Meningiomas in the clival region are not common. These tumors present some of the most formidable challenges in skull base surgery. Total removal of clival meningoma has carried a significant mortality and morbidity. Several approches and combinations of approaches have been used remove clival meningiomas. Transpetrosal operations have been shown to offer distinct advantages over traditional operations in approaching lesions of the clival area. The authors report a case of a huge clival meningioma that was totally removed using posterior transpetrosal translabyrinthine approach.
Cranial Fossa, Posterior ; Meningioma* ; Mortality ; Skull Base

OBJECTIVE: We analysed various surgical approaches and surgical results of 28 middle cranial base tumors for the purpose of selecting optimal surgical approach to the middle cranial base tumor. METHODS: In this retrospective review, 28 patients, including 16 meningioma, 6 trigeminal neurinoma, 2 pituitary adenoma, 2 craniopharyngioma, 1 facial neurinoma, and 1 metastatic tumor, underwent surgical treatment using skull base technique. Of theses, 16 tumors were mainly confined to middle cranial fossae, 5 tumors with extension into both anterior and middle fossa, and 7 tumors with extension into both middle and posterior fossa. Tumors that confined to the middle cranial fossa or extended into the anterior cranial fossa were operated with modified pterional, orbitozygomatic or Dolen'c approach, and tumors that extended into the posterior cranial fossa were operated with anterior, posterior or combined transpetrosal approach. Completeness of tumor resection, surgical outcome, postoperative complication, and follow up result were studied. RESULTS: Total tumor removal was achieved in 9 tumors of 10 tumors that did not extended to the cavernous sinus, and was achieved in 7 tumors of 8 tumors that extended to the lateral wall of the cavernous sinus. Of 10 tumors that extended to the venous channel of the cavernous sinus, only 2 were removed totally. Surgical outcome was excellent in 14 patients, good in 10, fair in 2 and poor in 2. There were no death in this series. Dumbell type tumor which extended into both middle and posterior fossae showed tendency of poor prognosis as compared with tumors that confined middle cranial fossa and extended into both anterior and middle cranial fossa. Postoperative dysfunctions were trieminal hypesthesia in 3, oculomotor nerve palsy in 2, abducens nerve palsy in 2, hemiparesis in 2, cerebellar sign in 1, facial palsy in 1 and hearing impairment in 1. CONCLUSION: Based on our findings and a review of the literature, we conclude that, when selecting the surgical approach to the middle cranial fossa tumors, the most important factors to be considered were exact location of the tumor mass and existence of the cavernous sinus invasion by tumor mass. We recommend modified pterional or orbitozygomatic approach in cases with tumors located anterior and middle cranial base, without cavernous sinus invasion. In cases with tumors invading into cavernous sinus, we recommend Dolen'c or orbitozygomatic approach. And in lateral wall mass and the cavernous sinus, it is preferred to approach the tumor extradurally. For the tumor involing with middle fossa and posterior fossa(dumbell type) a combined petrosal approach is necessary. In cases with cavernous sinus invasion and internal carotid artery encasement, we recommend subtotal resection of the tumor and radiation therapy to prevent permanent postoperative sequele.
Abducens Nerve Diseases ; Carotid Artery, Internal ; Cavernous Sinus ; Cranial Fossa, Anterior ; Cranial Fossa, Middle ; Cranial Fossa, Posterior ; Craniopharyngioma ; Facial Paralysis ; Follow-Up Studies ; Hearing Loss ; Humans ; Hypesthesia ; Meningioma ; Neurilemmoma ; Oculomotor Nerve Diseases ; Paresis ; Pituitary Neoplasms ; Postoperative Complications ; Prognosis ; Retrospective Studies ; Skull Base*

