Magnetic resonance imaging (MRI) of pituitary adenomas

MRI of 20 patients, 17-82 years old, with pituitary adenomas confirmed histopathologically, and 30 normal patients without pituitary dysfunction were reviewed. The studies were performed with a 0.5 Tesla MR scanner with a slice thickness of 10 mm. Inversion recovery sequences were employed as T 1-weighted examination, with repetition time (TR) of 2100-2500 msec, an inversion time (TI) of 600 msec and an echo time (TE) of 40 msec. The T 2-weighted examination had a TR of 1800-2500 msec and a TE of 120 msec. T 1-weighted images were obtained in all cases and T 2-weighted images in 14 cases. Spin echo images with a TR of 600-1000 msec and a TE of 40 msec (SE 40/600-1000) were also obtained in 14 cases. On T 1-weighted images, 20 adenomas were classified into six groups, according to their signal intensities; marked low intensity (1), low intensity (1), isointensity (11), high intensity (3), marked high intensity (1) and mixed intensity (3). On T 2-weighted images, 14 adenomas were classified into five groups; low intensity (1), isointensity (2), high intensity (4), marked high intensity (6) and mixed intensity (1). On SE 40/600-1000 images, 14 adenomas were also classified into four groups; low intensity (8), high intensity (2) and mixed intensity (3). Two adenomas with recent intratumoral hemorrhage had marked high intensity on both T1 and T2-weighted images. SE 40/600-1000 images were useful in evaluating the size and the extent of the visual pathway was best appreciated on IR images. Comparison between normal and involved cavernous sinus by adenomas was made.     

Delayed radiation necrosis of the temporal lobe following radiation therapy of maxillary carcinoma

A case of delayed radiation necrosis following radiation therapy for maxillary carcinoma was reported. The diagnosis of this case for the radiation necrosis was clinically suggestive and established by the pathological findings of autopsy. This 66 year-old man had been treated by the partial resection for the right maxillary carcinoma with chemotherapy (pepleomycin 110 mg, adriamycin 20 mg). Pre- and postoperatively total dose of 5040 rads were irradiated with cobalt therapy during 42 days at a dose of 180 rads and 5 times in a week through two ports at 8 x 8 cm field including right orbital region. Three years 7 months after radiation therapy he complained of disorientation, recent memory disturbance and slight left hemiparesis. On enhanced CT irregular ring enhanced mass lesion was seen in left temporal lobe inside the radiation field with extensive low density over temporal lobe on plain CT. MR imaging demonstrated that T 1-weighted spin echo images with a 50-msec repetition time (TR) and 22-msec echo time (TE) had irregular low signal intensity and extensive high signal intensity combined with partially low intensity in the central area on T2 weighted spin echo images with 2300 msec TR and 100 msec TR. There were not appeared vascular obstruction and stenosis on right carotid angiogram. He improved remarkably on clinical symptoms and CT by treating of dexamethasone and osmotic diuretics, but died of pneumonia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of fluid-attenuated inversion recovery (FLAIR) images in brain check-up]

Fluid-attenuated inversion recovery (FLAIR) images are magnetic resonance (MR) images obtained with an inversion recovery sequence having a long inversion time (T 1) and a long echo time (TE). The purpose of this study was to evaluate the utility of FLAIR images in brain check-up. 320 healthy adults (229 males, 91 females) were examined with FLAIR sequences of several types having repetitive time (TR) of 7000 msec, inversion times of 1700 msec and echo times (TE) of 110 msec. All studies were performed on a SHIMAZU MAGNEX 100 HP 1.0 T imaging system. FLAIR images were useful in detecting cortical and subcortical lesions near the brain surface, which were unclear in the conventional T 2 weighted images. FLAIR images were useful in evaluation of periventricular hyperintensity area (PVH). Frequency and degree of PVH were increased in aging. FLAIR images were useful in the differential diagnosis of lacuna and perivascular space. In conclusion, FLAIR images were very sensitive for the detection of brain lesions in brain check-up.     

