795 Trends in Cerebrospinal Fluid Leak Rates Following the Extended Endoscopic Endonasal Approach for Anterior Skull Base Meningioma: A Meta-Analysis Over the Last 20 Years

Abstract Introduction The extended endoscopic approach (EEA) provides direct access for resection of tuberculum sellae (TSM) and olfactory groove meningiomas (OGM) but is associated with cerebrospinal fluid (CSF) leak in up to 25% of patients. To evaluate the impact of improved skull base reconstructive techniques, we assessed published CSF leak percentages in EEA over the last two decades. Method Random-effects meta-analyses were performed for studies published between 2004-2020. Outcomes assessed were CSF leak, gross total resection, visual improvement, intraoperative arterial injury and 30-day mortality. For the main analyses, publications were pragmatically grouped based on publication year in three categories: 2004-2010, 2011-2015, and 2016-2020. Results We included 29 studies describing 540 TSM and 115 OGM patients. CSF leak incidence dropped over time from 22% (95% CI: 6-43%) in studies published between 2004 and 2010, to 16% (95% CI: 11-23%) between 2011 and 2015, and 4% (95% CI: 1-9%) between 2016 and 2020. Outcomes of gross total resection, visual improvement, intraoperative arterial injury, and 30-day mortality remained stable over time Conclusions We report a noticeable decrease in CSF leak over time, which might be attributed to the development of reconstructive techniques (e.g., hadad bassagasteguy flap, and gasket seal), refined multilayer repair protocols, and selected lumbar drain usage.

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Trends in cerebrospinal fluid leak rates following the extended endoscopic endonasal approach for anterior skull base meningioma: a meta-analysis over the last 20 years

Acta Neurochirurgica ◽

10.1007/s00701-020-04641-x ◽

2020 ◽

Author(s):

Amir H. Zamanipoor Najafabadi ◽

Danyal Z. Khan ◽

Ivo S Muskens ◽

Marike L. D. Broekman ◽

Neil L. Dorward ◽

...

Keyword(s):

Skull Base ◽

Arterial Injury ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Total Resection ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Olfactory Groove Meningioma ◽

Tuberculum Sellae ◽

Over Time

Abstract Objective The extended endoscopic approach provides unimpaired visualization and direct access to ventral skull base pathology, but is associated with cerebrospinal fluid (CSF) leak in up to 25% of patients. To evaluate the impact of improved surgical techniques and devices to better repair skull base defects, we assessed published surgical outcomes of the extended endoscopic endonasal approach in the last two decades for a well-defined homogenous group of tuberculum sellae and olfactory groove meningioma patients. Methods Random-effects meta-analyses were performed for studies published between 2004 (first publications) and April 2020. We evaluated CSF leak as primary outcome. Secondary outcomes were gross total resection, improvement in visual outcomes in those presenting with a deficit, intraoperative arterial injury, and 30-day mortality. For the main analyses, publications were pragmatically grouped based on publication year in three categories: 2004–2010, 2011–2015, and 2016–2020. Results We included 29 studies describing 540 patients with tuberculum sellae and 115 with olfactory groove meningioma. The percentage patients with CSF leak dropped over time from 22% (95% CI: 6–43%) in studies published between 2004 and 2010, to 16% (95% CI: 11–23%) between 2011 and 2015, and 4% (95% CI: 1–9%) between 2016 and 2020. Outcomes of gross total resection, visual improvement, intraoperative arterial injury, and 30-day mortality remained stable over time Conclusions We report a noticeable decrease in CSF leak over time, which might be attributed to the development and improvement of new closure techniques (e.g., Hadad-Bassagasteguy flap, and gasket seal), refined multilayer repair protocols, and lumbar drain usage.

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Corridor-Based Endonasal Endoscopic Surgery for Pediatric Skull Base Pathology With Detailed Radioanatomic Measurements

Operative Neurosurgery ◽

10.1227/neu.0000000000000252 ◽

2013 ◽

Vol 10 (2) ◽

pp. 273-293 ◽

Cited By ~ 15

Author(s):

Matei A. Banu ◽

Allison Rathman ◽

Kunal S. Patel ◽

Mark M. Souweidane ◽

Vijay K. Anand ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Pediatric Population ◽

