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Meningioma causing superior canal dehiscence syndrome [Case Report]

Crane, Benjamin T; Carey, John P; McMenomey, Sean; Minor, Lloyd B
PMID: 19395985
ISSN: 1531-7129
CID: 167952

Modified orbitozygomatic craniotomy for large medial sphenoid wing meningiomas

Cheng, Cheng-Mao; Chang, Cheng-Fu; Ma, Hsin-I; Chiang, Yung-Hsiao; McMenomey, Sean O; Delashaw, Johnny B Jr
Modified orbitozygomatic craniotomy (MOZC) is an anterior lateral skull base approach characterized by simplicity and wide exposure. The approach was first introduced in 2003 and there are few clinical reports. This report details treatment of patients with large (>4 cm) sphenoid wing meningiomas via a MOZC approach, and to the authors' knowledge, the first published in English. Total resection was achieved in all 5 patients in this study. One patient experienced a postoperative epidural hematoma that was successfully treated. All patients returned to daily activity without neurological sequellae. The advantages of MOZC are sparing of the zygomatic arch and removal of the orbital rim; hence, the surgeon can plan a capacious operative field without excessive brain retraction and resect the tumor before opening the dura. The MOZC approach is a clinically feasible, low morbidity, surgical option for paraclinoid lesions, such as large sphenoid wing meningiomas.
PMID: 19560361
ISSN: 0967-5868
CID: 167953

Dural arteriovenous fistula of the anterior condylar confluence and hypoglossal canal mimicking a jugular foramen tumor [Case Report]

Liu, James K; Mahaney, Kelly; Barnwell, Stanley L; McMenomey, Sean O; Delashaw, Johnny B Jr
The anterior condylar confluence (ACC) is located on the external orifice of the canal of the hypoglossal nerve and provides multiple connections with the dural venous sinuses of the posterior fossa, internal jugular vein, and the vertebral venous plexus. Dural arteriovenous fistulas (DAVFs) of the ACC and hypoglossal canal (anterior condylar vein) are extremely rare. The authors present a case involving an ACC DAVF and hypoglossal canal that mimicked a hypervascular jugular bulb tumor. This 53-year-old man presented with right hypoglossal nerve palsy. A right pulsatile tinnitus had resolved several months previously. Magnetic resonance imaging demonstrated an enhancing right-sided jugular foramen lesion involving the hypoglossal canal. Cerebral angiography revealed a hypervascular lesion at the jugular bulb, with early venous drainage into the extracranial vertebral venous plexus. This was thought to represent either a glomus jugulare tumor or a DAVF. The patient underwent preoperative transarterial embolization followed by surgical exploration via a far-lateral transcondylar approach. At surgery, a DAVF was identified draining into the ACC and hypoglossal canal. The fistula was surgically obliterated, and this was confirmed on postoperative angiography. The patient's hypoglossal nerve palsy resolved. Dural arteriovenous fistulas of the ACC and hypoglossal canal are rare lesions that can present with isolated hypoglossal nerve palsies. They should be included in the differential diagnosis of hypervascular jugular bulb lesions. The authors review the anatomy of the ACC and discuss the literature on DAVFs involving the hypoglossal canal.
PMID: 18671650
ISSN: 0022-3085
CID: 167954

Spontaneous middle fossa encephalocele and cerebrospinal fluid leakage: diagnosis and management

Gubbels, Samuel P; Selden, Nathan R; Delashaw, Johnny B Jr; McMenomey, Sean O
OBJECTIVE: To evaluate the clinical presentation, operative findings, and surgical management of patients with spontaneous middle fossa encephalocele (SMFE) and cerebrospinal fluid (CSF) leakage repaired using a middle fossa craniotomy (MFC) approach. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS: Fifteen consecutive patients with 16 SMFE repaired using an MFC approach between January 1999 and April 2006 were included. INTERVENTIONS: Patients were evaluated clinically and radiologically with computed tomography or magnetic resonance imaging. Encephaloceles were approached via MFC, and the cranial base was repaired in multilayered fashion using a variety of materials, including hydroxyapatite cement. Patients were followed clinically after discharge. MAIN OUTCOME MEASURES: Postoperative complications, including CSF leak and the need for surgical revision, are evaluated. Patient factors, diagnostic testing, and operative findings are reviewed. RESULTS: Diagnosis was made using clinical and radiologic evaluation in most patients. Beta2-transferrin testing was occasionally used in the diagnostic workup. Intraoperatively, multiple defects of the floor of the middle fossa were found in more than half of patients. Fifteen SMFE in 14 patients were successfully repaired via MFC alone. One patient required revision with a combined transmastoid/MFC approach due to recurrent CSF leakage. Hydroxyapatite cement was used for repair of the cranial base in 9 patients without complication. CONCLUSION: An MFC approach can be used to repair SMFE with CSF leakage with a high level of success. Hydroxyapatite cement is a safe and useful adjunct to aid in reconstruction of the cranial base defects in cases of SMFE.
PMID: 17921911
ISSN: 1531-7129
CID: 167955

