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Abstract Background and Importance Tegmen defects associated with cerebrospinal fluid (CSF) leaks are a rare pathology that can result in severe complications if left untreated. There is no universal optimal surgical algorithm for repair, although the most common techniques are the middle fossa craniotomy (traditionally 25 cm2 in area), the transmastoid approach, or both. Here, we describe successful use of a keyhole mini-craniotomy, only 6 cm2 in area, without mastoidectomy or days of lumbar drainage. Clinical Presentation Three patients presented with right-sided CSF otorrhea and hearing loss, with varying sizes of tegmen defects and associated encephaloceles. Keyhole craniotomies measuring 3 × 2 cm were used to perform a multilayer repair comprising an intradural collagen dural substitute, extradural fascial graft, extradural collagen dural substitute, fibrin sealant, and sometimes bony reconstruction using partial thickness craniotomy grafting. All patients were discharged on postoperative day 1 or 2, with no recurrence of symptoms at 6 months. Conclusion The keyhole craniotomy approach does not sacrifice the extent of operative access for this pathology. This minimally invasive approach can likely be used more often without need for concomitant mastoidectomy, ultimately enabling shorter hospital stays and more rapid recovery. 

OBJECTIVECranial nerve (CN) preservation remains a challenge for skull base neurosurgeons, and neurophysiological intraoperative monitoring presents many methods for CN identification and mapping. The blink reflex, which is the electrophysiological representation of the corneal reflex, can be used to test both trigeminal and facial nerve function. The objective of this study was to present a method for obtaining a reliable blink reflex response and maintaining it during the course of a procedure. METHODSA method for robust blink reflex recording is presented. Electrode placement, recording parameters, stimulation parameters, anesthetic considerations, and reliability troubleshooting are described. RESULTSThis method has been iteratively developed at the authors’ institution across multiple sites for more than 5 years. The blink reflex was monitored in multiple cranial approaches and for various pathologies. The most common cases monitored were vestibular schwannoma resections and microvascular decompressions. The most common cranial approaches were the translabyrinthine, retrosigmoid/suboccipital, and middle cranial fossa approaches. CONCLUSIONSTo gain a more comprehensive understanding of the clinical utility of the blink reflex in surgical decision-making and outcome prediction, prospective studies involving larger patient cohorts are warranted. This report outlines a reproducible methodology and invites validation and constructive input from the broader neurosurgical and neuromonitoring communities.