Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes

Background and importance: Transorbital penetrating brain injury (PBI) due to a non-projectile foreign body is rare. It can lead to life-threatening severe neurovascular damage. Surgery is the primary treatment choice; however, there are a number of approaches that can be considered based on the patient's condition in terms of foreign body location and state of the patient. Clinical presentation: An 18-year-old male carpenter was hit by a log and sustained transorbital PBI while cutting wood with a machine. Computed tomography (CT) scan showed a wooden spike that was approximately 11 cm from the left medial orbital to the superior part of the posterolateral of the petrous bone, crossing the right side at the base of the skull. CT angiography (CTA), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) revealed no internal carotid artery (ICA) and cavernous sinus lesions, respectively. We had a 3D-printed model for preoperative planning, and surgery was performed using a transorbital approach to extract the wood 14 days after the accident. The impacted wood was removed without any complications. Conclusion: There are many surgical approaches for transorbital PBI. We decided to perform the transorbital approach because it is perpendicular to the entry zone. Surgeons should consistently perform minimally invasive procedures based on the clinical and radiological findings.

An Enlarged Right Jugular Foramen

Jugular foramina are two openings in the base of the skull. Difference in diameter between two sides is noted, while right sided foramen is usually mentioned as the larger one. Rare cases have been reported with an enlarged jugular foramen. We report such a case with a right jugular foramen of a diameter 24mmX13mm. Microsurgery in the near future may exploid cases with greater openings. KEY WORDS: Base of the skull, Dry bone, Microsurgery.

Proton therapy with a fixed beamline for skull-base chordomas and chondrosarcomas: outcomes and toxicity

Aim This study presents an analysis (efficacy and toxicity) of outcomes in patients with skull-base chordomas or chondrosarcomas treated with a fixed horizontal pencil proton beam. Background Chordomas (CAs) and chondrosarcomas (CSAs) are rare tumours that are usually located near the base of the skull and very close to the brain's most critical structures. Proton therapy (PT) is often considered the best radiation treatment for these diseases, but it is still a limited resource. Active scanning PT delivered via a fixed pencil beamline might be a promising option. Methods This is a single-centre experience describing the results of proton therapy for 31 patients with CA (n = 23) or CSA (n = 8) located near the base of the skull. Proton therapy was utilized by a fixed pencil beamline with a chair to position the patient between May 2016 and November 2020. Ten patients underwent resection (32.2%), 15 patients (48.4%) underwent R2 resection, and 6 patients had unresectable tumours (19.4%). In 4 cases, the tumours had been previously irradiated. The median PT dose was 70 GyRBE (relative biological efficacy, 1.1) [range, 60 to 74] with 2.0 GyRBE per fraction. The mean GTV volume was 25.6 cm3 [range, 4.2–115.6]. Patient demographics, pathology, treatment parameters, and toxicity were collected and analysed. Radiation-induced reactions were assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v 4.0. Results The median follow-up time was 21 months [range, 4 to 52]. The median overall survival (OS) was 40 months. The 1- and 2-year OS was 100%, and the 3-year OS was 66.3%. Four patients died due to non-cancer-related reasons, 1 patient died due to tumour progression, and 1 patient died due to treatment-related injuries. The 1-year local control (LC) rate was 100%, the 2-year LC rate was 93.7%, and the 3-year LC rate was 85.3%. Two patients with CSA exhibited progression in the neck lymph nodes and lungs. All patients tolerated PT well without any treatment interruptions. We observed 2 cases of ≥ grade 3 toxicity, with 1 case of grade 3 myelitis and 1 case of grade 5 brainstem injury. Conclusion Treatment with a fixed proton beam shows promising disease control and an acceptable toxicity rate, even the difficult-to-treat subpopulation of patients with skull-base chordomas or chondrosarcomas requiring dose escalation.