High resolution Magnetic Resonance Imaging of the rat spinal cord

Abstract

A two turn saddle shaped surface coil receiver was developed that allowed high resolution magnetic o resonance imaging of the rat spinal cord. This is particularly important in laboratory animals where central nervous system regions of interest are relatively small. A continuous copper wire 1.5 mm in diameter was wound into two turns 28 mm in diameter. The saddle shape of the second turn improved the homogeneity of the signal within the region of interest and maintained sufficient field of view and depth of penetration. The quality factor (Q) for the surface coil was Q= 199 unloaded, and Q=60 loaded. Using this surface coil with a GE CSI II 2.0 Tesla small bore magnet, spin echo T1 (TR= 500 msec, TE=25 msec) and T2 (TR=2000 msec, TE= 100 msec) weighted images were obtained in cross section, using 2 mm slice thickness with 2 excitations per phase encoding step. A sagittal gradient echo (rapid scan, TR=85 msec, TE= 10 msec) was used to document reestablishment of vascular flow following ischemia. Spinal cord ischemia was induced by 14 minute temporary occlusion of spinal cord blood supply. MRI was performed at 18 hours following ischemia. There was a 1.4 fold increase in T2 image intensity in ischemic rat spinal cord (\i = 4), consistent with edema formation, compared to normal rat spinal cord (n = 4). Preliminary studies show that similar high resolution images can be performed on the rat brain. This technique uses standard MRI equipment and the surface coil is made from inexpensive readily available materials. There are various animal models of cerebral and spinal cord injury that would benefit from improved high resolution MRI. This coil design may have application in larger animal models and the clinical setting. [Neurol Res 1996; 18: 471-474]     

White matter hyperintensity in neurologically asymptomatic subjects

Recent advances in magnetic resonance imaging (MRI) technology have had a great impact on the delectability of minute, asymptomatic lesions of the central nervous system. The clinical significance and treatment modes of these lesions, such as white matter hyperintensity (WMH) lesions detected by T2 MRI, remain controversial. To address these problems, we retrospectively evaluated WMH lesions in relation to clinical parameters for 240 neurologically asymptomatic persons who had visited a hospital for a medical check-up of the brain. Proton and T2–weighted MRI were obtained using a 0.5 T superconducting MR imager using the spin echo technique with a repetition time (TR) of 2800 msec. An echo delay times (TE) of 40 msec was used for the proton MRI, and a TE of 100 msec was used for the T2-weighted MRI. The images were visually analyzed according to a four-point grading system. The MRI findings were correlated with clinical parameters including age, gender, presenting symptoms, and hypertension. The overall frequency of WMH increased with age. Grades 2 and 3 of WMH were more frequent in aged persons, whereas the occurrence of grade 1 WMH remained relatively constant across age groups. Based on multiple regression analysis, age was the most significant variable influencing the frequency of WMH, followed by hypertension. These results imply that WMH lesions may simply be a phenomenon of aging, or may be an indicator of prepathologic state in an ischemic brain.     

The preliminary experience of MRI diagnoses in multiple sclerosis: a report of 3 cases

In this report, 3 patients with suspected MS were studied by MRI. All patients were performed with spin-echo (SE) pulse sequence. A pulse repetition time (TR) of 1800 msec. and echo time (TE) of 33, 66, 99, 132 msec. producing a T2-weighted image. The result showed that MS is characterized by numerous long T2 lesions in the paraventricular white matter. Brain stem lesions were seed in all 3 patients. MRI is a very useful diagnostic tool for diagnosis of MS.     

Magnetic resonance imaging of parkinsonism

We have analyzed magnetic resonance images in 33 patients; 18 patients with Parkinson's disease, 1 patient with diurnally fluctuating progressive dystonia, 1 patient with pure akinesia, 6 patients with multiple system atrophy, 1 patient with flunarizine induced parkinsonism, and 4 patients with unclassified parkinsonism. The MR images were obtained using a 1.5-T GE MR System. A spin-echo pulse sequence was used with a TE of 30 msec and 80 msec and a TR of 2000 msec. No signal abnormalities were seen in any patient with Parkinson's disease but 3 showed slightly decreased signal intensity of the putamen on T2-weighted sequences. Patients with diurnally fluctuating progressive dystonia and pure akinesia evidenced no abnormal findings. All six patients with multiple system atrophy demonstrated decreased signal intensity of the putamen, particularly along their lateral and posterior portions, and an enlarged substantia nigra. Atrophy of the pons and cerebellum was detected in all cases with multiple system atrophy. One case of flunarizine induced parkinsonism showed slightly decreased signal intensity of the putamen. Four cases of unclassified parkinsonism showed decreased signal in the putamen on T2-weighted sequences. Magnetic resonance imaging has the potential to become a useful diagnostic tool in the management of parkinsonism.     

