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Objective  While postoperative cerebrospinal fluid (CSF) leak rates of pituitary tumors have been frequently studied, there are fewer studies examining postoperative CSF leak rates for extrasellar tumors. The purpose of this study was to identify risk factors for the development of postoperative CSF leak in patients undergoing endoscopic surgery for extrasellar tumors. Methods  A retrospective chart review was done for patients who underwent endoscopic resection for extrasellar tumors between 2008 and 2020. Age, gender, tumor type, tumor location, tumor size, reconstruction technique, medical comorbidities, and other potential risk factors were identified. Data was analyzed to identify significant risk factors for development of postoperative CSF leak. Results  There were 100 patients with extrasellar tumors who developed intraoperative CSF leaks. Seventeen patients (17%) developed postoperative CSF leaks. Leaks occurred at a median of 2 days following surgery (range 0-34 days). Clival tumors had a significantly higher incidence of postoperative leak than those in other sites ( p

Background: With modern treatment paradigms, olfactory neuroblastoma (ONB) has favorable overall survival (OS); however, the incidence of recurrence remains high. The primary aims of this study were to delineate the prognosis of recurrence of ONB and explore how recurrence subsites are associated with OS, disease‐specific survival (DSS), and further recurrence. Methods: A retrospective chart review of ONB cases from nine academic centers between 2005 and 2021 was completed. Tumor characteristics, recurrence subsites, timelines to recurrence, additional recurrences, and survival estimates were determined using descriptive and time‐to‐event analyses. Results: A final cohort of 233 patients was identified, with 70 (30.0%) patients recurring within 50.4 (standard deviation ±40.9) months of diagnosis on average, consisting of local (50%), neck (36%), intracranial (9%), and distant (6%) recurrence. Compared with subjects without recurrence, patients with recurrence had significantly different primary American Joint Committee on Cancer T stage (p < 0.001), overall stage (p < 0.001), and modified Kadish scores (p < 0.001). Histopathology identified that dural involvement and positive margins were significantly greater in recurrent cases. First recurrence was significantly associated with worse 5‐year DSS (hazard ratio = 5.62; p = 0.003), and subjects with neck or local recurrence had a significantly better DSS compared to intracranial or distant recurrence. Conclusions: Recurrent cases of ONB have significantly different stages and preoperative imaging factors. Patients with local or neck recurrence, however, have better DSS than those with intracranial or distant recurrence, independent of initial tumor stage or Hyams grade. Identifying specific factors that confer an increased risk of recurrence and DSS is important for patient counseling in addition to surveillance planning. [ABSTRACT FROM AUTHOR]

Key points: Clear visualization during transnasal endoscopic surgery (TNES) is crucial for safe, efficient surgery.The endoscopic surgical field clarity index (ESFCI) is an artificial intelligence‐enabled measure of surgical field quality.The ESFCI allows researchers to evaluate interventions to improve visualization during TNES. [ABSTRACT FROM AUTHOR]

Objective The clinical signs of base of skull fracture (BSF) are often ambiguous and difficult to identify, but are often used to make decisions on early medical interventions. This study aimed to assess the prevalence of the clinical signs of BSF, their dependency to diagnose this injury and to assess the correlation between the presence of these clinical signs and the severity of head injury and patient outcome. Materials and Methods A cross-sectional study was conducted in a tertiary care hospital in South India over a period of 3 years (2020–2023). Patients older than 18 years, with radiological or surgical evidence of BSF were monitored for developing the clinical signs including Battle's signs, raccoon's sign, otorrhea, and rhinorrhea. The presence of these clinical signs was correlated with demographical characteristics, patient presentation, complications, and their outcome. Results A total of 292 patients were included in the study. The mean age of the cohort was 36.27 ± 18.68 years. A total of 55 (18.8%) showed at least one of the four signs of BSF. Raccoon's sign was seen in 9.5% cases, Battle's sign in 5.5%, otorrhea in 5.5%, and rhinorrhea in 2.4% cases. Patients with frontal (p = 0.021) or ethmoid (0.049) fractures and ENT bleeding (p = 0.022) were significantly more likely to present with at least one sign of BSF. The patients who presented with clinical signs were more likely to have a complication during the course of the hospital stay (p = 0.024) than those without clinical signs, including cranial nerve palsy (p < 0.001) and cerebrospinal fluid leak (p < 0.001). The outcome of the patient did not change based on the presence of clinical signs (p = 0.926). Conclusion These study results indicate a limited diagnostic value of BSF clinical signs in the South Indian population. Thus, other modalities should be considered for the diagnosis when suspected. These results also discourage the use of the nasal route in all patients with suspected head injury and emphasize that during the nasal aspiration procedure, the use of a rigid device is fundamental to avoid false passage of the aspiration tube from the nasal to the intracranial region. [ABSTRACT FROM AUTHOR]

Introduction: Medullary thyroid carcinoma constitutes 5% to 10% of all thyroid cancers. Metastatic adenopathies may pose challenges in intricate anatomical locations, such as the parapharyngeal space. A rare case of metastatic medullary thyroid carcinoma in the parapharyngeal space has been treated in our unit using combined trans-cervical trans-oral robotic surgery. Our objective was to provide a detailed description of the surgery performed on this patient. Method: We reported a singular case report worth of interest. Result: A 42-year-old woman was addressed in our unit for the management of a medullary thyroid carcinoma adenopathy located in the right parapharyngeal space. A parapharyngeal 40.0 mm × 25.0 mm × 12.0 mm adenopathy was removed using a combined trans-cervical and trans-oral robotic approach without sacrifice or injury of vascular or nervous structure. Neither the tracheostomy nor the feeding tube was implemented. Feeding was resumed on postoperative day 1 and hospitalization spanned 7 days. Conclusion: An innovative combined trans-cervical and trans-oral robotic surgery approach was conducted to address a metastatic medullary thyroid carcinoma in the parapharyngeal space. This surgical technique allowed us to circumvent the need for a trans-mandibular approach, tracheostomy, and feeding tube and enabling successful tumor removal without fragmentation. Postoperative care was significantly eased. The sole complication observed was dysphonia, likely resulting from intra-operative stretching of the vagus nerve during the dissection of the carotid artery. [ABSTRACT FROM AUTHOR]

Background: Acalvaria, or acrania, is a rare congenital cranial vault defect with neurocranium absences, including complete or part of calvaria flat bones, dura mater, and associated muscles, but with a still present in the central nervous system, skull base, facial bones, and skin-covered the defect. It is a sporadic incidence without apparent genetic factors confirmed. Acalvaria is often misdiagnosed as anencephaly; the distinguishable difference is that anencephaly has an absence (partial or complete) of the brain tissue, including the skull and scalp. Acalvaria is considered a fatal anomaly with a low survival rate, and only a few cases of extended survival have been reported until now. To the best of the author's knowledge, no acalvaria case has been published in Papua, and only one reported case of the coexistence of acalvaria with schizencephaly in Brazil (2018). Case report: Herein, we present a case of an indigenous South Papuan living newborn with primary acalvaria and open-lip schizencephaly in a frontoparietal region. A male newborn baby was born from a 39-year-old female Marind-Anim tribe patient with a 38th week of gestation, with no previous history of miscarriage, is not a consanguineous marriage, and had an unremarkable medical history during this pregnancy. Post-natal physical examinations showed an irregularly shaped head with 11.5 cm diameter concave of the right side, with a soft brain-like consistency palpable and the absence of half right frontoparietal calvarium covered with a presence of scalp and hair. Cranial 2-dimension ultrasonography shows an absence of half right frontoparietal calvaria bone with a complete presence of scalp and periosteum covering the defect with a fluid accumulation (anechoic) below the periosteum. A transverse axis view shows a complete structure but hypoplasia of brain cortex with visible slightly dysgenesis of gyrus and sulcus in both hemispheres convincing the acalvaria condition not anencephaly. A fluid accumulation above brain parenchyma of the frontoparietal region happened to be a cerebrospinal fluid coming from a wide-open cleft extending from the left lateral and fourth ventricles to the cerebral cortex, suggesting a typical condition of open-lip schizencephaly. Further health follow-ups until 6 months old showed still normal physical and behavioral development with no sign of complications. Conclusions: No standard acalvaria treatment is being established; conservative and supportive therapy is mostly taken considering their low survival rate. With the advancement of medical technology nowadays, surgical approaches, including scalp defect closure, bone graft, and 3D-printed defect filling, are being performed and have succeeded in a few cases. Long-term follow-up is required to monitor their neuro-psychological development and complication incidences that need further intervention. [ABSTRACT FROM AUTHOR]

