Classification and Microvascular Flap Selection for Anterior Cranial Fossa Reconstruction

Background Microvascular reconstruction of the anterior cranial fossa (ACF) creates difficult challenges. Reconstructive goals and flap selection vary based on the defect location within the ACF. This study evaluates the feasibility and reliability of free tissue transfer for salvage reconstruction of low, middle, and high ACF defects. Methods A retrospective review was performed. Reconstructions were anatomically classified as low (anterior skull base), middle (frontal bar/sinus), and high (frontal bone/soft tissue). Subjects were evaluated based on pathologic indication and goal, type of flap used, and complications observed. Results Eleven flaps in 10 subjects were identified and anatomic sites included: low (n = 5), middle (n = 3), and high (n = 3). Eight of 11 reconstructions utilized osteocutaneous flaps including the osteocutaneous radial forearm free flap (OCRFFF) (n = 7) and fibula (n = 1). Other reconstructions included a split calvarial graft wrapped within a temporoparietal fascia free flap (n = 1), latissimus myocutaneous flap (n = 1), and rectus abdominis myofascial flap (n = 1). All 11 flaps were successful without microvascular compromise. No complications were observed in the high and middle ACF defect groups. Two of five flaps in the low defect group using OCRFFF flaps failed to achieve surgical goals despite demonstrating healthy flaps upon re-exploration. Complications included persistent cerebrospinal fluid leak (n = 1) and pneumocephalus (n = 1), requiring flap repositioning in one subject and a second microvascular flap in the second subject to achieve surgical goals. Conclusion In our experience, osteocutaneous flaps (especially the OCRFFF) are preferred for complete autologous reconstruction of high and middle ACF defects. Low skull base defects are more difficult to reconstruct, and consideration of free muscle flaps (no bone) should be weighed as an option in this anatomic area.

Download Full-text

Free Flap Reconstruction of the Anterior Skull Base: A Systematic Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1718909 ◽

2021 ◽

Author(s):

Rajan P. Dang ◽

Abhinav R. Ettyreddy ◽

Zain Rizvi ◽

Michelle Doering ◽

Angela L. Mazul ◽

...

Keyword(s):

Systematic Review ◽

Skull Base ◽

Free Flap ◽

High Reliability ◽

Anterior Skull Base ◽

Microvascular Reconstruction ◽

Complication Rates ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Comprehensive Search

Abstract Objectives Given the limitations in the available literature, the precise indications, techniques, and outcomes of anterior skull base free flap reconstruction remain uncertain. The objective of this study was to perform a systematic review of published literature and evaluate indications, methods, and complications for anterior skull base free flap reconstruction. Methods A systematic review of the literature was performed using a set of search criteria to identify patients who underwent free flap reconstruction of the anterior skull base. Articles were reviewed for inclusion based on relevance, with the primary outcome being surgical complications. Results After a comprehensive search, 406 articles were obtained and 16 articles were ultimately found to be relevant to this review—79 patients undergoing free flap reconstruction were identified. Overall complication rates were 17.7% (95% confidence interval [CI]: 16.6–33.1%) for major complications and 19.0% (95% CI: 17.8–35.5%) for minor complications. Conclusion Microvascular reconstruction of the anterior skull base is feasible with high reliability reported in the literature.

Download Full-text

Lateral Skull Base Attenuation in Patients with Anterior Cranial Fossa Spontaneous Cerebrospinal Fluid Leaks

Otolaryngology ◽

10.1177/0194599816630738 ◽

2016 ◽

Vol 154 (6) ◽

pp. 1138-1144 ◽

Cited By ~ 14

Author(s):

Brendan P. O’Connell ◽

Shawn M. Stevens ◽

Christopher C. Xiao ◽

Ted A. Meyer ◽

Rodney J. Schlosser

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Anterior Cranial Fossa ◽

Lateral Skull Base ◽

Cerebrospinal Fluid Leaks ◽

Cranial Fossa

Download Full-text

Eyelid approach to the anterior cranial base

Journal of Neurosurgery ◽

10.3171/jns/2008/109/8/0341 ◽

2008 ◽

Vol 109 (2) ◽

pp. 341-346 ◽

Cited By ~ 40

Author(s):

