Precise placement of sphenoidal electrodes via fluoroscopic guidance

Fluoroscopically guided placement of sphenoidal electrodes for the assessment of epileptiform activity in the mesial-basal-temporal lobes offers distinct advantages over standard techniques, such as more precision in placement, reduced likelihood of facial pain, and fewer complications (vessel perforation or nerve injury). We describe our instrumentation, technique, and results in over 40 patients.

Primary intraosseous hemangioma of the orbit: CT and MR appearance

An 8-year-old girl had acute onset of blurred vision, proptosis, and lateral and vertical gaze palsies on the right. CT and MR examinations showed an expansile mass involving the greater wing of the right sphenoid bone. Pathologic analysis of the surgical specimen revealed a capillary hemangioma. The lesion was inhomogeneous but predominantly isointense with gray matter on T1-weighted images. On T2-weighted images the lesion was inhomogeneous with areas of both high and low signal intensity. The rim enhanced uniformly, and there was inhomogeneous enhancement of the bulk of the lesion.

Percutaneous biopsy of cavernous sinus tumors through the foramen ovale

OBJECTIVE

We present a new application to the widely used Hartel percutaneous route through the foramen ovale to the parasellar region to obtain aspiration biopsies of lesions arising from or invading the posterolateral part of the cavernous sinus.

METHODS

Thirteen patients with cavernous sinus lesions that were diagnosed using imaging underwent aspiration biopsy by this route. Nine of them were subsequently operated on, and two will undergo surgery in the near future. For the remaining two, surgical removal of the tumor was not indicated. One of these two patients had a meningioma without any related symptoms and no growth revealed by repeated computed tomographic scans, and the other was diagnosed as having a nasopharyngeal carcinoma and consequently received radiotherapy.

RESULTS

The accuracy of diagnosis with this technique was 84%. There was no complication related to the procedure. Having knowledge of the pathological diagnosis before determining the correct treatment helped to define the most appropriate strategy.

CONCLUSION

We suggest that aspiration biopsy procedures through the foramen ovale be performed in cavernous sinus tumors before making any decision to indicate open surgical, radiosurgical, and/or radiotherapeutic treatments.

When do sphenoidal electrodes yield additional data to that obtained with antero-temporal electrodes?

The advantage of using sphenoidal (SE) over antero-temporal electrodes (ATE) remains controversial among epileptologists. Yet, in a recently published study of 17 patients with seizures of antero-temporal origin (Kanner et al., 1995), we demonstrated that SE placed under fluoroscopic guidance (FPSE), in order to insure that their recording tips are positioned immediately below the foramen ovale (FO), yielded a significant advantage over SE placed with the standard blind method of insertion (BPSE), in both interictal and ictal recordings. This study was done to test the following hypothesis: FPSE advantage over BPSE and ATE resides in the recording of epileptiform activity with a restricted electric field. We compared spike voltages at FPSE, BPSE and ATE in sets of 5 randomly selected spikes per interictal focus, recorded in the course of separate monitoring studies with BPSE and FPSE. We represented the voltage differences as ratios, VATE/FPSE and VATE/BPSE and calculated a mean ratio for each spike set. The spikes' voltage was almost identical at BPSE and at ATE (mean VATE/BPSE = 0.94), while it was significantly higher at FPSE than at ATE (mean VATE/FPSE = 0.66; P < 0.001, t test). A significantly narrower electric field contour was found among interictal foci in which FPSE yielded additional data during interictal (P < 0.001) and ictal (P = 0.016) recordings. Conversely, VATE/FPSE did not differ from VATE/BPSE among interictal foci where FPSE failed to yield any advantage over BPSE in either interictal (P = 0.240), or ictal (P = 0.311) recordings. These findings prove that SE yield additional localizing data when recording epileptiform activity with a restricted field, provided that its recording tip is positioned below the FO. When distant from FO, SE can be expected to yield comparable data to that obtained with ATE.

Hydatid cyst of the pterygopalatine-infratemporal fossa

Hydatid disease is caused by the parasitic tapeworm. Echinococcus. This parasite in larval stage can thrive in many parts of the body, most commonly in the liver and the lung. Hydatid disease in the head and neck region is rare. An unusual location for hydatid disease in the pterygopalatine fossa-infratemporal fossa is presented. The patient did not have evidence of any other cyst on a ten-year follow-up.

Surgical results and the related topographic anatomy in paraclinoid internal carotid artery aneurysms

Paraclinoid internal carotid artery aneurysms arising between the roof of the cavernous sinus and the origin of the posterior communicating artery are of considerable interest with regard to their anatomical variations and technical surgical challenges. Twenty-seven patients with 30 paraclinoid aneurysms were treated surgically through pterional intradural approach. Neck clipping was performed in 22 (73%) of the 30 aneurysms, coating in seven, and trapping in one. The surgical outcome was excellent in 24 patients (24/27, 89%), with two patients showing ipsilateral partial visual field defect (2/27, 7%). There was one death (4%) due to infarction after unintended carotid artery trapping. The characteristic topographic anatomical features which we considered to pose technical difficulties and to be responsible for the complications or failure in neck clipping were aneurysmal dome extending into the anterior clinoid process, atheroma at the neck, multiple paraclinoid aneurysms, ophthalmic artery originating at the neck, and marked supero-medial shift of the C2 segment of the carotid artery. pre-operative depiction of the topographical anatomy around the paraclinoid aneurysm is essential but not always possible on the basis of conventional angiography. Magnetic resonance or three-dimensional computerized tomographic angiography, and their axial source imaging, were useful in delineating the topography with unusual aneurysmal growth, overlap of aneurysm with the parent artery, and uncommon variations of the surrounding structures.