Purpose: Langerhans cell histiocytosis (LCH) is a rare condition arising from the monoclonal expansion of myeloid precursor cells, which results in granulomatous lesions that characteristically express CD1a/CD207. We report a case of LCH in a 3-year-old male involving the sphenoid bone with extension into the sellar/suprasellar region. Case report: A 3-year-old male presented with progressively worsening headaches and associated night sweats, neck stiffness, and fatigue over the previous 4 weeks. Magnetic resonance imaging (MRI) revealed a 2.4-cm lytic lesion within the basisphenoid, exerting mass effect upon the pituitary gland. A biopsy was performed to determine the etiology of the lesion. Postoperatively, the patient developed an intralesional hematoma with visual complications requiring emergent surgical resection via endoscopic endonasal approach. Final pathology confirmed LCH. The patient had improvement in his vision long term. Conclusions: LCH extending into the sella is a rare but important diagnosis to consider in pediatric patients presenting with lesions in this region. We presented a case of a pediatric patient presenting with LCH of the sphenoid bone extending into the sella, with subsequent apoplexy and vision loss. Review of the literature showed varying treatment options for these patients, including purely surgical and non-surgical treatments. Early intervention may be necessary to avoid potentially devastating neurologic sequelae. [ABSTRACT FROM AUTHOR]

Previous studies have poorly described the initial development process of the tendinous intersections of the rectus abdominis muscle (RAM). The present study aimed to observe the formation of tendinous intersections in the RAM during the early fetal period using diffusion tensor imaging (DTI). Fifteen human fetal specimens (crown‐rump length [CRL]: 39.5–93.7 mm) were selected. Three‐dimensional measurements revealed that Zone‐4 (i.e., the zone between the pubic symphysis and the caudal base of the umbilical ring in the RAM) had a smaller width and was thicker than Zone‐1 and Zone‐2 (i.e., the zones between the costal arch and the cranial base of the umbilical ring) and Zone‐3 (i.e., the zone at the umbilical ring). Characteristics of tendinous intersections in the RAM during the early fetal period were assessed according to number, size, type, laterality, and sex. The mean number of tendinous intersections on both sides was 3.1 (range: 2.0–4.0), and 21% of specimens had only two tendinous intersections, which was higher than that reported in previous adult studies. The present data suggest that the formation of tendinous intersections was still in progress in specimens with two tendinous intersections in the RAM and that the third tendinous intersection was formed in Zone‐2. Ordinal logistic regression via generalized estimating equations revealed that the odds for a higher type of tendinous intersections in Zone‐1 and Zone‐2 were significantly higher than those in Zone‐4 (adjusted odds ratio: 14.85, 8.84). The odds for the presence of incomplete types (tendinous intersections that could not completely transverse the RAM) in Zone‐3 were significantly higher than those in Zone‐1 (adjusted odds ratio: 7.4). The odds for missing tendinous intersections in Zone‐4 were significantly higher than those in Zone‐1 (adjusted odds ratio: 20.5). These zonal differences in the formation of tendinous intersections were consistent with those observed in previous adult studies. In this study, DTI detected tendinous intersections in a sample with a CRL of 45.8 mm (approximately 11 weeks of gestation), which is earlier than that in previous histological findings, indicating that the RAM does not have mature tendinous intersections until the 17th week of gestation. In conclusion, DTI could detect the premature differentiation of tendinous intersection formation. Our data may aid in elucidating the developmental processes of tendinous intersections in the RAM. [ABSTRACT FROM AUTHOR]

Introduction: Study aimed to ole of surgery along with antimicrobials to improve clinical outcomes in treating refractory cases of skull base osteomyelitis (SBO). Methods: A prospective observational study in a tertiary care centre with 70 SBO patients meeting eligibility criteria. The study population comprised 35 patients refractory to systemic antimicrobials of at least 4 weeks duration who later underwent surgery in addition to medication (surgical group). They were compared with a medical group that responded to medications alone. The outcome variables studied were the resolution of clinical features (pain, discharge, radiology, and inflammatory markers), culture yield, and total duration of treatment. Results: According to our study, relief of pain was faster in the surgical group (1.66 against 4.57 months) with statistical significance (p < 0.001). Relief of symptoms (p < 0.001), radiological improvement (p = 0.001), and normalising of inflammatory markers (p < 0.001) were better in the surgical group than in the medical group. The duration of treatment was an average of 9.2 months in the surgical group compared to 11.3 months in the medical group (p = 0.019). Microbial culture from deep tissue sampling was positive in 24 surgical patients (68.57%). Conclusions: The treatment response in selected patients of refractory SBO who underwent surgery along with antimicrobials was better than the group who responded to antimicrobials alone. Surgery provided higher microbial yield resulting in culture‐specific antimicrobials. The surgical group observed faster relief of symptoms, reduced hospital stay, and total treatment duration. [ABSTRACT FROM AUTHOR]

Background: Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks. Methods: Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression. Results: Seventy‐nine patients (57.7%) had high‐flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76–64.44]), throat drainage (3.42 [0.35–33.86]), salty/metallic taste (4.22 [0.66–27.04]), severe headache (3.00 [0.48–18.62]), dizziness (0.54 [0.06–4.94]), fever (3.16 [0.50–19.99]), and nausea/vomiting (1.33 [0.22–8.21]), associated with postoperative CSF leak. Conclusions: A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response. [ABSTRACT FROM AUTHOR]

Statement of the Problem: Determination of remaining growth potential of patients is the most important factor in orthodontic treatment. Purpose: This study aimed to assess the correlation of clivus length and angle with age, gender, sagittal growth pattern of the jaws, and skeletal maturation using lateral cephalometry. Materials and Method: This cross-sectional study was conducted on 390 lateral cephalograms (Vatech, paX-i3D Green, South Korea) of patients aged 6 to 25 years. The patients were assigned to three groups of skeletal class I, II, III (n=130) with equal gender distribution. The clivus length and angle, Welcher angle, maxillary and mandibular effective length, sella turcica to Nasion (SN), and the angles between SN and point A (SNA), between SN and point B (SNB), and between NA and NB (ANB )were measured. Correlations of variables with age and gender, and cervical vertebral maturation stage (CVMS) were analyzed using the Pearson and Spearman’s correlation tests, independent t-test, and one-way ANOVA at 0.05 level of significance. Results: Clivus length had a significant correlation with SNA (r= 0.103, p= 0.042), SNB (r= 0.108, p= 0.033), maxillary (r= 0.547, p< 0.001) and mandibular (r= 0.589, p< 0.001) effective lengths, SN length (r= 0.586, p< 0.001), and CVMS (r= 0.697, p< 0.001). Clivus angle had a significant correlation with SNA (r= 0.105, p= 0.039), SNB (r= 0.155, p= 0.002), maxillary (r= 0.507, p< 0.001) and mandibular (r= 0.596, p= 0.001) effective lengths, SN length (r= 0.566, p< 0.001), and CVMS (r= 0.699, p< 0.001). The mean clivus length (p= 0.006) and angle (p= 0.002) were significantly higher in males, and had a significant correlation with age (r= 0.636 and r= 0.718, p< 0.001). The mean clivus length and angle were not significantly different in class I, II, III (p> 0.05). Conclusion: All parameters were greater in males, and increased with age (except Welcher angle). Clivus length and angle had significant correlations with position of both jaws but not with sagittal relationship. [ABSTRACT FROM AUTHOR]

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Tumors located in the nasal cavity, paranasal sinuses and the skull base comprise a wide range of histologic subtypes. Among them, neuroendocrine and undifferentiated tumors are rare but noteworthy, because of their distinctive features, aggressive nature, and diagnostic complexities. A literature search was conducted in the PubMed/MEDLINE and the Scopus databases from 2019 until inception. The keywords "neuroendocrine", "undifferentiated", "nose", "sinonasal", "paranasal", "skull base" were used. Thirty-eight articles referring to neuroendocrine and undifferentiated tumors of the nose, paranasal sinuses and the skull base were finally included and analyzed. Neuroendocrine and undifferentiated tumors of the nose, paranasal sinuses and the skull base are infrequent malignancies, most commonly affecting middle-aged men. They usually present with non-specific symptoms, even though ocular or neurologic manifestations may occur. Prognosis is generally poor; however, novel targeted and immunological therapies have shown promising results. Sinonasal Neuroendocrine Carcinomas (SNECs) carry distinct histological and immunohistochemical features. Management consists of surgical resection coupled with systematic therapy. Sinonasal Undifferentiated Carcinomas (SNUCs) lack specific squamous or glandular features. They typically stain positive for pancytokeratin and INI1 antibody. Treatment includes induction chemotherapy, followed by a combination of chemotherapy and radiotherapy. Olfactory neuroblastomas (ONBs) have neuroepithelial or neuroblastic features. They show diffuse positivity for various markers, including synaptophysin, chromogranin, and neuron-specific enolase (NSE). Surgical resection plus radiotherapy is considered the treatment of choice. In conclusion, neuroendocrine and undifferentiated tumors arising from the nose, paranasal sinuses and the skull base represent a unique group of malignancies. A thorough understanding of their clinical features, molecular changes, diagnostic approaches, treatment modalities, and prognostic factors is critical for providing optimal patient care. Still, continued research efforts and multidisciplinary collaboration are warranted, in order to improve outcomes for patients diagnosed with these rare and aggressive tumors. [ABSTRACT FROM AUTHOR]