New data on human skulls from the ritual complex of the Bystrovka-2 Early Iron Age burial ground

Various kinds of postmortem manipulations with the bodies of the dead were widespread in the ritual practice of the Scythian tribes of Eurasia. One of the evidences of such practice is finds of isolated skeletal bones or skulls buried in an unusual context. One of the sites where such finds was discovered is the Bystrovka-2 burial ground of the Kamenka archaeological culture in the Novosibirsk Ob region. In the kurgan 9 of this site, a ritual complex containing the burial of three human skulls, previously displayed on stakes or poles was excavated. In this article we present the results of recent anthropological analyzes of these skulls and discuss the question concerning the origin of the sacrificed people. The analyzed data allow us to say that in the Kamenka society, putting heads on poles rather had an apotropic function than was connected with military cults. The sacrificed people were selected from the strongest and healthiest young people. The condition of the bones of the skull and dentition of the examined individuals definitely indicates a relatively low level of biological stress. Comparison of the skulls from Bystrovka-2 with the skull found at the Kulayka settlement of Bolshoi Log in Omsk showed the possibility of coincidence of some mythical and ritual practices among the Kamenka and Kulayka archaeological cultures. The intentional lesions found on the skulls from these two sites are functionally and anatomically fully identical. The first group of injuries observed at the base of the skull are traces of postmortem decapitation, the second found on the cranial vault is technological holes for fixing the head on a pole. The central element of the ritual in both cases was precisely placing the head on a pole and thus creating an apotrope indicating the border of the “clean” territory.

Role of Radiology Methods in Differential Diagnosis of Fibrous Dysplasia of Base of the Skull

Purpose: Improvement of the differential diagnosis of fibrous dysplasia of the of the base of the skull on the basis of X-ray computed tomography data, taking into account clinical and medical data.Material and methods: The results of examination of 24 patients with lesions of the base of the skull were analyzed. Group 1: 15 patients with fibrous dysplasia, directed to examination with a diagnosis of osteoplastic metastases of the base of the skull. Group 2: 9 patients with metastases to the base of the skull. All patients underwent computer tomography and SPECT/CT.Results: Comparison of clinical and radiological symptoms in patients with metastatic lesions of the base of the skull (group 2) and patients with fibrous dysplasia of the base of the skull (group 1) allows us to state that errors in the differential diagnosis of bone metastases and fibrous dysplasia of the base of the skull in a number of cases are associated with a lack of awareness of radiologists.Conclusion: The presented data will help to improve the diagnosis of fibrous dysplasia of the base of the skull.

The cranial nerves

There are 12 pairs of cranial nerves that are individually named and numbered using Roman numerals. Only some cranial nerves are mixed in function, i.e. they carry both sensory and motor fibres; others are purely sensory or motor and some may also carry pre- or post-ganglionic parasympathetic fibres. They pass through foramina in the base of the skull and are the olfactory (through cribriform plate to the nasal cavity), optic (through the optic foramen to the eye), oculomotor (through the cavernous sinus and superior orbital fissure to supply the eye), trochlear (as per oculomotor), trigeminal (three main branches that pass through the superior orbital fissure, foramen rotundum and foramen ovale, respectively), abducens (as per oculomotor), facial (through stylomastoid foramen to supply muscles of facial expression), vestibulocochlear (through the internal acoustic canal to control balance and hearing), glossopharyngeal, vagus, accessory (all pass through the jugular foramen) and hypoglossal (through the hypoglossal canal to control movements of the tongue) nerves.

The neck

The neck occupies the space between the clavicles and thoracic inlet inferiorly, to the base of the skull and inferior border of the mandible superiorly. The cervical part of the vertebral column provides the support for the skull above and strength and movement to the neck proper. The anterior neck provides passage for the major neurovascular supply to and drainage from the head, neck and intracranial region, transmits the upper aerodigestive tract and houses the thyroid and parathyroid glands. In the posterior neck a large mass of extensor musculature is situated posterior to the cervical vertebrae. Cranial nerves nine through twelve descend into the neck: nine (glossopharyngeal) and twelve (hypoglossal) meander towards the oropharynx and tongue, respectively; cranial nerve eleven (accessory) deflects backwards to supply the sternocleidomastoid and trapezius muscles whilst the tenth cranial nerve (vagus) wanders inferiorly within the carotid sheath between and posterior to the common carotid artery and internal jugular vein, before disappearing into the thoracic and abdominal cavities.