[The microsurgical treatment of large and giant aneurysms of the internal carotid artery located parasphenoidally]

Internal carotid aneurysms in the ophthalmic area presents a challenge in cerebrovascular neurosurgery. The study was undertaken to provide evidence for the application of intravascular aspiration during direct surgical interventions and to outline their variants used at the N. N. Burdenko Institute of Neurosurgery. The study included 4 (3 females and 1 male) patients with large and giant internal carotid aneurysms of parasphenoidal site who were treated at the Institute. Clipping of the aneurysmal neck was made by employing intravascular blood aspiration from the aneurysm. The technique proved to be effective in proximal monitoring the carotid artery at surgery. It substantially reduced aneurysmal blood flow and wall tension, thus favouring aneurysmal dissection to make clipping.

Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial

OBJECTIVE

To evaluate the effectiveness of intranasal lidocaine for treatment of acute migraine headache.

DESIGN

Prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Community urgent care department.

PATIENTS

A total of 81 patients (67 women and 14 men; median age, 42 years; range, 19-68 years) with a chief complaint of headache who fulfilled criteria of the International Headache Society for migraine participated. Patients were excluded if headache had lasted more than 3 days or if the frequency of severe headache was more than once per week.

INTERVENTION

Patients were randomized in a 2:1 ratio to receive a 4 percent solution of intranasal lidocaine or saline placebo, respectively.

MAIN OUTCOME MEASURES

The primary outcome measure was at least 50 percent reduction of headache within 15 minutes after treatment. Secondary measures include reduction in nausea and photophobia, use of rescue medication, relapse of headache, and change in headache disability scores.

RESULTS

Of 53 patients who received intranasal lidocaine, 29 (55 percent) had at least a 50 percent reduction of headache compared with 6 (21 percent) of 28 controls (P=.004). Nausea and photophobia were significantly reduced (P=.03 and P=.001, respectively). Rescue medication for headache relief was needed in 15 (28 percent) of 53 patients in the lidocaine group vs 20 (71 percent) of 28 controls (P<.001). Among those with initial relief of headache, relapse of headache occurred in 10 (42 percent) of 24 in the lidocaine group vs 5 (83 percent) of 6 in the control group (P=.17), usually within the first hour after treatment.

CONCLUSIONS

Intranasal lidocaine provides rapid relief of headache in approximately 55 percent of ambulatory patients with migraine. Relapse of headache is common and occurs early after treatment.

Comparison of coronal sphenoidal versus standard anteroposterior temporal montage in the EEG recording of temporal lobe seizures

Chronic sphenoidal electrodes were developed to facilitate the recording and localization of temporal lobe seizures during long term monitoring. Many reports demonstrate their utility in displaying temporal interictal epileptiform activity, but there have been few direct comparisons of sphenoidal electrodes and surface temporal recordings actually. We compared simultaneous portions of 74 EEG recordings of temporal lobe seizures (from 42 patients), with one portion including sphenoidal electrodes in a coronal montage and one with a standard anterior posterior temporal montage. Separated tracings were reviewed by readers blinded to the other portion of the tracing. The coronal sphenoidal montage allowed recognition of temporal lobe seizures inapparent with standard surface temporal electrodes in 19% of seizures and led to an earlier identification (usually by > or = 5 s) of the onset in 70% of seizures. Indwelling, flexible sphenoidal electrodes assist in ambulatory recording of temporal lobe seizures, both in demonstrating the presence of seizures and in determining the localization and time of seizure onset.

[Report of a rare case of Langerhans-cell histiocytosis of the skull base]

INTRODUCTION

Langerhans cell histiocytosis, once called histiocytosis X, is a rare disease. Usually it can occur in children and is characterized by granulomas (eosinophilic granuloma and Hand-Schueller-Christian disease) or by a extensive involvement of various organs (Letterer-Siwe disease). The etiology remains uncertain and could be related to undefined immunologic disturbance. Lesions can involve bone marrow, skin, oral mucosa, retro-orbital tissue, central nervous system, lymph nodes, spleen, liver, lung, and gastroenteric tract. Surgery, radiotherapy and chemotherapy can be employed as treatment. Prognosis is different in relation to the extension of the disease.

CASE REPORT

In our case (a 33 year old female) came to observation for swelling in temporal region. The patient underwent clinical and radiological examinations: the lesion involved the skull base in the right part of the sphenoid bone. CT and MRI showed a "clepsydra" lesion with wider extension to infratemporal fossa and to intracranial middle fossa and shrinking in the base of the skull; inside the lesion a lot of wider calcifications were present. A biopsy proved a diagnosis of Langerhans cell histiocytosis. No other localizations of disease were found. The patient was treated with chemotherapy followed by localized radiotherapy. Chemotherapy was performed with 3 cycles of etoposide 260 mg for 3 days every month. After this treatment a response of 25% was observed. Afterwards a radiotherapy with cobalt 60 was employed through two angled wedged fields for a total dose of 22 Gy and conventional fractionation. During the follow-up a slow, partial regression of the lesion with increase of the extension of the calcifications documented by CT and MRI was observed. After 5 years follow-up no progression of disease was observed.

