Transorbital Neuroendoscopic Management of Sinogenic Complications Involving the Frontal Sinus,Orbit, and Anterior Cranial Fossa

Transnasal endoscopic surgery has remained at the forefront of surgical management of sinogenic complications involving the frontal sinus, orbit, and anterior skull base. However, the difficulty in accessing certain areas of these anatomical regions can potentially limit its use. Transorbital neuroendoscopic surgery (TONES) was recently introduced to transgress the limits of transnasal endoscopic surgery; the access that it provides could add additional surgical pathways for treating sinogenic complications involving the frontal sinus, orbit, and anterior cranial fossa. We describe a prospective series of 13 patients who underwent TONES for the management of various sinogenic complications, including epidural abscess, orbital abscess, and fronto-orbital mucocele or mucopyocele, as well as subperiosteal abscess presenting with orbital apex syndrome. The primary outcome measurement was the efficacy of TONES in treating these pathologies. TONES provided effective access to the frontal sinus, orbit, and the anterior cranial fossa. All patients demonstrated postoperative resolution of initial clinical symptoms with well-hidden surgical scars. There were no ophthalmologic complications or recurrence of pathology. Based on our experience, TONES appears to provide a valuable addition to the current surgical armamentarium for treating selected complications of sinusitis.     

A ruptured cerebral aneurysm of the fronto-orbital artery and a coexisting anastomosis with the anterior ethmoidal artery--a case report

The authors present a case with a ruptured saccular aneurysm of the left fronto-orbital artery and the coexisting anastomosis with the left anterior ethmoidal artery, accompanied by subarachnoid hemorrhage and intracerebral hematoma in the left frontal lobe. A 44-year-old male, whose past history had been uneventful, was admitted complaining severe headache and vomiting, followed by confusion. CT examinations revealed subarachnoid hemorrhage and intracerebral hematoma in the left frontal lobe. Left carotid angiograms disclosed a saccular aneurysm described above. Emergency operation in a state of grade 3 according to Hunt and Kosnik revealed a saccular aneurysm and its parent artery which was thought to be proximally a left fronto-orbital artery and distally a left anterior ethmoidal artery, which was seen to penetrate the anterior cranial fossa at the lamina cribrosa. Then the aneurysm was excised following clipping of the neck. Thereafter, the patient showed favorable recovery. The histological examination revealed absence of the media and the internal elastic lamina in the wall of the aneurysm with slight infiltration of round cells. Generally speaking, distal anterior cerebral artery aneurysms, which arise on branches beyond the anterior communicating artery, occupy 2-5% of all cerebral aneurysms, and most of them are found at the branching site of the pericallosal artery. As far as the authors know, there was few or no report referring to the aneurysm arising on the fronto-orbital artery, as shown in this case. Also, as for the aneurysm arising on the anterior ethmoidal artery, there are a few reports.(ABSTRACT TRUNCATED AT 250 WORDS)     

Chondrosarcoma of the ethmoid sinus extending to the anterior fossa

A 27-year-old women with chondrosarcoma of the ethmoid sinus extending to the anterior fossa had initial symptoms of blurred vision on the left and slight proptosis. Neuroradiological examination, however, disclosed that the tumor extended not only to the anterior cranial fossa, but also to the orbit, nasal cavity, and maxillary sinus. It is difficult to predict the biological behavior of chondrosarcoma by means of histological examination. The effectiveness of radiotherapy, chemotherapy, or both is also a matter of controversy. Clinical aspects of chondrosarcoma are briefly discussed.     

Supero-lateral orbitotomy for resection of spheno-orbital meningioma: a case report

Spheno-orbital meningioma have traditionally been defined as secondary tumors of the orbit originating from the dura of the sphenoid wing bone. Nevertheless, pathologic findings reveal a distinct periorbital component as a defining feature of these lesions. These tumors are characterized by an intraosseous mass growth leading to a significant hyperostosis involving the sphenoid wing, the orbital roof, the lateral orbital wall and the middle fossa cranial base and to a thin, usually soft-tissue growth at the dura. We report here on the extension of the primary tumor into the orbital cavity and present the surgical approach performed.     

