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Background: Jugular paragangliomas are highly vascularized tumors that can grow in challenging neurovascular compartments and are particularly challenging to resect. There is still no consensus whether preoperative embolization should be employed to minimize intraoperative morbidity., Methods: A systematic review and meta-analysis was conducted by searching PubMed, Web of Science, and Embase databases for key terms including "embolization," "jugular paragangliomas," and "surgery.", Results: This review included 25 studies with 706 patients and 475 (67%) preoperative embolizations. Polyvinyl alcohol particles were the most common embolic agent (97.8% of all patients who underwent embolization). Complication rate of embolization was 1% (95% confidence interval [CI]: 0%, 2%). Preoperative embolization was significantly associated with less intraoperative estimated blood loss (mean difference of -7.92 dL [95% CI: -9.31 dL, -6.53 dL]), shorter operating room times (mean difference of -55.24 minutes [95% CI: -77.10 minutes, -33.39 minutes]), and less overall tumor recurrence (odds ratio = 0.23 [95% CI: 0.06, 0.91]) compared with resective surgery alone. Preoperative embolization had no impact on the development of postoperative new cranial nerve deficits not associated with embolization (odds ratio = 1.17 [95% CI: 0.47, 2.91]) and achievement of gross total resection (odds ratio = 1.92 [95% CI: 0.67, 5.53])., Conclusions: Preoperative embolization may provide surgical efficiency with faster surgical times and less bleeding and safety with diminished overall recurrence via safe embolization with minimal risks. These results must be considered taking into account the nonrandomness of studies., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Objectives: Traditional and well-established transcranial approaches to the spheno-orbital region and middle cranial fossa guarantee optimal intracranial exposure, and additional orbital and zygomatic osteotomies provide further control over extracranial components to be resected; however, these techniques come at the cost of additional morbidity. The introduction of minimally invasive endoscopic approaches and the conceptualization of the so-called "multiportal" paradigm might provide an alternative route. This preliminary study investigates the feasibility of the combined Biportal Endoscopic TransOrbital and transMaxillary Approach (bETOMA) approach to the spheno-orbital and middle cranial fossa regions., Methods: Using 4 silicon-injected adult cadaver heads (8 sides; 16 approaches), we systematically dissected through superior eyelid ETOA and endoscopic TMA approaches. The analysis focused on pterygopalatine, infratemporal, anterior and middle cranial fossae, Meckel cave, and cavernous sinus access. We evaluated the feasibility of bETOMA using linear distances, angles of attack, and exposure areas. We also introduced volume of operative maneuverability, its standardized derivative (sVOM), target distance, visuo-operative angle, and working zone volume as novel metrics., Results: The analysis revealed comparable angles of attack between approaches. ETOA and TMA exposure areas were 918.38 ± 223.93 mm2 and 257.07 ± 86.07 mm2, respectively. TMA showed a larger VOM in the greater sphenoid wing, but ETOA offered superior distal maneuverability (sVOM: 5.39 ± 1.94 vs 2.54 ± 0.79 cm3) and closer intracranial space access (27.45 vs 50.83 mm). The combined approaches yielded a mean working zone volume of 13.75 ± 3.73 cm3 in the spheno-orbital interface., Conclusion: The bETOMA approach provides adequate neurovascular exposure and maneuverability to the spheno-orbital region, infratemporal, and anterior and middle cranial fossae, addressing significant limitations of previously investigated monoportal techniques (ie, optic nerve decompression, hyperostotic bone resection, and infratemporal exposure). This combined minimally invasive approach might help manage lesions harbored within the cranio-orbital interface region invading the extracranial space., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background: Vestibular schwannomas (VS) are benign tumors arising from vestibular nerve's Schwann cells. Surgical resection via retrosigmoid (RS) or middle fossa (MF) is standard, but the optimal approach remains debated. This meta-analysis evaluated RS and MF approaches for VS management, emphasizing hearing preservation and Cranial nerve seven (CN VII) outcomes stratified by tumor size., Methods: Systematic searches across PubMed, Cochrane, Web of Science, and Embase identified relevant studies. Hearing and CN VII outcomes were gauged using the American Academy of Otolaryngology-Head and Neck Surgery, Gardner Robertson, and House-Brackmann scores., Results: Among 7228 patients, 56 % underwent RS and 44 % MF. For intracanalicular tumors, MF recorded 38 % hearing loss, compared to RS's 54 %. In small tumors (<1.5 cm), MF showed 41 % hearing loss, contrasting RS's lower 15 %. Medium-sized tumors (1.5 cm-2.9 cm) revealed 68 % hearing loss in MF and 55 % in RS. Large tumors (>3cm) were only reported in RS with a hearing loss rate of 62 %., Conclusion: Conclusively, while MF may be preferable for intracanalicular tumors, RS demonstrated superior hearing preservation for small to medium-sized tumors. This research underlines the significance of stratified outcomes by tumor size, guiding surgical decisions and enhancing patient outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