DISCUSSION

The usual treatment of Langerhans cell histiocytosis is surgery and eventually radiotherapy for localized disease and chemotherapy for extended disease. The prognosis is related to the number of involved organs: usually favorable with only one site of disease and unfavorable when more organs are involved. Other unfavorable prognostic factors are the age < 2 years, the presence of anemia, liver and spleen involvement and respiratory failure. In our case only one site of disease was evident and the clinical behavior has been quite favorable. The main peculiarities are the radiologic aspect and the slow, partial regression after the treatment; this fact could be related to the presence of wide calcifications inside the lesion. After 5 years follow-up it is possible to consider the absence of progression as a response to the treatment.

The start-stop-start phenomenon in scalp-sphenoidal ictal recordings

The start-stop-start (SSS) phenomenon is an apparent abortive ictal onset separated from the main seizure discharge. It was previously described in seizures recorded with subdural electrodes. We have observed this phenomenon in scalp-sphenoidal ictal recordings as well. We retrospectively reviewed 435 seizures recorded with scalp-sphenoidal electrodes from 61 patients with temporal lobe epilepsy. We found SSS onset in 15 seizures of 8 patients, representing 26% of these patients' seizures. The first "start" usually had a narrow field, typically in the sphenoidal electrode. The mean duration of the first "start" was 11 sec and that of the stop 8 sec. The restart had a different morphology and frequency in 87% and had a wider field in 67% of seizures. The clinical onset followed the first start and preceded the restart in most of the seizures. In 1 patient, 1 seizure with SSS was correctly localized and lateralized, whereas 5 of 7 without SSS were falsely lateralized. The recognition of the SSS phenomenon may improve the accuracy of seizure localization in scalp-sphenoidal recordings.

Osteogenic sarcoma of sphenoid bone: an extended lateral skull base approach

Osteogenic sarcoma involving the sphenoid bone is an extremely rare condition. The rarity of the disease and the close proximity of the sphenoid bone to the various important intracranial structures poses a real challenge in diagnosis and surgical management of these lesions. An extended lateral craniofacial resection by a multidisciplinary approach was carried out in one such case to attempt en bloc resection. This case is presented and also a review of the relevant literature.

Predictive value of the first ictal recording in determining localization of the epileptogenic region by scalp/sphenoidal EEG

The number of seizures recorded during a noninvasive evaluation for epilepsy surgery varies across centers. We retrospectively studied the accuracy of the first recorded seizure in predicting the final localization of the epileptogenic region. Sixty-six consecutive patients undergoing continuous EEG monitoring with scalp and sphenoidal electrodes were studied. The first recorded seizure was determined to be either well localized or nonlocalized and was compared with the ultimate localization after multiple seizures were recorded. The first seizure was well localized in 28 and nonlocalized in 38 patients. In the localized group, the first seizure correctly predicted the final localization of the EEG monitoring study in 26 patients, whereas 2 patients had bilateral independent temporal seizures. In the nonlocalized group, ictal onset remained nonlocalized in 34 patients despite recording of multiple (median of five) seizures. This gave a sensitivity of 87% and specificity of 94% for the first recorded seizure to predict the final results of noninvasive EEG monitoring. We conclude that the first recorded seizure is highly predictive of the final results of prolonged noninvasive ictal EEG recordings but it cannot exclude the possibility of multiple epileptogenic foci.

[Leiomyosarcoma metastatizing to the sphenoid bone presenting exophthalmos: a case report]

A rare subcutaneous leiomyosarcoma metastatizing to the sphenoid bone and presenting exophthalmos is reported. A 56-year-old female presented with protrusion of the right eye and a slowly growing lump on the right temporal region. Six years previously, she had undergone removal of a subcutaneous mass in the back, which was histologically diagnosed in another hospital as leiomyosarcoma. She had undergone four other operations, including removal of local recurrences and a right renal metastasis. On admission, physical examination showed no neurological deficits. Craniogram revealed an osteolytic lesion without marginal sclerosis in the right sphenoid bone. CT showed an inhomogeneously enhanced mass with irregular expansion of the diploic space, which was partly invading the right orbit. MRI demonstrated an extradural mass in the right sphenoid region, which was slightly low-intense in T1-weighted image, high-intense in T2-weighted image, and inhomogeneously enhanced by Gd-DTPA. Right external carotid angiogram showed a highly vascular stain fed by meningeal arteries. Radionuclide bone scintigram showed multiple high-uptake areas in the left femoral head, the ribs, and the sphenoid bone. Preoperative embolization of the tumor vessels fed by the external carotid artery was performed. Following this procedure, the tumor stain disappeared completely. The tumor was totally excised with minimal bleeding through an orbitozygomatic approach. The tumor was loosely adherent to the dura and periorbit. The bone defect was covered with a methylmethacrylate resin plate. the histological examination demonstrated fascicular arrangement of the spindle shaped cells with mitotic figures. Immunohistochemical studies showed that most tumor cells were positive for actin and myosin, but negative for desmin.(ABSTRACT TRUNCATED AT 250 WORDS)

Embolization of carotid cavernous fistula by means of direct puncture through the superior orbital fissure

PURPOSE

To embolize carotid cavernous fistulas (CCFs) by means of transorbital puncture of the cavernous sinus (CS) and the cavernous segment of the internal carotid artery (ICA) through the superior orbital fissure.

