Indications and Limitations of the Endoscopic Endonasal Approach for Anterior Cranial Base Meningiomas

ABSTRACT OBJECTIVE The endonasal route may be feasible for the resection of anterior cranial base tumors that abut the paranasal sinuses. There are several case reports and mixed case series discussing this approach. Other than pituitary adenomas, there is a lack of literature describing the outcomes of endonasal approaches for single-tumor types such as meningiomas. METHODS In this study, we describe our current endoscopic endonasal technique and demonstrate the feasibility of using it to access anterior cranial base meningiomas from the back wall of the frontal sinus to the sella and laterally to the region of the midorbit. After this discussion, which includes key technical considerations and nuances, we address safety and efficacy by reporting the outcomes of our early experience with endoscopic endonasal resection of 35 anterior cranial base meningiomas. RESULTS A total of 35 patients underwent endoscopic endonasal resection of anterior cranial base meningiomas from October 2002 to October 2005. Degree of resection by tumor location was as follows: 10 of the 12 (83%) patients with olfactory groove meningiomas planned for complete resection underwent gross total (seven of 12) or near-total (>95%) (three of 12) resection (67% of all 15 olfactory tumors); 12 of 13 patients (92%) with tuberculum meningiomas underwent gross (11 of 13) or near (>95%) (one of 13) total resection; five patients diagnosed with petroclival meningiomas had successful resection of the parasellar portion of their tumors with relief of visual symptoms (no patients underwent complete resection of their tumors via the endoscopic, endonasal approach); two giant petroclival meningiomas were debulked with 63 and 89% resection, respectively. All patients experienced resolution or improvement of visual symptoms. No patient experienced permanent worsening of vision after surgery. Only one (3%) patient without preoperative endocrine dysfunction experienced a new, permanent pituitary deficit, diabetes insipidus. One (3%) patient experienced a new neurological deficit after experiencing a hemorrhage 3 weeks after surgery. The postoperative cerebrospinal fluid leak rate was 40% (14 of 35) and varied by tumor location. All leaks were resolved without craniotomy. There were no cases of bacterial meningitis. One patient developed a superinfection of a sterile granuloma from a sinusitis 2 years after surgery. There were two cases of deep venous thrombosis and one pulmonary embolus. There were no operative or perioperative deaths. CONCLUSION Cranial base meningiomas can be successfully managed via a purely endoscopic endonasal approach with acceptable morbidity and mortality rates. The extent of resection is guided by patient factors and symptoms, not by approach. This series had a high cerebrospinal fluid leak rate. With the evolution of new reconstruction techniques, these rates have been substantially reduced.

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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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Endoscopic Endonasal Approach for Resection of Cranial Base Chordomas

Neurosurgery ◽

10.1227/neu.0b013e31825ea3e0 ◽

2012 ◽

Vol 71 (3) ◽

pp. 614-625 ◽

Cited By ~ 122

Author(s):

Maria Koutourousiou ◽

Paul A. Gardner ◽

Matthew J. Tormenti ◽

Stephanie L. Henry ◽

Susan T. Stefko ◽

...

Keyword(s):

Cerebrospinal Fluid Leak ◽

Neurological Complications ◽

Tumor Location ◽

Cranial Base ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Success Rates ◽

Endoscopic Endonasal ◽

Previously Treated Patients ◽

Previously Treated

Abstract BACKGROUND: Gross total resection (GTR) of cranial base chordomas represents a surgical challenge because of the location, invasiveness, and tumor extension. In the past decade, the endoscopic endonasal approach (EEA) has been used with notable outcomes. OBJECTIVE: To present the endoscopic endonasal experience in the treatment of cranial base chordomas at our institution. METHODS: From April 2003 to March 2011, 60 patients underwent an EEA for primary (n = 35) or previously treated (n = 25) cranial base chordomas. We evaluated the degree of GTR and complications. We studied the factors that influenced outcomes and compared our surgical results in the early and late years of our experience. RESULTS: The overall rate of GTR of cranial base chordomas was 66.7% (82.9% in primary and 44% in previously treated patients). The most important limitations for GTR were tumor volume greater than 20 cm3 (P = .042), tumor location in the lower clivus with lateral extension (P = .022), and previously treated disease (P = .002). The learning curve had a significant impact on GTR, increasing the success rate to 88.9% (92.6% in primary patients and 63.6% in previously treated patients) during recent years (P < .0001). The most frequent complication was cerebrospinal fluid leak (20%) resulting in meningitis in 3.3%. Carotid injuries occurred in 2 patients without any resulting deficit. Neurological complications included new cranial neuropathies (6.7%) and long tract deficits (1.7%). There was no operative mortality in our series. CONCLUSION: For the treatment of cranial base chordomas, the EEA is a competitive alternative to transcranial approaches with minimal morbidity and high success rates of GTR when performed by experienced cranial base surgeons.