Background: Sinonasal malignancies with orbital invasion have dismal prognosis even when treated with orbital exenteration (OE). Sugawara et al. developed a surgical strategy called "extended‐OE (EOE)," showing encouraging outcomes. We hypothesized that a similar resection is achievable under endoscopic guidance through the exenterated orbit (endoscopic‐EOE). Methods: The study was conducted in three institutions: University of Vienna; Mayo Clinic; University of Insubria; 48 orbital dissections were performed. A questionnaire was developed to evaluate feasibility and safety of each step, scoring from 1 to 10, ("impossible" to "easy," and "high risk" to "low risk," respectively), most likely complication(s) were hypothesized. Results: The step‐by‐step technique is thoroughly described. The questionnaire was answered by 25 anterior skull base surgeons from six countries. Mean, median, range, and interquartile range of both feasibility and safety scores are reported. Conclusions: Endoscopic‐EOE is a challenging but feasible procedure. Clinical validation is required to assess real‐life outcomes. [ABSTRACT FROM AUTHOR]

Background: There are no large studies reporting oncological or survival outcomes for patients diagnosed with perineural spread (PNS) of cutaneous squamous cell carcinoma (cSCC) via the ophthalmic nerve (V1). Where orbital exenteration may be necessary for curative treatment, it is critical to have survival data with which the morbidity associated with surgical treatment can be justified. Furthermore, with the emerging treatment option of immunotherapy, current standard of care outcomes are needed to help guide future trial design and eventually changed management guidelines. Objective: To determine the oncological and survival outcomes observed in patients with PNS of cSCC via V1. Materials and methods: Retrospective analysis of prospectively maintained cohort of patients with PNS of cSCC via V1 treated in a tertiary Australian head and neck oncology/skull base referral center. Consecutive sample of 53 patients managed between March 1, 1999 and April 30, 2020. Follow‐up closure date was September 1, 2021. Curative‐intent surgery, curative‐intent radiotherapy, or palliative care was undertaken. Endpoints included five‐year overall, disease‐specific, and disease‐free survival from the date of treatment. Results: Five‐year Kaplan–Meier overall survival was 61.9% (95% CI 46.2%–74.3%), with disease‐specific survival of 74.6% (95% CI 58.8%–85.3%), and disease‐free survival 62.1% (95% CI 46.5%–74.3%). Survival was superior in patients treated via surgery and adjuvant radiotherapy than in those receiving surgery alone or definitive radiotherapy. Survival was superior among patients with less advanced disease as assessed by the Williams zonal staging system; patients with Zone 1 disease had disease‐specific survival of 94.1% at 5 years with 82.5% disease‐free survival. Discussion: Five‐year oncological and survival outcomes in this cohort were favorable. Superior survival was observed in patients treated with curative‐intent surgery and adjuvant radiotherapy. Less extensive disease as delineated by the Williams zonal staging system was associated with improved survival. Conclusion: Surgical resection with adjuvant radiotherapy confers favourable oncological and survival outcome in patients with V1 PNS, particularly with early disease limited to Zone 1. [ABSTRACT FROM AUTHOR]

Background: The aim of this retrospective study was to compare the efficacy of transcervical (TC), endoscope‐assisted transoral (TO), and endoscope‐assisted TC for resection of retrostyloid space schwannomas. Methods: The study included patients who underwent complete resection of schwannomas by only one surgical approach. The data we collected included tumor size, estimated blood loss, postoperative complications, and so on. Statistical analysis was performed using one‐way analysis of variance and Fisher's exact test. Results: The study collected 85 patients with tumors mostly located at the oropharyngeal level who were followed up 6 months at least. The results showed that endoscope‐assisted TO had certain advantages over others. Additionally, the endoscope‐assisted TO set the lowest incidence of neurological complications. Conclusion: Our findings demonstrate that for team with rich experience in the skull base surgery, endoscope‐assisted TO is a superior option compared to the other two groups for resection of retrostyloid space schwannomas, with the better preservation of neurological function. [ABSTRACT FROM AUTHOR]

Key Points Positive pressure transmitted from continuous positive airway pressure (CPAP) to the sinuses and skull base in the early post‐operative period has not been studied in live subjects and controversy exists in when to restart this post‐operatively. This study found that approximately 32.76% and 13.52% of the delivered CPAP pressures reached the post‐surgical sphenoid sinus and the mid‐nasal cavity, respectively, suggesting that surgical factors such as tissue edema, nasal packing, blood, and nasal secretions may provide a protective effect. Positive pressure transmitted from continuous positive airway pressure (CPAP) to the sinuses and skull base in the early post‐operative period has not been studied in live subjects and controversy exists in when to restart this post‐operatively.This study found that approximately 32.76% and 13.52% of the delivered CPAP pressures reached the post‐surgical sphenoid sinus and the mid‐nasal cavity, respectively, suggesting that surgical factors such as tissue edema, nasal packing, blood, and nasal secretions may provide a protective effect. [ABSTRACT FROM AUTHOR]

Palaeogene South American faunas include enigmatic ungulates that cannot be classified unequivocally within any of the main South American (SA) Native Ungulates clades (Litopterna, Notoungulata, Astrapotheria, Pyrotheria and Xenungulata) because they retain plesiomorphic features, resembling Laurasian ‘archaic ungulates’ traditionally classified within the order ‘Condylarthra’. Most SA ‘condylarths’ are known by partial dental series and isolated teeth and unassociated postcranial remains, hampering comparisons with better-known ungulates. Here, we describe a nearly complete skull and associated mandible of an SA ‘condylarth’, Talquinodus puertai gen. et sp. nov., preserving most of the dentition and basicranium, derived from middle Eocene rocks of the Sarmiento Formation at Central Patagonia. Talquinodus shows a combination of plesiomorphic traits (complete dentition with bunolophodont cheek teeth, ring like ectotympanic, retention of stapedial system, etc.), combined with some autapomorphies, as the reduction of the m3 talonid. Our phylogenetic analyses support consistently that Talquinodus belongs to the SA radiation of Euungulata along with Litopterna, Notoungulata and Astrapotheria. However, the internal relationships could not be resolved unambiguously: Talquinodus could be a didolodontid related to the origin of Litopterna, or could be part of a separate radiation of South American archaic ungulates, along Depaulacoutoia, Lamegoia and Escribania, with no descendants in post-Eocene faunas. [ABSTRACT FROM AUTHOR]

Purpose: Posterior circulation cerebral bypasses often show higher risks and lower patency. Only few reports discussed occipital artery (OA)-vertebral artery (VA) bypasses. We present our illustrative cases to address current gaps in the literature on OA-VA bypass. Methods: A single-center retrospective review was conducted to include all institutional cases of OA-VA bypass, discussing the technique and outcomes. Results: Four institutional cases undergoing a total of 5 bypasses were evaluated, including 3 males and 1 female, with median age of 65 years (range, 62–73). All patients had vertebrobasilar insufficiency (VBI) with recurrent strokes/TIAs due to intracranial atherosclerosis, leading to unilateral VA stenosis with contralateral occlusion (1, 25%), bilateral VA stenosis (1, 25%) or occlusion (1, 25%). Medical management included aspirin for all cases (100%), with clopidogrel in 3 (75%). Surgery was performed through a far lateral approach, connecting the OA to the VA-3 segment, with no inter-positional graft. One patient underwent contralateral OA-VA bypass 6 months after the prior surgery due to worsening of the contralateral VA stenosis. Bypass patency was confirmed in all cases with post-operative angiography. All patients had clinical improvement, with one case of wound dehiscence managed conservatively. All patients were alive at last follow-up (median 7.0 months; range: 1.5–18). Conclusion: OA-VA bypass is a challenging yet effective strategy in selected patients with VBI. Current literature lacks unique definitions of surgical indications and techniques, which we addressed in our series. Surgical education should focus on expanding the microsurgery anatomy knowledge. [ABSTRACT FROM AUTHOR]