Embryology of the head and neck

Development of the head is dominated by the changing shape of the brain and the formation of pharyngeal arches through which blood from the ventrally placed heart can pass to the dorsal aorta. The origin of the cell population within the head and neck is important as it predicts the behaviour and attributes of the cells and their progeny. The neural crest gives rise to an extensive mesenchymal population which contributes to the skull and enters and patterns the pharyngeal arches. The skull (neurocranium) forms around the developing brain and its emerging nerves. The base of the skull forms initially in cartilage (endochondral ossification) and the vault forms from neural crest mesenchyme (intramembranous ossification). The face and jaws (viscerocranium) form around the developing pharynx from a series of pharyngeal arches (numbered 1,2,3,4 and 6) which pass from the lateral sides of the pharynx to meet ventromedially.

Constitutional Features of the Maxillofacial Area of Omsk Young Men

The aim was to determine the morphometric parameters of the maxillofacial area of Omsk young men of 18-20 years of age according to the teleroentgenography of the head (in a lateral projection), taking into account the indicators of cephalometry and anthropometry, to identify regional constitutional features of quantitative values.Material and methods. A cephalometric and somatometric examination of 26 Omsk Slavic young men of 18-20 years of age without concomitant pathology was performed, supplemented by an X-ray examination of the head (to obtain teleroentgenograms in a lateral projection). The analysis of teleroentgenograms was carried out in the online service Mave Cloud.Results. According to the results of anthropometry, the longitudinal and transverse dimensions of the young men's heads, the zygomatic diameter and the full height of the face were assessed; the indicators of body growth, body weight, chest circumference and transverse chest diameter were determined. These indicators were used to calculate the indices. The value of the facial index was 81.86 (79.31; 88.88), the value of the head index was 76.65 (74.27; 79.47), the Rees-Eisenck index corresponded to 97.58 (94.62; 107.48), the Rohrer index was 13.34 (12.07; 15.48), the Pinier index was 11.1 (-10; 22), the Quetelet II index was 23.33 (22.03; 27.71). When analyzing teleroentgenograms, it was revealed that the values of some parameters in Omsk young men of 18-20 years of age differ from the values of the «norm». Thus, the indicators of the lower jaw length (Go-Gn), the ratio of the body of the lower jaw length to the length of the anterior base of the skull (Go-Me/S-N), the length of the posterior base of the skull (S-Ar), the height of the branch of the lower jaw (Ar-Go), the ratio of the heights of the face (S-Go/N-Me), the angle between the axis of the lower incisor and the plane of the lower jaw (IM IMPA) have greater values than the «norm»; and the figures of the angles sum according to Bjork (∠SUM Bjork), mandibular angle (∠Ar-Go-Me), maxillary angle (∠N-Go-Ar), upper jaw inclination angle (∠NSL-NL), lower jaw inclination angle (∠NSL-ML), intermaxillary angle (∠NL-ML), the angle between the lower jaw plane and the Frankfurt horizontal (∠FMA), have values less than the «norm». The values of the saddle angle (∠N-S-Ar) differed in young men with euryprosopic and leptoprosopic facial forms. The quantitative values of the lower jaw angle (ArGo-Me) and the upper jaw angle (N-Go-Ar) differed only in the representatives of the dolichocephalic and mesocephalic forms of the head.Conclusion. Quantitative values of cephalometric and somatometric parameters in Omsk young men of 18-20 years of age have distinctive features. Individual parameters of the maxillofacial area (according to teleroentgenograms) differ in persons with dolichocephalic and mesocephalic forms of the head and in the representatives of euryprosopic and leptoprosopic forms of the face.

Facial asymmetry with torticollis. О. Beck (Zentr. f. Chir.. 1926, № 16)

An interesting view of the causal relationship between these two anomalies is expressed in his report by O. Beck (Zentr. F. Chir .. 1926, no. 16). Based on Vigchow's research, observations by Ghaawitz and his own, Beck believes that facial asymmetry in caput obstipum musculare is caused by basilar depression of the base of the skull due to unilateral pressure of the atlas on the proc, condyloideus of the occipital bone. The latter causes a disorder of the growth of the base of the skull and, as a consequence, basilar kyphosis and scoliosis.