Rafael Martinez-Perez

BACKGROUND: Pediatric aneurysms are rare and challenging to treat, and long-term prospective data comparing endovascular and microsurgical approaches are limited. The growing incidence of recurrent coiled aneurysms in children further complicates surgical decision-making. OBSERVATIONS: A literature review of the PubMed and Cochrane Central databases (January 2000–December 2022) identified 32 studies encompassing 868 pediatric patients with intracranial aneurysms. Of these patients, 334 underwent endovascular treatment, 410 underwent microsurgical treatment, and the remainder were managed conservatively. Reinterventions were required in 22 endovascularly treated patients and 9 surgically treated patients. Among the 22 patients with endovascular reintervention, 12 ultimately transitioned to microsurgical management, with the rest receiving additional endovascular therapy. The authors describe a representative case of an adolescent with a ruptured internal carotid terminus aneurysm who required microsurgical rescue clipping after initial coil embolization. LESSONS: Management of ruptured pediatric aneurysms warrants distinct consideration and lacks consensus because of scarce long-term prospective evidence. Given children’s extended life expectancy, treatment strategies should prioritize high obliteration and low recurrence rates, tailoring modality selection to minimize delayed flow insufficiency and the need for retreatment. https://thejns.org/doi/10.3171/CASE26681

Reconstruction of the middle cranial fossa following extensive dural resection remains challenging, particularly in ensuring watertight closure and minimizing complications. We present a consecutive case series of five patients undergoing skull base surgery via a minipretemporal approach, in whom direct dural closure was not feasible due to resection-related dural loss or intraoperative dehiscence. A vascularized “superfascial” flap was used for reconstruction. This flap combines periosteum, galea, and superficial temporalis fascia in a single vascularized layer, preserving branches of the superficial temporal artery and minimizing risk to the frontal branch of the facial nerve. All patients underwent successful reconstruction without postoperative CSF leak, infection, pseudomeningocele, or wound dehiscence. One patient experienced transient frontalis weakness resolving within 6 weeks. No readmissions or returns to the OR were required. A surgical video and illustrative figures demonstrate flap harvesting and application. Compared to conventional options like the pericranial flap or autologous fat grafts, the superfascial flap offers enhanced vascularity, broader reach to lateral skull base defects, and excellent cosmetic outcomes. This technique is a reliable alternative in cases where primary closure is not achievable, providing robust coverage without additional donor site morbidity. Its implementation may reduce wound-related complications in select skull base cases.

Introduction Although recent trends currently favor the endoscopic endonasal transcavernous approach (EETA) over the pretemporal transcavernous approach (PTA) for certain cavernous sinus pathologies, dedicated assessment of the surgical exposure and maneuverability is wanting. Toward this aim, this morphometric study quantifies these variables within four cavernous sinus compartments by comparing the PTA, EETA, and a combined approach to achieve a circumferential dissection (EETA-PTA). Material In five latex-injected specimens, exposure volumes of the EETA, PTA, and circumferential EETA-PTA approaches were quantified; the latter combined the most conservative options of both the endoscopic and open approaches. Two clinical cases illustrate the combined approach. Results EETA-PTA provided the largest volume of exposure (65.6% vs 35% PTA vs 44.6% EETA, P = 0.01) and eliminated the need to mobilize the ICA or cross cranial nerves. Although EETA and PTA approaches afforded comparable exposure volumes along the entire cavernous sinus (34.9 vs 44.6%), the EETA better exposed medial and inferior compartments (whereas the PTA exposed larger volumes in the lateral and superior compartments. The combined EETA-PTA yielded 66% of total cavernous sinus exposure volumes and eliminated the need to mobilize the ICA or cross cranial nerves. Conclusions Our methodology aligns with strategies that use a modular concept to divide the skull base into compartments for maximal safe resection. Excluding soft tumors, the EETA is preferred for medial and inferior lesions and the PTA for superior and lateral lesions. A staged combined EETA-PTA may safely yield a 360-degree access for extensive multi-compartment lesions that span neurovascular structures within the cavernous sinus.

BACKGROUND AND OBJECTIVES: Beyond qualitative evidence legitimizing endoscopic corridors through contralateral transmaxillary (CTM) and endonasal ipsilateral transpterygoid (ITP) corridors to the petrous apex and petroclival region, surgical feasibility by direct quantitative comparative anatomy is sparse. Our cadaveric study addresses this by performing the CTM approach followed by ITP extension to quantify the extent of petrous apex resection, instrument maneuverability, and working distance to petrous apex. METHODS: Anatomic dissections were performed bilaterally on 5 latex-injected human cadaveric heads (10 petrous bones). After CTM dissections were quantified, the ITP approach was added enlarging initial exposure. Differences were measured with statistical significance when P values are < .05. RESULTS: The mean petrosectomy volume was 0.958 cm³ with CTM and 1.987 cm³ with CTM + ITP, corresponding to 14.53% and 30.52% petrous apex resection, respectively. Craniocaudal instrument mobility was more limited in the lateral extent of dissection compared with the midline for both CTM (8.062° vs 14.416°) and CTM + ITP (5.4° vs 14.4°). The CTM approach achieved the lateral-most dissection at the body of the petrous apex (15.936 mm), with lateralization more limited in the superior petroclival region (9.628 mm) and the inferior petroclival region (8.508 mm). Angle of surgical maneuverability increased superiorly vs inferiorly in the CTM approach (mean 12.596° vs 8.336°, respectively). The CTM approach offered the shortest mean working distance (88.624 mm) to the petroclival region compared with the bi-nares approach (100.5 mm). CTM + ITP achieved greater lateralization in the superior (21.237 mm) and inferior (22.087 mm) aspects of the petroclival region compared with the CTM approach. CONCLUSION: Operative considerations are discussed in accessing target neurovascular structures through the uniquely shaped corridors formed by the CTM or combined CTM + ITP. Allowing mobilization of the internal carotid artery laterally and eustachian tube inferiorly, addition of the ITP allowed for larger petrosectomy than CTM alone, especially in the inferior and lateral aspects of the petrous bone.