Eosinophilic angiocentric fibrosis (EAF) is a rare, benign fibroinflammatory condition primarily affecting the sinonasal and upper respiratory tract, with a few cases reported beyond these regions. Primary intracranial EAF is rare. To date, only one case of intracranial EAF has been reported; ours is the second. This case report presents a case of EAF in a 55‐year‐old man, initially misdiagnosed as meningioma based on clinical and radiological features. The patient complained of a persistent dull headache for six months without associated neurological symptoms. Brain magnetic resonance imaging revealed a dural‐based lesion with characteristics suggestive of meningioma. However, histopathological examination post‐surgical resection revealed a nodular vascular lesion with concentric angiocentric fibrosis, a distinctive onion skin pattern, and an inflammatory infiltrate rich in eosinophils, plasma cells, and histiocytes. Immunohistochemistry ruled out IgG4‐related disease, and other systemic disorders were ruled out based on combined clinical and histological features. This case underscores the need for considering EAF in the differential diagnosis of dural‐based lesions. Awareness of its potential mimicking of meningioma is crucial for accurate diagnosis and appropriate management, emphasizing the importance of histopathological examination in challenging cases. [ABSTRACT FROM AUTHOR]

Objective: Resections of symptomatic Rathke's cleft cysts (RCCs) are mainly performed via an endonasal transsphenoidal approach. However, there is a lack of equivalent data in current literature concerning transcranial keyhole approach in the treatment of RCCs. In order to find general recommendations for the surgical treatment of RCCs also with regard to recurrence, the object of this study is the analysis and comparison of both techniques. Methods: Twenty-nine patients having been surgically treated between January 2004 and August 2019 were retrospectively analysed. The transsphenoidal approach was chosen in 16 cases and the transcranial keyhole approach in 13 cases. Both surgical techniques were analyzed and compared concerning preoperative symptoms and cyst characteristics, complications, surgical radicality, endocrinological and ophthalmological outcome and recurrences in patients´ follow up. Results: The postoperative outcome of both techniques was identic and showed highly satisfying success rates with 92% for neurological deficits, 82% for endocrinological dysfunctions and 86% for visual deficits. In contrast, momentous postoperative complications were significantly more likely after transsphenoidal operations. After a mean follow-up time of 5.7 years, the recurrence rates of both cohorts were the same with 0% each. Conclusions: Regarding its equal outcome with its lower complication rate, the authors suggest using the supraorbital keyhole approach for RCCs whose anatomical configuration allow both techniques. Yet, the decision should always consider the surgeon's personal experience and other individual patient characteristics. Further studies with higher numbers of cases and longer follow-up periods are necessary to analyse the effect of the selected approach on recurrence. [ABSTRACT FROM AUTHOR]

La radiothérapie cérébrale peut entraîner des complications neurologiques à long terme, notamment des troubles mnésiques. L'objectif de cette étude prospective est d'évaluer l'impact de l'irradiation des tumeurs bénignes de la base du crâne situées à proximité des hippocampes sur la mémoire autobiographique. De 2016 à 2019, les patients atteints de méningiome du sinus caverneux ou d'un adénome hypophysaire et traités par irradiation normofractionnée, ont été inclus. Les patients ont eu une évaluation neuropsychologique complète initiale, à 1 an puis à 2 ans après le traitement. Les tests neuropsychologiques ont été convertis en Z-Score pour être comparables. Douze patients sur les 19 inclus ont eu une évaluation complète sur le plan neuropsychologique à 2 ans et ont fait l'objet de l'analyse. Sur le Test épisodique de mémoire du passé autobiographique (« TEMPau »), aucune différence significative à 2 ans de la mémoire autobiographique n'a été constatée, quelle que soit la période concernant cette mémoire. La dose moyenne hippocampique n'avait pas d'impact sur la variation de la mémoire autobiographique. Il n'existait pas de dégradation cognitive significative dans les autres domaines évalués comme l'attention, la mémoire antérograde, la mémoire de travail et les fonctions exécutives. La mémoire autobiographique était indépendante de ces autres domaines cognitifs, ce qui justifie de son étude spécifique. La radiothérapie de la base du crâne pour une pathologie bénigne n'entraîne pas de différence de mémoire autobiographique à 2 ans. Un suivi plus long serait nécessaire afin de conforter ces résultats. Cranial irradiation can lead to long-term neurological complications, in particular memory disorders. The aim of this prospective study is to evaluate the impact of irradiation of benign skull base tumours located near the hippocampi on autobiographical memory. From 2016 to 2019, patients with cavernous sinus meningioma or pituitary adenoma treated with normofractionated irradiation were included. Patients underwent full neuropsychological assessment at baseline, 1 year and 2 years post-treatment. Neuropsychological tests were converted to Z-Score for comparability. Twelve of the 19 patients included had a complete neuropsychological evaluation at 2 years and were analysed. On the "TEMPau" test, no significant difference in autobiographical memory was found at 2 years, regardless of the period of autobiographical memory. The mean hippocampal dose had no impact on the variation in autobiographical memory. There was no significant cognitive impairment in the other domains assessed, such as attention, anterograde memory, working memory and executive functions. Autobiographical memory was independent of these other cognitive domains, which justifies its specific study. Radiotherapy to the skull base for a benign pathology does not lead to significant cognitive impairment. Longer follow-up would be needed to confirm these results. [ABSTRACT FROM AUTHOR]

It is possible that the reproductive strategy of the short-beaked echidna is related to seasonal changes in fat deposition and energy availability, regulated by seasonal changes in endocrine function. We predicted that circulating leptin levels would be directly proportional to adiposity during most of the year, but that a change in this relationship would occur during the pre-breeding season to allow increased fat deposition. To test this hypothesis, we made use of a captive colony of echidnas to describe and quantify changes in fat distribution and the adipostatic hormone leptin. First we assessed seasonal changes in circulating leptin levels, body mass and adiposity for three male and three female adult echidnas maintained on a standard diet. Second, we explored the relationship between circulating leptin levels and increased caloric intake for an additional five adult female echidnas that were provided with supplemented nutrition. Third we visualised fat distribution in male and female adult echidnas using magnetic resonance imaging (MRI) before and after the breeding season, to determine where fat is deposited in this species. For echidnas maintained on the standard diet, there were no seasonal changes in body mass, body fat or plasma leptin levels. However, female echidnas provided with supplemented nutrition had significantly elevated plasma leptin levels during the breeding season, compared to the pre-and post- breeding periods. MRI showed substantial subcutaneous fat depots extending dorso-laterally from the base of the skull to the base of the tail, in both sexes. Pre-breeding season, both sexes had considerable fat deposition in the pelvic/rump region, whilst the female echidna accumulated most fat in the abdominal region. This study shows that male and female echidnas accumulate body fat in the pelvic/rump and the abdominal regions, respectively and that circulating leptin may promote fattening in female echidnas during the breeding season by means of leptin resistance. However, further research is required to evaluate the precise relationship between seasonal changes in leptin and adiposity. [ABSTRACT FROM AUTHOR]

Background: Cephalometric studies indicate that craniofacial morphology in patients with cleft palate only (CPO) differs from other forms of orofacial clefts and healthy patients. Planning orthodontic treatment for patients with different craniofacial deformities requires knowledge on the craniofacial complex. The aim of the present study was to describe the cephalometric craniofacial morphology in adolescents with cleft palate only compared to generally healthy orthodontic patients. Methods: The study comprised 100 lateral cephalograms (taken in the years 2003–2020) of Polish patients with cleft palate only aged from 11.1 to 14.2 (mean age 12.43 y) and a matched control group of 100 children without orofacial clefts aged 12–14 (mean age 12.25). All digital images were analyzed in specialized cephalometric software. Results: Statistically significantly lower values of both SNA (p < 0.001) and ANB (p < 0.001) were found in the study group versus the control group. Mandibular line to cranial base angle (ML-NSL) as well as maxillary base to cranial base (NL-NSL) were significantly higher in the CPO group. Both the maxilla and mandible were rotated distally in CPO. Moreover, the intermaxillary vertical angle (ML-NL) was reduced in CPO. Mandibular angle in CPO was significantly higher (p = 0.005), reflecting posterior mandibular rotation. Conclusions: In adolescents with CPO, maxillary deficiency is found, without a severe sagittal jaw discrepancy, with a slight compensatory lingual inclination of the lower incisors. Mandibular deficiency in CPO is concurrent with posterior rotation and an increased mandibular angle. [ABSTRACT FROM AUTHOR]