Proton magnetic resonance in myelin deficient brains of mutant mice

The role of myelin in determining the magnetic resonance (MR) characterization of the central nervous system (CNS) was investigated in unmyelinated brains of normal fetal mice, as well as myelin-deficient adult mutant mice (shi, qk, mld) and their age-matched controls. In vitro NMR relaxation time measurements at 10 MHz for whole brains showed consistently longer T1 (range 558 +/- 8 to 580 +/- 27 msec) and T2 (range 81 +/- 3 to 89 +/- 3 msec) values for the adult myelin-deficient animals than the age-matched controls (T1 = 496 +/- 31, T2 = 79 +/- 4 msec). The fetal brains exhibited even more prolonged relaxation times (T1 = 976 +/- 60, T2 = 158 +/- 7 msec). MR images obtained at 81 MHz using spin echo (SE) sequences, which unlike the in vitro approach allowed discrimination between white and gray matter areas, revealed an absence of gray-white matter contrast in the brains of mutant mice, consistent with longer than normal relaxation of the myelin-deficient white matter. While larger tissue water components such as those present in the immature brain and edematous white matter contribute a greater effect, myelin and its associated bound water may still play an important role in the MR characterization of normal gray and white matter.     

Magnetic resonance imaging in epilepsy with a fast FLAIR sequence.

OBJECTIVE: To assess the diagnostic value of the fast FLAIR sequence in patients with epilepsy. METHODS: One hundred and twenty eight patients with epilepsy and 10 control subjects were scanned with the fast FLAIR sequence with 5 mm slices, a coronal gradient echo (GRE) T1 weighted sequence with 1.5 mm slices and spin echo (SE) or fast spin echo (FSE) proton density and T2 weighted sequences with 5 mm slices. All images were compared by an unblinded neuroradiologist and neurologist. Fast FLAIR images of patients with hippocampal sclerosis (HS) and normal control subjects were also evaluated by two blinded independent raters. RESULTS: Fast FLAIR provided a high conspicuity of neocortical damage, hamartomas, dysembryoplastic neuroepithelial tumours, and clear cut hippocampal sclerosis. However, the same information could be obtained from the coronal T1 and T2 weighted images. In three patients fast FLAIR showed a clearly abnormal signal when SE T2 weighted images had not been definitely abnormal. Heterotopia was less conspicuous on fast FLAIR than GRE T1 weighted images. The two blinded raters detected all but one of the patients with clear cut hippocampal sclerosis on fast FLAIR images but missed all borderline cases of hippocampal atrophy and there were two false positives. Clear cut hippocampal sclerosis was more conspicuous on fast FLAIR images than on SE T2 weighted images in most patients, but additional patients were not identified. CONCLUSION: Fast FLAIR has the advantage of identifying neocortical lesions and definite hippocampal sclerosis with a short scanning time and may also demonstrate lesions when other sequences are normal in a limited number of cases. The technique was not useful, however, for identifying mild hippocampal sclerosis or heterotopia.     

Structural consequences of status epilepticus demonstrated with serial magnetic resonance imaging

Objectives - To investigate MRI changes during tonicclonic and focal motor status epilepticus. Material and methods - Serial MRI-investigations with saggital, coronal and axial spin-echo (SE) T₁ weighted 500/15 (repetition time [TR] msec/echo time [TE] msec) with and without application of gadolinium-DTPA, proton-density-SE 2100/30 and SE T₂-weighted 2100/90 images. Correlation with seizure frequency and general clinical state and by using constant EEG recordings as well as video-EEG monitoring. Results - Initially, images were normal but several days after onset of status epilepticus focal hyperintensive signal changes on T₂-weighted images consistent with focal oedema were seen. The oedema produced a local mass effect as demonstrated with angiography. These changes occurred at a time when there were massive epileptic discharges registered by EEG monitoring in both cases. On subsequent images the oedema resolved but atrophy in combination with a high signal on T₂-weighted images suggestive of gliosis were noted in identical regions. In the 1st case it could not completely be ruled out that the signal changes were caused by an encephalitis. However, the signal changes occurred in close time correlation with the epileptic seizure activity rendering the assumption less likely that the signal changes were caused by the encephalitis. In the 2nd case the signal changes could not be attributed to cortical dysplasia or any other condition than the epileptic activity itself. Conclusion - Prolonged epileptic seizure activity may cause neuronal damage associated with a typical pattern of MRI signal changes.     