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Endonasal management of pediatric congenital transsphenoidal encephaloceles: nuances of a modified reconstruction technique. Technical note and report of 3 cases

Journal of Neurosurgery Pediatrics ◽

10.3171/2016.10.peds16270 ◽

2017 ◽

Vol 19 (3) ◽

pp. 312-318 ◽

Cited By ~ 9

Author(s):

Mehdi Zeinalizadeh ◽

Seyed Mousa Sadrehosseini ◽

Zohreh Habibi ◽

Farideh Nejat ◽

Harley Brito da Silva ◽

...

Keyword(s):

Surgical Treatment ◽

Failure To Thrive ◽

Cranial Base ◽

Technical Note ◽

Reconstruction Technique ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Titanium Mesh ◽

Endoscopic Endonasal ◽

Management Algorithm

OBJECTIVE Congenital transsphenoidal encephaloceles are rare malformations, and their surgical treatment remains challenging. This paper reports 3 cases of transsphenoidal encephalocele in 8- to 24-month-old infants, who presented mainly with airway obstruction, respiratory distress, and failure to thrive. METHODS The authors discuss the surgical management of these lesions via a minimally invasive endoscopic endonasal approach, as compared with the traditional transcranial and transpalatal approaches. A unique endonasal management algorithm for these lesions is outlined. The lesions were repaired with no resection of the encephalocele sac, and the cranial base defects were reconstructed with titanium mesh plates and vascular nasoseptal flaps. RESULTS Reduction of the encephalocele and reconstruction of the skull base was successfully accomplished in all 3 cases, with favorable results. CONCLUSIONS The described endonasal management algorithm for congenital transsphenoidal encephaloceles is a safe, viable alternative to traditional transcranial and transpalatal approaches, and avoids much of the morbidity associated with these open techniques.

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ENDOSCOPIC ENDONASAL APPROACH FOR CLIVAL CHORDOMAS

Neurosurgery ◽

10.1227/01.neu.0000338071.01241.e2 ◽

2009 ◽

Vol 64 (2) ◽

pp. 268-278 ◽

Cited By ~ 177

Author(s):

Martina Stippler ◽

Paul A. Gardner ◽

Carl H. Snyderman ◽

Ricardo L. Carrau ◽

Daniel M. Prevedello ◽

...

Keyword(s):

Systematic Review ◽

Medical Center ◽

Neurological Complication ◽

Cranial Base ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Review Of The Literature ◽

Endoscopic Endonasal ◽

Invasive Approach

Abstract OBJECTIVE Cranial base chordomas are difficult lesions to treat. The endoscopic endonasal approach (EEA) takes advantage of the natural sinus corridor and may provide a less invasive approach for these midline tumors. METHODS Patients undergoing EEA for chordomas were selected from a database of more than 800 consecutive patients undergoing EEA at the University of Pittsburgh Medical Center and were retrospectively evaluated. Additionally, a systematic review of the literature of endoscopic endonasally resected chordomas was performed and compared with our personal experience. RESULTS Twenty patients (8 females and 12 males) underwent 26 endoscopic EEAs for cranial base chordomas. Eight chordomas (40%) were recurrent. Treatment of the 12 newly diagnosed chordomas included 8 total resections (66.7%), 2 near total resections (16.7%), and 2 subtotal resections (16.7%). Treatment of the 8 recurrent chordomas included 1 gross total resection (12.5%), 2 near total resections (25.0%), and 5 subtotal resections (62.5%). Two patients (10%) had recurrences, and 5 patients (25%) progressed during the mean follow-up period of 13 months (range, 1–45 months). Five patients (25%) underwent re-resection, 1 patient was lost to follow-up, and 1 patient died secondary to progression of disease. There was 1 intraoperative vascular complication with no sequelae. The cerebrospinal fluid leak rate was 25%, and there were no cases of bacterial meningitis. The incidence of a new permanent neurological complication was 5%. A systematic review of the literature yielded a total of 26 cases of chordomas resected via a completely endoscopic endonasal technique. CONCLUSION Endoscopic endonasal resection of cranial base chordomas is safe once adequate experience is gained with the technique. This approach provides the potential for, at the least, similar resections compared with traditional cranial base approaches while potentially limiting morbidity.

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