Introduction: Ectopic parathyroid glands have been reported with an incidence of 2–22%. Undescended parathyroid glands, defined as glands situated above the carotid bifurcation or > 1 cm cranial to the superior pole of the thyroid gland, comprise 2–7% of all ectopic parathyroid glands. We report a case of incidentally discovered parathyroid gland located in the retropharyngeal space at the level of the oropharynx. Case Presentation: The patient in this report was a 60-year-old female with squamous cell carcinoma of the tonsil T2N0M0 with MRI showing a hyperintense ovoid structure, medial to the carotids at the level of the oropharynx, corresponding to the location of the lateral group of retropharyngeal lymph nodes. Patient underwent transoral ultrasonic radical tonsillectomy along with a retropharyngeal lymph node dissection by the transcervical route. Postoperative histopathology revealed the retropharyngeal node sampled to be a normal parathyroid gland. Discussion: "High" undescended parathyroid gland as reported here along with 4 other cases of infratemporal fossa parathyroid glands reported previously, can be the cause for recurrent missed adenomas. Being extracervical in location, these are likely to be missed if the skull base has not been included in the preoperative Tc-99 sestamibi scan and also during bilateral neck exploration. [ABSTRACT FROM AUTHOR]

Pediatric cholesteatomas (PC) have multifactorial aetiology, spread aggressively and there are high chances of residual/ recurrent disease after treatment. The surgical technique to manage this entity has been debatable. This study was done to (i) enumerate the presentation of PC and the surgical techniques adopted (ii) analyse the outcomes viz., residual/ recurrence rates and hearing results. A cross sectional record based study was done on 618 cases of PC operated between 1983 and 2015, at a centre dedicated to otology and lateral skull base surgery. The data which was maintained on the basis of clinical and peri- operative findings was analysed. Otorrhea (59.2%) and hearing loss (54.2%) were the common symptoms. The surgeries done were: canal wall up (CWU) (44.3%), canal wall down (CWD) (41.1%), modified bondy's mastoidectomy (5.7%), radical mastoidectomy (4.9%), trans canal excision (1.8%) and subtotal petrosectomy (2.3%). The residual and recurrence rates were 12.6% and 7.9% respectively. A significant difference between the pre and post operative hearing was observed. The mean improvement in air bone gap was 7.7db. Residual/ recurrent disease were higher in CWU as compared to CWD group. The surgery should be individualised so that the patient remains disease free. [ABSTRACT FROM AUTHOR]

Fungal rhinosinusitis (FRS) includes non-invasive and invasive subtypes with the latter having significant morbidity and mortality. This systematic review aims to identify the imaging features most correlated with invasive fungal rhinosinusitis (IFRS) and present a checklist of these features to aid diagnosis. PubMed, Embase, CENTRAL, and Science Direct were searched from inception to May 2023, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Primary research articles published in English describing the imaging features of IFRS were included. The systematic review was conducted in accordance with the PRISMA guidelines. Forty-eight articles were identified for inclusion. Six studies examined radiological features in acute invasive fungal rhinosinusitis (AIFRS), and 9 studies of chronic invasive fungal rhinosinusitis (CIFRS). A majority of studies did not specify whether IFRS cases were acute or chronic. On CT, bony erosion and mucosal thickening were the most common features. Other features include nasal soft tissue thickening, nasal cavity opacification, opacification of the affected sinus, and perisinus soft tissue infiltration. Extra-sinus extension was commonly observed on MRI, most often invading intraorbitally and intracranially. Other sites of extra-sinus extension included the cavernous sinus, pterygopalatine fossa, infratemporal fossa, masticator space, and facial soft tissue. IFRS is a condition with potential for high morbidity and mortality. Several radiological features are highly suggestive of IFRS. Early identification of high-risk radiological features using a checklist may aid prompt diagnosis and early treatment. Future research investigating the radiological differentiation between IFRS and other significant pathology including bacterial orbital cellulitis would be beneficial. [ABSTRACT FROM AUTHOR]

Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment. [ABSTRACT FROM AUTHOR]

Recent advances in neuroendoscopic surgery have led to the minimally invasive treatment of brain abscesses using various endoscopy techniques. The endoscopic diving technique (EDT) involving the formation of fluid lenses to improve the visibility of the endoscope has been reported to be useful in the endoscopic endonasal approach (EEA) for pituitary and midline cranial base lesions. Here, we report a case of brain abscess treated endoscopically using EDT in cylinder surgery. A 29-year-old man with 11q trisomy syndrome developed a fever and progressive right hemiparesis was observed. A diagnosis of a brain abscess was made based on neuroradiological imaging, and endoscopic irrigation and drainage with EDT via a transparent endoscopic sheath were performed, which provided a clear operative field and allowed satisfactory irrigation without bacterial contamination. The bacterium identified by PCR was Streptococcus intermedius, and antibiotic therapy was administered. Postoperatively, his symptoms gradually improved. This is the first technical case report describing the clinical experience of EDT in brain abscess surgery. EDT may be a useful technique not only in EEA but also in cylinder surgery for brain abscesses. [ABSTRACT FROM AUTHOR]

Purpose: The topic of osseous variations of the craniocervical junction is a complex morphological and embryological chapter of human anatomy, with a possible impact on neurogical and vascular functionality in this morphological variable region. Material & methods: An until now undescribed anatomical variation of the exoccipital part of the occipital bone has been observed after maceration at the outer skull base of a West-European 68-year-old male body donor. Results: On both sites of the foramen magnum accessory osseous processes were observed that arise from the jugular process and point towards the lateral margin of the foramen magnum. On the left site this process forms a full arc that bridges the condylar fossa completely. Conclusion: The observed osseous bridge over the condylar fossa has not been reported on before and can be explained by the partial persistence of a primordial vertebra between atlas and occipital bone: the Proatlas. The resulting accessory structure may affect due to its topographic conditions the V3-Segment of the vertebral artery and its accompanying nerves, and thus, play a role in diagnosis and therapy of vascular and/or neurological symptoms of head and neck. [ABSTRACT FROM AUTHOR]

Purpose: Our study aims to investigate three parts of the intracranial cavity, their distances to essential anatomical landmarks, and the correlations between these distances with sex, laterality, and surgical significance. Methods: The cranial nerve foraminae and essential surgical landmarks of each fossa were investigated bilaterally in 30 adult formalin-fixed cadaveric heads. Measurements, including lengths, depths, diameters, and horizontal distances to each other, to the midline of the skull, and to the outer lateral margin of the skull, were recorded on both sides. Results: The optic canal (OC) depth, internal auditory meatus (IAM) width, CNVII and CNIX diameters, and accessory hypoglossal canal (HC) distance were significantly greater on the left side (p < 0.05). CNVI length, CNV diameter, CNXI length, and the distances of the HC and accessory HC from the skull were significantly greater on the right side (p < 0.05). In males, correlations were found between the length of the left CNVIII and the right IAM diameter (r = 0.864, p = 0.001), right CNVIII length (r = 0.709, p = 0.022), right accessory HC length (r = 0.847, p = 0.016), and right-sided skull distance (r = 0.829, p = 0.042). In females, correlations were noted between IAM depth and length, right IAM location relative to the skull, left CNIX and CNX lengths, left CNXII length, left accessory HC location relative to the skull, and accessory HC length. Conclusions: The findings of the current study indicate inherent asymmetry, sexual dimorphism, and variability in certain cranial nerves among cadaveric heads, which could have implications for surgical procedures, neuroanatomical studies, and clinical assessments. The study revealed side disparities and correlations within cranial fossa formations and essential surgical landmarks in both genders. [ABSTRACT FROM AUTHOR]

Tension pneumocephalus (PMC) is a rare and feared complication following the endonasal endoscopic approach (EEA) to skull base procedures. This is a neurosurgical emergency that requires urgent decompression to avoid catastrophic neurologic damage or death. An avoidable cause is the application of positive pressure ventilation (PPV) in EEA patients for postoperative hypoxia. Our institution implemented a hospital-wide protocol in response to this to identify and manage at-risk patients; this paper aims to identify if this protocol was effective in lowering the rates of tension PMC secondary to PPV. In the 3 years following the implementation of the protocol, 110 patients underwent EEAs, from which 1 case of tension PMC (found to be not secondary to PPV) was identified. This is compared with 2 cases of tension PMC secondary to PPV over the preceding 5 years, out of 406 EEA patients. This constitutes a quantifiable reduction in PPV-related tension PMC in both standard and extended approach EEAs, signifying the effective uptake of the protocol. We found no cases of tension PMC after PPV following EEA skull base surgery in our institution since the implementation of an institution-wide guideline. This underscores the utility of our simple and cost-effective preventative protocol in reducing the overall rates of tension PMC following the inadvertent postoperative application of PPV. Further research is needed to study the comparative risks and benefits of PPV in the post-EEA patient and thus inform future iterations of the protocol. [ABSTRACT FROM AUTHOR]

