Publications by authors named "Ossama Al-Mefty"

176 Publications

Letter to the Editor: "The Treasure of Cushing's Records: I Would Rather Live with the Power of Observation than Die with Statistical Power".

World Neurosurg 2022 Aug;164:451-452

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2022.04.054DOI Listing
August 2022

Extended Transcondylar Approach With C-1 Lateral Mass Resection for the Removal of a Calcified Ventral "Spinocranial" Meningioma: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Aug 9;23(2):e117-e118. Epub 2022 May 9.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000278DOI Listing
August 2022

Dejerine Syndrome Variant Due to Medullary Perforating Artery Ischemia During Foramen Magnum Meningioma Resection: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 07 20;23(1):e52-e53. Epub 2022 Apr 20.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000211DOI Listing
July 2022

Resection of Skull Base Meningioma With Extensive Extracranial Extension: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 07 20;23(1):e51. Epub 2022 Apr 20.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000220DOI Listing
July 2022

Multimodality resection of Oliveira Type IIIC* cerebellar AVM: A distinct entity.

Surg Neurol Int 2022 22;13:163. Epub 2022 Apr 22.

Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, United States.

Background: Posterior fossa AVMs constitute about 10% of AVMs and are associated with a higher rate of hemorrhage and increased morbidity and mortality rates necessitating treatment with rare exception. Cerebellar AVMs differ markedly from their supratentorial counterparts in that there are no perforating vessels involvement, drainage into the deep cerebral venous system, or presence of eloquent functional area except for the dentate nucleus. While Yaşargil has classified cerebellar AVMs into seven subtypes according to their location, de Oliveira . have classified them using a more impactful grading system based on the size, location, and involvement of the dentate nucleus with the highest risk being III (size over 4 cm) C (mixed superficial and deep location) * (dentate involvement). In this extensive AVM with multiple arterial feeders from the SCA, AICA, and PICAs, preoperative embolization facilitates the safe surgical removal.

Case Description: We present the case of resection of de Oliveira . IIIC* cerebellar AVM highlighting the tenets of preoperative embolization, wide surgical exposure with an extended retrosigmoid approach, arachnoidal dissection of the SAC, AICA, and PICA feeders, parenchymal dissection with preservation of the dentate nucleus, and preservation of venous drainage until complete disconnection. The patient consented to surgery after presenting with hemorrhage and developed hydrocephalus and CSF leak, managed successfully.

Conclusion: de Oliveira . classification is highly impactful in grading posterior fossa AVMs.
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http://dx.doi.org/10.25259/SNI_217_2022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9062940PMC
April 2022

Posterior Clinoid Meningioma-A Formidable Entity: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 05;22(5):e216

Department of Neurosurgery, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000138DOI Listing
May 2022

Brachytherapy as Salvage Treatment for Meningioma With Malignant Progression After Exhausting Other Treatment Options: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 05;22(5):e215

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000129DOI Listing
May 2022

Cavernous Hemangioma of the Cavernous Sinus-Same Pathology, Different Disease: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 06 11;22(6):e265-e266. Epub 2022 Apr 11.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000180DOI Listing
June 2022

Resolution of Primary or Recalcitrant Chiari-Associated Syringomyelia Requires Adequate Cerebrospinal Fluid Egress from the Fourth Ventricle.

World Neurosurg 2022 Jul 6;163:24. Epub 2022 Apr 6.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston. Electronic address:

Syringomyelia is often resistant to various treatment modalities. Chiari I malformations are associated with syringomyelia in approximately 69% of operative cases. Failure to resolve syringomyelia after Chiari decompression is common. The pathophysiology of Chiari-associated syringomyelia has been well studied, with Oldfield emphasizing the water-hammer mechanism, with treatment limited to bony decompression and duraplasty. On the other hand, capacious fourth ventricular drainage is thought to be essential for syrinx resolution. Persistence or progression of the syrinx after decompression is an indication for reoperation. Direct shunting of the syrinx is associated with high failure rates. The technique of shunting the fourth ventricle has been applied successfully in the pediatric population. We emphasize the need to ensure outflow from the fourth ventricle in Chiari decompressions associated with syringomyelia. In revisions to treat progressive syringomyelia after failed decompression, we undertake the following steps: 1) adequate lateral bony decompression, 2) lysis of scar/adhesions around the cisterna magna, 3) opening the fourth ventricle outlet by releasing any web/adhesions, 4) insertion of a shunt from the fourth ventricle to the cervical subarachnoid space, and 5) bipolar coagulation of the lateral tonsillar pia to maintain patency of cerebrospinal fluid pathways. We favor autologous fascia or pericranium for expansile duraplasty, as the use of nonautologous materials may cause excessive scarring. In this video, we demonstrate these tenets in 3 cases of Chiari-associated syringomyelia, 2 revisions and 1 primary case, with excellent resolution of the syrinx (Video 1). The patients consented to surgery and publication of images.
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http://dx.doi.org/10.1016/j.wneu.2022.03.132DOI Listing
July 2022