Capillary telangiectasis, angiographically occult vascular malformations. MRI symptomatology apropos of 7 cases

OBJECTIVE: Describe the MRI findings in capillary telangiectasias. MATERIALS AND METHODS: Between 1996 and 1999, we observed 9 cases of capillary telangiectasia in 7 patients explored 5 times for posterior fossa symptoms. In two cases capillary telangiectasia was a fortuitous discovery. All patients were explored by MRI with T1 sequences with and without gadolinium injections, turbo spin echo T2 coupled in 5 cases with a double echo gradient echo T2 sequence (TR: 970 ms, TE: 15 and 35 ms). Two patients also underwent vertebral angiography. RESULTS: The telangiectasia gave a low intensity signal on T1 sequences in 2 of the 9 cases and a discretely high intensity signal on T2 sequences in all cases. After gadolinium injection, 9 telangiectasias showed homogeneous or speckled enhancement. The echo-gradient T2 images showed a very low intensity signal in 7 out of 7 cases on the second echo. At the first echo, 4 capillary telangiectasias were undetectable. The two vertebral angiographies were normal and the follow-up MRI in 5 patients showed lesion stability. CONCLUSION: Pontile lesions with no mass effect showing enhancement after gadolinium injection and with or without a discrete T2 high intensity signal but with a frank echo-gradient T2 signal strongly suggest capillary telangiectasia.     

High-field-strength magnetic resonance imaging and SPECT of multiple system atrophy]

Two cases of multiple system atrophy (MSA) showing similar abnormalities by magnetic resonance (MR) imaging and SPECT are reported. The clinical diagnoses of the two cases were striatonigral degeneration (SND) and sporadic olivopontocerebellar atrophy (OPCA). In addition, one case of sporadic OPCA without parkinsonism was used for comparison. The MR images were obtained using a 1.5-T MR system and included spin-echo transverse sections with T1-weighted images (TR = 450 ms and TE = 15 ms) and T2-weighted images (TR = 2500 ms and TE = 90 ms). The T1-weighted images demonstrated atrophy of cerebellum and pons, with increased signal intensity in the bilateral putamen. The T2-weighted images demonstrated decreased signal intensity in the putamen, as reported recently. SPECT demonstrated reduced uptake in the celleberum, basal ganglia and frontal lobe cortex. The putaminal changes evident on T1-weighted images may have resulted from deposition of pigments such as neuromelanin and lipofuscin, related to parkinsonism. Both T1- and T2-weighted MRI seem to be useful clinical diagnosis of MSA.     

经鼻内窥镜颅底手术患儿发生脑脊液漏的危险因素（英文）

OBJECTIVES To determine the risk factors associated with cerebrospinal fluid(CSF)leak following endoscopic endonasal surgery(EES)for pediatric skull base lesions.METHODS Retrospective chart review of pediatric patients(ages 1 month to18 years)treated for skull base lesions with EES from 1999 to 2014.Five pathologies were reviewed:craniopharyngioma,clival chordoma,pituitary adenoma,pituitary carcinoma,and Rathke's cleft cyst.Fisher's exact tests were used to evaluate the different factors to determine which had a statistically higher risk of leading to a post-operative CSF leak.RESULTS 55 pediatric patients were identified who underwent 70 EES's for tumor resection.Of the 70 surgeries,47 surgeries had intraoperative CSF leaks that were repaired at the time of surgery.11 of 47(23%)surgeries had post-operative CSF leaks that required secondary operative repair.Clival chordomas had the highest CSF leak rate at 36%.There was no statistical difference in leak rate based on the type of reconstruction,although 28%of cases that used a vascularized flap had a post-operative leak,whereas only 9%of those cases not using a vascularized flap had a leak.Postoperative hydrocephalus and perioperative use of a lumbar drain were not significant risk factors.ONCLUSIONS Pediatric patients with an intra-operative CSF leak during EES of the skull base have a high rate of post-operative CSF leaks.Clival chordomas appear to be a particularly highrisk group.The use of vascularized flaps and perioperative lumbar drains did not statistically decrease the rate of post-operative CSF leak.     