Supratentorial craniotomy represents the upper part of the combined trans-tentorial or the supra-infratentorial presigmoid approach. In this study, we provide qualitative and quantitative analyses for the supratentorial extension of the presigmoid retrolabyrinthine suprameatal approach (PRSA). The infratentorial PRSA followed by the supratentorial extension craniotomy with dividing and removal of the tentorial strip were performed on both sides of 5 injected human cadaver heads (n = 10 sides). Quantitative analysis was performed for the surface area gained (surgical accessibility) by adding the supratentorial craniotomy. Qualitative analysis was performed for the parts of the brainstem, cranial nerves, and vascular structures that became accessible by adding the supratentorial craniotomy. The anatomical obstacles encountered in the added operative corridor were analyzed. The supratentorial extension of PRSA provides an increase in surgical accessibility of 102.65% as compared to the PRSA standalone. The mean surface area of the exposed brainstem is 197.98 (standard deviation: 76.222) and 401.209 (standard deviation: 123.96) for the infratentorial and the combined supra-infratentorial presigmoid approach, respectively. Exposure for parts of III, IV, and V cranial nerves is added after the extension, and the surface area of the outer craniotomy defect has increased by 60.32%. Parts of the basilar, anterior inferior cerebellar, and superior cerebellar arteries are accessible after the supratentorial extension. The supratentorial extension of PRSA allows access to the supra-trigeminal area of the pons and the lower part of the midbrain. Considering this surgical accessibility and exposure significantly assists in planning such complex approaches while targeting central skull base lesions. [ABSTRACT FROM AUTHOR]

Objective While the transcondylar approach is technically challenging, it provides generous ventral and caudal exposure to the craniovertebral junction. This approach requires navigation around multiple eloquent neurovascular structures including the lower cranial nerves, vertebral artery and its branches, and the brainstem. Superficial exposure, including incision location and muscle dissection, can dramatically affect the surgical angle and maneuverability at depth. Methods We demonstrate the transcondylar approach in a step-by-step fashion in a formalin-embalmed, latex-injected cadaver head. Dissection within each layer of the suboccipital muscles was performed. A small cohort with an illustrative case is also included herein. Results The sternocleidomastoid (SCM) muscle was retracted anteriorly; the splenium capitis, semispinalis capitis, and longissimus capitis muscles were disconnected from the superior nuchal line and reflected inferomedially. The suboccipital muscle group was fully exposed. The superior and inferior oblique muscles were disconnected from the transverse process of C1. The superior oblique and the rectus capitis posterior major muscles were then dissected off the inferior nuchal line, and the suboccipital muscle group was retracted inferomedially en bloc. The greater auricular nerve was retracted laterally with the SCM, and the greater occipital nerve was retracted inferomedially with the suboccipital muscle group. Conclusion This technique avoids the obstructive muscle bulk that results from a myocutaneous approach while maximizing deep exposure. Understanding the detailed muscular anatomical relationship with the insertion location and suboccipital nerves is key to complete and safe extracranial dissection. Diligent dissection helps minimize postoperative pain and muscle spasm while optimizing the closure technique. [ABSTRACT FROM AUTHOR]

Background Advances in skull base surgery have increased the need for a detailed understanding of skull base anatomy and its intrinsic relationship to surrounding structures. This has resulted in an improvement in patient outcomes. The frontotemporal orbitozygomatic (FTOZ) transcavernous approach (TCA) is an excellent option for treating complex lesions involving multiple compartments of the skull base, including the sellar and parasellar, third ventricle, orbit, and petroclival region. Objective This article aimed to provide a detailed cadaveric dissection accompanying a thorough procedure description, including some tips and pitfalls of this technique. Methods Microsurgical dissection was performed in four freshly injected cadaver heads at the Cranial Base Neuroanatomy Laboratory, Cleveland Clinic Florida. The FTOZ TCA was performed on both sides of the four specimens. The advantages and disadvantages were discussed based on the anatomic nuances of this approach. Results The FTOZ TCA represented a wide access to the anterior, middle, and posterior fossa. When combined with an anterior clinoidectomy, it allowed for significant and safe internal carotid artery mobilization. This approach created numerous windows, including opticocarotid, carotid-oculomotor, supratrochlear, infratrochlear, anteromedial, anterolateral, and posteromedial triangles. The only drawback was the length of the dissection and the level of surgical acumen required to perform it. Conclusion Despite its technical difficulty, the FTOZ TCA should be considered for the surgical management of basilar apex aneurysms and tumors surrounding the cavernous sinus, sellar/parasellar, retrochiasmatic, and petroclival region. Continuous training and dedicated time in the skull base laboratory can help achieve the necessary skills required to perform this approach. [ABSTRACT FROM AUTHOR]

Objectives Malignant tumors of the sinonasal cavities with extension to the frontal skull base are rare and challenging pathologies. Combined-approach surgery using a frontobasal craniotomy and endoscopic sinus surgery with reconstruction of the anterior skull base followed by adjuvant radiotherapy is a preferred treatment strategy in selected cases. Morbidity and mortality rates are high in this population. We aim to add our experience to the current literature. Design We performed a retrospective cross-sectional single center study of the long-term clinical outcome in a tertiary university referral hospital in the Netherlands between 2010 and 2021. Descriptive statistics and frequency distributions were performed Participants Patient, tumor, treatment, complications and survival characteristics of eighteen consecutive patients were extracted from the electronic health records. Main Outcome Measures The primary outcome measures are progression free survival, overall survival and complication rate. Results Eighteen consecutive patients were included with a mean age of 61 (SD ± 10) years (range 38-80); ten males and eight females. Gross total resection was achieved in 14 (77%) patients. Eleven (61%) patients underwent local radiotherapy, one (5%) chemotherapy and three (17%) a combination of both. Mean follow-up duration was 49 months (range 3 – 138). Three (17%) patients died in hospital due to post-operative complications. Six (33%) patients died during follow-up due to disease progression. Mean progression-free survival was 47 months (range 0 – 113). Conclusion In conclusion, the overall survival was 50% for this group of patients with large sinonasal tumors. Progressive disease affects survival rate severely. Surgical complications were seen in five (28%) patients. Radiotherapy is associated with high complication rates. Radiation necrosis was a serious complication in two patients and could be treated with high dose steroids. [ABSTRACT FROM AUTHOR]

Introduction Pituitary neuroendocrine tumors (PitNETs) are rare skull base tumors which can impart significant disability owing to their locally invasive potential. To date, the gamut of PitNET subtypes remains ill-understood at the ligand-receptor (LR) interactome level, potentially limiting therapeutic options. Here, we present findings from in silico analysis of LR complexes formed by PitNETs with clinical presentations of acromegaly, Cushing's disease, high prolactin production, and without symptoms of hormone hypersecretion. Methods Previously published PitNET gene expression data was acquired from ArrayExpress. These data represented all secretion types. LR interactions were analyzed via a crosstalk score approach. Results Cortisol (CORT) ligand was significantly involved in tumor-to-tumor signaling across all PitNET subtypes but prolactinomas, which evidenced active CORT depletion. Likewise, CCL25 ligand was implicated in 20% of the top LR complex interactions along the tumor-to-stroma signaling axis, but silent PitNETs reported unique depletion of the CCL25 ligand. Along the stroma-to-tumor signaling axis, all clinical PitNET subtypes enriched stromal vasoactive intestinal polypeptide ligand interactions with tumor secretin receptor. All clinical PitNET subtypes enriched stromal DEFB103B (human β-defensin 103B) ligand interactions with stromal chemokine receptors along the stroma-to-stroma signaling axis. In PitNETs causing Cushing's disease, immune checkpoint ligand CD274 reported high stromal expression, and prolactinomas reported low stromal expression. Moreover, prolactinomas evidenced distinctly high stromal expression of immune-exhausted T cell response marker IL10RA compared with other clinical subtypes. Conclusion Relative crosstalk score analysis revealed a great diversity of LR complex interactions across clinical PitNET subtypes and between solid tumor compartments. More data are needed to validate these findings and exact clinical importance. [ABSTRACT FROM AUTHOR]