Brainstem Pilocytic Astrocytoma, a Surgical Disease: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 06 5;22(6):e264. Epub 2022 Apr 5.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000157DOI Listing
June 2022

Early Detection and Management of Venous Thrombosis in Skull Base Surgery: Role of Routine Doppler Ultrasound Monitoring.

Neurosurgery 2022 07 7;91(1):115-122. Epub 2022 Apr 7.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: Venous thromboembolism (VTE), encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE), causes postoperative morbidity and mortality in neurosurgical patients. The use of pharmacological prophylaxis for DVT prevention in the immediate postoperative period carries increased risk of intracranial hemorrhage, especially after skull base surgeries.

Objective: To investigate the impact of routine Doppler ultrasound monitoring in prevention and tiered management of VTE after skull base surgery.

Methods: We retrospectively analyzed a large cohort of consecutive adult patients who were prospectively and uniformly managed with routine monitoring by Doppler ultrasound for DVT after resection of a skull base tumor.

Results: A total of 389 patients who underwent 459 surgeries for intracranial tumor resection were analyzed. Skull base meningioma was the most common pathology. Forty-four (9.59%) postoperative VTEs were detected: 9 (1.96%) with PE with or without DVT and 35 (7.63%) with DVT alone. Four cases of subsegmental PE were diagnosed without evidence of lower extremity DVT, possibly in the setting of peripherally inserted central catheters maintenance. One patient had a preoperative proximal DVT and underwent a prophylactic inferior vena cava filter but expired from PE after discharge. Prior history of VTE (risk ratio [RR] 5.13; 95% CI 2.76-7.18; P < .01), anesthesia duration (RR 1.14; 95% CI 1.03-1.27; P = .02), and blood transfusion (RR 1.95; 95% CI 1.01-3.37; P = .04) were associated with VTE development on multivariate analysis.

Conclusion: Routine postoperative venous ultrasound monitoring detects asymptomatic DVT guiding management. This is an alternative strategy to prescribing pharmacological VTE prophylaxis immediately after lengthy surgeries for intracranial tumors. Peripherally inserted central catheters were associated with subsegmental PE.
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http://dx.doi.org/10.1227/neu.0000000000001936DOI Listing
July 2022

Surgical Presets of Ruptured Dermoid Cyst Resection: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 05;22(5):e217

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ons.0000000000000142DOI Listing
May 2022

Multimodal Intraoperative Image-Driven Surgery for Skull Base Chordomas and Chondrosarcomas.

Cancers (Basel) 2022 Feb 15;14(4). Epub 2022 Feb 15.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Given the difficulty and importance of achieving maximal resection in chordomas and chondrosarcomas, all available tools offered by modern neurosurgery are to be deployed for planning and resection of these complex lesions. As demonstrated by the review of our series of skull base chordoma and chondrosarcoma resections in the Advanced Multimodality Image-Guided Operating (AMIGO) suite, as well as by the recently published literature, we describe the use of advanced multimodality intraoperative imaging and neuronavigation as pivotal to successful radical resection of these skull base lesions while preventing and managing eventual complications.
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http://dx.doi.org/10.3390/cancers14040966DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8870528PMC
February 2022

Middle Fossa Approach for Resection of a Giant Trigeminal Schwannoma Through an Expanded Meckel Cave: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 03;22(3):e122-e123

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000071DOI Listing
March 2022

"Grade Zero" Removal of a Falcine Meningioma: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Apr;22(4):e158

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000093DOI Listing
April 2022

Sealing the Box: Microsurgical Repair of Skull Base Encephaloceles: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Apr;22(4):e159-e160

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000102DOI Listing
April 2022

Resection of a Giant Atypical Pediatric Meningioma Encasing the Cerebral Arterial Tree: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 03;22(3):e126-e127

