scholarly journals Endoscopic Endonasal Transplanum Transtuberculum Approach for the Resection of a Large Suprasellar Craniopharyngioma

2018 ◽  
Vol 79 (S 03) ◽  
pp. S249-S250
Author(s):  
João Mangussi-Gomes ◽  
Eduardo Vellutini ◽  
Huy Truong ◽  
Felix Pahl ◽  
Aldo Stamm
Keyword(s):  
Skull Base ◽  
Male Patient ◽  
Single Case ◽  
Tumor Resection ◽  
Magnetic Resonance Images ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Cystic Component ◽  
Tertiary Center ◽  
Neurovascular Structures

Objectives To demonstrate an endoscopic endonasal transplanum transtuberculum approach for the resection of a large suprasellar craniopharyngioma. Design Single-case-based operative video. Setting Tertiary center with dedicated skull base team. Participants A 72-year-old male patient diagnosed with a suprasellar craniopharyngioma. Main Outcomes Measured Surgical resection of the tumor and preservation of the normal surrounding neurovascular structures. Results A 72-year-old male patient presented with a 1-year history of progressive bitemporal visual loss. He also referred symptoms suggestive of hypogonadism. Neurological examination was unremarkable and endocrine workup demonstrated mildly elevated prolactin levels. Magnetic resonance images demonstrated a large solid-cystic suprasellar lesion, consistent with the diagnosis of craniopharyngioma. The lesion was retrochiasmatic, compressed the optic chiasm, and extended into the interpeduncular cistern (Fig. 1). Because of that, the patient underwent an endoscopic endonasal transplanum transtuberculum approach.1 2 3 The nasal stage consisted of a transnasal transseptal approach, with complete preservation of the patient's left nasal cavity.4 The cystic component of the tumor was decompressed and its solid part was resected. It was possible to preserve the surrounding normal neurovascular structures (Fig. 2). Skull base reconstruction was performed with a dural substitute, a fascia lata graft, and a right nasoseptal flap (Video 1). The patient did well after surgery and referred complete visual improvement. However, he also presented pan-hypopituitarism on long-term follow-up. Conclusions The endoscopic endonasal route is a good alternative for the resection of suprasellar lesions. It permits tumor resection and preservation of the surrounding neurovascular structures while avoiding external incisions and brain retraction.The link to the video can be found at: https://youtu.be/zmgxQe8w-JQ.

scholarly journals Sellar trough technique for endoscopic endonasal transclival repair

2020 ◽  
Vol 11 ◽  
pp. 99
Author(s):  
Andrew K. Wong ◽  
Joseph Raviv ◽  
Ricky H. Wong
Keyword(s):  
Skull Base ◽  
Tumor Resection ◽  
Spinal Fluid ◽  
Direct Access ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Ventral Skull Base ◽  
Fluid Leak ◽  
The Brain

Background: Endoscopic endonasal transclival approaches provide direct access to the ventral skull base allowing the treating of clival and paraclival pathology without the manipulation of the brain or neurovascular structures. Postoperative spinal fluid leak, however, remains a challenge and various techniques have been described to reconstruct the operative defect. The “gasket seal” has been well-described, but has anatomic challenges when applied to clival defects. We describe a modification of this technique for use in endonasal transclival approaches. Methods: Two patients who underwent an endoscopic endonasal transclival approach for tumor resection with an intraoperative spinal fluid leak underwent a modified “gasket seal” closure technique for skull base reconstruction. Results: A 71-year-old woman with a petroclival meningioma and a 22 year old with a clival chordoma underwent endoscopic endonasal transclival resection with the modified repair. No new postoperative deficits occurred and no postoperative spinal fluid leak was seen with a follow-up of 17 and 23 months, respectively. Conclusion: We describe the successful use of a simple, low risk, and technique modification of the “gasket seal” technique adapted to the clivus that allows for hard reconstruction and facilitates placement of the nasoseptal flap.

