The Anterior (Endoscopic Endonasal) Approach and Outcomes for Foramen Magnum Tumors

Abstract Background Despite the use of vascularized intranasal flaps, endoscopic endonasal posterior fossa defects remain surgically challenging with high rates of postoperative cerebrospinal fluid leak. Objective The aim of the study is to describe a novel surgical technique that allows complete drilling of the clivus and exposure of the craniovertebral junction with preservation of the nasopharynx. Methods Two formalin-fixed latex-injected anatomical specimens were used to confirm feasibility of the technique. Two surgical approaches were used: sole endoscopic endonasal approach and transnasion approach. The sole endonasal approach was used in a patient with a petroclival meningioma. Results In both anatomical dissections, the inferior clivectomy with exposure of the foramen magnum was achieved with a sole endoscopic endonasal approach. The addition of the transnasion approach helped to complete drilling of the inferior border of the foramen magnum and exposure of the arch of C1. Conclusion This study shows the anatomical feasibility of total clivectomy and exposure of the craniovertebral junction with preservation of the nasopharynx. A more favorable anatomical posterior fossa defect for the reconstruction is achieved with this technique. Further clinical studies are needed to assess if this change would impact the postoperative CSF leak rate.

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Endoscopic Endonasal Approach to Foramen Magnum Meningioma: Two-Dimensional Surgical Video

World Neurosurgery ◽

10.1016/j.wneu.2020.02.026 ◽

2020 ◽

Vol 137 ◽

pp. 362

Author(s):

Raíssa Mansilla ◽

Daniel Monte Serrat Prevedello ◽

Lázaro de Lima ◽

Ricardo L. Carrau ◽

José Alberto Landeiro

Keyword(s):

Foramen Magnum ◽

Two Dimensional ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Surgical Video

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Endoscopic Endonasal Approach to Foramen Magnum Meningioma—Technical Note and Case Example

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1673428 ◽

2018 ◽

Vol 37 (04) ◽

pp. 362-366

Author(s):

Flavio Romero ◽

Rodolfo Vieira ◽

Bruno Ancheschi

Keyword(s):

Cranial Nerves ◽

Craniocervical Junction ◽

Foramen Magnum ◽

Technical Note ◽

Open Approach ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Midline Approach ◽

Lower Cranial Nerves

AbstractForamen magnum (FM) tumors represent one of the most complex cases for the neurosurgeon, due to their location in a very anatomically complex region surrounded by the brainstem and the lower cranial nerves, by bony elements of the craniocervical junction, and by the vertebrobasilar vessels. Currently, the open approach of choice is a lateral extension of the posterior midline approach including far lateral, and extreme lateral routes. However, the transoraltranspharyngeal approach remains the treatment of choice in cases of diseases affecting the craniocervical junction. For very selective cases, the endoscopic endonasal route to this region is another option. We present a case of a ventral FM meningioma treated exclusively with the endoscopic endonasal approach.

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Atlanto-occipital Instability Following Endoscopic Endonasal Approach for Lower Clival Lesions

Neurosurgery ◽

10.1227/neu.0000000000000922 ◽

2015 ◽

Vol 77 (6) ◽

pp. 888-897 ◽

Cited By ~ 17

Author(s):

Ali Kooshkabadi ◽

Phillip A. Choi ◽

Maria Koutourousiou ◽

Carl H. Snyderman ◽

Eric W. Wang ◽

...

Keyword(s):

Foramen Magnum ◽

Open Approach ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Combined Approach ◽

Endoscopic Endonasal ◽

Primary Bone Tumors ◽

Far Lateral Approach ◽

Lower Clivus ◽

Occipital Condyles

BACKGROUND: The endoscopic endonasal approach (EEA) for craniocervical lesions involving the lower clivus and occipital condyles carries an unclear risk of atlanto-occipital (AO) instability requiring arthrodesis. OBJECTIVE: Elucidate risk factors for AO instability following EEA for clival lesions. METHODS: We reviewed patients with clival tumors who underwent EEA at our institution between 2002 and 2012. Resection of the lower clivus, foramen magnum, AO joint, and occipital condyles were evaluated on fine-cut postoperative computed tomography. RESULTS: Two hundred twelve patients (mean age 47.9 years, 57.1% male) underwent transclival EEA for lower clival lesions. In addition to the lower clivus, resection involved the condyle in 14.2% of patients, the foramen magnum in 16.5%, and the AO joint in 1.4%. Quantification of condyle resection revealed complete resection in 3 cases, 75% resection in 8 cases, 50% resection in 6 cases, and 25% resection in 13 cases. Seven of these patients had EEA combined with an open, far-lateral approach. In total, 7 patients required arthrodesis following EEA (3.3%), 4 of them after a combined approach. All patients who underwent arthrodesis had primary bone tumors such as chordoma, chondrosarcoma, or osteosarcoma (P = .022). Degree of condyle resection was a significant factor predisposing to occipitocervical instability (P = .001 and P < .001 for 75% and 100% condyle resection, respectively). Use of a combined approach was significantly associated with arthrodesis (P < .001). CONCLUSION: EEA resection of the occipital condyles that results in greater than 75% condyle resection or EEA in combination with an open approach significantly increases the risk of AO instability and likely necessitates AO fixation.