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000107DOI Listing
March 2022

Orbital Cavernous Venous Malformation Resection Through Supraorbital Craniotomy: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 03;22(3):e128

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000100DOI Listing
March 2022

Clival Meningioma: Remove the Bone to Pursue Ventral Exposure: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 03;22(3):e129

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000108DOI Listing
March 2022

Hyperostotic Invasive Meningioma of the Sphenoid Ridge Surgical Considerations: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 03;22(3):e124-e125

Department of Neurosurgery, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000074DOI Listing
March 2022

Anterior Petrosal: A Key Approach to Upper Petroclival Meningiomas: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 02;22(2):e81

Department of Neurosurgery, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000046DOI Listing
February 2022

Resection of Peritorcular Meningioma With Sinus Intimal Layer Preservation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 02;22(2):e82

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000002DOI Listing
February 2022

Grade Zero Removal of a Pterional Meningioma: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 02;22(2):e80

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1227/ONS.0000000000000041DOI Listing
February 2022

Sugita-Kobayashi Maneuver for Preservation of Large Bridging Veins in the Interhemispheric Approach: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Jan;22(1):e46

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Giants of neurosurgery have made contributions that might at times seem to be minor maneuvers but have a major impact on safe surgery, such as Sugita and Kobayashi's description of the preservation of the bridging sagittal veins.1 The interhemispheric approach is haunted by risk to the bridging veins and resultant venous infarction. At the midsegment, this could produce devastating neurological deficits.2 This is an especially critical factor in falcine meningiomas in which the location of the tumor narrows the options for the surgical corridor, particularly if an additional falcine margin, "Grade Zero" resection, is to be performed.3 Detailed preoperative neuroimaging workup is required to plan the appropriate surgical strategy and minimize risk for venous complications. This may include magnetic resonance or computed tomography venogram, dynamic computed tomography angiography,4 or in some cases formal angiography to assess the relationship with the superior sagittal sinus, the anatomy of parasagittal bridging veins in relation to the lesion, and the patterns of collateral venous drainage. While bridging veins may be displaced, compressed, or obscured by tumor involvement,5 microsurgical technique can facilitate the safe identification and preservation of this crucial anatomy. Bridging veins are separated from the underlying cortex to a distance from the sinus, allowing for improved relaxation of the ipsilateral cortex, without venous compromise.1,6 Herein, we demonstrate a case of a large falcine meningioma with a "Grade Zero" resection, with mobilization of the parasagittal bridging veins to develop the interhemispheric surgical corridor. The patient consented for surgery.
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http://dx.doi.org/10.1227/ONS.0000000000000022DOI Listing
January 2022

The Utilization of the Cranio-Orbital Zygomatic Approach for the Resection of Juvenile Nasopharyngeal Angiofibroma: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Jan;22(1):e44-e45

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Juvenile angiofibroma is a rare benign expansive lesion typically affecting young men. Surgery is the current mainstay of treatment. Because it is a very vascular lesion, preoperative transarterial embolization can decrease intraoperative bleeding.1,2 Transmaxillary or transpalatal approaches were used for totally extracranial lesions. Endonasal endoscopic resection became wildly used for radical excision with limited morbidity.2 In large lesions with intracranial extension and cavernous sinus involvement (Fisch type 4), purely anterior approaches (endoscopic or transmaxillary) can be associated with significant carotid artery and cranial nerves injuries and excessive hemorrhage from internal carotid artery supply that cannot be eliminated by preoperative embolization.3 Subtotal resection has been preconized in such cases, but tumor progression, cranial nerves and vision compromise, and major nasal postoperative bleeding could ensue. Radiotherapy of residual tumor has been associated with long-term complications, particularly given the young age of these patients.2 The cranio-orbital zygomatic approach provides an excellent exposure to the extensions into the middle fossa, anterior fossa, cavernous sinus, paranasal sinus, and infratemporal fossa components of large angiofibromas.4-6 It is particularly advantageous in the early interruption of the cavernous carotid feeders that are not amenable to safe embolization, rendering the tumor devascularized and bloodlessly resected. This article demonstrates the details and the advantages of this approach in a 13-year-old adolescent boy operated in 1997 for giant juvenile angiofibroma with extension in the middle fossa and the parasellar space with major vascularization from the cavernous carotid artery. The guardian consented to the procedure and publication of images. Image at 3:05 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998. Image at 3:25 from Arnautović KI, Al-Mefty O, Angtuaco E. A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms. Surg Neurol. 1998;50(6):504-520; © Elsevier, 1998. Used with permission. Image at 9:21 reprinted from Kempe LG and Krekorian EA,6 with permission from John Wiley and Sons, © 1969 The Triological Society.
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http://dx.doi.org/10.1227/ONS.0000000000000008DOI Listing
January 2022