Dural arteriovenous fistulas supplied by ethmoidal arteries

Eight patients with dural arteriovenous fistulas (DAVFs) located on the floor of the anterior cranial fossa and supplied by enlarged ethmoidal branches of the ophthalmic artery are described. Five patients showed the classical symptom of intracerebral hemorrhage (all five had ipsilateral frontal lobe hematomas and one also had an associated a subdural hematoma). Two patients exhibited atypical symptoms of proptosis, chemosis, elevated intraocular pressure, and loss of vision secondary to an ethmoidal DAVF, which drained posteriorly to the cavernous sinus. The eighth patient exhibited proptosis and chemosis secondary to a cavernous sinus DAVF and was incidentally found to have an asymptomatic ethmoidal DAVF. One additional patient had two separate dural fistulas: one located on the cribriform plate and the second located in the posterior fossa. Seven of the eight patients were cured by surgical excision of the fistula site; in the remaining patient spontaneous obliteration followed a surgical procedure for a cavernous DAVF. DAVFs involving the floor of the anterior cranial fossa usually present with hemorrhage, but can present with ocular symptoms or be entirely asymptomatic and are effectively treated by surgical excision of the fistula site.     

Compressive optic neuropathy following use of intracranial oxidized cellulose hemostat

A 35-year-old white male sustained head injuries in a motor vehicle accident. He underwent neurosurgical repair of a frontotemporal skull fracture and lacerated left frontal lobe; regenerated oxidized cellulose (Surgicel) was placed into the anterior cranial fossa for hemostasis. Forty-eight hours after surgery he suffered rapid deterioration of vision to no light perception from optic nerve compression. Radiologic and echographic evaluation demonstrated a subperiosteal soft tissue density in the orbital apex consistent with hematoma. At surgery for optic canal decompression, the cellulose hemostat was found in the apex of the left orbit, having migrated through orbital roof fractures, and had apparently caused the compressive optic neuropathy. Decompression resulted in return of vision to the level of counting fingers.     

Solitary fibrous tumor of the orbit with extraorbital extension: case report

OBJECTIVE AND IMPORTANCE: Solitary fibrous tumors (SFTs) are rare tumors of mesenchymal origin that typically arise in the pleura. Only 24 cases of SFTs in the orbit have been reported, all located within the orbit and generally with a benign course. We report the first case of an orbital SFT with extraorbital extension and short-term regrowth. CLINICAL PRESENTATION: A 54-year-old man presented with proptosis and double vision that had persisted for 7 months. The tumor extended from the right extraconal inferolateral orbit to the extradural middle cranial fossa and cavernous sinus, via the superior orbital fissure, on magnetic resonance imaging scans. Positron emission tomography with [(18)F]fluorodeoxyglucose demonstrated faint uptake in the orbital portion. INTERVENTION: Resection of the tumor was performed twice, because of short-term regrowth of the residual tumor in the orbit. The histological diagnosis was a SFT. The MIB-1 labeling index was 7% and the mitotic count was 5 mitotic figures/10 high-power fields at the time of the second operation. These findings indicate the malignant nature of the tumor. CONCLUSION: The natural history of SFTs of the orbit remains unclear, and the importance of careful and continued follow-up monitoring of the tumor should be emphasized.     

Traumatic orbital encephalocele in an adult: report of one case

Orbital roof fractures after head injury is rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 24 cases published to date. We report the case of an adult with a post-traumatic orbital encephalocele. One day after a road traffic accident with head injury, the patient developed progressive pulsatile proptosis. Computed tomography and magnetic resonance imaging revealed an isolated blow-in fracture of the orbital roof with herniation of the left frontal lobe into the orbit. Neurosurgery to repair the orbital defect led to full recovery.     