scholarly journals Extended Endoscopic Endonasal Approach for Suprasellar Craniopharyngioma

2018 ◽  
Vol 79 (S 02) ◽  
pp. S196-S198 ◽  
Author(s):  
D. Locatelli ◽  
F. Pozzi ◽  
G. Agresta ◽  
S. Padovan ◽  
A. Karligkiotis ◽  
...  
Keyword(s):  
Skull Base ◽  
Third Ventricle ◽  
Neurological Status ◽  
University Hospital ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Cystic Component ◽  
Suprasellar Region

Objectives We illustrate a suprasellar craniopharyngiomas treated with an extended endoscopic endonasal approach (EEEA). Design Case report of a 43-year-old male affected by cerebral lesion located in suprasellar region involving the third ventricle and compressing the neurovascular structures, causing an anterosuperior dislocation of the chiasma. There is a complete disruption of the pituitary stalk that can explain the clinical finding of partial anterior hypopituitarism and hyperprolactinemia. The lesion is characterized by a solid and cystic component. Considering the absence of lateral extension and the suprasellar location of the lesion, an EEEA is preferred. Setting University Hospital “Ospedale di Circolo,” Department of Neurosurgery, Varese, Italy. Participants Neurosurgical and ENT Skull Base Team. Main Outcome Measures A bilateral parasagittal approach is performed using a four-hand technique. The first step of the surgery is the preparation of the Hadad's flap. The approach is extended to the planum sphenoidalis to expose the suprasellar region. The lesion is completely removed employing also an ultrasound aspirator. Skull base reconstruction is performed with three-layer technique: graft of fat tissue, fascia lata, and nasoseptal flap. Results No postoperative complications occurred. In the post-op, the patient presents a panhypopituitarism and an improvement in neurological status. The visual deficit remains stable. Post-op magnetic resonance imaging at 1 year documents the complete absence of pathological contrast enhancement. Conclusions EEEA is a feasible approach in treating craniopharyngioma with suprasellar extension. The advantages include optimal visualization, good resection rate, and absence of brain retraction.The link to the video can be found at: https://youtu.be/IYm-8P1jbBo.

scholarly journals Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma

2021 ◽  
Author(s):  
Gianluca Agresta ◽  
Alberto Campione ◽  
Fabio Pozzi ◽  
Pierlorenzo Veiceschi ◽  
Martina Venturini ◽  
...  
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Conformal Radiotherapy ◽  
Residual Tumor ◽  
Complete Recovery ◽  
Tumor Location ◽  
Transsphenoidal Approach ◽  
Low Grade ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction

Abstract Objective We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach. Design Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots (Fig. 1). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy. Setting The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy. Participants Skull base team was participated in the study. Main Outcome Measures A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus (Fig. 2) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap. Results No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus (Fig. 1). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion. Conclusion Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved.The link to the video can be found at: https://youtu.be/TsqXjqpuOws.

Anatomic Considerations of Microvascular Free Tissue Transfer in Endoscopic Endonasal Skull Base Surgery

2021 ◽  
Author(s):  
Leila J. Mady ◽  
Thomas M. Kaffenberger ◽  
Khalil Baddour ◽  
Katie Melder ◽  
Neal R. Godse ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Free Tissue Transfer ◽  
Level Of Evidence ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Recipient Vessel ◽  
Tissue Transfer ◽  
Anterior Cranial Base ◽  
Pedicle Length