Preservation of Cranial Nerves Function in Glomus Jugulare Surgery: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 01;22(1):e43

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Owing to their invasive character, extreme vascularity, and critical location, glomus jugulare tumors present a formidable challenge. Techniques have been developed for safe and successful removal of even giant glomus paragangliomas.1-3 Preoperative evaluation including genetic, hormonal, and multiplicity workup4 has enhanced the safety of surgical management, as did modern preoperative embolization by eliminating excessive blood loss.5 Despite these advancements, surgical outcomes of glomus jugulare remain haunted by cranial nerve dysfunction such as facial nerve palsies and hearing loss, with lower cranial nerves dysfunction being the most morbid. These can be avoided by technical maneuvers to preserve the cranial nerves. The external ear canal is not closed to maintain conductive hearing. The facial nerve is not transpositioned and kept inside a bony protective canal. Cranial nerves IX, X, and XI are the most vulnerable because they pass through the jugular foramen ventral to the venous bulb wall. They are preserved by intrabulbar dissection that maintains a protective segment of the venous wall over the nerves. By mastering the anatomy of the upper neck, meticulous dissection is performed to preserve the course of IX, X, XI, and XII.6,7 Ligation of the jugular vein is delayed until the tumor is totally isolated to avoid diffuse bleeding.7 We present the case of a 60-yr-old woman with a glomus jugulare tumor with intradural, extradural, and cervical extension. The technical nuances of cranial nerves preservation are demonstrated. The patient consented to the procedure and publication of her images. Images at 2:12, 2:50, and 3:09 from Al-Mefty and Teixeira,6 with permission from JNSPG.
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http://dx.doi.org/10.1227/ONS.0000000000000021DOI Listing
January 2022

Falcotentorial Meningioma Resection Through the Supracerebellar Infratentorial Approach: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Jan;22(1):e42

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Meningiomas are a common pineal region tumor in adults.1 They frequently reach large size with pending serious neurological consequences.1 Although they are more common in women, their presence in men might raise concerns about a higher-grade meningioma. Accordingly, their treatment starts with surgical resection. Their origin is the falcotentorial junction involving the midbrain tectum and the vital deep venous system. The torcular, transverse sinuses, cerebellar veins, straight sinus, internal occipital veins, basal veins, and internal cerebral veins are encountered requiring a cautious fine intra-arachnoidal dissection under high magnification.2 Multiple surgical approaches are described for pineal area tumors with the advantages and disadvantages of each guiding the selection of the approach.3 We believe that the main deciding factor is the relationship of the vein of Galen and its tributaries to the tumor, simply choosing the route that encounters the tumor first and the vein last. We demonstrate the surgical nuances of removing a pineal area meningioma that displaced the vein of Galen superiorly, prompting the resection through a lateral infratentorial supracerebellar approach. We currently prefer the 3/4 concord position because it provides a superb direct exposure over one cerebellar hemisphere, with the cerebellum relaxed downward while the bridging veins are not severely stretched with gravity.4 The sitting surgeon with resting arms in an ergonomic position is able to perform fine microsurgical dissection over extended time.5 The patient was a 57-year-old man with a large falcotentorial meningioma. The patient consented to the surgery and publication of his images.
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http://dx.doi.org/10.1227/ONS.0000000000000004DOI Listing
January 2022

Syringomyelia From Extramedullary Compression: Resolution After Microsurgical Resection of a High-Cervical Spine Schwannoma: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Jan;22(1):e39