OBJECTIVE: The frontal sinus is frequently a troublesome anatomical obstacle to gain access to the medial anterior cranial base. Surgical approaches to and through the frontal sinus using osteoplastic frontal sinusotomy provide significant advantages to the treatment of lesions of the medial anterior cranial base in addition to the frontal sinus itself. However, appropriate management is necessary to avoid postoperative complications such as cerebrospinal fluid leakage, infection, mucocele formation, and deformity of the forehead. METHODS: The advantages and shortcomings of the approach along with the surgical technique are reported based on our clinical experience with pertinent literature review. The approach using the osteoplastic frontal sinusotomy was applied to two cases of osteoma in the frontal sinus, seven cases of craniofacial tumors, a case of chordoma in the sphenoid and clivus, and two cases of intradural lesions in the anterior cranial fossa. The frontal sinus was managed in such a way as to prevent the postoperative complications. RESULTS: All patients underwent gross total resection of the tumors. With a mean follow-up of 26 months, there were no postoperative complications related to frontal sinus violation. CONCLUSION: The neurosurgical approaches via the frontal sinus using osteoplastic frontal sinusotomy are versatile for various lesions of the anterior cranial base in patients with large frontal sinuses. In situations that the frontal sinus have to be violated to approach medial anterior cranial base, the osteoplastic frontal sinusotomy provides such advantages as optimal frontal sinus control to prevent postoperative complications; increases viewing angle with superior trajectory from nasofrontal suture; lower incidence of pnemocephalus due to minimal dural exposure; and excellent cosmesis without frontal burr holes.
Cerebrospinal Fluid ; Chordoma ; Congenital Abnormalities ; Cranial Fossa, Anterior ; Cranial Fossa, Posterior ; Follow-Up Studies ; Forehead ; Frontal Sinus* ; Humans ; Incidence ; Mucocele ; Osteoma ; Postoperative Complications ; Skull Base ; Sutures

Cranial Fossa, Posterior ; Cranial Nerve Neoplasms ; diagnosis ; pathology ; Ganglioneuroma ; diagnosis ; pathology ; Humans ; Male ; Middle Aged ; Skull Base Neoplasms ; diagnosis ; pathology ; Trigeminal Ganglion

Aspergillus clival abscess, especially without a sphenoid sinus lesion, is a very rare infection of central nervous system. In this report, we describe the successful treatment of a patient with aspergillus clival abscess. A 63-year-old man was referred to our hospital with the diagnosis of sphenoid mass lesion in magnetic resonance image accompanied by headache and diplopia. The computed tomography scan revealed a clival cystic lesion without connection with the sphenoid sinus. The patient underwent the endoscopic endonasal clival approach and histopathological examination revealed aspergillosis. Postoperatively, the patient was given IV amphotericin-B for 2 weeks and oral voriconazole for 3 months. After surgery, patient's headache and diplopia disappeared. Aspergillus abscess originating from the skull base is rare but has a high mortality rate. Histopathological confirmation via endonasal approach and intensive antifungal therapy should be started for a successful treatment.
Abscess* ; Aspergillosis ; Aspergillus* ; Central Nervous System ; Cranial Fossa, Posterior ; Diagnosis ; Diplopia ; Endoscopy ; Headache ; Humans ; Middle Aged ; Mortality ; Skull Base ; Sphenoid Sinus

OBJECTIVETo review our experience with endoscopic endonasal approach for surgical management of clival tumors.

METHODSTwenty-four patients with clival tumors treated by endoscopic endonasal surgery between August 2002 and November 2005 were studied prospectively. The operative technique was described in detail. There were 5 chordoma, 2 ossifying fibroma, 1 meningioma, 1 craniopharyngioma, 1 hemangioblastoma, 6 squamous cancer, 2 chondrosarcoma, 2 chondrosarcoma, 1 lymphoma, 1 malignant giant cell tumor and 2 metastatic carcinoma.

RESULTSTotal tumor removal was obtained in 22 cases, subtotal removal in 2 case. Follow-up ranged 12 to 51 months. Three patients dead. Five patients with total removal recurred, one of them dead. Two patients with subtotal removal dead, one with chondrosarcoma and one with chordoma. The complications included subarachnoid hemorrhage in 1 patient, and transient cerebrospinal leakage in 2 cases.

CONCLUSIONSThe use of nasoendoscopy to perform clival tumor surgery is not only limited to the minimally invasive aspect, it also provides better visualization of deeper structures in the skull base, provides the ability to 'look around corners' and wide exposed field. This approach permits us to manage clival lesions properly.

