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Jugular Foramen Tumors : Paragangliomas and Schwannomas

Clinical Pearls Progressive deficits of cranial nerves IX, X, and XI associated with pulsatile tinnitus and hearing loss are the most common presenting features of jugular foramen tumors. The differential diagnosis of jugular foramen tumors is highly reliant on magnetic resonance and computed tomography imaging. Although paragangliomas and schwannomas are the most common intrinsic tumors that arise in the jugular foramen, numerous other tumor types must…

Endoscopic Approaches to Skull Base Lesions

Clinical Pearls Become knowledgeable about the equipment and practice on a cadaver or under the guidance of an experienced neuroendoscopist. Orientation and anatomy of the cranial skull base are everything. Absolutely know where you are, what you are looking at, and your orientation at all times. In this chapter, the most important neurovascular structures related to the cranial skull base approaches are defined. If you are…

Skull Base Tumors: Evaluation and Microsurgery

Clinical Pearls As a general principle, a skull base approach should provide optimal exposure of the lesion in question without retraction or other injury to normal neurologic structures. Planning an operation for individual skull base tumors involves identifying the anatomic zones that require exposure as well as understanding the limits of individual approaches. The ideal approach for each case thus varies from a minimal keyhole or…

Microsurgical Approaches to the Ventricular System

Clinical Pearls Intraventricular lesions often present with nonspecific symptoms and clinical signs and can affect patients of all ages. They may grow quite large before the diagnosis is secured. Imaging studies, in concert with a detailed knowledge of the surrounding microsurgical anatomy and neural function, permit the surgeon to determine the most effective and safest approach to resection of the lesion. The key principle for microsurgical…

Endoscopic Approaches to Ventricular Tumors and Colloid Cysts

Clinical Pearls It is essential to be knowledgeable about the equipment and practice on a cadaver or to be under the guidance of an experienced neuroendoscopist. Orientation and anatomy are everything. Knowledge of the anatomy will ensure that you know where you are, what you are looking at, and your orientation at all times. If you are not sure, abort the procedure. Use the endoscope for…

Pituitary Tumors: Diagnosis and Management

Clinical Pearls Pituitary tumors present in various ways as a result of excess or deficient secretion of pituitary hormones or extrinsic compression on the pituitary stalk or adjacent structures. Approximately 75% of pituitary adenomas are functioning tumors; of these, half are prolactinomas, less than 25% secrete growth hormone, and the rest secrete adrenocorticotropic hormone, follicle-stimulating hormone, luteinizing hormone, or thyroid-stimulating hormone. Functioning tumors often present with…

Cerebellopontine Angle Tumors

Clinical Pearls Comprehensive knowledge of the complex anatomy of the cerebellopontine (CP) angle is a prerequisite for achieving good surgical results. The crucial neurovascular structures should be identified as early as possible during surgery, which enables their preservation and guides subsequent operative steps. Whatever the tumor size and extension, the anatomic relationships of the cranial nerves in the area of the fundus of the internal auditory…

Pineal Region Tumors

Clinical Pearls The pineal region is bordered posteriorly by the tentorial apex, inferiorly by the culmen of the cerebellar vermis, superiorly by the splenium of the corpus callosum, and anteriorly by the third ventricle, quadrigeminal plate, and midbrain tectum. Pineal region tumors most commonly present with symptoms related to elevated intracranial pressure, hydrocephalus, and local compression to the dorsal midbrain. An endoscopic biopsy and ETV is…

Convexity and Parasagittal Versus Skull Base Meningiomas

Clinical Pearls Meningiomas are the most common primary brain tumors, and the knowledge of these tumors and their management has evolved over the years. With better and more affordable radiologic investigations and changes to the World Health Organization classification grading, there has been a stark increase in diagnosed cases. As common as meningiomas are, there is still a paucity of related clinical trials to serve as…

Brain Metastasis

Clinical Pearls A metastatic brain tumor means that the patient has stage IV cancer, with median survival of less than 1 year. When a patient presents with a new brain metastasis, without a known primary site, the chance of finding the primary tumor during the patient's lifetime is approximately 50%. As long as brain metastases undergo some form of treatment, the majority of patients will succumb…