A novel treatment approach to cholesterol granulomas. Technical note [Case Report]

Sincoff, Eric H; Liu, James K; Matsen, Laura; Dogan, Aclan; Kim, Ilman; McMenomey, Sean O; Delashaw, Johnny B Jr
The authors report a novel technique for the treatment of cholesterol granulomas. An extradural middle fossa approach was used to access the granuloma, with drainage through silastic tubes into the sphenoid sinus via the anteromedial triangle between V1 and V2. Cholesterol granulomas occur when the normal aeration and drainage of temporal bone air cells is occluded, resulting in vacuum formation and transudation of blood into the air cells. This process results in anaerobic breakdown of the blood with resulting cholesterol crystal formation and an inflammatory reaction. Traditional treatment of this lesion involves extensive drilling of the temporal bone to drain the granuloma cyst and establish a drainage tract into the middle ear. Such drainage procedures can be time consuming and difficult, and potentially involve structural damage to the inner ear and facial nerve. An extradural middle fossa approach provides easy access to the granuloma and anterior petrous bone entry into the granuloma for resection. Granuloma drainage is then achieved using shunt tubing in the sphenoid sinus via a small hole in the anteromedial triangle between V1 and V2. Five patients with symptomatic cholesterol granuloma were treated without complication using this novel extradural middle fossa approach. One patient required reoperation 1-year postoperatively for cyst regrowth and occlusion of the drainage tube. At the 5-year follow-up examination, no patient reported recurrent symptoms. Extradural middle fossa craniotomy and silastic tube drainage into the sphenoid sinus is a viable alternative method for treatment of cholesterol granuloma.
PMID: 17695405
ISSN: 0022-3085
CID: 167956

Management of complications in neurotology

Liu, James K; Saedi, Targol; Delashaw, Johnny B Jr; McMenomey, Sean O
Neurotologic and skull base surgery involves working around important neurovascular and neurotologic structures and can incur unwarranted complications. Knowledge of surgical anatomy, good preoperative planning, intraoperative monitoring, and excellent microsurgical technique contribute to minimizing and avoiding complications. In the event of a complication, however, the neurotologic surgeon should be prepared to manage it. In this article, the authors focus on the management of complications encountered in neurotologic skull base surgery, including hemorrhage, stroke, cerebrospinal fluid leak, extraocular motility deficits, facial paralysis, hearing loss, dizziness, lower cranial nerve palsies, and postoperative headache.
PMID: 17544700
ISSN: 0030-6665
CID: 167957

Posterior transpetrosal approach: less is more [Case Report]

Sincoff, Eric H; McMenomey, Sean O; Delashaw, Johnny B Jr
OBJECTIVE: We describe our surgical posterior transpetrosal technique, particularly the transcrusal variant for lesions involving the upper and middle clivus, petroclival regions, and lesions that involve both the posterior and middle fossae. METHODS: An outline of the posterior transpetrosal technique involved, particularly the transcrusal variant, is described. Important superficial landmarks are identified, and a radical mastoidectomy is performed. The antrum is identified and entered, and, upon completion of the mastoidectomy and when Trautman's triangle is defined, the temporal and suboccipital craniotomies are completed. After bone flap elevation, dura opening, and incision along the middle fossa dura, the superior petrosal sinus is ligated and cut. Tentorium cut completion is at the incisura posterior to the trochlear nerve. Watertight dural closure and standard flap replacement and skin closure complete the technique. RESULTS: Clival exposure and the degree of temporal bone resection increase. Operative freedom also increases with increased temporal bone resection, especially when going from the retrolabyrinthine to transcrusal variants. Little is gained in terms of operative freedom and exposure of the clivus with resection of additional temporal bone beyond that of the transcrusal variant, and resection carries the cost of increasing morbidity, especially with respect to VIIth and VIIIth nerve function. CONCLUSION: The posterior transpetrosal approach and the transcrusal variant provide a lateral operative corridor to lesions of the upper and middle clivus. The transcrusal variant provides increased exposure and operative freedom similar to that provided by the transcochlear approach while minimizing cranial nerve morbidity.
PMID: 17297365
ISSN: 0148-396x
CID: 167958