Proton magnetic resonance spectroscopy pattern of progressive multifocal leukoencephalopathy in AIDS

The objective was to determine whether the use of intermediate echo times (135 ms) in proton magnetic resonance spectroscopy (1H-MRS) detects a homogenous pattern in progressive multifocal leukoencephalopathy (PML) in HIV-1 infected people, and to confirm the results of previous studies. Six patients infected with HIV-1, with PML established by biopsy, and six healthy age and sex matched volunteers were evaluated to define their spectroscopic pattern. 1H-MRS spectra performed at 1.5 T were obtained with the STEAM sequence: TE/TM/TR, 20 ms/13.7 ms/2000 ms; 2500 Hz, size 2048 points, 256 acquisitions (STEAM-20) and with the PRESS sequence; TE/TR, 135 ms/2000 ms; 2500 Hz, size 2048 points, 256 acquisitions (PRESS-135). A single voxel was placed on the lesions and on the parieto-occipital white matter of controls. The peaks of N-acetylaspartate (NAA), choline (Cho), myoinositol (mI), lactate, and lipids were considered, and the results were expressed using creatine as reference. Spectra of PML lesions were characterised by significantly reduced NAA, lactate presence, and by significantly increased Cho and lipids compared with control group values. These results indicate that 1H-MRS detects a homogenous pattern in PML lesions. Recent studies, together with this, suggest that 1H-MRS may help in the diagnostic approach to patients with suspected PML lesions associated with AIDS.     

Diagnostic value of fluid attenuated inversion recovery versus T2-weighted image in diffuse axonal injury

BACKGROUND: At present, the most common examination modality for diffuse axonal injury (DAI) is CT or MRI. However, both methods exhibit low sensitivity in the diagnosis of DAI lesions.OBJECTIVE: To investigate the value of fluid attenuated inversion recovery (FLAIR) in the clinical diagnosis of DAI, and to compare with T2-weighted images.DESIGN, TIME AND SETTING: This prospective study was based on imaging analysis, and wasperformed in the First Affiliated Hospital of Chongqing Medical University (Chongqing, China) between October 2002 and April 2004.PARTICIPANTS: Sixty-three patients with craniocerebral injury were admitted to the Department of Neurosurgery at the First Affiliated Hospital of Chongqing Medical University, including 50 males and 13females. The patients were included in the experiment and were divided into DAI (n=24) and non-DAl (n=39)groups, according to the emergent CT findings and clinical manifestations.METHODS: Both groups underwent MR examinations, including axial and sagittal T1 weighted images (TR=450 ms, TE = 8-9 ms), T2-weighted images (TR = 3600 ms, TE = 100 ms), and FLAIR (TR = 10 000 ms,TI = 2500 ms, TE = 40 ms), 8-mm thick and 2-mm wide, using a GE Sigma MRI device.MAIN OUTCOME MEASURES: The DAI diagnostic rate and lesion-detecting rate of T2-weighted images and FLAIR were determined.RESULTS: All 63 patients were included in the final analysis. The DAI diagnosis rates of FLAIR and T2-weighted images were 88% (21/24) and 62% (15/24), respectively, of which the difference was statistically significant (P < 0.05). T2-weighted images and FLAIR detected lesions located in the gray matter-white matter junction in parasagittal areas, the corpus callosum, deep periventricular white matter,basal ganglia, internal capsule, hippocampus, cerebellum, and brain stem, with a detailed amount of 123 and 256, respectively. FLAIR was significantly greater than T2-weighted images (P < 0.01 ).CONCLUSION: FLAIR is superior to T2-weighted images for improving the DAI diagnostic rate and lesion-detecting rate, as well as revealing the extent and severity of DAI.     

重T2加权灰阶反转成像对大垂体腺瘤视路的显示作用

目的 探讨重T2加权灰阶反转成像检查对大垂体腺瘤及其周围结构的显示作用。方法对15例术前有视力障碍的垂体瘤病人行重T2加权灰阶反转成像及常规T1加权成像，前者TR／TE为5800ms／259ms，后者为600ms／20ms；层厚3mm。结果 重T2加权灰阶反转成像可清晰显示肿瘤与终板、前连合及前交通动脉丛的空间关系；其视神经、视交叉和视束的检测率分别为93.3％、100％和86．7％，而在T1加权成像中则分别为66．7％、93．3％和66．7％，前者对视路的检测率显著性高于后者。结论 重T2加权灰阶反转成像可清楚显示垂体大腺瘤与视路的位置关系，有助于垂体瘤经颅手术的术前策略制定。     

Fast(er) MR imaging.

