior cranial base surgery (either open craniotomy or an endonasal approach) done at another institution. The mean length of stay was 3.8 days; mean follow-up was 6 months. Surgery was considered successful in all cases (negative margins or no leak recurrence); diplopia was noted in one patient postoperatively. Conclusions The transconjunctival medial orbital craniectomy provides a minimally invasive keyhole approach to lesions located anteriorly along the anterior cranial fossa that are in the midline with lateral extension over the orbital roof. Based on our initial experience with this technique, the working space afforded limits complex surgical dissection; this approach is primarily well suited for less extensive pathology.

Glioblastoma (GB) is rarely found in the cerebellum. Because of its rarity, it is poorly understood if cerebellar GB (CGB) behaves similarly to supratentorial GB. Studies have been limited to case reports and small case series. A better understanding of CGB may help guide treatment strategies.Surveillance, Epidemiology and End Results database was analyzed from 1973 to 2009 for all adult patients with GB located in the cerebellum. Stepwise multivariate proportional hazards regression analyses were used to identify factors independently associated with survival.Two hundred eight (0.9%) patients with CGB were identified from 23,329 GB patients with known locality. The mean age was 58 years. Median survival was 8 months, with 1-, 2- and 5-year survival rates of 21%, 13%, and 2%. When compared to supratentorial GB, CGB occurred in younger patients (58 ± 16 vs. 61 ± 13 years, P = 0.001), less commonly in Whites (85.6% vs. 91.3%, P = 0.005), and were smaller (3.7 ± 1.1 vs. 4.5 ± 1.7 cm, P = 0.001). A cerebellar location independently predicted poorer survival when compared to other GB locations (P = 0.048). In multivariate analysis for patients with CGB, younger age (P0.001), Asian or Pacific Islander race (P = 0.046), and radiation therapy (P0.001) were independently associated with prolonged survival.CGBs are difficult to analyze using institutional series because of their rarity. This study shows they are clinically different from supratentorial GB. Among patients with CGB, radiation therapy may prolong survival. This may help guide treatment strategies aimed at prolonging survival for patients with these extremely rare lesions.

Objective Craniofacial resection has been considered the gold standard in the management of malignancies involving the anterior skull base, where the goal of surgery is negative margins with minimal morbidity. In recent years, there has been growing enthusiasm for purely endoscopic techniques for craniofacial malignancies. Given recent advancements in open surgical approaches, there is a need to review the technique of open craniofacial resection in the modern surgical era. Methods We review our experience of open craniofacial resection of midline anterior cranial fossa malignancies in the modern era. Results Between 1995 and 2009, 41 patients underwent bifrontal craniotomy/craniofacial resection for malignancy. A subset of patients had undergone previous treatment, i.e., transfacial resection (34%), chemotherapy (5%), and radiation therapy (10%). Esthesioneuroblastoma (29%) was the most common pathology, followed by squamous cell carcinoma (27%) and the remaining patients presented with various histologic subtypes. All tumors invaded the cribriform plate; tumors invaded dura in 51%, parenchyma in 17% and orbit in 54% of patients. Negative margins were obtained in 85% of the cohort. Postoperative complications included seizure (one patient), cerebrospinal leak (one patient), and symptomatic pneumocephalus (two patients). Conclusion Since its introduction more than 50 years ago, craniofacial resection has undergone several important technical advancements concurrent to the introduction of endoscopy. With these improvements, our results indicate good oncologic disease control with minimal morbidity for extensive malignancies invading the intracranial cavity. With improvements in both open and endoscopic techniques, there is a need to reassess outcomes to determine relative indications.

This study examined the single-center treatment outcomes of arteriovenous malformations (AVMs) of the brain using stereotactic radiosurgery, with regard to obliteration, predictive factors, morbidities, and patient performance status.127 patients were treated between 1990 and 2008 by use of linear accelerator or Gamma Knife. Their median age was 37 years, the median AVM volume was 7.3 cc (range, 0.014-113.13 cc), and the median follow-up duration was 42 months (range, 6-209 months). Forty-two percent of patients presented with intracranial hemorrhage, 31% received embolization, and 8% underwent prior resection. Thirty-one percent of patients received more than one round of radiosurgery.64% of patients had complete obliteration confirmed by magnetic resonance imaging or angiography. Positive predictors of obliteration included pretreatment hemorrhage (p = 0.042), smaller AVM volume (odds ratio = 1.25; 95% CI, 1.03-1.52), and larger marginal dose (odds ratio = 0.292; 95% CI, 0.100-0.820), whereas embolization (p0.001) was a negative predictor . The annual risk of hemorrhage after radiosurgery was 2.2%, and the risk of death as a result of hemorrhage was 0.6-1.3%. Eleven percent of patients reported new or worsened neurologic symptoms. Radiosurgery was effective in treating AVM-related headaches (p0.001) but did not improve the performance status of patients.Stereotactic radiosurgery is an effective tool in the treatment of AVMs and amelioration of AVM-related headaches, but it did not affect the patients' performance status. Factors affecting obliteration include prior hemorrhage, marginal dose, prior embolization, and AVM volume. Risk of hemorrhage persists in the latency period after radiosurgery, and it remains finite even after complete obliteration.

a b s t r a c t Objectives: Trigeminal neuralgia is a sensory nerve disorder characterized by lancinating pain and treated most commonly with carbamazepine, rhizotomy treatment, or open surgical management with microvascular decompression. We describe a novel technique to complement surgical treatment for trigeminal neuralgia via direct injection of the trigeminal nerve with glycerin in the cisternal portion of the nerve. Patients and methods: We performed a retrospective analysis of patients who received standard microvas- cular decompression and injection of glycerin to the inferior third of the cisternal portion of the nerve anterior to the root entry zone with lack of a compressive vessel on MRI as the primary indication. Four- teen patients were identified and demographic information, post-operative course and complications were recorded. Results: There were eleven females and three males with an average age at time of surgery of 54.8 years. 100% of patients reported that their trigeminal pain was significantly improved following surgical inter- vention. Four out of fourteen patients reported a 50-80% decrease from the pre-surgery baseline pain at one month and three month follow up. One patient developed a CSF leak, and no surgical site infections or motor deficits were observed. Conclusion: Intra-operative glycerin rhizotomy in conjunction with microvascular decompression can be used to safely treat patients suffering from trigeminal neuralgia.