Abstract Objective Though microvascular free tissue transfer is well established for open skull base reconstruction, normative data regarding flap design and inset after endoscopic endonasal skull base surgery (ESBS) is lacking. We aim to describe anatomical considerations of endoscopic endonasal inset of free tissue transfer of transclival (TC) and anterior cranial base resection (ACBR) defects. Design and Setting Radial forearm free tissue transfer (RFFTT) model. Participants Six cadaveric specimens. Main Outcome Measures Pedicle orientation, pedicle length, and recipient vessel intraluminal diameter. Results TC and ACBR defects averaged 17.2 and 11.7 cm2, respectively. Anterior and lateral maxillotomies and endoscopic medial maxillectomies were prepared as corridors for flap and pedicle passage. Premasseteric space tunnels were created for pedicle tunneling to recipient facial vessels. For TC defects, the RFFTT pedicle was oriented cranially with the flap placed against the clival defect (mean pedicle length 13.1 ± 0.6 cm). For ACBR defects, the RFFTT pedicle was examined in three orientations with respect to anterior–posterior axis of the RFFTT: anteriorly, posteriorly, and laterally. Lateral orientation offered the shortest average pedicle length required for anastomosis in the neck (11.6 ± 1.29 cm), followed by posterior (13.4 ± 0.7cm) and anterior orientations (14.4 ± 1.1cm) (p < 0.00001, analysis of variance). Conclusions In ACBR reconstruction using RFFTT, our data suggests lateral pedicle orientation shortens the length required to safely anastomose facial vessels and protects the frontal sinus outflow anteriorly while limiting pedicle exposure through a maxillary corridor within the nasal cavity. With greater understanding of anatomical factors related to successful preoperative flap planning, free tissue transfer may be added to the ESBS reconstruction ladder. Level of Evidence NA

Combined endoscopy-assisted cranionasal approach for resection of infantile myofibromatosis of the ethmoid and anterior skull base

2008 ◽  
Vol 2 (1) ◽  
pp. 58-62 ◽  
Author(s):  
Ercole Galassi ◽  
Ernesto Pasquini ◽  
Giorgio Frank ◽  
Gianluca Marucci
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Radical Resection ◽  
Permanent Tooth ◽  
Anterior Skull Base ◽  
Facial Growth ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Endoscopic Techniques ◽  
Tooth Roots

The advent and widespread development of endonasal endoscopic techniques have recently expanded the frontiers of skull base surgery. The reduced invasiveness, wider and adjustable visualization of the operative field, and lack of postoperative cosmetic defects are well-known advantages of the endonasal endoscopic approaches compared with traditional surgical exposures both in adults and in children. The need to avoid disruption of facial growth centers and permanent tooth roots represents a further special consideration in favor of these endoscopic techniques in children. The authors report on a case of solitary myofibroma involving the ethmoid, mesial orbits, and anterior skull base with intracranial intradural expansion in a 17-month-old girl. The occurrence of such proliferative disease along the skull base is exceedingly rare. The tumor was successfully excised via an endoscopy-assisted cranionasal approach in which a transcranial microsurgical exposure was combined with endonasal endoscopic access to ensure a radical resection and optimize skull base reconstruction. To the authors' knowledge, the patient in this case is the youngest reported patient in the literature who has undergone treatment with this surgical strategy. The outcome in this patient underscores the feasibility and safety of endoscopic endonasal surgery even in toddlers and early childhood.

scholarly journals Use of Collagen Matrix for Skull Base Reconstruction following Endoscopic Endonasal Resection of Pituitary Adenoma

2018 ◽  
Vol 79 (S 01) ◽  
pp. S1-S188
Author(s):  
Alaa Montaser ◽  
Mostafa Shahein ◽  
Juan Revuelta Barbero ◽  
Guillermo Malve ◽  
Alexandre Todeschini ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Skull Base ◽  
Collagen Matrix ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction

scholarly journals Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

2019 ◽  
Vol 81 (06) ◽  
pp. 645-650
Author(s):  
Roshni V. Khatiwala ◽  
Karthik S. Shastri ◽  
Maria Peris-Celda ◽  
Tyler Kenning ◽  
Carlos D. Pinheiro-Neto
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Fascia Lata ◽  
High Flow ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Csf Diversion ◽  
Csf Leaks

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

scholarly journals Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Maria Belen Vega ◽  
Philippe Lavigne ◽  
Vanessa Hernandez-Hernandez ◽  
Aldo Eguiluz-Menendez ◽  
Eric Wang ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Free Flaps ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Skull Base Defects

