ELSEVIER Technical Note BRAIN STEM COMPRESSION SECONDARY TO ADIPOSE GRAFT PROLAPSE AFTER TRANSPETROSAL APPROACH: CASE REPORT Aldo Spallone, M.D.* and Antonella Rizzo, M.D.** *University of Rome “TOY Vergata” and **Clinica Nuova Latina, Rome, Italy SpalloneA, RizzoA. Brain stem compression secondary to adi- pose graft prolapse after transpetrosal approach: case report. Surg Neural 1997;48:80-4. A case of fat graft prolapse into the prepontine cistern with clinical deterioration is presented. The patient had undergone a transpetrosal approach for a very large cra- niopharyngioma and had autologous thigh fat strips to obliterate the mastoid cavity: postoperatively she suf- fered an important deterioration from adipose graft pro- lapse. Clinical presentation, MRI findings, treatment, and avoidance of this complication are discussed. 0 1997 by Elsevier Science Inc. KEY WORDS Craniopharyngioma, skrrlt base surgery, fat gratt prolapse, CSFleak, magnetic resonance. A dipose tissue grafts are, as a rule, utilized for filling air containing sinuses after cranial base surgery to prevent CSF leak [8]. Complications of fat graft include: necrosis (usu- ally if the fat graft is too large), infection, epidural hematoma, and prolapse. As far as the latter is concerned, this appears to be a rather rare, though potentially disastrous occurrence following cranial base surgery. A review of the literature disclosed only four cases of brain stem compression with clinical deterioration secondary to adipose graft prolapse after cranial base surgery [ 1,9]. We present a case of adipose graft prolapse after a transpetrosal approach for a giant craniopharyn- gioma. Address reprint requests to: Aldo SpaIlone, M.D., Dept. of Neurosurgery, 2nd University of Rome, “Tor Vergata,” Via 0. Rahnondo 8, 00173 Rome, Italy. Received June 9, 1995; accepted March 13, 1996. 00903019/97/$17.00 PI1 SOO90-3019(96)00212-l CASEREPORT A 23-year-old, right-handed woman was admitted with a lo-year history of left sided headache, to which more recently left temporal hemianopsi, dys- menorrhea, polyuria, polydipsia, and epileptic sei- zures had been added. Preoperative examination revealed left temporal hemianopia. EEG showed occasional spikes in the left temporal region. An MRI of the brain was performed, which re- vealed a large intradural craniobasal tumor, that appeared hyperintense in both T, and T,-sequences and did not change after i.v. Gadolinium-EDTA. The tumor extended from prepontine, suprachiasmatic cisterns, and middle cranial fossa from both sides, more on the left, and to the right cerebellopontine angle (Figure 1). Pancerebral angiography showed only vessel displacement related to the mass. The patient underwent operation via a left trans- petrosal approach. This rather unusual approach for the pathology in point was chosen because of anatomosurgical considerations related to the ac- tual location and the size of the lesion. The petrous bone was drilled including the petrous apex; how- ever with full respect for the semicircular canals and the auditory apparatus. The tumor was subto- tally removed, with the exception of a calcified frag- ment encircling the left posterior communicating artery. Pathology revealed a craniopharyngioma. Brain retraction was almost unnecessary during this long (11 hours) procedure, and all the sur- rounding structures were fully respected. The third and fourth left cranial nerves had to be extensively dissected away from the tumor capsule. At the end of the procedure, the dura was loosely reapproxi- 0 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010