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.

Objective: The objective of this paper was to describe the volumetric natural history of meningiomas in patients with neurofibromatosis type 2 (NF2)., Methods: The authors performed a retrospective descriptive study by reviewing NF2 patients with meningiomas at their institution between 2000 and 2019. Demographic data were collected from the electronic medical records. Tumor volume was collected using volumetric segmentation software. Imaging characteristics including peritumoral brain edema (PTBE) and tumor calcification were collected for each patient from their first to most recent MRI at the authors' institution. An increase of 15% or more per year from original tumor size was used as the cutoff to define growth., Results: A total of 137 meningiomas from 48 patients were included in the analysis. The average number of tumors per person was 2.9. Ninety-nine (72.3%) tumors were in female patients. The median length of follow-up from first imaging to last imaging was 32 months (IQR 10.9, 68.3 months). Most tumors were located in the cerebral convexity (24.8%), followed by the falcine region (18.2%) and spine (10.2%). The median tumor growth was 0.12 cm3/yr (IQR 0.03, 0.52 cm3/yr). At the time of first imaging, 21.9% of tumors had calcifications, while 13.9% of meningiomas had PTBE. Of 137 tumors, 52 showed growth. Characteristics associated with tumor growth included PTBE (OR 9.12, 95% CI 1.48-56.4), tumor volume (per cm3) at first imaging (OR 0.91, 95% CI 0.83-0.99), and 10-year increased age at first imaging (OR 0.57, 95% CI 0.43-0.74). PTBE had the shortest median time to growth at 9.2 months., Conclusions: Although the majority of NF2-associated meningiomas do not grow in the short term, a wide range of growth patterns can be seen. Younger age at first imaging and presence of PTBE are associated with growth. Patients with these characteristics likely benefit from closer follow-up.

The development of extended endoscopic endonasal approaches (EEA) to the anterior skull base has allowed successful resection of selected extradural and intradural skull base tumors through an endonasal corridor, minimizing brain and cranial nerve manipulation. However, as the complexity of the approaches has increased, so has the need for more robust and reliable reconstructive options to minimize morbidity. Reconstructive decision-making after extended EEA for anterior skull base tumors must take into consideration multiple factors including patient characteristics (Body Mass Index, previous surgeries, and radiation), location and the size of the skull base defect. A multilayered reconstruction which includes a combination of free grafts and a vascularized flap is the standard approach to anterior skull base defects after EEA and should be applied in a stepwise manner tailored to each patient. The techniques and materials used to accomplish skull base repair are discussed, the outcomes in the literature are reviewed, and our reconstructive paradigm presented.