A case of ruptured aneurysm of the middle cerebral artery associated with dural arteriovenous fistula in the anterior cranial fossa

A 66-year-old man suffered from subarachnoid hemorrhage due to the rupture of a right middle cerebral artery aneurysm that was detected by 3D-CTA. He underwent an emergent clipping operation. Incidentally, postoperative DSA demonstrated dural arteriovenous fistula in the left anterior cranial fossa, which was fed by the left anterior ethmoidal artery and drained into the superior sagittal sinus via the cortical vein of the left frontal lobe. We performed electrocoagulation and division of the fistula at the second surgery. Subsequently, he underwent a ventriculo-peritoneal shunt and was discharged without any neurological deficits. We reviewed reported cases of rare association of ruptured cerebral aneurysm and dural arteriovenous fistula in the left anterior cranial fossa.     

Dural arteriovenous fistula of the anterior cranial fossa associated with occlusion of the internal carotid artery: a case report]

We reported a case with dural arteriovenous fistula (dAVF) of the anterior cranial fossa associated with occlusion of the left cervical internal carotid artery. A 73-year-old man was admitted with total aphasia and right hemiparesis. Computed tomography showed an ischemic lesion of the left cerebral hemisphere and old infarction of the left occipital lobe. Angiography revealed occlusion of the left cervical internal carotid artery and dAVF of the anterior cranial fossa, fed by the left middle meningeal and the right anterior ethmoidal artery. Follow-up angiography revealed spontaneous recanalization and severe arteriosclerosis of the left internal carotid artery. After marked improvement of neurological deficits, the patient underwent surgical clipping of the draining veins to occlude the dAVF of the anterior cranial fossa. We speculated that marked development of the collateral circulation from the external carotid system might result in the occurrence of dAVF of the anterior cranial fossa.     

The improvement in regional cerebral blood flow in the anterior cranial fossa which was affected by a dural arteriovenous fistula: case report

We report a case of dural arteriovenous fistula of the anterior cranial fossa with venous ischemia. A 55-year-old man presented with headache and visual disturbance. Neurological examination showed no abnormality. MR images demonstrated flow void at the right anterior cranial fossa. Right internal carotid angiograms showed a dural arteriovenous fistula of the anterior cranial fossa, fed by the anterior ethmoidal artery. The draining vein was the leptomeningeal vein draining into the basal vein, the straight sinus, and the left transverse sinus. 123I-IMP SPECT revealed a low perfusion area in the left occipital region. We interrupted the draining vein at the anterior cranial fossa. Angiographic cure was obtained and venous circulation was improved. 123I-IMP SPECT revealed improvement in the low perfusion area in the left occipital region. The postoperative course was uneventful. We discuss the clinical features, the hemodynamic findings and the management of this case.     

A case of adenomatoid odontogenic tumor with intracranial extension

A 49-year-old female of adenomatoid odontogenic tumor with intracranial extension was reported. She had 3 months history of left nasal obstruction and visual disturbance. Endocrinological examinations revealed a low basal level of serum cortisol and low level of urinary 17-OHCS. Neurological examinations revealed left anosmia and left visual disturbance (hand movement, marked afferent pupillary defect, and lower hemianopsia). Plain X-ray films and frontal tomograms of the skull showed a mass of soft tissue density in the left upper maxillary, left posterior ethmoid, and sphenoid sinuses with extensive destruction of the sella turcica, dorsum sellae, and anterior clinoid process. Plain axial CT scans demonstrated a low density mass filling up the left maxillary, left posterior ethmoid, and sphenoid sinuses and extending into the left middle fossa with bony destructions. Contrast-enhanced coronal CT scans demonstrated an extradural extension of the tumor into the left middle fossa and upward displacement of the pituitary complex. Left carotid angiograms showed a faint narrowing of the left internal carotid artery between the cisternal portion and the origin of the ophthalmic artery. Subtotal removal of the tumor and decompression of the optic canal and superior orbital fissure were performed via a left subtemporal extradural approach. Adenomatoid odontogenic tumor is a comparatively rare benign lesion which exhibits a slowly expansive growth without recurrence or metastasis after the surgical removal. No other case that recurred several times and extended into the intracranial space has been reported in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pediatric orbital eosinophilic granuloma with intra- and extracranial extension--case report.

