A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess

Spontaneous cerebrospinal fluid leak with meningoencephaloceles in sphenoid sinus lateral recess is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of this study is to assess the real effectiveness of a modification of the endoscopic endonasal approach for their management. This is a prospective case series study and was conducted at Otolaryngology department, Ain Shams University Hospitals, Cairo, Egypt. Seven patients with spontaneous cerebrospinal fluid leak with meningoencephaloceles in the sphenoid sinus lateral recess were included. Diagnosis was confirmed by: analysis for beta-2 transferrin and imaging. They were managed with endoscopic endonasal retrograde trans-sphenoid approach described in this study with multilayered reconstruction of the defect. Mean age of our patients was 40.14 ± 8.35 years; mean BMI was 36.37 ± 2.59 kg/m². Primary empty sella was present and osteodural defect was identified in superior wall of sphenoid sinus lateral recess with punched out and regular smooth edges. Mean intra-cranial pressure was (26.42 ± 3.87 mmH₂O) and size of defect was less than 10 mm, mean 7.85 ± 1.34. Mean-operative time was 169.28 ± 21.87 min. The mean hospital stay was 7.42 ± 1.39 days. No cerebrospinal fluid leak recurrences were observed during follow-up period that ranged from 37 to 48 months. Endoscopic endonasal retrograde trans-sphenoid approach provides a wide, safe, and direct route to the management of sphenoid sinus lateral recess cerebrospinal fluid leak.

[A case of transverse-sigmoid sinus dural arteriovenous fistula that became symptomatic after removal of coexisting sphenoid ridge meningioma]

Here, we describe a case with a transverse-sigmoid sinus(TSS)dural arteriovenous fistula(DAVF)with sinus occlusion at its proximal and distal ends;the TSS DAVF turned symptomatic after removal of a coexisting symptomatic sphenoid ridge meningioma. The patient was a 70-year-old man presenting with decreased daily activities and mentation due to dysphasia. Magnetic resonance imaging revealed a large, left sphenoid ridge meningioma. Angiography revealed a tumor stain and a coexisting left TSS DAVF with sinus occlusion at its proximal and distal ends. Cortical venous reflux(CVR)into the temporal veins was observed. After successful tumor removal, the superficial middle cerebral vein was arterialized intraoperatively. However, the patient showed worsened consciousness and dysphasia after the operation. Repeated angiography revealed CVR into the superficial middle cerebral vein through a sphenopetrosal sinus. Transvenous embolization was performed via the contralateral inferior petrosal and intercavernous sinus, which allowed access to the ipsilateral superior petrosal sinus(SPS);the procedure successfully eliminated CVR, while preserving the SPS. The patient demonstrated full recovery. This case exemplifies a coexisting TSS DAVF after tumor resection, and superficial middle cerebral vein decompression due to the sphenopetrosal sinus, an alternate drainage pathway for the superficial middle cerebral vein.

Managing ocean information in the digital era--events in Canada open questions about the role of marine science libraries

Information is the foundation of evidence-based policies for effective marine environmental protection and conservation. In Canada, the cutback of marine science libraries introduces key questions about the role of such institutions and the management of ocean information in the digital age. How vital are such libraries in the mission of studying and protecting the oceans? What is the fate and value of the massive grey literature holdings, including archival materials, much of which is not in digital form but which often contains vital data? How important is this literature generally in the marine environmental sciences? Are we likely to forget the history of the marine pollution field if our digital focus eclipses the need for and access to comprehensive collections and skilled information specialists? This paper explores these and other questions against the backdrop of unprecedented changes in the federal libraries, marine environmental science and legislation in Canada.

Unilateral transverse sinus stenting of patients with idiopathic intracranial hypertension

BACKGROUND AND PURPOSE

The pathophysiology of IIH remains unknown. TS stenoses have been observed in a high proportion of these patients. Stent placement to remove this potential obstruction to venous outflow has been proposed as a treatment option for patients with IIH refractory to medical treatment.

MATERIALS AND METHODS

The clinical presentation, treatment, and outcome of patients with refractory IIH evaluated for venous sinus stent placement at a tertiary care center was retrospectively reviewed.

RESULTS

Thirteen female patients with IIH were evaluated for sinovenous stent placement. Moderate sinus stenoses with normal intrasinus pressures were found in 3 patients and therefore stent placement was not performed. Ten patients had elevated intrasinus pressures (pressure gradient across stenosis, 11-50 mm Hg), which decreased following unilateral TS stent placement. Headaches improved or resolved in all stented patients. Papilledema resolved completely or almost completely in 8 patients and significantly improved in 2 patients. One patient developed optic atrophy. There were no major periprocedural complications.

CONCLUSIONS

In this small case series, restoring the patency of stenotic venous sinuses with a stent in patients with refractory IIH resulted in symptomatic improvement in all treated patients. The safety and efficacy of this procedure should be evaluated in a randomized controlled study to determine its role within the armamentarium of therapeutic options for patients with IIH.

[Endovascular treatment for dural arteriovenous fistula]

Intracranial dural arteriovenous fistulas (DAVFs) are acquired abnormal epidural arteriovenous shunts, particularly at the sinus wall. Most of the DAVFs are associated with progressive sinus occlusion. They are located in the cavernous sinus, lateral (transverse-sigmoid) sinus, superior-sagittal sinus, anterior condylar confluence, tentorial sinus, craniocervical junction, and anterior skull base (ethmoidal sinus). The treatment strategy differs based on the etiology and drainage pattern of DAVFs. The most effective treatment for DAVFs at the sinus wall is transvenous embolization (TVE) with coils. The target coil packing is effective if the sinus point is identified. Certain cases that are difficult to approach transvenously are treated with transarterial embolization (TAE) by using liquid materials like such glue. In particular cases with sinus occlusive lesion sinus reconstruction with sinoplasty is effective. The cases with failed or impossible endovascular approach should be treated with surgical interruption of shunts or by radiosurgery. The most frequent complication of TAE is brain and nerve ischemia due to the overembolization or migration, and that in TVE is the bleeding due to obstruction of the drainage route and nerve compression due to overpacking of coils.

[Radiosurgery for intracranial dural arteriovenous fistulas--indications for limitations for gamma knife treatment]

We summarize the results of gamma knife treatment for dural arterivenous fistula (DAVF), are report our study. Since the early 1990s, DAVFs have been treated in the same manner as arteriovenous malformations (AVMs), i.e., by radiosurgery, performed with or without embolization. DAVFs in the cavernous sinus, transverse-sigmoid sinus, and cerebellar tent were treated with a marginal dose of 18 to 20 Gy. The current obliteration rates of DAVF reported in literature are not low when compared with those of AVM. Excellent DAVF obliteration rates were observed in our study, which were similar to those reported in the literature. In fact, complete response (CR) was observed in 9 cases, partial response (PR) in 9 cases, and partical obliteration in 6 cases during the mean follow-up of 27 months. Moreover, considerable neurological improvements were noted, which apparently began at an early stage post radiosurgery. Bleeding was observed 2 cases associated with cortical reflux during the follow-up. In conclusion, radiosurgery for DAVF is very useful for both the obliteration of the fistula and for the improvement of clinical signs. However, prior to performing radiosurgery, the lesions with cortical reflux should be interrupted by initially treated with surgery or embolization.