Neural—dural transition at the medial anterior cranial base: an anatomical and histological study with clinical applications

2003 ◽  
Vol 99 (2) ◽  
pp. 362-365 ◽  
Author(s):  
Amos O. Dare ◽  
Lucy L. Balos ◽  
Walter Grand
Keyword(s):  
Subarachnoid Space ◽  
Cranial Base ◽  
Cribriform Plate ◽  
Fistula Formation ◽  
Arachnoid Membrane ◽  
Ethmoid Bone ◽  
Csf Rhinorrhea ◽  
Content Type ◽  
Anterior Cranial Base ◽  
Fine Print

Object. Few anatomical studies have been focused on the morphological features and microscopic anatomy of the transition from the intracranial space to the medial anterior cranial base. The authors of the current study performed histological analyses to define the structure of the transition from neural foramina to the cranial base (neural—dural transition) at the cribriform plate, particularly as related to cerebrospinal fluid (CSF) fistula formation and surgical intervention in the region. Methods. The medial anterior cranial base was resected in six cadaveric specimens. Histological methods were used to study the anatomy of the region on the microscopic level. Results of these examinations revealed a multilayered neural—dural transition at the cribriform plate, which consisted of an arachnoid membrane and a potential subarachnoid space as well as dura mater, periosteum, ethmoid bone, and associated layers of submucosa and mucosa of the paranasal air spaces. A subarachnoid space was identified around the olfactory nerves as they exited the neural foramina of the cribriform plates. The dura mater eventually thinned out and became continuous with the periosteum in the ethmoid bone. The dura, arachnoid membrane, and associated potential subarachnoid space were obliterated at a place 1 to 2 mm into the olfactory foramen. The authors present a case of recurrent CSF rhinorrhea successfully treated using a technique of multilayered reconstruction with pericranium, fat, and bone. Conclusions. The findings provide an anatomical basis for CSF fistula formation in the region of the cribriform plate and help to explain the unusual presentations in patients who have CSF rhinorrhea and meningitis. These results may facilitate the treatment of CSF fistulas, repair of defects in the medial anterior cranial base, and approaches to tumors and other pathological entities in the region.

Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair

1998 ◽  
Vol 88 (3) ◽  
pp. 471-477 ◽  
Author(s):  
Damianos E. Sakas ◽  
David J. Beale ◽  
Ameen A. Ameen ◽  
Helen L. Whitwell ◽  
Karl W. Whittaker ◽  
...  
Keyword(s):  
Computerized Tomography ◽  
Cumulative Effect ◽  
Ct Scanning ◽  
Cranial Base ◽  
Type I ◽  
Csf Rhinorrhea ◽  
Content Type ◽  
Anterior Cranial Base ◽  
Fine Print

Object. A classification is proposed to organize anterior cranial base fractures systematically according to their location and size. The goal of this study was to determine whether these two variables, irrespective of cerebrospinal fluid (CSF) rhinorrhea, are related to the long-term risk of posttraumatic meningitis and, hence, to standardize decision making concerning surgical repair of associated CSF fistulas. Methods. With the aid of high-resolution thin-section coronal computerized tomography (CT) scanning, anterior cranial base fractures were classified into the following four major types: I, cribriform; II, frontoethmoidal; III, lateral frontal; and IV, complex (any combination of the other three types). Fractures with a maximum bone displacement that extended farther than 1 cm in any plane were classified as “large” and those less than 1 cm as “small.” The authors used this classification in a study of 48 patients who were treated by conservative (20 patients) or surgical (28 patients) means. The results showed a gradation of risk: the fracture most likely to develop infection was a large cribriform (Type I) and the least likely was a small lateral frontal (Type III). Statistical analysis showed that the trend for an increased infection rate was related to the cumulative effect of three variables in the following order: 1) prolonged duration of rhinorrhea (analysis of variance [ANOVA], p = 0.017); 2) large size of fracture displacement (ANOVA, p = 0.079); and 3) fracture's proximity to the midline (ANOVA, p = 0.015). Conclusions. In this series, microsurgical repair was accompanied by a minimum complication rate. Hence, the authors recommend that patients with fractures that combine the aforementioned variables should be considered to have a high long-term risk of infection and their injury should be surgically repaired as soon as the posttraumatic edema has subsided. This applies to the following fractures: large cribriform (Type I) with transient rhinorrhea lasting 5 to 8 days and large frontoethmoidal (Type II) with prolonged rhinorrhea lasting longer than 8 days. Furthermore, the authors conclude that this classification can improve the management of posttraumatic CSF fistulas of the anterior cranial base and may provide insights into the mechanisms underlying their spontaneous repair and susceptibility to meningitis.