A rare case of eosinophilic granuloma of the orbit in a 3-year-old boy presented as right upper eyelid swelling and proptosis. Computed tomographic scanning revealed a soft-tissue dense mass in the lateral wall of the right orbit. Magnetic resonance (MR) imaging demonstrated tumor extension into the orbit, anterior and middle cranial fossae, and extracranial region. The tumor was completely removed. Histological diagnosis was eosinophilic granuloma. No evidence of recurrence was found 14 months later. MR imaging is useful for diagnosis of the lesion, and particularly for surgical management.     

Eyelid approach to the anterior cranial base

Skull base approaches play a fundamental role in modern neurosurgery by reducing surgical morbidity. Increasing experience has allowed surgeons to perform minimally invasive approaches without straying from the premises of skull base surgery. The eyelid approach has evolved from the orbitopterional osteotomy into a more effective and targeted approach to disease of the anterior cranial fossa. In this technique, after an incision is made on the supratarsal fold, the orbicularis oculi muscle is incised, and a myocutaneous flap composed of the elements of the anterior lamella is elevated. Subperiosteal dissection is used to expose the superior and lateral walls of the orbit, the superior and lateral orbital rim, and the frontosphenoidal suture. A MacCarty bur hole is drilled, and a frontal osteotomy is fashioned medial to the supraorbital notch and extending through the orbital roof back toward the orbital half of the MacCarty bur hole, exposing the frontobasal brain. A conventional microsurgical technique is used to treat tumors and aneurysms of the anterior cranial fossa under the operative microscope. Five patients were treated for unruptured aneurysms of the anterior circulation (3 anterior communicating artery aneurysms, 1 ophthalmic artery aneurysm, and 1 posterior communicating artery aneurysm) using the eyelid approach. The mean aneurysm size was 5 mm, and all aneurysms were approached from the right side. Three tumors in the anterior fossa (2 suprasellar pituitary adenomas and 1 craniopharyngioma) were also excised using this approach. There was no surgical morbidity. Three months after surgery all patients presented excellent cosmetic results. The eyelid approach may be considered as an effective, cosmetically beneficial, and minimally invasive skull base approach to selected aneurysms and tumors of the anterior circulation.     

Proptosis with mastication: an unusual presentation of an orbital dermoid cyst

A 25-year-old woman presented in 1973 with the complaint of proptosis of the left eye with mastication. A firm retrobulbar orbital mass was detected, and diagnosis of possible dermoid cyst was made. She was subsequently lost to follow-up. Computed tomographic (CT) scanning and surgical excision done in 1984 confirmed the presence of an orbital dermoid cyst communicating with the temporal fossa through a bony defect in the lateral orbital wall. We suspect that pressure by the temporalis muscle on the dumbbell-shaped cyst caused the proptosis with mastication.     

Pediatric cranial osteoblastoma: Technical note of surgical treatment and review of the literature

Osteoblastoma of the skull is a rare entity, and they account only for 2-4% of all the cases of osteoblastoma. We perform a comprehensive review of the pertinent literature on the subject and we report a case of a 3-year-old girl presenting with a 6-month history of a supraorbital mass and exophthalmos due to an osteoblastoma of the frontal and ethmoid bones involving the orbit and anterior skull base. A 3D printed model of the patient's skull was used for the preoperative planning and reconstruction strategy. Total en-bloc resection of the tumor followed by immediate reconstruction was achieved. No recurrence was detected 3 years after the surgery. Gross total resection is strongly advised with skull osteoblastoma, especially in young age, because of the risk of the recurrence and malignant transformation. 3D printing is proven to be a valuable tool to enhance surgical performance by avoiding complications while achieving total resection with accurate reconstruction. Long-term follow-up is important to detect recurrences and improve the management of these young patients.     

