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Background: The efficacy and safety of radiosurgery led to paradigm shift in the management of cavernous sinus meningiomas. Nevertheless, patients are still significantly affected by cranial nerve deficits related to the mass effect of these tumors. Our management strategy involves the combination of a functional surgical decompression followed by radiation therapy. Methods: We reviewed a single institution's cohort of patients who underwent endoscopic endonasal decompression (EED) for symptomatic meningiomas primarily involving the cavernous sinus (CS) from 2010 to 2016. The preoperative neuro-ophthalmological exam was compared to the 1- and 6-month postoperative exams. The patient's length of hospital stay, complications, and radiological and clinical follow-up were noted. Results: A total of 17 patients underwent EED for CS meningiomas that fit our radiological criteria. The final outcome at the 6-month visit showed five patients (62.5%) with normalization of deficit and three patients (37.5%) with partial improvement of the CNII deficit. Out of the 12 patients who had cavernous sinus cranial nerves (CSCN) deficits, the final outcome at the 6-month visit showed four patients (33.33%) with normalization of deficit, seven patients (58.3%) with partial improvement, and one patient (8.33%) with no improvement. There were no intraoperative complications. Conclusion: The EED for CS meningiomas is a valuable technique when addressing acute/subacute CNII and CSCN deficits. This conservative surgical approach showed good functional outcomes, low morbidity, and low complication rates. However, it does not exempt the need for radiosurgery/radiation therapy for control of tumor growth. [ABSTRACT FROM AUTHOR]

Objectives The pedicled nasoseptal flap (NSF) has dramatically reduced postoperative cerebrospinal fluid leakage following endoscopic endonasal approach (EEA) surgery. Although rare, its arterial supply may be damaged during harvest or may be preoperatively damaged for numerous reasons. Early recognition permits harvesting a contralateral flap before sacrificing its pedicle as part of the surgical exposure or use of an alternative flap. Design Technical feasibility study and case series. Setting Tertiary care university-associated medical center. Participants Five patients requiring an EEA with NSF reconstruction. Main OutcomeMeasures During NSF harvest, intravenous indocyanine green (IVICG) was administered, and a customized endoscopic system was used to visualize the emerging fluorescence. At the end of each case, just before final positioning of the NSF, additional IVICG was administered, and the customendoscope was again introduced to evaluate fluorescence. Results In four patients, the entire NSF fluoresced brightly with IVICG on initial harvest and before final positioning. One patient showed heterogeneous fluorescence of the pedicle and distal parts of the NSFat both stages. All NSFs healedwellwithout complication. Conclusion IVICG facilitates real-time evaluation NSF's arterial supply. This may provide early recognition of arterial compromise, allowing the harvest of alternate flaps or modification of surgery. [ABSTRACT FROM AUTHOR]

Introduction Malignancies of the clivus and petroclival region are mainly chordomas and chondrosarcomas. Although a spectrum of malignancies may present in this area, a finite group of commonly encountered malignant pathologies will be the focus of this review, as they are recognized to be formidable pathologies due to adjacent critical neurovascular structures and challenging surgical approaches. Objectives The objective is to review the literature regarding medical and surgical management of malignant tumors of the clival and petroclival region with a focus on clinical presentation, diagnostic identification, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to the skull base. Data Synthesis A literature review was conducted, searching for basic science and clinical evidence from PubMed, Medline, and the Cochrane Database. The selection criteria encompassed original articles including data from both basic science and clinical literature, case series, case reports, and review articles on the etiology, diagnosis, treatment, and management of skull base malignancies in the clival and petroclival region. Conclusions The management of petroclival malignancies requires a multidisciplinary team to deliver the most complete surgical resection, with minimal morbidity, followed by appropriate adjuvant therapy. We advocate the combination of endoscopic and open approaches (traditional or minimally invasive) as required by the particular tumor followed by radiation therapy to optimize oncologic outcomes. [ABSTRACT FROM AUTHOR]