Endoscopic endonasal approaches (EEA) to the skull base have significantly impacted the management of lesions located in the cranial base. Specifically, lesions arising from the anterior cranial fossa, such as pituitary macroadenomas, craniopharyngiomas meningiomas and craniofacial malignancies have benefited from the development of such approaches. Understanding of the anatomy of the anterior fossa is of utmost importance for the successful selection of the approach and application of surgical techniques in EEA. In the current manuscript, we review the most relevant points of surgical anatomy and nuances of the surgical technique of EEA to the anterior fossa. Anatomical landmarks for the transtuberculum transplanum and transcribriform approaches are discussed and a step-by-step description for those approaches is presented. We reinforce that safe and effective application of such techniques follow the same principles of other skull base surgery techniques: mastering of surgical anatomy, adequate case selection, correct instrumentation and surgical experience.

Background: Despite the various treatment protocols available, survival evaluation is a fundamental criterion for the definition of surgical management; there are still many inconsistencies in the literature on this topic, especially in terms of the value of surgery and its morbidity in patients with very short survival., Objective: The objective was to analyze the association of clinical, oncological, and surgical factors in the survival of patients undergoing spinal surgery for spinal metastases (SM)., Materials and Methods: A retrospective cohort of forty patients who were surgically treated at our institution for SM between 2010 and 2018 were included in the study. We applied the prognostic scales of Tomita and Tokuhashi in each patient and evaluated the systemic status using Karnofsky Performance Scale (KPS) and Eastern Cooperative Oncology Group Performance Scale. Survival rate in months was estimated using the Kaplan-Meier curve, with death considered as primary outcome and, for the evaluation of the association between the variables, the Chi-square test, Fisher's exact test, or Fisher-Freeman-Halton test was applied for better survival. The level of statistical significance was considered as 5% ( P ≤ 0.05)., Results: The mean survival was 8.4 months. Patients with KPS <70 had a mean survival of 6.36 months, while those with KPS >70 had a mean survival of 14.48 months ( P = 0.04). The mean survival of patients classified as ECOG 2 was 7.05 months (95% confidence interval [CI]: 3.4-10.7), and that of patients classified as ECOG 3 and 4 was 1.24 months (95% CI: 0.8-1.59). The mean survival rate among the patients with unresectable metastases in other organs was 6.3 months (95% CI: 3.9-8.9), while the survival rate of those who did not have metastases was 13.8 months (95% CI: 10.0-17.68; P = 0.022)., Conclusion: Survival was associated with the preoperative functional status defined by the KPS and ECOG scales and with the presence of nonresectable visceral metastases., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Craniovertebral Junction and Spine.)

Study Design: Retrospective cohort., Objective: Evaluate the epidemiology of surgical patients with spinal metastases, identify the complications, and evaluate their neurological prognoses., Summary of Background Data: The development of new oncological treatments and screening tests have increased the survival of oncologic patients, and consequently, the incidence of metastatic lesions of the spine., Methods: Retrospective cohort of 40 patients surgically treated at the Hospital de Clínicas of UNICAMP for spinal metastases from January 2010 to September 2018, after diagnosis of symptomatic spinal cord compression and/or mechanical instability of the spine. Retrospectively analyzed patient charts applied the SINS score to evaluate the presence of mechanical instability. Neurological function was classified based on the Frankel index preoperative and postoperatively. To evaluate the association between variables, the Chi-square test, Fisher exact test, or Fisher-Freeman-Halton test was applied. For evaluating the improvement of neurological status between the Frankel scores before and after surgery, the McNemar test was applied for categorical and qualitative variables. In both the tests, variables with values of P > 0.05 were considered., Results: Pain as the reason for the first visit presented an odds ratio (OR) = 2.44 (95% [CI]: 1.14-5.2) for instrumentation need (P = 0.024). A higher SINS score corresponded to the indication for instrumentation surgery due to the instability of the spine (P = 0.004). Within 30 days postoperative, five patients (11.1%) had complications. There was a statistically significant neurological improvement in patients who underwent surgery (P = 0.002)., Conclusion: Pain as the first symptom was related to mechanical instability of the spine and surgical instrumentation. Patients treated with surgery presented improvement of the neurological function in the postoperative period., Level of Evidence: 3.