Dural arteriovenous malformations in the anterior cranial fossa

Summary Two cases of dural arteriovenous malformation (DAVM) fed by the anterior ethmoidal artery in the anterior cranial fossa are reported, one of them examined by magnet resonance imaging (MRI). Only one other case with MRI findings so far has been published. Fourty-eight previously reported cases are reviewed.One of our patients presented with subdural haematoma (SDH) without subarachnoid or intracerebral haemorrhage. The other patient had a nasal bleed without any neurological manifestations. In comparison with previously reported cases, the clinical manifestation of our cases is infrequent (1 patient with nasal bleed, and 2 patients with pure SDH that is 2 and 4%, respectively, in the literature). Feeder was the anterior ethmoidal artery either unilateral or bilateral. Drainage of DAVMs was through a markedly dilated vascular sac into the superior sagittal sinus (SSS). The high incidence of haemorrhage from DAVM in the anterior fossa is related to this vascular sac. Magnetic resonance imaging (MRI) showed a flow void area in the left frontal region on T 1-weighted images in one case.These cases were treated by surgical excision of the malformation with good results. Aetiology, clinical presentation, and treatment of these rare DAVMs in the anterior cranial fossa is discussed.     

The frontotemporal (pterional) approach: an historical perspective

The frontotemporal, so-called pterional, approach has evolved with the contribution of many neurosurgeons over the past century. It has stood the test of time and has been the most commonly used transcranial approach in neurosurgery. In its current form, drilling the sphenoid wing as far down as the superior orbital fissure with or without the removal of the anterior clinoid, thinning the orbital roof, and opening the Sylvian fissure and basal cisterns are the hallmarks of this approach. Tumoral and vascular lesions involving the sellar/parasellar area, anterior and anterolateral circle of Willis, middle cerebral artery, anterior brainstem, upper basilar artery, insula, basal ganglia, mesial temporal region, anterior cranial fossa, orbit, and optic nerve are within the reach of the frontotemporal approach. In this article, we review the origins, evolution, and modifications of the frontotemporal approach and update the discussion of some of the related derivative procedures.     

Nasal Eosinophilic Angiocentric Fibrosis with Orbital Extension

Eosinophilic angiocentric fibrosis (EAF) is an extremely rare, chronic, benign, idiopathic disorder that mostly affects the upper respiratory tract, particularly the nasal cavity, and features progressive submucosal perivascular fibrosis. To the best of our knowledge, only seven cases of EAF with orbital involvement have been reported. We report a case of sinonasal EAF with orbital extension that presented with left nasolacrimal duct obstruction. A 35-year-old man presented with left epiphora, proptosis, anterolateral globe displacement and nasal obstruction. Endoscopic sinus examination showed a firm, gritty, creamy, yellow, fibrous, adherent mass of maxillary sinus. Diagnosis was established with histopathological examination of excisional biopsy of the lesion. Although EAF is very rare, it should be considered in the differential diagnosis of lesions of upper airway tract, particularly the nasal cavity. Biopsy is necessary for diagnosis and treatment planning. Resecting of the involved tissues completely is essential for prevention of recurrence.     

Association of cerebral aneurysm and dural arteriovenous malformation in the anterior cranial fossa: a case report

A case of dural arteriovenous malformation (AVM) in the base of the anterior cranial fossa associated with a ruptured anterior communicating aneurysm was reported in a 67-year-old man. The dural AVM was fed by the left anterior ethmoidal artery and drained by the left frontal ascending vein with a varicose dilatation. The aneurysm was clipped and the dural AVM was removed in two stages. Dural AVM in the base of the anterior cranial fossa is rare, and we could find only 17 previous reports. Two of them presented with exophthalmos, whereas the remaining 15 cases presented with an intracranial hemorrhage from rupture of the dural AVM. An association of an aneurysm with the dural AVM in this location has not been reported previously.