Anatomical analysis of transoral surgical approaches to the clivus

Balasingam, Vijayabalan; Anderson, Gregory J; Gross, Neil D; Cheng, Cheng-Mao; Noguchi, Akio; Dogan, Aclan; McMenomey, Sean O; Delashaw, Johnny B Jr; Andersen, Peter E
OBJECT: The authors conducted a cadaveric anatomical study to quantify and compare the area of surgical exposure and the freedom available for instrument manipulation provided by the following four surgical approaches to the extracranial periclival region: simple transoral (STO), transoral with a palate split (TOPS), Le Fort I osteotomy (LFO), and median labioglossomandibulotomy (MLM). METHODS: Twelve unembalmed cadaveric heads with normal mouth opening capacity were serially dissected. For each approach, quantitation of extracranial periclival exposure and freedom for instrument manipulation (known here as surgical freedom) was accomplished by stereotactic localization. To quantify the extent of extracranial clival exposure obtained, anatomical measurements of the extracranial clivus were performed on 17 dry skull bases. The values (means +/- standard deviations in mm2) for periclival exposure and surgical freedom, respectively, for the surgical approaches studied were as follows: STO = 492 +/- 229 and 3164 +/- 1900; TOPS = 743 +/- 319 and 3478 +/- 2363; LFO = 689 +/- 248 and 2760 +/- 1922; and MLM 1312 +/- 384 and 8074 +/- 6451. The extent of linear midline clival exposure and the percentage of linear midline clival exposure relative to the total linear midline exposure were as follows, respectively: STO = 0.6 +/- 4.9 mm and 7.8 +/- 11%; TOPS = 8.9 +/- 5.5 mm and 24.2 +/- 16.7%; LFO = 32.9 +/- 10.2 mm and 85.0 +/- 18.7%; and MLM = 2.1 +/- 4.4 mm and 6.7 +/- 11.1%. CONCLUSIONS: The choice of approach and the resulting degree of complexity and associated morbidity depends on the location of the pathological entity. The authors found that the MLM approach, like the STO approach, provided good exposure of the craniocervical junction but limited exposure of the clivus. The TOPS approach, an approach attended by a lesser risk of morbidity, provided adequate exposure of the extracranial inferior clivus. Maximal exposure of the extracranial clivus proper was provided by the LFO approach.
PMID: 17219838
ISSN: 0022-3085
CID: 167959

Safety study of the Cochlear Nucleus 24 device with internal magnet in the 1.5 Tesla magnetic resonance imaging scanner

Gubbels, Samuel P; McMenomey, Sean O
OBJECTIVES: To evaluate the effect of the 1.5 Tesla magnetic resonance imager (MRI) on the Cochlear Nucleus 24 Device without removing the internal magnet. To determine whether device fixation using a compression dressing could prevent internal magnet displacement in the MRI scanner and potentially obviate the need for surgical removal of the internal magnet. STUDY DESIGN: Prospective cadaveric study. METHODS: Four cadaver heads were implanted bilaterally with the Nucleus device with the internal magnet in place and placed into the 1.5 Tesla MRI scanner. The devices were then explanted after interaction with the MRI and evaluated for displacement of the internal magnet. Conditions tested include device fixation with a commercially available compression dressing and no fixation (worst-case scenario). Magnet strength was measured before and after each of the test conditions. RESULTS: Moderate to severe displacement of the magnet from the internal device occurred in 14 of 16 (87%) implants when no compression dressing was placed. Displacement occurred in 0 of 16 (0%) implants when the compression dressing was applied. No decrease in the strength of the implant magnet was found with the initial or subsequent MRI/implant interactions. CONCLUSIONS: Use of the 1.5 Tesla MRI on subjects with Cochlear Nucleus 24 implants did not result in any significant demagnetization of the internal magnet and did not cause displacement of the magnet when an external compression dressing was applied. Surgical removal of the internal magnet before scanning with the 1.5 Tesla MRI may not be necessary if a compression dressing is applied.
PMID: 16735911
ISSN: 0023-852x
CID: 167960

Indications for cerebrospinal fluid drainage and avoidance of complications

Moza, Kapil; McMenomey, Sean O; Delashaw, Johnny B Jr
An understanding of normal CSF physiology is a prerequisite to treating problems such as CSF fistulae and pseudomeningoceles. CSF diversion techniques fall into two categories, external and internal. External lumbar drainage is useful when temporary CSF diversion is necessary (eg, in cases necessitating manipulation and retraction of the brain to gain access to deep lesions) and in treating otorrhea or rhinorrhea following traumatic or iatrogenic insults to the cranial base. Drawbacks include insertion discomfort and limited duration of therapy.LP and VP shunts came into widespread use in the 1970s, and both systems share risks of bowel perforation, obstruction, over drainage and wound-related complications. In addition, VP shunts add the risks of intracerebral hematoma and ventriculitis. New valve technology has made it possible to alter the volume drained, thus alleviating problems of over-and under drainage.
PMID: 16005718
ISSN: 0030-6665
CID: 167961