MATERIALS AND METHODS

Five patients with CCF were treated with embolization of the CS, and six were treated with embolization of both the CS and the cavernous portion of the ICA after transorbital puncture. All except one had previously undergone occlusion of the ipsilateral proximal ICA before direct transorbital puncture.

RESULTS

The fistulas in these cases were all obliterated completely. Only two patients had temporary ptosis. No other remarkable complications were noted. The patent ICA on the side of the fistula in one patient remained patent after embolization.

CONCLUSION

Direct transorbital puncture through the superior orbital fissure is an alternate treatment for CCF, especially when the ipsilateral ICA has been occluded.

The utility of placing sphenoidal electrodes under the foramen ovale with fluoroscopic guidance

Although sphenoidal electrodes are widely used to detect epileptiform activity, there is no agreement on an optimal target to which electrodes should be aimed. The purpose of this study was to determine whether fluoroscopic guidance is a reliable method for placing electrodes directly below the foramen ovale and whether such positioning enhances their capacity to detect epileptiform activity when compared to similar electrodes placed blindly into the infratemporal fossa. We examined the surface/sphenoidal EEG recordings of 17 patients with intractable partial seizures of anterotemporal origin, after fluoroscopically placed sphenoidal electrodes (FPSE) had been inserted to lie just below the foramen ovale. A criterion for eligibility was a previous prolonged video/EEG monitoring with blindly placed sphenoidal electrodes (BPSE) that failed to detect seizures with a focal onset. No blindly placed electrode, for which there was radiographic documentation, reached the foramen ovale. Fluoroscopic guidance assured accurate targeting. FPSE detected a unilateral anterotemporal interictal focus in four patients in whom BPSE had failed to record any interictal spikes and detected bitemporal independent interictal foci in one patient in whom BPSE had identified only unilateral spikes. In nine other patients, the spike count obtained with FPSE recordings increased by > 100% when compared to that obtained with BPSE recordings. FPSE recorded seizures with an anterotemporal focal onset pattern in 10 patients in whom BPSE had recorded seizures with a regional, lateralized, or nonlocalized onset pattern. In nine of these 10 patients, this was adequate to recommend surgery and avoid invasive monitoring. Fluoroscopic guidance assures accurate targeting of the foramen ovale. When compared to BPSE, FPSE resulted in better detection of interictal and ictal epileptiform activity of mesial-basal-temporal origin.

[Further experience in the diagnosis and treatment of sphenoidal ridge meningioma]

72 cases with sphenoidal ridge meningioma operated on in recent 12 years in our department were reported. In the microsurgical group and non-microsurgical group, the rate of total removal of medial tumors was 65% and 20% respectively (P < 0.01); lateral tumors was 100% and 77% respectively (P > 0.05); the mortality was 6.7% and 11.9% respectively (P > 0.05); the rate of neurological impaired was 33.3% and 64.3% respectively (P < 0.001); good rate of following up for a long time was 87.5% and 16.7% in medial group respectively (P < 0.05); 66.7% and 75% in lateral group respectively (P > 0.05). It is believed that application of CT and angiography and microsurgical technique is helpful to the diagnosis and treatment of sphenoidal ridge meningioma.

P3 latency jitter assessed using 2 techniques. II. Surface and sphenoidal recordings in subjects with focal epilepsy

We compared the latency variability in auditory P3s of 13 subjects with unilateral temporal lobe epilepsy (TLE) to that of normal controls. We predicted that increased latency jitter would occur in TLE subjects, particularly on the epileptic side. ERPs were recorded from scalp and sphenoidal sites relative to a balanced non-cephalic reference. Signal-to-noise ratios (SNRs) were calculated for each subject. Data were excluded if SNRs fell below 0.4. P3 latency jitter was estimated using 2 methods: Woody's algorithm and the maximum likelihood technique (MLT), a novel method of jitter assessment. SNRs were significantly higher in controls and were maximal posteriorly for both groups. P3 peak amplitude was significantly smaller in TLE subjects at temporal sites. Latency jitter (MLT method) was greatest in posterior sites and mirrored the jitter profiles of controls. Latency jitter was significantly higher in TLE subjects in bilateral frontal and temporal sites, but was not higher on the side of the focus and could not be attributed to lower SNRs. The increased bilateral latency jitter in these patients may be related to effects of anticonvulsants or the more extensive nature of the underlying epileptic disorder.

[Multiple meningioma associated with intraosseous and tentorial meningioma--case report]

We report a case of multiple meningioma associated with intraosseous and tentorial meningioma. A 75-year-old woman was admitted to our hospital with blurred vision and exophthalmos in the left eye. Left lower hemianopsia, deterioration of visual acuity and right cerebellar signs were found on neurological examination. CT and MR image revealed an intraosseous tumor of the left sphenoid bone and a right tentorial mass. Cytogenetic analysis failed to reveal any abnormalities of chromosome 22. The intraosseous tumor which was transitional type meningioma and the tentorial mass, which was a fibroblastic meningioma were successfully excised. Postoperatively, the patient's symptoms and signs improved. Intraosseous meningioma associated with multiple meningioma is extremely rare and the histogenesis of meningioma arising from ectopic arachnoid cells is discussed.

Assessment of changes in blood flow through the lungs and foramen ovale in the normal human fetus with gestational age: a prospective Doppler echocardiographic study

OBJECTIVE

To measure lung blood flow and flow through the foramen ovale in the normal human fetus and to assess the changes in each with gestational age and the proportions of combined ventricular output that the respective flows represent.