High-Grade Gliomas

Clinical Pearls High-grade gliomas are malignant brain tumors with a median survival of 14 months with maximal therapy, and they are considered incurable. Mainstays of therapy include maximal safe surgical resection combined with adjuvant radiation and chemotherapy. Although previously controversial, most modern series support a benefit to extent of resection in high-grade glioma. Surgical adjuvants including fluorescence-guided resection, intraoperative magnetic resonance imaging, and intraoperative ultrasound can…

Low-Grade Gliomas

Open full size image Overview The term low-grade glioma (LGG) is used to describe World Health Organization (WHO) grade II gliomas, including diffuse astrocytomas, oligodendrogliomas, and oligoastrocytomas. Unlike high-grade gliomas, LGGs tend to grow slowly, but persistently, at roughly 3.5 mm per year. Although most of these tumors do not cause neurologic deficits at the time of diagnosis, they are locally invasive and frequently exhibit malignant degeneration…

Pediatric and Adult Scoliosis

Clinical Pearls The clinician must be alert for any evidence of underlying neurologic disease, including asymmetrical abdominal reflexes, abnormalities on neurologic examination, or a cavovarus foot deformity. On radiographs, hyperkyphosis over the apex of the curvature, an unusual curve pattern, marked trunk shift, a left thoracic curve, or lack of curve rotation may indicate an underlying neurologic condition. These patients should undergo magnetic resonance imaging (MRI).…

Degenerative Spinal Disease (Lumbar)

Clinical Pearls A detailed history and neurologic exam can be used to isolate the level at which the underlying pathology originated. Understanding the presenting symptoms can help one to appreciate the significance of the extent of degeneration present and therefore start to formulate the most efficient treatment plan. Nonoperative treatment is a feasible first course of action to address the clinical manifestations of new-onset degenerative spinal…

Degenerative Spinal Disease (Cervical)

Clinical Pearls Degeneration in the spine is a naturally occurring process that can be understood through the “three-joint complex,” which is composed of the intervertebral disk and the two dorsal articulating joints. Degeneration of any one joint leads to degeneration of the other two, initiating a cascade that leads to spinal degenerative disease. A detailed history and neurologic examination can be used to isolate the level…

Craniovertebral Junction: A Reappraisal

Clinical Pearls Atlantoaxial joint opening, manual manipulation of the facets, denuding of the articular cartilage, packing of bone graft into the joint cavity, and direct screw fixation of the facets of atlas and axis form a biomechanically strong mode of atlantoaxial stabilization and a background for segmental arthrodesis. Reduction of basilar invagination can be performed by distraction of the facets of atlas and axis in a…

Spinal Cord Injury

Clinical Pearls Spinal cord injuries (SCIs) have devastating impacts on patients in both developed and developing countries and are associated with tremendous long-term morbidity, mortality, and staggering financial costs. SCI is a medical emergency where rapid diagnosis, imaging, and treatment can provide lifelong functional benefits for patients. This requires a thorough clinical examination, expedited transfer to specialized spine care centers, and a working knowledge of all…

Management of Spinal Metastatic Tumors

Clinical Pearls Metastatic tumors to the spine mandate a multidisciplinary approach involving the surgeon, radiation oncologist, oncologist, and interventional radiologist. Patients presenting with metastatic tumors to the spine are stage 4 cancer patients, with poor systemic disease control. Management in these tumors is aimed at palliation rather than complete cure. Various options exist, and management is tailored according to the general condition of the patient, systemic…

Intradural Extramedullary and Intramedullary Spinal Cord Tumors

Clinical Pearls Intramedullary spinal cord tumors (IMSCTs) are challenging lesions that cause significant neurologic morbidity and mortality in patients of all ages. Gross total resection should be the mainstay of treatment, if possible, as survival is directly related to extent of resection in this subset of patients. Careful evaluation of imaging to distinguish between the various IMSCTs is essential, and if hemangioblastoma is a possible diagnosis,…

Thoracolumbar Spine Fractures

Clinical Pearls The thoracolumbar junction is a flexible transition region in the spine, susceptible to injury due to the transfer of kinetic energy. Clinicians should maintain a high suspicion of injury with thoracolumbar trauma because the incidence of a second vertebral fracture is 10% to 15%, and soft tissue injury may be as high as 50%. The most common mechanism of abdominal injuries is distraction or…