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

scholarly journals Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

2014 ◽  
Vol 37 (4) ◽  
pp. E13 ◽  
Author(s):  
Paulo M. Mesquita Filho ◽  
Leo F. S. Ditzel Filho ◽  
Daniel M. Prevedello ◽  
Cristian A. N. Martinez ◽  
Mariano E. Fiore ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Cerebellopontine Angle ◽  
Tumor Resection ◽  
Petrous Bone ◽  
Petrous Apex ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Female Ratio ◽  
Male Female Ratio

Object Skull base chondrosarcomas are slow-growing, locally invasive tumors that arise from the petroclival synchondrosis. These characteristics allow them to erode the clivus and petrous bone and slowly compress the contents of the posterior fossa progressively until the patient becomes symptomatic, typically from cranial neuropathies. Given the site of their genesis, surrounded by the petrous apex and the clival recess, these tumors can project to the middle fossa, cervical area, and posteriorly, toward the cerebellopontine angle (CPA). Expanded endoscopic endonasal approaches are versatile techniques that grant access to the petroclival synchondrosis, the core of these lesions. The ability to access multiple compartments, remove infiltrated bone, and achieve tumor resection without the need for neural retraction makes these techniques particularly appealing in the management of these complex lesions. Methods Analysis of the authors’ database yielded 19 cases of skull base chondrosarcomas; among these were 5 cases with predominant CPA involvement. The electronic medical records of the 5 patients were retrospectively reviewed for age, sex, presentation, pre- and postoperative imaging, surgical technique, pathology, and follow-up. These cases were used to illustrate the surgical nuances involved in the endonasal resection of CPA chondrosarcomas. Results The male/female ratio was 1:4, and the patients’ mean age was 55.2 ±11.2 years. All cases involved petrous bone and apex, with variable extensions to the posterior fossa and parapharyngeal space. The main clinical scenario was cranial nerve (CN) palsy, evidenced by diplopia (20%), ptosis (20%), CN VI palsy (20%), dysphagia (40%), impaired phonation (40%), hearing loss (20%), tinnitus (20%), and vertigo/dizziness (40%). Gross-total resection of the CPA component of the tumor was achieved in 4 cases (80%); near-total resection of the CPA component was performed in 1 case (20%). Two patients (40%) harbored high-grade chondrosarcomas. No patient experienced worsening neurological symptoms postoperatively. In 2 cases (40%), the symptoms were completely normalized after surgery. Conclusions Expanded endoscopic endonasal approaches appear to be safe and effective in the resection of select skull base chondrosarcomas; those with predominant CPA involvement seem particularly amenable to resection through this technique. Further studies with larger cohorts are necessary to test these preliminary impressions and to compare their effectiveness with the results obtained with open approaches.

Reconstruction of the skull base after tumor resection: an overview of methods

2002 ◽  
Vol 12 (5) ◽  
pp. 1-5 ◽  
Author(s):  
James K. Liu ◽  
Zahid Niazi ◽  
William T. Couldwell
Keyword(s):  
Skull Base ◽  
Malignant Tumors ◽  
Tumor Resection ◽  
Infectious Complications ◽  
Skull Base Tumors ◽  
Skull Base Reconstruction ◽  
Life Threatening ◽  
Dural Defects ◽  
Reconstructive Techniques ◽  
Do So

Successful surgical management of malignant skull base tumors depends on both tumor resection and reconstruction of the cranial base defect. The primary goals of skull base reconstruction are to repair dural defects, to prevent the development of cerebrospinal fluid fistulas, and to provide a protective barrier that isolates the intracranial contents from the nasopharynx and paranasal sinuses. Failure to do so can result in potentially life-threatening infectious complications. With modern skull base and reconstructive techniques, malignant tumors in this region, which were once deemed inoperable, can now be safely removed. The authors review the different modalities available for skull base reconstruction following tumor resection.

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