Osteoblastoma of the nasal cavity invading the anterior skull base in a young child

1997 ◽  
Vol 87 (4) ◽  
pp. 625-628 ◽  
Author(s):  
Keisuke Imai ◽  
Kounosuke Tsujiguchi ◽  
Chiaya Toda ◽  
Ki-Chul Sung ◽  
Sadao Tajima ◽  
...  
Keyword(s):  
Nasal Cavity ◽  
Nasal Bone ◽  
Cranial Base ◽  
Magnetic Resonance Images ◽  
Content Type ◽  
X Ray ◽  
Anterior Cranial Base ◽  
Radiological Images ◽  
Benign Osteoblastoma ◽  
Fine Print

✓ The benign osteoblastoma is rarely seen as a tumor of the facial bone in infancy or early childhood. Only five cases with nasal involvement have been reported in the literature. The authors present a case of osteoblastoma of the nasal cavity, the nasal bone, the ethmoid sinus, and the anterior cranial base. This 3-year-old girl presented with a tumor surrounding the left medial canthus. Imaging studies, including x-ray films, computerized tomography scans, magnetic resonance images, a 99mTc-scintigram, and angiograms, confirmed the location of the tumor. A biopsy specimen of tumor was obtained intranasally and the pathological diagnosis was an osteoblastic tumor suggestive of osteoblastoma. Although the tumor margin was well defined on the radiological images, it was difficult to determine the exact margin during the operation. Therefore, it is important to show how to excise the tumor completely under direct view. With the use of a “dismasking flap,” it was possible to resect the benign osteoblastoma completely from the nasal cavity, even though it extended into the orbit, the maxilla, and the anterior cranial base.

Frontal plagiocephaly secondary to synostosis of the frontosphenoidal suture

1995 ◽  
Vol 83 (4) ◽  
pp. 733-736 ◽  
Author(s):  
Paul C. Francel ◽  
T. S. Park ◽  
Jeffrey L. Marsh ◽  
Bruce A. Kaufman
Keyword(s):  
Physical Examination ◽  
Three Dimensional ◽  
Cranial Base ◽  
Facial Skeleton ◽  
Deformational Plagiocephaly ◽  
Content Type ◽  
X Ray ◽  
Anterior Cranial Base ◽  
Coronal Synostosis ◽  
Fine Print

✓ Frontal plagiocephaly may arise from either synostotic or deformational forces. Deformational causes of frontal plagiocephaly can be distinguished from synostotic causes by differences seen on physical examination, which can then be confirmed by skull x-ray films and if necessary three-dimensional computerized tomography (CT). Unilateral coronal synostosis is the main synostotic cause of frontal plagiocephaly, although it has also been seen with fusion of the frontozygomatic suture. In several syndromes presenting with bilateral coronal synostosis, fusion of the frontosphenoidal and frontoethmoidal sutures is also present. The authors report, for perhaps the first time, a case showing synostotic frontal plagiocephaly secondary to fusion of the frontosphenoidal suture alone. Although the phenotypic appearance is superficially similar to that seen in unilateral coronal synostosis, analysis of the cranial base shows markedly different effects: angulation of the anterior cranial base with respect to the posterior cranial base away from the synostotic side and angulation of the posterior cranial base with respect to the midpalatal suture also away from the synostotic side. In unilateral coronal synostosis, both angulations are toward the synostotic side. These effects on the cranial base alter its relationship to the cranial vault and the facial skeleton. Most important, frontal plagiocephaly secondary to fusion of the frontosphenoidal suture should not be overlooked as being deformational. Because this fusion is difficult or impossible to visualize by skull x-ray films, three dimensional CT must be obtained in cases that are not clearly identified as deformational plagiocephaly by physical examination.