Norberto Andaluz ◽

Alberto Romano ◽

Likith V. Reddy ◽

Mario Zuccarello

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

Artery Aneurysm ◽

Anterior Cranial Fossa ◽

Anterior Communicating Artery ◽

Surgical Morbidity ◽

Anterior Circulation ◽

Unruptured Aneurysms ◽

Anterior Cranial Base ◽

Cranial Fossa

Skull base approaches play a fundamental role in modern neurosurgery by reducing surgical morbidity. Increasing experience has allowed surgeons to perform minimally invasive approaches without straying from the premises of skull base surgery. The eyelid approach has evolved from the orbitopterional osteotomy into a more effective and targeted approach to disease of the anterior cranial fossa. In this technique, after an incision is made on the supratarsal fold, the orbicularis oculi muscle is incised, and a myocutaneous flap composed of the elements of the anterior lamella is elevated. Subperiosteal dissection is used to expose the superior and lateral walls of the orbit, the superior and lateral orbital rim, and the frontosphenoidal suture. A MacCarty bur hole is drilled, and a frontal osteotomy is fashioned medial to the supraorbital notch and extending through the orbital roof back toward the orbital half of the MacCarty bur hole, exposing the frontobasal brain. A conventional microsurgical technique is used to treat tumors and aneurysms of the anterior cranial fossa under the operative microscope. Five patients were treated for unruptured aneurysms of the anterior circulation (3 anterior communicating artery aneurysms, 1 ophthalmic artery aneurysm, and 1 posterior communicating artery aneurysm) using the eyelid approach. The mean aneurysm size was 5 mm, and all aneurysms were approached from the right side. Three tumors in the anterior fossa (2 suprasellar pituitary adenomas and 1 craniopharyngioma) were also excised using this approach. There was no surgical morbidity. Three months after surgery all patients presented excellent cosmetic results. The eyelid approach may be considered as an effective, cosmetically beneficial, and minimally invasive skull base approach to selected aneurysms and tumors of the anterior circulation.

Download Full-text

Endoscopic Endonasal Transethmoidal Transcribriform Transfovea Ethmoidalis Approach to the Anterior Cranial Fossa and Skull Base

Neurosurgery ◽

10.1227/01.neu.0000368395.82329.c4 ◽

2010 ◽

Vol 66 (5) ◽

pp. 883-892 ◽

Cited By ~ 66

Author(s):

Jeffrey P. Greenfield ◽

Vijay K. Anand ◽

Ashutosh Kacker ◽

Michael J. Seibert ◽

Ameet Singh ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Sphenoid Sinus ◽

Malignant Tumors ◽

Anterior Skull Base ◽

Anterior Cranial Fossa ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Lumbar Drainage ◽

Cranial Fossa

Abstract OBJECTIVE The anterior skull base, in front of the sphenoid sinus, can be approached using a variety of techniques including extended subfrontal, transfacial, and craniofacial approaches. These methods include risks of brain retraction, contusion, cerebrospinal fluid leak, meningitis, and cosmetic deformity. An alternate and more direct approach is the endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach. METHODS An endoscopic, endonasal approach was used to treat a variety of conditions of the anterior skull base arising in front of the sphenoid sinus and between the orbits in a series of 44 patients. A prospective database was used to detail the corridor of approach, closure technique, use of intraoperative lumbar drainage, operative time, and postoperative complications. Extent of resection was determined by a radiologist using volumetric analysis. RESULTS Pathology included meningo/encephaloceles (19), benign tumors (14), malignant tumors (9), and infectious lesions (2). Lumbar drains were placed intraoperatively in 20 patients. The CSF leak rate was 6.8% for the whole series and 9% for intradural cases. Leaks were effectively managed with lumbar drainage. Early reoperation for cerebrospinal fluid (CSF) leak occurred in 1 patient (2.2%). There were no intracranial infections. Greater than 98% resection was achieved in 12 of 14 benign and 5 of 9 malignant tumors. CONCLUSION The endoscopic, endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach is versatile and suitable for managing a variety of pathological entities. This minimal access surgery is a feasible alternative to transcranial, transfacial, or combined craniofacial approaches to the anterior skull base and anterior cranial fossa in front of the sphenoid sinus. The risk of CSF leak and infection are reasonably low and decrease with experience. Longer follow-up and larger series of patients will be required to validate the long-term efficacy of this minimally invasive approach.