Introduction Although many neuroanatomic atlases have been published, few have detailed complex cranial approaches and pertinent anatomic considerations in a stepwise fashion intended for rapid comprehension by neurosurgery students, residents, and fellows. Methods Five sides of formalin-fixed latex-injected specimens were dissected under microscopic magnification. The frontotemporal and orbitozygomatic approaches were performed by neurosurgical residents and fellows at different training levels with limited previous experience in anatomical dissection mentored by the senior authors (M.P.C. and M.J.L.). Meticulous surgical anatomic dissections were performed until sufficient visual and technical completion was attained, with parameters of effectively demonstrating key surgical steps for educational training purposes. Following the completion of dissection and three-dimensional photography, illustrative case examples were reviewed to demonstrate the relative benefits and optimal applications of each approach. Results The frontotemporal and orbitozygomatic approaches afford excellent access to anterior and middle skull base pathologies, as well as the exposure of the infratemporal fossa. Key considerations include head positioning, skin incision, scalp retraction, fat pad dissection and facial nerve protection, true or false MacCarty keyhole fashioning, sphenoid wing drilling and anterior clinoidectomy, completion of the craniotomy and accessory orbital osteotomy cuts, dural opening, and intradural neurovascular access. Conclusion The frontotemporal and orbitozygomatic approaches are core craniotomies that offer distinct advantages for complex cranial operations. Learning and internalizing their key steps and nuanced applications in a clinical context is critical for trainees of many levels. The orbitozygomatic craniotomy in particular is a versatile but challenging approach; operative-style laboratory dissection is an essential component of its mastery and one that will be powerfully enhanced by the current work. [ABSTRACT FROM AUTHOR]

Objective Current transnasal endoscopic techniques for sinus and skull base surgery use a single endoscope to provide visualization from one perspective curtailing depth perception and compromising visualization of the instrument–target interface. The view can be blocked by instruments, and collisions between instruments often occur. The objective of this study was to investigate the use of multiportal retrograde endoscopy to provide more accurate manipulation of the surgical target. Design Maxillary antrostomy and frontal sinusotomy were performed on three different cadavers by three different surgeons. A zero-degree rigid endoscope was introduced through the nose for the standard transnasal approach. A flexible endoscope was introduced transorally, directed past the palate superiorly, and then flexed 180 degrees for the retrograde view. Videos of the standard transnasal view from the rigid endoscope and retrograde view from the flexible endoscope were recorded simultaneously. Results All surgeries were able to be performed with dual-screen viewing of the standard and retrograde view. The surgeons noted that they utilized the retrograde view to adjust the location of ends/tips of their instruments. Four surgeons reviewed the videos and individually agreed that the visualization achieved provided a perspective otherwise not attainable with rigid transnasal endoscopy alone. Conclusion High-quality visualization of surgical targets such as the frontal or maxillary ostia can be challenging with rigid endoscopes alone. Multiportal retrograde endoscopy provides proof of concept that additional views of a surgical target can be achieved. Additional work is needed to further develop indications, techniques, and generalizability to targets beyond those investigated here. [ABSTRACT FROM AUTHOR]

Background Skull base approaches are utilized to improve microsurgical treatment of cerebral aneurysms. Advantages include early proximal and distal control, increased visualization, and minimal brain retraction. Orbitozygomatic (OZ) craniotomies via pterional incision are commonly used for the treatment of anterior communicating artery (ACoA) aneurysms. A smaller, less invasive OZ craniotomy performed through an eyebrow incision may provide several advantages over a standard OZ approach. Objective We compare surgical outcomes of the standard and eyebrow OZ for the treatment of ACoA aneurysms. Design All patients who underwent microsurgical treatment for ACoA aneurysms by a single surgeon over an 8-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. Participants Thirty-seven consecutive patients were identified, with 15 receiving eyebrow OZ and 22 receiving standard OZ. Main Outcome Measures Data were collected on patient demographics, pathology, intraoperative and perioperative data, and 30-day morbidity. Results A total of 100% of the eyebrow OZ group and 95.5% of the standard OZ group had complete aneurysmal occlusion. Four eyebrow OZ and six standard OZ patients had an intraoperative rupture. All were managed without complication. Two eyebrow OZ and one standard OZ patient died within 30 days of surgery. No patients in either group had aneurysm recurrence, required retreatment, or were limited intraoperatively by exposure. Conclusions The OZ approach via an eyebrow incision has similar outcomes to a standard OZ approach and is a safe option for the treatment of ACoA aneurysms. [ABSTRACT FROM AUTHOR]

Background: For a minimally invasive treatment approach to the anteromedial part of the anterior cranial fossa (ACF), a small incision and craniotomy of the posterolateral part of the ACF are preferable. Method: We described the concept and technique of suprapterional keyhole approach (SPKA), which uses an exoscope and endoscope to treat ACF lesions. Conclusion: The SPKA enables ACF observation from the lateral direction; the endoscope's extended viewing angles enable the observation of the anteromedial part of the ACF, including the bilateral olfactory groove. Facial skin and large scalp incisions are avoided, making this approach efficient for ACF lesions. [ABSTRACT FROM AUTHOR]

Purpose: Sinus thrombosis is a common post-operative finding after posterior fossa surgery performed in the vicinity of the dural venous sinuses. The SARS-CoV-2 virus has been shown to confer an increased risk of venous thromboembolic events owing to eliciting a hyper-inflammatory and pro-thrombotic state. In this study, we examine the incidence of post-operative venous sinus thrombosis in patients undergoing peri-sigmoid posterior fossa surgery in the pre- and post-COVID era and investigate whether COVID infection confers an increased risk of sinus thrombosis. Methods: A retrospective review of a single institution case series of patients underwent peri-sigmoid surgery (retrosigmoid, translabyrinthine, or far lateral) approach. Relevant clinical variables were investigated that may confer an increased risk of sinus thrombosis. Results: A total of 311 patients (178 in the pre-COVID era, and 133 operated on after the pandemic began in March 2020) are included in the study. The composite incidence of sinus thrombosis seen on post-operative imaging was 7.8%. The incidence of sinus thrombosis in the pre-COVID cohort was N = 12 patients (6.7%) versus N = 12 (9%) in the post-COVID cohort (p = 0.46). A history of COVID infection was not shown to confer an increased risk of post-operative sinus thrombosis (OR: 0.61; 95% CI: 0.08–4.79, p = 0.64). Only a small number of patients (N = 7, 2.3%) required either medical or surgical intervention for post-operative sinus thrombosis. Conclusion: The overall incidence of post-operative sinus thrombosis is similar in the pre- and post-COVID era. The findings of this study suggest that COVID infection is not associated with a higher risk of venous sinus thrombosis. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Sinonasal malignancy surveillance paradigms are often based on Head and Neck National Comprehensive Cancer Network guidelines, which do not recommend standard surveillance imaging beyond 6 months without concerning symptomatology or physical examination findings.This was a retrospective analysis of all patients who underwent resection of sinonasal malignancy at a tertiary care center over a 20‐year period from 2000 to 2020, with an ensuing surveillance period demonstrating recurrence.Fifty‐two patients with sinonasal malignancy recurrence were included, with an average time to recurrence of 30.9 months and a follow‐up period of over 60 months. Recurrence was diagnosed by routine imaging or endoscopy in asymptomatic patients in a majority (60%) of cases, while the remaining minority of diagnoses followed new symptomatology. Asymptomatic recurrence was associated with perineural spread of tumor at initial resection (p = 0.025), but not with age (p = 0.85) or stage at diagnosis (p = 0.68). Expectedly, positron emission tomography/computed tomography (CT) more often detected regional or distant recurrence, while structural imaging (CT/magnetic resonance imaging) demonstrated more frequent detection of recurrence in those with perineural spread of tumor (p = 0.01).Our findings support high rates of asymptomatic recurrence in sinonasal malignancy, with the majority of recurrences diagnosed by routine endoscopy or imaging. Tailored and extended surveillance guidelines are necessary relative to those utilized for other head and neck mucosal cancers, and are especially appropriate when features such as perineural spread are present. [ABSTRACT FROM AUTHOR]

Limited vouchered records exist for Cuniculus paca, the second-largest living caviomorph rodent, documenting its southernmost occurrence. Here, we introduce four new recording sites based on skulls probably discarded by local hunters, with three located in Misiones Province and the fourth marking the first supported evidence in the neighboring Corrientes Province in Argentina. The data remains inconclusive as to whether the latter location signifies a southern expansion of this rodent due to climate change or simply an overlooked population that has long been established. Regardless, these findings underscore the importance of increased fieldwork and specimen collection. [ABSTRACT FROM AUTHOR]