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The Endoscopic Endonasal Approach to the Inferior Clivus and Foramen Magnum: Anatomical Landmarks in the Surgical Window

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0035-1546720 ◽

2015 ◽

Vol 76 (S 01) ◽

Author(s):

Satyan Sreenath ◽

Benjamin McClintock ◽

Benjamin Huang ◽

Kibwei McKinney ◽

Brian Thorp ◽

...

Keyword(s):

Foramen Magnum ◽

Anatomical Landmarks ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

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The Caudal Expanded Endonasal Approach: A Fully Endoscopic Endonasal Approach for Resection of Lower Clival, Foramen Magnum, and Atlantoaxial Pathologies

Skull Base ◽

10.1055/s-2006-958365 ◽

2007 ◽

Vol 16 (S 1) ◽

Author(s):

Amin Kassam ◽

Paul Gardner ◽

Carl Snyderman ◽

Ricardo Carrau ◽

Richard Spiro

Keyword(s):

Foramen Magnum ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Expanded Endonasal Approach

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Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations

Neurosurgical FOCUS ◽

10.3171/foc.2005.19.1.3 ◽

2005 ◽

Vol 19 (1) ◽

pp. 1-14 ◽

Cited By ~ 24

Author(s):

Luigi M. Cavallo ◽

Andrea Messina ◽

Paolo Cappabianca ◽

Felice Esposito ◽

Enrico de Divitiis ◽

...

Keyword(s):

Skull Base ◽

Dura Mater ◽

Cranial Nerves ◽

Foramen Magnum ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Lateral Direction ◽

Endoscopic Endonasal ◽

Fresh Cadaver ◽

Csf Leakage

Object The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens. Methods To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach. Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable. Conclusions The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach. Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

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EXPANDED ENDOSCOPIC ENDONASAL APPROACH FOR ANTERIOR CRANIAL BASE AND SUPRASELLAR LESIONS

Neurosurgery ◽

10.1227/01.neu.0000339121.20101.85 ◽

2009 ◽

Vol 64 (4) ◽

pp. 677-689 ◽

Cited By ~ 175

Author(s):

Amir R. Dehdashti ◽

Ahmed Ganna ◽

Ian Witterick ◽

Fred Gentili

Keyword(s):

Visual Disturbance ◽

Neurological Complications ◽

Cranial Base ◽

Foramen Magnum ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Brain Invasion ◽

Anterior Cranial Base ◽

Total Tumor Removal

Abstract OBJECTIVE The traditional boundaries of the transsphenoidal approach can be expanded to include the region from the cribriform plate of the anterior cranial fossa to the foramen magnum in the anteroposterior plane. The introduction of endoscopy to transsphenoidal surgery, with its improved illumination and wider field of view, has added significant further potential for the resection of a variety of cranial base lesions. We review our experience with the expanded endoscopic endonasal approach in a series of 22 patients with anterior cranial base and supradiaphragmatic lesions. METHODS From June 2005 to June 2007, the expanded endoscopic endonasal approach was used in 22 patients with the following pathologies: 6 craniopharyngiomas; 4 esthesioneuroblastomas; 3 giant pituitary macroadenomas; 2 suprasellar Rathke's pouch cysts; 2 angiofibromas; and 1 each of suprasellar meningioma, germinoma, ethmoidal carcinoma, adenoid cystic carcinoma, and large suprasellar arachnoid cyst. This study specifically focused on the surgical indications and approaches to these lesions and the surgical results, complications, and limitations associated with this technique. RESULTS Gross total tumor removal, as assessed by postoperative magnetic resonance imaging, was possible in the majority of patients (73%), with the exception of the craniopharyngioma group, in which only 1 lesion was completely removed. There were no permanent neurological complications except for increased visual disturbance in 1 patient. Other complications included cerebrospinal fluid fistulae in 4 patients (18%) and meningitis in 1 patient (5%). There was no operative mortality. Large lesions, significant lateral extension, encasement of neurovascular structures, and brain invasion in malignant lesions are considered some of the contraindications for this technique. CONCLUSION The expanded endoscopic endonasal approach is a promising minimally invasive alternative to open transcranial approaches for selective lesions of the midline anterior cranial base. The avoidance of craniotomy and brain retraction and reduced neurovascular manipulation with less morbidity are potential advantages. Major complications have been few, but there are also limitations with this technique. This approach should be included in the armamentarium of cranial base surgeons and considered as an option in the management of selected patients with these complex pathologies.

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