PATIENTS AND DESIGN

38 normal fetuses (gestational age 18-37 weeks) were studied prospectively with Doppler echocardiography.

METHODS

Echocardiographic images and Doppler velocity signals were obtained from the ascending aorta, main pulmonary artery, and ductus arteriosus from each fetus and digitised to obtain arterial diameters, heart rates, and velocity-time integrals. Blood flow in each artery was calculated as the product of heart rate, flow-velocity integral, and arterial cross sectional area. Blood flow through the lung was assessed as the difference between flow in the pulmonary artery and ductal flow; combined ventricular output as the sum of aortic and pulmonary artery flows; and flow through the foramen ovale as the difference between flows through the aorta and lungs.

RESULTS

Blood flow through the lungs increased exponentially with gestational age (r = 0.89, p < 0.001), by almost four-fold over the period of gestation studied, and was a mean (SD) of 22% (7%) of combined ventricular output. Blood flow through the foramen ovale increased exponentially by threefold (r = 0.77, p < 0.001), representing between 17% and 31% of combined ventricular output.

CONCLUSIONS

Blood flow through the lungs and across the foramen ovale can be calculated non-invasively in the normal human fetus. Both flows increase exponentially with age and comprise between one fifth and one quarter of the combined ventricular output, proportions that remain unchanged through the second and third trimesters of pregnancy.

Recurrent spheno-orbital meningioma

A series of 15 patients who underwent neurosurgical procedures for recurrent spheno-orbital meningioma is reported. There were 11 women and four men, with a mean age of 46 years. The mean duration between the first and second operations was 46 months. Progressive proptosis without neurological deficit was the most common symptom. All tumors were large at the time of reoperation and involved the greater and lesser wings of the sphenoid bone and the orbit. Aggressive resection in all patients resulted in no deaths and only slight morbidity, with the exception of one patient who developed blindness 24 hours after surgery due to central retinal artery occlusion. Fourteen patients were improved cosmetically and one patient, treated early in the series, had persistent proptosis due to inadequate bone removal. No attempt was made to remove tumor within the cavernous sinus in patients who were neurologically normal. Although postoperative imaging demonstrated complete gross excision of tumor in nine patients, 10 underwent conventional radiation therapy for residual tumor visualized at the time of surgery in the dura of the superior orbital fissure, the cavernous sinus, or the basal optic canal. Although this study is inconclusive and requires further long-term documentation, no recurrences have been seen to date in the follow-up period, ranging from 16 to 95 months. The following important points are discussed: 1) the failure by experienced surgeons to radically excise bone, tumor, and involved dura at the first operation; 2) the importance of early aggressive therapy, depending upon the patient's age and medical condition; 3) the almost invariable intracranial dural involvement, which at times was seen only by gadolinium-enhanced magnetic resonance imaging and not visualized on computerized tomography; 4) an illustrated stepwise surgical technique for complete resection through a small craniotomy without the need for complicated reconstruction of the orbit or temporal fossa; 5) the role of radiation therapy when removal is incomplete or deemed hazardous because of cavernous sinus involvement; and 6) the excellent cosmetic results possible with minimal morbidity and no mortality.

Pituitary adenomas in childhood and adolescence. Results of transsphenoidal surgery

Pituitary adenomas are uncommon in childhood. Between 1975 and 1988, 36 patients underwent transsphenoidal resection at the Mayo Clinic before their 17th birthday. Fifteen (41.7%) had prolactin (PRL)-secreting tumors, 16 (44.4%) had adrenocorticotropic hormone (ACTH)-secreting tumors (including two patients with Nelson-Salassa syndrome), and three (8.3%) had tumors secreting growth hormone (GH); two patients (5.6%) had clinically nonfunctioning tumors. Of the 36 patients, 21 (58.3%) were girls, and girls predominated in every group except that with ACTH-secreting tumors, where they accounted for only 37.5% of the patients. The average age at the time of surgery was 14.7 +/- 2.2 years, the youngest patient being 7.3 years old. The ACTH-secreting tumors were associated with an earlier onset of symptoms than the other tumor types: six (37.5%) of 16 patients became symptomatic before 10 years of age, compared with two (10.0%) of the 20 other patients. Presenting symptoms primarily reflected endocrine dysfunction, with neurological presentation (visual field deficits) occurring in only two patients. There were no deaths in this patient group. Significant operative morbidity included steroid-induced psychosis in one patient and diabetes insipidus in three, which resolved in two. Plurihormonal tumors, broadly defined as tumors producing more than one hormone, were common, comprising five (36%) of 14 PRL-secreting tumors, all three GH-secreting tumors, and one of two clinically nonfunctioning tumors, or 25.7% overall. Macroadenomas accounted for 89% of plurihormonal tumors. Long-term follow-up review (median > 5 years) revealed good control of PRL-secreting tumors (although five of 15 patients had received postoperative radiotherapy), contrasted with a 25% late recurrence rate for ACTH-secreting tumors, which had an 80% initial remission rate. The majority of patients had good endocrine function, including reproductive function. It is concluded that: 1) although pediatric pituitary adenomas occur primarily in adolescence, Cushing's disease is found at any age; 2) transsphenoidal surgery is feasible and safe in this age group; 3) plurihormonal tumors occur more frequently in the pediatric age group than in adults; and 4) long-term control rates in PRL- and ACTH-secreting tumors are probably similar to those seen in adults.