Simple Summary: Chordoma is a rare cancer that often occurs at the base of the skull. Treating skull base chordoma is challenging because the tumor is difficult to completely remove with surgery and has low radiosensitivity. This study compared two types of radiation modality: particle beam therapy (PT) and photon radiotherapy (RT). We found that PT provides better progression-free survival compared to photon RT. However, PT also has a higher risk of causing brain necrosis. Our findings suggest that PT is more effective for controlling skull base chordoma, but careful planning is needed to minimize side effects. [Objective] The aim of this study was to compare the efficacy of particle beam therapy (PT) with photon radiotherapy (RT) for treatment of skull base chordoma. [Methods] A systematic review was conducted for skull base chordoma treated with PT or photon RT reported from 1990 to 2022. Data were extracted for overall survival (OS) and progression-free survival (PFS), late adverse events, age, gender, gross total resection (GTR) rates, tumor volume, total irradiation dose, and treatment modality. Random-effects meta-regression analysis with the treatment modality as an explanatory variable was performed for each outcome to compare the modalities. [Results] A meta-analysis of 30 selected articles found 3- and 5-year OS rates for PT vs. photon RT or combined photon RT/proton beam therapy (PBT) of 90.8% (95% CI: 87.4–93.3%) vs. 89.5% (95% CI: 83.0–93.6%), p = 0.6543; 80.0% (95% CI: 75.7–83.6%) vs. 89.5% (95% CI: 83.0–93.6%), p = 0.6787. The 5-year PFS rates for PT vs. photon RT or photon RT/PBT were 67.8% (95% CI: 56.5–76.7%) vs. 40.2% (95% CI: 31.6–48.7%), p = 0.0004. A random-effects model revealed that the treatment modality (PT vs. photon RT or photon RT/PBT) was not a significant factor for 3-year OS (p = 0.42) and 5-year OS (p = 0.11), but was a significant factor for 5-year PFS (p < 0.0001). The rates of brain necrosis were 8–50% after PT and 0–4% after photon RT or photon RT/PBT. [Conclusion] This study shows that PT results in higher PFS compared to photon RT for skull base chordoma, but that there is a tendency for a higher incidence of brain necrosis with PT. Publication and analysis of further studies is needed to validate these findings. [ABSTRACT FROM AUTHOR]

Purpose: The past two decades have witnessed the rise of keyhole microscopic minimally invasive surgeries, including the transciliary supraorbital approach (TCA) and transpalpebral approach (TPA), commonly known as the transorbital approach. This study aims to elucidate the nuances, specific indications, and advantages of each approach. Methods: A series of dissections were conducted on five formalin-fixed, alcohol-preserved cadaver heads. The TCA was performed on one side, and the TPA on the other. Virtual measurements of working angles for both approaches were recorded. Additionally, three clinical cases were presented to illustrate the practical application of the techniques. Results: For TCA, the craniotomy dimensions were 1.7 cm x 2.5 cm (Cranial-Caudal (CC) x Lateral-Lateral (LL)), while for TPA, they measured 2.1 cm x 2.9 cm (CC x LL). The measurements of anterior clinoid processes (ACP) were obtained and compared between approaches. In the TCA, the mean ipsilateral ACP measurement was 62 mm (Range: 61 –63 mm), and the mean contralateral ACP measurement was 71.2 mm (Range: 70 –72 mm). In TPA, these measurements were 47.8 mm (Range: 47 –49 mm) and 62.8 mm (Range: 62 –64 mm), respectively. TCA exhibited an average cranial-caudal angle of 14.9°, while TPA demonstrated an average of 8.3°. Conclusion: The anterior cranial fossa was better exposed by a TCA, which also featured shorter operative times, enhanced midline visualization, and a quicker learning curve. Conversely, the middle fossa was better exposed by a TPA, making it an excellent option for middle fossa pathologies, including those in the anterior temporal lobe. After sphenoid bone wing drilling, the TPA offers superior visualization from the lateral to the medial aspect and enhances the CC angle. Additionally, the TPA reduces the risk of postoperative frontalis palsy based on anatomic landmarks. However, the TPA requires a greater cranial osteotomy, and due to unfamiliarity with eyelid anatomy, the learning curve for most neurosurgeons is lengthier for this procedure. [ABSTRACT FROM AUTHOR]

The National Association for Proton Therapy conducted 8 surveys of all operational United States proton centers (2012-2021) and analyzed the patients treated, diagnoses, and treatment complexity to evaluate trends and diversification of patients receiving proton therapy. Detailed surveys were sent in 2015, which requested data from 2012 to 2014, and then annually thereafter to active proton centers in the United States. The numbers of patient treated at each center for the preceding calendar year(s) were collated for tumors in the following categories: central nervous system, intraocular, pituitary, skull base/skeleton, head/neck, lung, retroperitoneal/soft tissue sarcoma, pediatric (solid tumors in children of age ≤18), gastrointestinal tract, urinary tract, female pelvic, prostate, breast, and "other." Complexity levels were assessed using Current Procedural Terminology codes 77520-77525. Survey response rates were excellent (100% in 2015 to 94.9% in 2021); additional publicly available information provided near-complete information on all centers. Trend comparisons between 2012 and 2021 showed that the total annual number of patients treated with protons gradually increased from 5377 to 15,829. The largest numeric increases were for head/neck (316 to 2303; 7.3-fold), breast (93 to 1452; 15.6-fold), and gastrointestinal tumors (170 to 1259; 7.4-fold). Patient numbers also increased significantly for central nervous system (598 to 1743; 2.9-fold), pediatric (685 to 1870; 2.7-fold), and skull base tumors (179 to 514; 2.9-fold). For prostate cancer, the percentage of proton-treated patients decreased from 43.4% to 25.0% of the total. Simple compensated treatments decreased from 43% in 2012 to 7% in 2021, whereas intermediate complexity treatments increased from 45% to 73%. The number of patients treated with protons is gradually increasing, with a substantial proportionate decline in patients with prostate cancer receiving proton therapy. The number of patients treated for "commonly accepted" indications for protons (eg, pediatric, central nervous system, and skull base tumors) is gradually increasing. Greater proportional increases were observed for breast, lung, head/neck, and gastrointestinal tumors. Treatment complexity is gradually increasing over time. [ABSTRACT FROM AUTHOR]

Sinus mucoceles are nonmalignant cystic tumors lined by non-neoplastic epithelium, typically involving the frontal and ethmoid sinuses. Although it is common for these mucoceles to cause destruction of surrounding bone tissue due to their growth, cerebrospinal fluid leaks resulting from skull base penetration by an ethmoid sinus mucocele have rarely been reported. A 24-year-old male patient presented with right proptosis and right periorbital pain, who underwent bilateral endoscopic sinus sur gery 12 years ago. Endoscopic sinus surgery was performed to treat the right ethmoid sinus mucocele, and confirmed the presence of a basal skull de fect during surgery. We reconstructed the skull base defect using septal cartialge and free mucosal graft. The symptoms were completely resolved after surgery and no cerebrospinal fluid leakage was noted during follow up period. This case report highlights a rare instance of direct mucocele extension to the skull base. [ABSTRACT FROM AUTHOR]

There are very few sex estimation methods specifically designed for or tested on Belgian skulls. The currently used methods for European populations have been developed using North American collections where individuals are categorized as White and/or having European ancestry. These frequently show discordance between the pelvic sex and cranial sex estimations highlighting the need for population specific methods. To fill this gap in our knowledge, several sex estimation methods, using 15 qualitative skull features, were tested on two Flemish (northern Belgium) skeletal collections; one archaeological (15th–17th century) and one forensic (20th century). The features were tested by themselves as well as in different combinations using logistic regression. The glabella is considered the best lone feature with a minimal accuracy of 78.4% and a sex bias of −5.2%. Furthermore, four sex estimation equations were developed for the skull, the cranium, the mandible, and the frontal bone separately. The skull has an accuracy of 89.3% and a bias of 0.8%. For the cranium, this is 87.5% and −0.3%, respectively, for the mandible 85.1% and −0.1%, and for the frontal bone it is 80.4% and −4.6%. The various tests confirm that many skull features can be used for sex estimation and can generate high sex estimation accuracy. [ABSTRACT FROM AUTHOR]

A patient with a non-missile penetrating brain injury might present fully conscious without any neurological deficit with a small linear laceration on skull as the only sign of injury. We present a 27-year-old man who was referred to us with new onset CSF leakage as rhinorrhea and history of penetrating stab wound injury to his right temporal region, 3 months ago. The imaging showed the tract of removed sharp object which was piercing the calvaria and the temporal lobe from the right temporal bone, entering the lateral wall of the cavernous sinus, adjacent to the siphon of the carotid artery till the lateral wall of the right sphenoid sinus, ultimately its distal tip entered the sphenoid sinus. The patient was treated through an endoscopic endonasal approach to repair the defect of his skull base. As a result, we should be cautious in facing these patients even if they are asymptomatic. Also doing complementary imaging modalities and other evaluations are crucial to not ignore any possible complications based on their history and examinations. [ABSTRACT FROM AUTHOR]