Visual Fields ◽

Age Groups ◽

Cerebrospinal Fluid Leak ◽

Gross Total Resection ◽

Benign Tumors ◽

Minimal Risk ◽

Total Resection

Abstract BACKGROUND: Pediatric anatomy is more restricted, and the propagation of endonasal endoscopic approaches in the pediatric population has been limited. OBJECTIVE: To demonstrate the feasibility of the endonasal endoscopic approach in a variety of age groups and to perform measurements of the corridors and spaces available for surgery as a guide for case selection. METHODS: Only patients <18 years were included. The choice of operative corridor/approach is described in relation to pathological entity and location. Preoperative/postoperative visual fields and endocrine panels, extent of resection, as well as postoperative long-term complications are described. Prospective magnetic resonance image-based anatomic measurements of key distances were performed to determine age-dependent surgical indications and limitations. RESULTS: Forty purely endoscopic procedures were performed in 33 pediatric patients (5-18 years of age) harboring a variety of skull base lesions, from benign tumors to congenital malformations. For the 20 patients in whom gross total resection was the intended goal of surgery, gross total resection was attained in 15 (75%). There were 2 infections (5%) and no cerebrospinal fluid leaks. Significant improvement was shown in 58.3% of patients with visual deficits. Hormone overproduction resolved in 75% of patients, while preoperative hormone insufficiency only improved in 29.2%. Wider intercarotid distance at the superior clivus (P = .01) and shorter nare-dens working distance (P = .001) predicted improved outcomes and fewer postoperative complications. CONCLUSION: Endonasal endoscopic skull base approaches are viable in the pediatric population, they are not impeded by sphenoid sinus aeration, and they have minimal risk of cerebrospinal fluid leak and meningitis. Outcomes and complications can be predicted based on specific radio anatomical skull base measurements rather than age.

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The learning curve in endoscopic endonasal resection of craniopharyngiomas

Neurosurgical FOCUS ◽

10.3171/2016.9.focus16292 ◽

2016 ◽

Vol 41 (6) ◽

pp. E9 ◽

Cited By ~ 17

Author(s):

Varun R. Kshettry ◽

Hyunwoo Do ◽

Khaled Elshazly ◽

Christopher J. Farrell ◽

Gurston Nyquist ◽

...

Keyword(s):

Learning Curve ◽

Diabetes Insipidus ◽

Neurological Complications ◽

Csf Leak ◽

Categorical Variables ◽

Total Resection ◽

Endoscopic Endonasal ◽

Visual Improvement ◽

Early Cohort ◽

Over Time

OBJECTIVE There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas. METHODS A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005–2009, n = 20) and a late cohort (2010–2015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively. RESULTS Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001). CONCLUSIONS High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.

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Cerebrospinal Fluid Leak Rate after Vestibular Schwannoma Surgery via Middle Cranial Fossa Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1675752 ◽

2018 ◽

Vol 80 (04) ◽

pp. 437-440 ◽

Cited By ~ 1

Author(s):

Noga Lipschitz ◽

Gavriel D. Kohlberg ◽

Kareem O. Tawfik ◽

Zoe A. Walters ◽

Joseph T. Breen ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Vestibular Schwannoma ◽

Middle Cranial Fossa ◽

Leak Rate ◽

Gross Total Resection ◽

Csf Leak ◽

Tumor Diameter ◽

Total Resection ◽

Csf Leakage ◽

Cranial Fossa

Objective Evaluate the cerebrospinal fluid (CSF) leak rate after the middle cranial fossa (MCF) approach to vestibular schwannoma (VS) resection. Design Retrospective case series. Setting Quaternary referral academic center. Participants Of 161 patients undergoing the MCF approach for a variety of skull base pathologies, 66 patients underwent this approach for VS resection between 2007 and 2017. Main Outcome Measure Postoperative CSF leak rate. Results There were two instances of postoperative CSF leak (3.0%). Age, gender, and BMI were not significantly associated with CSF leak. In the two cases with CSF leakage, tumors were isolated to the internal auditory canal (IAC) and both underwent gross total resection. Both CSF leaks were successfully treated with lumbar drain diversion. For the 64 cases that did not have a CSF leak, 51 were isolated to the IAC, 1 was located only in the cerebellopontine angle (CPA), and 12 were located in both the IAC and CPA. 62 patients underwent gross total resection and 2 underwent near-total resection. Mean maximal tumor diameter in the CSF leak group was 4.5 mm (range: 3–6 mm) versus 10.2 mm (range: 3–19 mm) in patients with no CSF leak (p = 0.03). Conclusions The MCF approach for VS resection is a valuable technique that allows for hearing preservation and total tumor resection and can be performed with a low CSF leakage rate. This rate of CSF leak is less than the reported rates in the literature in regard to both translabyrinthine and retrosigmoid approaches.