Download Full-text

Fulminant presentation of a SMARCB1-deficient, anterior cranial fossa tumor in adult

Surgical Neurology International ◽

10.25259/sni_171_2020 ◽

2020 ◽

Vol 11 ◽

pp. 195

Author(s):

Idan Levitan ◽

Suzana Fichman ◽

Yosef Laviv

Keyword(s):

Skull Base ◽

Paranasal Sinuses ◽

Anterior Skull Base ◽

Anterior Cranial Fossa ◽

Sinonasal Carcinoma ◽

Rhabdoid Cells ◽

Atypical Teratoid ◽

Cranial Fossa ◽

Rhabdoid Glioblastoma ◽

Tumor Debulking

Background: Malignant atypical teratoid rhabdoid tumor (ATRT) usually develops in children. ATRTs are rare in adults, with only one case in the literature describing involvement of the anterior skull base. These primary intracranial tumors are characterized molecularly as SMARCB1 (INI1) deficient. Different types of such SMARCB1-deficient tumors exist in adulthood, usually in the form of extracranial tumors. Very few cases of such a new entity, named SMARCB1-deficient sinonasal carcinoma have been described with intracranial penetration and involvement of the anterior cranial fossa. Case Description: A 36-year-old male presented with acute cognitive deterioration. Over few hours, he developed a fulminant herniation syndrome. Imaging showed a tumor in the anterior cranial fossa surrounded by massive brain edema. The tumor has destroyed the frontal bone with involvement of the nasal cavities and paranasal sinuses. The patient underwent emergent decompressive craniectomy and tumor debulking but could not be saved. Pathological analysis revealed a highly cellular tumor without rhabdoid cells but with areas of necrosis. Further immunohistochemical stains revealed that neoplastic cells were diffusely and strongly positive for epithelial membrane antigen and P63 and negative for SMARCB1 (i.e., loss of expression), confirming the diagnosis of sinonasal carcinoma. Conclusion: To the best of our knowledge, this is the first report of a fulminant presentation of a SMARCB1- deficient tumor in young adult, involving the anterior cranial fossa and the paranasal sinuses. The main differential diagnosis of aggressive, primary, intracranial SMARCB1-deficient tumors in adults includes ATRT, SMARCB1- deficient sinonasal carcinoma, rhabdoid meningioma, and rhabdoid glioblastoma. Atypical tumors involving the anterior skull base without a clear histopathological pattern should therefore be checked for SMARCB1 expression.

Download Full-text

Combined Endonasal - Transorbital Approaches to the Skull Base: a Single Stage Minimally Invasive Technique for Anterior Cranial Fossa Pathology

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0036-1579895 ◽

2016 ◽

Vol 77 (S 01) ◽

Author(s):

Jordina Rincon-Torroella ◽

Karim Refaey ◽

Kofi Boahene ◽

Alfredo Quinones-Hinojosa

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

Single Stage ◽

Minimally Invasive Technique ◽

Anterior Cranial Fossa ◽

Invasive Technique ◽

Cranial Fossa

Download Full-text

Rhinotomy Approaches to the Paranasal Sinuses and Anterior Skull Base

Otolaryngology ◽

10.1016/s0194-5998(05)80135-4 ◽

1995 ◽

Vol 112 (5) ◽

pp. P63-P63

Author(s):

William Lawson ◽

Anthony J. Reino

Keyword(s):

Skull Base ◽

Paranasal Sinuses ◽

Anterior Skull Base ◽

Anterior Cranial Fossa ◽

Malignant Diseases ◽

Educational Objectives ◽

Cranial Fossa

Educational objectives: To understand and apply the three rhinotomy approaches for extirpation of benign and malignant diseases of the sinonasal cavity, skull base, and anterior cranial fossa.

Download Full-text

Pneumocephalus with meningitis secondary to an old traumatic anterior cranial fossa defect

BMJ Case Reports ◽

10.1136/bcr-2021-242855 ◽

2021 ◽

Vol 14 (6) ◽

pp. e242855

Author(s):

Freston Marc Sirur ◽

Akash Daswaney ◽

Roshini Raghu ◽

Mohammad Khalid

Keyword(s):

Skull Base ◽

Traumatic Event ◽

Altered Mental Status ◽

Anterior Cranial Fossa ◽

Bony Defect ◽

The Face ◽

Post Traumatic ◽

Cranial Fossa ◽

Skull Base Defect ◽

The Brain

We report a case of a 30-year-old man who presented with altered mental status, fever, headache and vomiting for 3 days. An initial CT scan of the brain revealed the presence of pneumocephalus with a bony defect in the anterior cranial fossa. The pneumocephalus was not explained initially and the patient was re-examined for any signs of trauma to the face, and a review of the history revealed a series of three traumatic events months prior to this illness. Further laboratory studies revealed Streptococcus pneumoniae in the blood and bacterial meningitis. He was treated with antibiotics and was later taken up for endoscopic repair of the skull base defect. This case highlights the importance of recognising post-traumatic pneumocephalus with superimposed meningitis and sepsis months after a traumatic event to the skull base.

Download Full-text