Improved visualization of the foramen ovale for percutaneous approaches to the gasserian ganglion. Technical note

Percutaneous procedures for treating trigeminal neuralgia involve the penetration of foramen ovale using cutaneous landmarks and radiological guidance. The placement of radiopaque markers over the commonly used "zygomatic points" in front of the ears provides landmarks on intraoperative radiological studies that facilitate localization of the foramen ovale. Speed and safety of percutaneous trigeminal procedures should be enhanced. There is no increase in radiation exposure over that in other commonly used approaches.

Seizure localization in temporal lobe epilepsy: a comparison of scalp-sphenoidal EEG and volumetric MRI

We determined the accuracy of volumetric MRI (based on identification of unilateral hippocampal atrophy) and scalp-sphenoidal EEG (based on concordant interpretations of scalp-sphenoidal ictal EEG by three independent interpreters) for seizure focus localization in 20 patients with temporal lobe epilepsy. All patients became seizure-free or had rare seizures following temporal lobectomy. Among the 20 patients, nine (45%) met both MRI and EEG localization criteria, six (30%) met MRI localization criteria alone, three (15%) met EEG localization criteria alone, and two patients (10%) did not meet either localization criteria. In the 18 patients meeting MRI or EEG localization criteria, the predicted localization agreed with the side of temporal lobectomy. These results suggest that a noninvasive approach combining MRI and EEG will correctly localize the side of seizure onset in most patients with temporal lobe epilepsy.

Chordoma and chondroid neoplasms of the spheno-occiput. An immunohistochemical study of 41 cases with prognostic and nosologic implications

BACKGROUND

Chordomas are rare neoplasms that show a proclivity for the spheno-occiput and sacral regions. A "chondroid" variant involving the spheno-occiput has been associated with improved survival. "Classic" or nonchondroid chordomas are uniformly immunoreactive for keratins. Chondroid chordomas are said to be immunonegative for epithelial markers, a feature used to support the concept that they represent chondrosarcomas.

METHODS

The authors performed immunohistochemical studies on 25 patients with chondroid chordoma (mean age, 40.0 years) and on 16 patients with classic chordomas (mean age, 44.2 years) to establish tumor subsets based upon immunophenotype, specifically reactivity for epithelial markers. Kaplan-Meier survival curves were then constructed for each group with age as an added variable.

RESULTS

All classic chordomas reacted for keratins as did 8 (32%) of the 25 chondroid chordomas. Forty-four percent of classic and 85% of chondroid chordomas were positive for S-100 protein. At 5 years, all patients younger than 40 years of age were alive in both the classic and chondroid groups. In contrast, of patients older than 40 years of age, only 22% with classic chordomas and 38% with chondroid chordomas were alive.

CONCLUSIONS

Regardless of tumor subtype, age is the single most important variable in determining survival; patients younger than 40 years of age do better than older patients. There are no significant survival differences between patients with cartilage-containing tumors that are keratin immunopositive ("true" chondroid chordoma) or negative (chondrosarcoma). Immunostaining for keratins is of no prognostic value in assessing chondroid lesions of the spheno-occiput.

[Initial central nervous system involvement in a case of non-secretory multiple myeloma]

A 56-year old woman with non-secretory multiple myeloma presented with involvement of the base of brain and meningeal infiltration. Initial involvement of central nervous system is very rare in multiple myeloma, no such pathology being reported in non-secretory myeloma thus far.

Salivary-type myxoid myoepithelioma of the sinonasal tract: a potential diagnostic pitfall

A 38-year-old woman presented with otalgia and facial pain. She was found to have a tumour involving the right maxillary sinus and pterygopalatine fossa. Exclusively composed of a myxoid population of spindle and stellate cells within a mucosubstance-rich matrix, it was originally interpreted as a mesenchymal neoplasm. However, immunophenotypic characterization revealed a pure population of salivary-type myoepithelial cells with cytoplasmic co-expression of cytokeratin, vimentin, muscle-specific actin, S-100 protein and glial fibrillary acidic protein. Sinonasal myxoid myoepithelial neoplasia is exceedingly rare and represents a potential diagnostic pitfall.

[Cerebrospinal fluid rhinorrhea as a postoperative complication of pituitary tumor surgery. Corrective surgery of sella turcica by own methods]

A relatively simple technically and effective own method of corrective operation of sella floor in cases of cerebrospinal fluid rhinorrhoea after transsphenoid operations for pituitary tumours is presented. This complication developed in 12 cases in a group of 720 patients operated on in the years 1973-1990. The described method was applied in 9 cases.

Solitary plasmacytoma of the greater sphenoid wing with secondary submandibular soft tissue metastasis

We report the follow-up of a case of solitary plasmacytoma of bone in the posterolateral orbital wall previously published in this journal. The patient presented three years after initial diagnosis and treatment with a submandibular soft tissue metastasis, probably in a lymph node. Reports of lymph node metastases from solitary plasmacytoma of bone are rare.

[The modern differential diagnostic possibilities in chordoma]

The authors report five cases with chordoma. The diagnosis has been determined histologically on the basis of the operative material. The chordomas have a slow growth and a tendency to infiltrate the adjacent tissues and organs. That makes their surgical treatment difficult. A characterizing feature for them is the tendency to make recidivations and the difficulty in setting the differential diagnosis in metastasis of light-cell carcinomas.