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Syringomyelia with compression at the foramen magnum is a well-studied subject with a pathophysiological hypothesis explaining syrinx development and treatment.1,2 However, compression of the cervical cord, as in cervical spondylosis, can also lead to cavitation in the spinal cord.3,4 Although the association of intramedullary spinal cord tumors with syringomyelia is well known,5 the association of extramedullary tumors with syringomyelia is scarcely reported, and it is of unknown mechanism and uncertain outcomes regarding syrinx resolution. Syringomyelia is reported to be associated with intramedullary spinal schwannoma.6 However, spinal schwannomas are by and large extramedullary tumors that produce deficits through compressive radiculopathy or myelopathy. The association of extramedullary schwannomas with syringomyelia is extremely rare. In this article, we present a patient with an extramedullary high-cervical schwannoma causing significant syringomyelia who underwent microsurgical resection of the schwannoma, with subsequent total resolution of the syringomyelia. The patient consented for surgery. Images from Lancet 1969 at 6:36 in video Reprinted from The Lancet, Vol. 294, Bernard Williams, The Distending Force in the Production of "Communicating Syringomyelia," Pages 189-193, Copyright 1969, with permission from Elsevier.
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http://dx.doi.org/10.1227/ONS.0000000000000003DOI Listing
January 2022

Multicentric Chordoma With Initial Resection by Bilateral Transcondylar Approach: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Jan;22(1):e37-e38

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Chordoma is a rare skull base tumor with malignant behavior.1-3 It invades locally with high recurrences, metastasizes distally, and seeds after interventions.1-4 Chordoma exemplifies the malignant progression doctrine as it accumulated genetic mutations. The natural history of untreated disease is 2.4 yr on average survival.5 Best tumor control is achieved by radical resection, followed by high doses radiation. Multicentric chordoma is an ill-defined challenging entity extremely rare in the literature. However, chordoma is known for distal metastasis, particularly to the lungs, iatrogenic cerebrospinal fluid (CSF) dissemination with drop metastasis, or surgical implantation. A subset of patients present with synchronous or metachronous regional or distal neuraxial lesions associated with the initial chordoma. Patients presenting with multicentric bony axial lesions and no extra-axial metastases point toward the multicentric chordoma concept rather than local, hematogenous, or CSF spread.6-12 Biopsy of these multicentric lesions can show a spectrum of abnormalities ranging from benign notochordal tumor to chordomas confirming the multicentric hypothesis.9 We present a patient who underwent a bilateral transcondylar approach for giant craniovertebral junction chordoma and then treated with radiation and a second lesion at the C6 transverse foramen. Six years later, she presented with a chordoma at the petrous apex. The patient consented to surgery and to the publications of her image. The participants and any identifiable individuals consented to publication of his/her image. Image at 1:39 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998.
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http://dx.doi.org/10.1227/ONS.0000000000000001DOI Listing
January 2022

Suprabulbar Approach to Jugular Fossa Tumors: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 11;21(6):E524-E525

Department of Neurosurgery, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts, USA.

Owing to their scarcity, location, and intricate neurovascular associations, jugular fossa tumors are among the most challenging pathologies encountered by the neurosurgeon.1 While paragangliomas originate within and often occlude the jugular bulb, schwannomas and meningiomas are extra-bulbar and typically do not impede venous flow.2 Schwannomas typically arise from an extradural origin, expanding the jugular foramen.3-5 Meningiomas are intradural and cause hyperostosis of the jugular tubercle.6 We described and have been exposing and resecting jugular fossa tumors through a presigmoid suprabulbar infralabyrinthine window6 that has been detailed in cadaveric studies.7,8 This approach maintains the patency of the jugular bulb without breaching the labyrinths or manipulating the facial nerve. It is applicable to cases with partially impaired hearing and intact lower cranial nerves. The carotid artery can be identified by neuronavigation and micro-Doppler ultrasonography. This approach provides a direct lateral trajectory with a short distance to the jugular fossa and cerebellopontine angle. Early exposure and central debulking of the tumor minimize manipulation of the exquisitely sensitive lower cranial nerves. The distal aspect of these tumors can be removed with endoscopic assisted techniques.9 The first patient is a 49-yr-old woman with a previously irradiated schwannoma who presented with worsening neurologic deficits-an extradural suprabulbar approach was used to resect this tumor. The second patient is a 27-yr-old woman with an enlarging meningioma and associated neurological dysfunction; this tumor was resected using the suprabulbar approach with opening of the presigmoid dura. Both patients have consented to surgery and publication of images. Image at 2:27 and 6:38 reprinted from Arnautović et al, with permission from JNSPG. Image at 2:50 and 6:45 ©Ossama Al-Mefty 1997, reused with permission.
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http://dx.doi.org/10.1093/ons/opab339DOI Listing
November 2021
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