Adolescent ; Adult ; Aged ; Cranial Fossa, Posterior ; surgery ; Endoscopy ; methods ; Female ; Humans ; Male ; Middle Aged ; Nose ; surgery ; Prospective Studies ; Skull Base Neoplasms ; surgery ; Treatment Outcome ; Young Adult

In most cases, skull base osteomyelitis arises from infections of external auditory canal, middle ear or paranasal sinuses. On the other hand, atypical or central skull base osteomyelitis has no evidence of external otitis or other infection sources. It is often found located on clivus and involves lower cranial nerves and brainstem through the foramina of skull base. The overall rate of mortality reaches 10% and long-term neurologic sequelae are seen in additional 31% of cases regardless of aggressive treatment. We recently encountered a 68-year-old man with right facial pain and generalized headache, and we achieved good outcome with the recovery of vocal cord palsy and disappearance of headache by surgical debridement and long-term antibiotics. We report it with a review of literature.
Aged ; Anti-Bacterial Agents ; Brain Stem ; Cranial Fossa, Posterior ; Cranial Nerve Diseases* ; Cranial Nerves ; Debridement ; Ear Canal ; Ear, Middle ; Facial Pain ; Hand ; Headache ; Humans ; Mortality ; Osteomyelitis* ; Otitis Externa ; Paranasal Sinuses ; Skull Base* ; Vocal Cord Paralysis

The aim of this report is to present two cases of canalis basilaris medianus as identified on cone-beam computed tomography (CBCT) in the base of the skull. The CBCT data sets were sent for radiographic consultation. In both cases, multi-planar views revealed an osseous defect in the base of the skull in the clivus region, the sagittal view showed a unilateral, well-defined, non-corticated, track-like low-attenuation osseous defect in the clivus. The appearance of the defect was highly reminiscent of a fracture of the clivus. The borders of osseous defect were smooth, and no other radiographic signs suggestive of osteolytic destructive processes were noted. Based on the overall radiographic examination, a radiographic impression of canalis basilaris medianus was made. Canalis basilaris medianus is a rare anatomical variant and is generally observed on the clivus. Due to its potential association with meningitis, it should be recognized and reported to avoid potential complications.
Cone-Beam Computed Tomography* ; Cranial Fossa, Posterior ; Dataset ; Meningitis ; Skull ; Skull Base

Bilateral hypoglossal nerve palsy is a rare clinical presentation. We report a case of central skull base osteomyelitis (SBO) presenting with complete tongue paralysis in a 53-year-old man who was not diabetic or immunocompromised. Magnetic resonance imaging demonstrated characteristic features including abnormal contrast enhancement in the clivus (T1-weighted images). Blood tests revealed elevated acute-phase reactants and leukocytosis, which prompted prolonged antibiotic treatment. He responded well to the antibiotics, which together with typical clinical and imaging findings led to the diagnosis of bacterial SBO.
Acute-Phase Proteins ; Anti-Bacterial Agents ; Cranial Fossa, Posterior ; Hematologic Tests ; Humans ; Hypoglossal Nerve ; Hypoglossal Nerve Diseases ; Leukocytosis ; Magnetic Resonance Imaging ; Middle Aged ; Osteomyelitis ; Paralysis ; Skull ; Skull Base ; Tongue

We report a rare case of petroclival craniopharyngioma with no connection to the sellar or suprasellar region. MRI and CT images revealed a homogenously enhancing retroclival solid mass with aggressive skull base destruction, mimicking chordoma or aggressive sarcoma. However, there was no calcification or cystic change found in the mass. Here, we report the clinical features and radiographic investigation of this uncommon craniopharyngioma arising primarily in the petroclival region.
Cranial Fossa, Posterior/*pathology/radiography/surgery ; Craniopharyngioma/*diagnosis/radiography/surgery ; Humans ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Pituitary Neoplasms/*diagnosis/radiography/surgery ; Skull Base Neoplasms/*diagnosis/radiography/surgery ; Tomography, X-Ray Computed