The role of transsphenoidal microsurgery in the management of sellar and parasellar meningioma

We report on eight meningiomas that have been operated on via the transsphenoidal route since May 1988. Six patients harbored cavernous sinus meningiomas with intrasellar extension. The intrasellar tumor extension and the parasellar tumor portion medial to the carotid artery were removed. Decompression of the pituitary gland with normalization of prolactin levels was achieved in all patients. It is a well-tolerated approach to confirm the diagnosis and still allows the option of major transcranial surgery in the event of tumor progression. Additionally, we report complete tumor removal in two rare cases with intrasellar and suprasellar merely subdiaphragmatic meningiomas.

Bilateral morning glory syndrome associated with sphenoid encephalocele. Case report

Morning glory syndrome is a congenital anomaly of the optic disc in which the disc is enlarged and excavated, with white glial tissue in the center. A case is presented of morning glory syndrome associated with sphenoid encephalocele, median cleft lip, and agenesis of the corpus callosum. A 22-day-old boy was referred to the Wakayama Medical College Hospital for management of dyspnea due to a soft-tissue mass in the oral cavity. Magnetic resonance imaging revealed a mass extending through a bone defect in the sphenoid region and into the oral cavity. Surgical repair was attempted through a bifrontal craniotomy. A bone defect was identified in the sphenoid plate, through which the arachnoid membrane was connected to the oral cavity. Both optic nerves were elongated and adhered to the encephalocele. The wall of the meningocele was compressed digitally through the oral cavity and sutured to the dura mater of the bone defect. The operative findings suggest that a basal encephalocele protruding from a bone defect in the sphenoid plate may disturb the normal development of the optic nerve.

[Sphenoidal hyperostosis. Problems of differential diagnosis: report of a case]

A case of sphenoid hyperostosis is described in a patient whose clinical history and radiological work up suggested fibrous dysplasia. A year later, the biopsy and MRI showed evidence of a meningioma en plaque. Problems in the differential diagnosis are discussed among entities which present sphenoid hyperostosis: osteoma, Paget's disease, sphenoid meningioma and fibrous dysplasia.

The excitation site of the trigeminal nerve to transcranial magnetic stimulation varies and lies proximal or distal to the foramen ovale: an intraoperative electrophysiological study in man

The excitation site of the trigeminal nerve using transcranial magnetic stimulation (magStim) was analyzed in 5 patients in whom the trigeminal nerve was surgically exposed in the posterior fossa during microvascular decompression of the facial nerve for hemifacial spasm. The trigeminal nerve was stimulated (1) magnetically immediately prior to craniotomy, and (2) electrically near the root exit zone (elREZ) of the nerve from the brainstem. Mean latency differences (delta) of masseter compound muscle action potentials (CMAPs) (delta elREZ minus magStim) were 0.7 (range: +0.3 to +1.3) ms (P less than or equal to 0.05, Wilcoxon-test). From these results, an analysis of anatomical data, and using a trigeminal nerve conduction velocity (NCV) of 50 m/s as reported in the literature, the following conclusions were drawn: the excitation site to magStim (1) is variable among individuals, (2) is located 3.4 (1.6-6.5) cm distal to the trigeminal REZ, and (3) which corresponds to segments of the nerve that are located either within or outside the cerebrospinal fluid (CSF), either proximal or distal to the foramen ovale. These findings are in contrast to those we obtained in a previous study of the facial nerve in which the excitation site was found to be constant among subjects and restricted to the location on the nerve where it exists the high conductivity CSF to enter the high-resistance petrous bone.

Diastasis of the maxillary bone: an unusual complication of transsphenoidal surgery

Diastasis of the intermaxillary suture is an unusual complication of the transsphenoidal approach to the sella turcica. Over the 1977-1989 twelve-year-period, 192 procedures were performed at our Center. This complication occurred only once, in a senile patient with marked osteoporosis. It did not alter the course of the operation, nor did it create additional problems during the postoperative period.

Sphenoidal electrode insertion under local analgesia in children

The indications for method and the results of sphenoidal electrode insertion under local analgesia are evaluated in children. This technique makes it possible to study the hippocampal area, which cannot be studied by other extracranial electrodes. It also localizes in a temporal lobe some complex seizures without electrical events on surface recordings, complex seizures with bilateral temporal spikes or a frontotemporal focus of spikes, as well as those with a temporal focus with bilateral synchronous spikes in standard EEG. Therefore, sphenoidal electrodes inserted without heavy general analgesia enable temporal seizures to be identified and localized, leading to more specific neuroradiological and neurophysiological explorations and helping in this way to select possible patients for epileptic surgery.

[Postoperative complications of trans-sphenoidal surgery]

One hundred and thirty three patients of both sexes were operated on for pituitary tumors with transphenoidal microsurgery. Postoperative complications are discussed.

[A new operative mode for sphenoclival regions; trans Le Fort I approach]

Tumors in the sphenoclival region have conventionally been approached transseptally (transsphenoidally) or transorally; however, the following disadvantages have not allowed wide application of these approaches; 1) limited operative field, especially at the lateral side, 2) unsatisfactory repair for the dural defects. We have applied Le Fort I osteotomy for lesions in this region, and we called the operative technique, by which we approached via the space that was obtained by moving the osteomized maxillary bone to the mandibular bone, trans Le Fort I approach. We have applied this approach in 5 patients and obtained a substantially wider operative field than that obtained by the conventional approach, with successful results. Three out of 5 patients were operated on via this trans Le Fort I approach, and the other 2 via this approach combined with mandibular midsplitting, which was performed to make a median osteotomy of the mandibular bone to accommodate osteomized maxillary bone (this technique is referred to as trans Le Fort I with mandibular midsplitting). The tumor was totally resected in 4 cases, and subtotally in 1 case with wide dural incision. One case was temporarily complicated with diabetes insipidus after the operation, but there were no complications in the remaining cases. Prognoses in patients were good in 2, fair in 1, and poor in 2 due to tumor progression. Although tracheostomy is inevitable with this approach, we think this technique is beneficial in operations of the skull base because, compared with conventional techniques, a somewhat wider operative field can be expected with this technique.

