World Neurosurg
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Dural repair during skull base approaches remains challenging, especially in the presence of significant defects. The autologous fat has become an alternative to various substitute materials being used previously. We report here our experience and technique for the repair of notable skull base dural defects using autologous fat as a dural substitute. ⋯ Dural repair can be effectively and durably achieved using autologous fat graft as a dural substitute during skull base approaches, even in cases of extended defects. The observed characteristics of the fat graft along with the achieved outcome make it an ideal dural substitute.
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Flow diversion is increasingly used for off-label treatments of distal circulation aneurysms. Reports of use in sub-2.0-mm vessels are scant. ⋯ Flow diversion can be safe and effective for aneurysms originating from vessels <2.0 mm in diameter. Heightened vigilance for the prevention and management of acute stent and vessel thrombosis is warranted in these cases.
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Primary optic apparatus involvement by lymphoma is an exceedingly rare entity, with only 3 cases previously reported in the literature. Whether this represents a distinct pathology, metastatic disease from an unidentified systemic lymphoma, or the first manifestation of evolving primary central nervous system lymphoma is not currently understood. ⋯ Primary optic nerve lymphoma is a rare disease that requires a systemic workup and a multidisciplinary approach to treatment.
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The 2016 World Health Organization Classification of Tumours of the Central Nervous System was revised to include a new diagnostic entity, diffuse midline glioma, H3 K27M-mutant (DMG-K27M), a highly aggressive tumor with a mean survival time of 1 year after diagnosis. DMG-K27M is classified as a World Health Organization grade IV tumor regardless of histopathologic features, and there is currently no effective treatment for it despite ongoing research. ⋯ There are currently no effective therapeutic options for treatment of DMG-K27M. The slow tumor growth and prolonged survival time (≥ 3 years) in the absence of intervention in this case serve as a reminder that much is still not known about histone H3 lysine 27-to-methionine mutation and how it impacts the pathophysiology, diagnosis, treatment, and prognosis of the disease. Careful evaluation is warranted to determine if early intervention is the best approach when treating DMG-K27M.
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Surgery for anterior cranial base lesions is challenging because tumors often spread from their origin to sinuses, orbits, and middle cranial fossa, resulting in risky surgeries.1,2 To approach such complex diseases, recently combined multiportal approaches have been proposed.3,4 At the best of our knowledge, operative application of a combined endoscopic endonasal and transcranial surgery for complex anterior cranial base lesions has not been described. Therefore a surgical video of such an approach is presented. A 37-year-old woman affected by a huge recurrence of a tuberculum meningioma extended to right orbit presented to our department, complaining of right ocular bulb dislocation with multidirectional limitations in eye movements (Video 1). ⋯ Such a combined approach, although demanding in terms of the presence of both otolaryngologist and neurosurgeon during the surgery, also requires strong synergy among them and permits them to control anterior cranial base lesions from both specialists' perspectives, simultaneously. In this case, while an endonasal corridor permitted an accurate excision of ethmoidal and medial orbital wall part of the lesion, a bicoronal approach allowed the aggression of the anterior cranial base portion of the tumor, allowing good control of cranial base neurovascular structures, eventually obtaining a gross total resection, without perioperative complications. Furthermore, a combined multiportal approach allows cooperative strategies among the surgeons involved, leading to safer, quicker, and more effective resections with less brain retraction, given the wide angles of views to the lesion that a multiportal approach can offer.