Cerebral gliomas are diffuse intrinsic primary brain tumors that are most commonly encountered in the frontal, temporal, and parietal lobes, and that can present with an array of symptoms including alterations in mental status, speech and language difficulties, motor or sensory abnormalities, and seizures. Maximal safe surgical debulking of the tumor reduces mass effect, provides a precise histological diagnosis, and facilitates genetic analysis that may shed light on the response to therapies and prognosis, reduces the oncological burden of the tumor facilitating the effectiveness of adjuvant treatments such as radiation and chemotherapy, and may reduce seizures. Preoperative and intraoperative cortical mapping strategies are used to delineate the relationship of the tumor with adjacent eloquent and association cortical areas to provide a maximal functionally safe surgical resection. This chapter describes the protocols used at our institution for the surgical management of patients with malignant gliomas in proximity to or involving eloquent cortical areas.
To evaluate the use of commercially available allogenic dural graft materials made of fetal bovine collagen, we present an analysis of our case series with use of autologous and allogenic graft materials. Patients who underwent surgical repair of a tegmen tympani defect associated with ipsilateral conductive hearing loss and cerebrospinal fluid (CSF) otorrhea using a middle cranial fossa (MCF) approach from 2004 to 2018 at Loyola University Medical Center were included. Resolution of CSF otorrhea, audiologic outcomes, facial nerve preservation, and surgical complications was analyzed. Thirty-three patients with an average age of 55.3 years (range: 21-78, standard deviation [SD]: 12.9) and body mass index of 34.4 (range: 22-51, SD: 7.4) underwent an MCF repair of a tegmen and dural defect. All patients presented with CSF otorrhea and conductive hearing loss ipsilateral to the defect. Repairs were made with combinations of allograft and autograft in 17 cases, allograft only in 15 cases, and autograft only in 5 cases. Improvement in hearing was noted in 33 cases, and resolution of CSF otorrhea was noted in 36 cases; one patient required repeat surgery which resolved CSF otorrhea. Three patients had minor complications; all these were in the autograft group. The MCF approach coupled with the use of fetal bovine collagen grafts is a safe and viable method to repair tegmen tympani and associated dural defects with salutary outcomes and low morbidity.
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