[Pansinusitis of the face caused by Streptococcus milleri with cerebral thrombophlebitis after naso-sphenoid surgery of the pituitary gland]

The authors report a patient operated on trans-nasosphenoidally for a pituitary adenoma (Cushing's disease) in whom a severe infection occurred with cavernous thrombophlebitis responsible for neurological complications.

[Complications of trans-sphenoidal surgery of the sellar lesions]

Trans-sphenoidal surgery has a very low rate of complications despite a series of apparently negative anatomo-topographical factors. Complications may be either mechanical or functional, transitory or permanent. The most important complications are: hematoma of the focus, sub-arachnoid hemorrhage, empty sella, liquoral fistula, opto-chiasmatic lesions, arterial lesions, lesions of the cavernous sinus, parenchymal damage, nasal and paranasal mechanical lesions, insipid diabetes, hypopituitarism. The overall mortality rate is 0.4-1% and is always associated with predisposing factors, such as previous treatment, voluminous extrasellar growth, concomitant causes of disease; the most frequent causes of death are: hemorrhagic phenomena in the extrasellar portion of large size adenomas; vascular lesions involving the intracavernous carotid artery; and hypothalamic lesions. The frequency of major complications is in the region of 2.3%. Predisposing factors are: volume, consistency, invasiveness, previous treatment, intratumoral necrotic-hemorrhagic phenomena, age. Surgery is only indicated for some of the above complications, including hematoma of the focus, acute postoperative empty sella, rhinoliquorrhea resistent to conservative treatment, excessive filling of the sellar cavity. All the other possible complications are results or functional alterations which must be treated medically, even if a specific therapy only exists for some (such as early hypotonic polyuria). The series of patients reported here refers to the period 1978-1989 and accounts for a total of 259 trans-sphenoidal operations performed in 245 patients. Of the secondary operations, 6 were due to postoperative complications (hematoma of the focus in 2 cases, rhinoliquorrhea in 2 cases; empty sella and hemorrhagic infarction of a large suprasellar site in the 2 remaining cases). There were 2 deaths related to direct mechanical complications (both caused by hemorrhagic infarction of large tumoural residues and the surrounding cerebral parenchyma). Complications which did not require re-operating were observed in 11 further cases: 6 cases of persistent rhinoliquorrhea which required protracted spinal drainage; 2 cases of deterioration of previous visual deficits unrelated to either hematoma of the focus or empty sella but caused by trauma to optic structures, either directly or on a vascular basis; 3 cases of dyplopia due to oculomotory deficiency. In terms of hypophyseal function, the ex-novo onset of postoperative pan-hypopituitarism and insipid diabetes was only observed in one case.(ABSTRACT TRUNCATED AT 400 WORDS)

Osteomyelitis of the skull base

Three cases of osteomyelitis of the skull base with associated problems in diagnosis and therapy are discussed. Patients with atypical skull base osteomyelitis are difficult to diagnose as they have no ear abnormalities, but they often develop multiple cranial nerve deficits mimicking symptoms of a posterior fossa mass. We conclude that computed tomographic scans, magnetic resonance imaging studies, bone scans indium-labeled white blood cell scans, and gallium scans are useful in making the diagnosis. A biopsy of the bony lesion often is needed to identify the causative organism and to rule out a tumor. Intravenously administered antibiotics are the mainstay of therapy and should be continued until 1 week after the gallium scan shows no abnormalities. Follow-up gallium scans then are done at 1 week and 3 months after the cessation of antibiotic therapy to search for a recurrence.

Transsphenoidal microsurgery for craniopharyngioma

We report on our series of 32 craniopharyngiomas operated on by the transsphenoidal route since 1983. In 15 of 19 patients (79%) with primary transsphenoidal surgery and in 8 of 13 patients (62%) with a transsphenoidal approach following previous surgical procedures, the craniopharyngioma was totally removed. Primary transsphenoidal surgery is a safe and successful procedure for intrasellar and suprasellar infradiaphragmatic craniopharyngiomas. In secondary surgery and in the presence of tumor calcifications the indication for this approach must be considered more carefully. Postoperative posterior pituitary deficiency is a frequent occurrence. Anterior pituitary function usually remains unchanged after surgery except for normalization of hyperprolactinemia.

Comparison and correlation of surface and sphenoidal electrodes with simultaneous intracranial recording: an interictal study

We prospectively compared and correlated interictal spikes recorded with simultaneous surface, sphenoidal, depth and subdural electrodes in 21 patients. Although the amplitude of sphenoidal spikes was often larger than that of surface spikes in patients with mesial basal temporal ictal and interictal foci, only 1 patient had exclusively sphenoidal spikes. Spikes with maximal amplitude at the sphenoidal electrode arose from mesial temporal, temporal neocortical and orbital frontal foci. An inferior vertical temporal dipole (hippocampal positive and inferior temporal neocortex negative) was associated with surface and sphenoidal spikes.