Background: The new AOSpine Upper Cervical Classification System (UCCS) was recently proposed by the AOSpine Knowledge Forum Trauma team to standardize the treatment of upper cervical traumatic injuries (UCI). In this context, evaluating its reliability is paramount prior to clinical use., Objective: To evaluate the reliability of the new AOSpine UCCS., Methods: A total of 32 patients with UCI treated either nonoperatively or with surgery by one of the authors were included in the study. Injuries were classified based on the new AO UCCS according to site and injury type using computed tomography scan images in 3 planes by 8 researchers at 2 different times, with a minimum interval of 4 wk between assessments. Intra- and interobserver reliability was assessed using the kappa index (K). Treatment options suggested by the evaluators were also assessed., Results: Intraobserver agreement for sites ranged from 0.830 to 0.999, 0.691 to 0.983 for types, and 0.679 to 0.982 for the recommended treatment. Interobserver analysis at the first assessment was 0.862 for injury sites, 0.660 for types, and 0.585 for the treatment, and at the second assessment, it was 0.883 for injury sites, 0.603 for types, and 0.580 for the treatment. These results correspond to a high level of agreement of answers for the site and type analysis and a moderate agreement for the recommended treatment., Conclusion: This study reported an acceptable reproducibility of the new AO UCCS and safety in recommending the treatment. Further clinical studies with a larger patient sample, multicenter and international, are necessary to sustain the universal and homogeneity quality of the new AO UCCS., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Objective: Many repair techniques have been proposed to treat large myelomeningocele (MMC), and although effective in many cases, some of these techniques can be complex and time consuming, with complications such as cerebrospinal fluid (CSF) leakage, flap loss, tip necrosis, and wound dehiscence. The purpose of this study was to analyze cases of large skin defects and the methods applied and to report the outcomes of the keystone design perforator island flap (KDPIF) technique for large MMC closure., Methods: The authors performed a retrospective review of all neonatal patients who had undergone KDPIF for MMC closure in the period from 2013 to 2018. All patients had a diagnosis of lumbosacral MMC based on obstetric ultrasound. The neurosurgeons and plastic surgeons had selected the cases after concluding that primary closure would be unlikely. The design of the flap is based on the randomly located vascular perforators, creating two identical opposing flaps to fashion a double keystone flap. During wound closure, V-Y advancement of each end of the double flap in the longitudinal axis creates redundancy in the central portion of the flap and reduces the horizontal tension. After discharge, both the neurosurgery and plastic surgery teams followed up all patients, tracking the results with photography., Results: No skin flap dehiscence or necrosis, infection, or CSF leakage was detected, proving the reliability of the flap. One of the patients required further surgery for the large skin defects after insufficient intrauterine closure of the MMC and successfully underwent KDPIF treatment. Another patient (14.3%) had severe neonatal sepsis, which ultimately led to death. A ventriculoperitoneal shunt was required after the skin defect repair in 5 (83.3%) of the 6 surviving patients. Exceptional aesthetic results were achieved for all patients during the follow-up., Conclusions: The KDPIF technique is based on well-known vascular perforators of the intercostal, lumbar, and gluteal regions. Wound tension is widely distributed by the flap and, as a consequence, relevant tissue bulk, reliable vascularity, and important geometrical versatility are provided. In addition, most of the muscles and fascia are preserved, which is another advantage in terms of minimizing secondary morbidity to local tissue rearrangement. The use of KDPIF closure was successfully shown to be a viable alternative for more complex MMCs that present with large skin defects.

Purpose: To detect the cardiac manifestations due to the state of hypothyroidism and reversibility after euthyroidism., Patients and Methods: Thirteen patients with documented primary hypothyroidism were evaluated through the echocardiography and other noninvasive techniques. A new evaluation was performed six months after thyroid hormone therapy., Results: Most of the changes were reversed after the patients became euthyroid. The main finding was the echocardiographic measurement of the velocity of circumferential fiber shortening that showed a significant positive linear correlation with serum thyroid hormones., Conclusion: These data demonstrate the existence of a hypothyroid cardiomyopathy.