A 50-year-old female with an incidentally diagnosed suprasellar lesion was initially managed conservatively due to the presence of an intrasellar persistent trigeminal artery going through the dorsumsellae and fundamentally forming the blood supply of the entire posterior circulation. Serial follow-up brain magnetic resonance imaging (MRI) revealed progressive enlargement of the suprasellar lesion over 4 years period. Surgery was indicated after the initial tumor growth; however, the patient refused surgery for fear of complications related to the persistent trigeminal artery. Two-and-ahalf years later, she presented with deterioration of vision. Formal visual field testing revealed a right temporal field defect. Brain MRI demonstrated significantly enlarged suprasellar lesion, most consistent with tuberculum sellae meningioma, exerting mass effect on the optic apparatus. The patient underwent endoscopic endonasal resection of the lesion through a transplanum/ transtuberculum approach. Intraoperatively, absence of hypertrophic McConnel arteries, hyperostosis, and the fact that the dura was soft and not under tension was against the diagnosis of tuberculum sellae meningioma. Additionally, the tumor consistency was similar to a pituitary adenoma. A complete resection was accomplished and multilayer skull base reconstruction was performed with no complications. On postoperative day 1 (POD 1), she was operated upon for the evacuation of small suprasellar hematoma associated with vision deterioration. Histopathological examination confirmed the diagnosis of atypical pituitary adenomawith Ki-67 labeling index of 4 to 5%. The patient ultimately recovered well with improved vision, and was discharged on POD 4 with no new neurological deficits. At 4 years follow-up, her vision was normalized and brain MRI showed no residual or recurrent lesion. [ABSTRACT FROM AUTHOR]

We present the case of a 67-year-old female with an incidental finding of a left-sided tuberculum sellae meningioma on a brain magnetic resonance imaging (MRI) for an unrelated complaint. Formal visual field testing showed a small defect in the inferior nasal and temporal fields of the left eye, compatible withmass effect on the optic nerve by the tumor. An endoscopic endonasal transtuberculum approach with decompression of the left optic nerve was performed using a standard binostril four-hand technique, with the patient positioned supine with the head turned to the right side and tilted to the left, fixed in a three-pin head clamp, under imaging guidance. After exposure, we drilled the tuberculum sellae and the floor of the sella and after opening the dura, the tumor and optic nerve came into view. The tumor was completely removed and we confirmed the patency of all perforating vessels using indocyanine green. Reconstruction was done in a multilayered fashion, using collagen matrix and a nasoseptal flap. Patient had an uneventful postoperative stay and was discharged on postoperative day 3, neurologically stable with no new hormonal deficits. Pathology report confirmed a WHO Grade Imeningioma with Ki-67 of 1% and 3-month postoperative MRI confirmed a gross total resection and visual fields exam showed a complete recovery. [ABSTRACT FROM AUTHOR]

A 49-year-old female presented with intense headaches of 3 months duration. Brain magnetic resonance imaging (MRI) was performed and showed a sellar--suprasellar lesion extending into the third ventricle. A presumptive diagnosis of a craniopharyngioma was made. Since the patient did not have any visual deficits, she opted for conservative management. Four months later, she started to have progressive deterioration of vision; thus, surgery was indicated. The patient underwent endoscopic endonasal resection of the lesion through a transtuberculum sellae approach. The patient was positioned supine with the head slightly extended and the face turned to the right side. Following the essence of a binostril four-hand technique, a total gross resection of the lesion was achieved and multilayer skull base reconstruction was performed utilizing collagen matrix and nasoseptal flap; with no intraoperative complications. The patient's postoperative course was uneventful with the improvement in her vision, and she was discharged on postoperative day 4 with no new neurological deficits. Histopathological examination confirmed the diagnosis of an epidermoid cyst. Postoperative pituitary gland function was within normal limits except for mild diabetes insipidus for which she is on DDAVP 0.1 mg twice daily. At 4 years follow-up, the patient was doing well, her vision was normalized, and brain MRI revealed no evidence of residual or recurrent lesion. [ABSTRACT FROM AUTHOR]