Traumatic cerebrospinal fluid fistula simulating tears

1978 ◽  
Vol 49 (1) ◽  
pp. 121-123 ◽  
Author(s):  
Kiran K. Joshi ◽  
H. Alan Crockard
Keyword(s):  
Cerebrospinal Fluid ◽  
Young Child ◽  
Cribriform Plate ◽  
Csf Leak ◽  
Cerebrospinal Fluid Fistula ◽  
Medial Aspect ◽  
Csf Rhinorrhea ◽  
Content Type ◽  
Fluid Fistula ◽  
Fine Print

✓ A young child developed delayed cerebrospinal fluid (CSF) rhinorrhea and CSF leak from the eye presenting as tears. The “tears” were CSF which had tracked from the cribriform plate through the ethmoidal air sinuses to the medial aspect of the left orbit. There was marked chemosis and it was considered likely that the tears had leaked through damaged conjunctiva.

Use of titanium mesh for reconstruction of large anterior cranial base defects

2000 ◽  
Vol 93 (4) ◽  
pp. 711-714 ◽  
Author(s):  
Behnam Badie ◽  
J. Keith Preston ◽  
Gregory K. Hartig
Keyword(s):  
Skull Base ◽  
Anterior Skull Base ◽  
Fistula Formation ◽  
Reconstruction Technique ◽  
Titanium Mesh ◽  
Csf Rhinorrhea ◽  
Content Type ◽  
Dural Defects ◽  
Skull Base Defects ◽  
Fine Print

✓ The authors evaluated the role of titanium mesh used in combination with vascularized pericranium to provide rigid support during reconstruction of anterior skull base defects.Thirteen patients with large anterior skull base defects caused by tumor invasion or traumatic injury involving the cribriform plate, orbital roof, and planum sphenoidale were included in the study. The reconstruction technique involved placement of titanium mesh between two layers of continuous vascularized pericranium. Surgical glue and routine lumbar cerebrospinal fluid (CSF) drainage were not used in any patient.At a mean postoperative follow-up time of 22 months (range 8–39 months), none of the patients had developed infection or meningocele. Postoperative CSF rhinorrhea occurred in two patients with extensive dural defects, which resolved with temporary lumbar drainage.Use of titanium mesh and a two-layer vascularized pericranial graft is a safe, reproducible, and feasible method for reconstructing the anterior skull base. Patients with large dural defects may need temporary CSF diversion to avoid postoperative fistula formation.

Pseudo-cerebrospinal fluid rhinorrhea

1994 ◽  
Vol 80 (1) ◽  
pp. 26-30 ◽  
Author(s):  
Michael D. Cusimano ◽  
Laligam N. Sekhar
Keyword(s):  
Cerebrospinal Fluid ◽  
Cranial Base ◽  
Skull Base Tumor ◽  
Csf Rhinorrhea ◽  
Content Type ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage ◽  
Greater Superficial Petrosal Nerve ◽  
Cavernous Carotid Artery ◽  
Fine Print

✓ Because of its potentially serious sequelae, cerebrospinal fluid (CSF) leakage following surgery for lesions of the cranial base is given immediate attention by neurosurgeons. Despite a multitude of approaches used to prevent its occurrence, CSF leakage complicates up to 30% of difficult skull-base tumor operations. The authors describe the cases of 11 patients who developed a syndrome, not previously described in the literature, termed “pseudo-CSF rhinorrhea.” This syndrome occurs after surgery of the cranial base, usually involving dissection or removal of the petrous or cavernous carotid artery, the greater superficial petrosal nerve, and the pericarotid sympathetic plexus. It is characterized by nasal stuffiness and nasal hypersecretion and is sometimes accompanied by facial flushing. The symptoms are characteristically exacerbated by exertion or by elevated ambient room temperatures. Lacrimation is typically absent ipsilateral to the pseudo-CSF rhinorrhea. It is believed that pseudo-CSF rhinorrhea developed in these patients because of a relative imbalance of the regulatory autonomic supply of the nasal mucosa.

The versatile frontal sinus approach to the floor of the anterior cranial fossa

1990 ◽  
Vol 72 (3) ◽  
pp. 513-516 ◽  
Author(s):  
John A. Persing ◽  
John A. Jane ◽  
Paul A. Levine ◽  
Robert W. Cantrell
Keyword(s):  
Frontal Sinus ◽  
Cranial Base ◽  
Anterior Cranial Fossa ◽  
Operative Field ◽  
Content Type ◽  
Cosmetic Results ◽  
Anterior Cranial Base ◽  
Cranial Fossa ◽  
Burr Holes ◽  
Fine Print

✓ A technique to expose the anterior cranial base is described with entry through the anterior and posterior walls of the frontal sinus. Burr holes are avoided in the visible portion of the forehead. Expansion of the operative field may be accomplished, if necessary, by supplemental superior frontal or supraorbital rim osteotomy. The technique is rapid, safe, and provides excellent operative exposure and superior cosmetic results.

Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

1999 ◽  
Vol 90 (4) ◽  
pp. 651-655 ◽  
Author(s):  
Marc S. Schwartz ◽  
James I. Cohen ◽  
Toby Meltzer ◽  
Michael J. Wheatley ◽  
Sean O. McMenomey ◽  
...  
Keyword(s):  
Skull Base ◽  
Free Flap ◽  
Cranial Base ◽  
Csf Leak ◽  
Content Type ◽  
Lateral Skull Base ◽  
Csf Leakage ◽  
Radial Forearm ◽  
Microvascular Free Flap ◽  
Fine Print

Object. Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage.Methods. Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation.Conclusions. Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to “low-volume” defects.

Preservation of olfaction in anterior craniofacial approaches

1993 ◽  
Vol 79 (1) ◽  
pp. 48-52 ◽  
Author(s):  
Robert F. Spetzler ◽  
James M. Herman ◽  
Stephen Beals ◽  
Edward Joganic ◽  
John Milligan
Keyword(s):  
Cribriform Plate ◽  
Csf Leak ◽  
En Bloc ◽  
Reconstructive Procedures ◽  
Content Type ◽  
The Mean ◽  
Ethmoid Sinuses ◽  
Fine Print ◽  
Csf Leaks

✓ Through the combined efforts of neurosurgeons, head and neck surgeons, and craniofacial surgeons, the standard transbasal approach to the frontal fossa has been modified to include removal of the orbital roofs, nasion, and ethmoid sinuses. This approach has been combined further with facial disassembly procedures to provide extensive midline exposure to the midface and clival region. Extended frontal approaches, however, necessitate removal of the crista galli and sectioning of the olfactory rootlets with the associated risk of anosmia, cerebrospinal fluid (CSF) leak, and the need for complex reconstruction of the frontal floor. To avoid these problems, the authors have modified the technique of handling the cribriform plate to preserve the olfactory unit. Circumferential osteotomy cuts are made around the cribriform plate to allow an en bloc removal with its attachment to both the dura and underlying mucosa. Opening of the dura is avoided and the cribriform bone is used to reconstruct the floor. Four patients underwent this approach, for treatment of an angiofibroma in three and a fibrosarcoma in one. The mean follow-up period was 7 months. No patients developed a CSF leak, and within 8 weeks olfaction had returned in all patients. There was no other associated morbidity. These data suggest that this modification of the transbasilar approach can alleviate extensive reconstructive procedures and CSF leaks while preserving olfaction.

Solitary primary intracranial extracerebral glioma

1984 ◽  
Vol 61 (4) ◽  
pp. 777-781 ◽  
Author(s):  
Samruay Shuangshoti ◽  
Vira Kasantikul ◽  
Nitaya Suwanwela ◽  
Charas Suwanwela
Keyword(s):  
Glial Fibrillary Acidic Protein ◽  
Tumor Cells ◽  
Cranial Base ◽  
Sylvian Fissure ◽  
Content Type ◽  
Mixed Glioma ◽  
The Third ◽  
Parasellar Region ◽  
The Right ◽  
Fine Print

✓ A case is presented of a solitary primary extracerebral mixed glioma occurring in the right suprasellar and parasellar region of a 49-year-old woman who had bilateral temporal hemianopsia for 3 months. At craniotomy, the well demarcated outline and extracerebral location of the tumor suggested that it was a meningioma. However, its gliomatous nature was confirmed by identification of glial fibrillary acidic protein (GFAP) in the tumor cells. Review of nine reported solitary primary intracranial extracerebral gliomas, including the present case, revealed that they tended to occur in the third to fifth decades of life, in patients with an average age of 42½ years, and without sexual predilection. All were supratentorial with a tendency to be situated in the vicinity of the Sylvian fissure. Only the glioma in the present case was at the cranial base. They were diagnosed as three astrocytomas, two glioblastomas, two oligodendrogliomas, one astroblastoma, and one mixed glioma. A suggestion is made that all these gliomas arose primarily from heterotopic neuroglia in the leptomeninges.

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