The author reviews the methods used for rapid MR scanning, including gradient echo, fast spin echo, and planar sequences. Each of these approaches can be understood by evaluation of the relationship of the fundamental MR parameters such as T1 and T2 values to operator selected variables such as TR, TE, and flip angles. Strategies for phase view acquisition and the application of high performance gradients are discussed.     

Spinal subdural empyema diagnosed by MRI and recovered by conservative treatment

Localized suppuration involving the spinal cord is uncommon. A case of spinal subdural empyema is reported. The patient is 54-year-old male who had been suffering a diabetes mellitus but did not receive any treatment. His initial symptom was lumbago. Then he noticed a palpitation and general malaise which made him visit a hospital. Because he did not show any improvement by a fluid therapy, he was transferred to our institute for the further evaluation. On admission, physical examination showed no abnormality. Blood pressure was 170/90 mmHg, heart rate 128/min. and body temperature 37.1 degrees C suggesting a septic shock state. Neurological examination revealed slight consciousness disturbance, mild tetraparesis and bilateral hypesthesia lower than the level of L3. Laboratory examination showed the elevated leukocyte count and fasting blood sugar and urine ketone body levels of 20,500/mm3, 257 mg/dl and 226 mg/dl respectively. Blood culture proved a septicemia of Streptococcus agalactiae afterwards. On the second day of admission, lumbar puncture revealed a purulent cerebrospinal fluid, though X-ray CT of lumbar spine did not confirm a diagnosis. Spinal magnetic resonance imaging (MRI) revealed a widespread abnormal intensity of the spinal canal from the level of Th11 to L4. On the T1-weighted image (TR 300 msec., TE 40 msec.), cerebrospinal fluid space was abnormally isointense. On the T2-weighted image (TR 2,000 msec., TE 80 msec.), subdural and cerebrospinal space was filled with an abnormal high-intense lesion especially on the ventral side. He developed semicoma due to hydrocephalus following a intraventricular empyema. He was also complicated disseminated intravascular coagulation.(ABSTRACT TRUNCATED AT 250 WORDS)     

MRI screening of vestibular schwannomas without gadolinium: usefulness of the turbo gradient spin echo T2-weighted pulse sequence

The purpose of this retrospective MRI work was to evaluate the use of turbo gradient spin echo (TGSE) high resolution imaging for the detection of eighth nerve schwannomas, without injection of gadolinium. The TGSE sequence (slice thickness: 3 mm with 1.5 mm interleaving; matrix: 512) was compared with a reference sequence: T1-weighted spin echo (SE) after gadolinium injection (slice thickness: 3 mm, matrix: 256). Among 380 internal auditory meatus (IAM) explored, 34 abnormalities were detected on T2-weighted TGSE images compared with 19 on contrast-enhanced T1-weighted SE images. This new sequence has a 100% sensitivity, a 96% specificity and a 100% negative predictive value. Using a rigorous protocol for IAM analysis with the TGSE sequence, gadolinium injection may no longer be needed systematically for vestibular schwannoma screening, but might only be necessary when an abnormality or a doubt persists after TGSE. This approach allows about 20% cost reduction for each patient, a savings of 11,433 euros considering only the true negatives observed in this study.     

Corridor surgery: the current paradigm for skull base surgery

Introduction Clival chordomas are rare tumors, especially in the pediatric population. In this report, we present the case of a 3-year-old boy who was found to have a large posterior pharyngeal, clival, and posterior fossa tumor detected on a CT scan after a closed head injury. Discussion Further questioning revealed a history of ataxia and dysphagia. Imaging confirmed severe extrinsic brain stem compression. The tumor was resected in multiple stages utilizing a minimally invasive endoscopic endonasal technique along with open transfacetal, transcondylar approach through the carotid–vertebral window. The child suffered no permanent complications as a result of our treatment and his dysphagia significantly improved. Although a complete resection was not feasible due to vascular encasement by the tumor, extensive decompression was obtained with minimal morbidity. Conclusion We present this case to illustrate a new paradigm of skull base surgical approaches for large clival lesions in pediatric patients that allows aggressive resection with minimal morbidity.