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Intrathecal Fluorescein in Endoscopic Skull Base Surgery

Otolaryngology ◽

10.1016/j.otohns.2006.11.012 ◽

2007 ◽

Vol 137 (2) ◽

pp. 316-320 ◽

Cited By ~ 66

Author(s):

Abtin Tabaee ◽

Dimitris G. Placantonakis ◽

Theodore H. Schwartz ◽

Vijay K. Anand

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Skull Base ◽

Retrospective Review ◽

Skull Base Surgery ◽

Csf Leak ◽

Skull Base Reconstruction ◽

Endoscopic Skull Base Surgery ◽

High Degree ◽

The Impact

OBJECTIVES: Reconstruction following endoscopic skull base surgery requires a high degree of success to avoid the morbidity of postoperative cerebrospinal fluid (CSF) leak. The impact on outcomes of CSF visualization with intrathecal fluorescein, however, is unknown. STUDY DESIGN: A retrospective review of patients undergoing endoscopic skull base surgery with intrathecal fluorescein. A possible correlation between intraoperative fluorescein identification and postoperative CSF leak was analyzed. RESULTS: 61 patients underwent surgery for a variety of lesions including pituitary adenoma (55.7%), encephalocele (14.8%), and meningioma (9.8%). Seven (19.4%) of the 37 patients with intraoperative fluorescein leak experienced postoperative CSF leak compared to 0 of the 24 patients who did not have intraoperative fluorescein leak ( P = 0.02). All cases of CSF leak resolved with lumbar drainage alone. CONCLUSIONS: The lack of intraoperative fluorescein leak-age correlates strongly with a low risk for postoperative CSF leak. This can be used to stratify the extent of skull base reconstruction required during endoscopic skull base surgeries.

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Endoscopic transtuberculum transplanum approach to suprasellar meningiomas

QJM ◽

10.1093/qjmed/hcaa055.008 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

A Elsawy ◽

S Hamada ◽

H Ibrahim ◽

O Yousef ◽

H Elhusseiny

Keyword(s):

Skull Base ◽

Surgical Repair ◽

Visual Outcome ◽

The Other ◽

Gross Total Resection ◽

Csf Leak ◽

Viable Option ◽

Total Resection ◽

Extended Endoscopic Approach ◽

Brain Retraction

Abstract Introduction Extended endoscopic approaches to suprasellarmeningiomas have been proposed recently as a viable option or alternative to traditional microsurgical transcranial approaches. Endoscopic approaches have been presented as a minimally invasive route to such formidable lesions of the skull base, obviating the need of large craniotomies & brain retraction. Endoscopic approaches were shown to provide comparable rates of gross total resection, in selected cases, better visual outcomes than transcranial approaches, on the other hand high CSF leak rate was a major cornerstone for criticism for endoscopic approaches. Objective Assessing the feasibility & safety of extended endoscopic approaches to suprasellarmeningiomas. Methods Interventional prospective study including 23 patients harboring suprasellarmeningiomas assessed for gross total resection, visual outcome, CSF leak rates & other surgical morbidities. Results 23 patients 18 females (78%) & 5 males (22%); mean age was 59 years with range of 37-86 years. Tuberculumsellae meningioma compromised 15 cases (65%), planumsphenoidale 2 cases (9%) &planum/tuberculum 6 patients (26%) of the studied patients. Gross total resection wash achieved in 17 patients (74%).Vision was improved in 80% of patients presenting with visual symptoms & was stable in 20% post-operatively. All patients (100%) without pre-operative visual deficit were able to preserve their pre-operative visual state. CSF leak was the most common compilation occurring in 4 patients (17%). Lumbar drainage was sufficient to control the CSF leak in 2 patients while the other 2 patients required surgical repair of the skull base reconstruct. Transient DI was encountered in 2 patients (9%). Conclusion Extended endoscopic approach to suprasellarmeningiomas is safe & feasible. Comparable outcomes regarding gross total resection with superior visual outcome can be attained in carefully selected patients. CSF leak is major limitation of endoscopic approaches, however the introduction of vascularized naso-septal flaps helped overcome this issue.

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RONC-12. TREATMENT AGE AND NEUROCOGNITIVE OUTCOMES FOLLOWING PROTON BEAM RADIOTHERAPY FOR PEDIATRIC LOW GRADE GLIOMA

Neuro-Oncology ◽

10.1093/neuonc/noaa222.782 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii457-iii458

Author(s):

Andrew Heitzer ◽

Lisa Kahalley ◽

David Grosshans ◽

M Fatih Okcu ◽

Kimberly Raghubar ◽

...

Keyword(s):

Cognitive Functioning ◽

Low Grade Glioma ◽

Gross Total Resection ◽

Low Grade ◽

Total Resection ◽

Prospective Longitudinal Study ◽

Prospective Longitudinal ◽

The Impact ◽

Over Time

Abstract INTRODUCTION Younger age at radiotherapy increases cognitive risk for patients with pediatric low grade glioma (LGG). We examined the impact of age at treatment on cognitive trajectories in LGG patients treated with proton radiotherapy (PRT) compared to patients treated without radiotherapy (surgery only; SO). METHODS We examined cognitive scores of 48 LGG patients on a prospective, longitudinal study. General linear mixed models evaluated change in cognitive scores over time. RESULTS The sample included 16 patients treated with PRT and 32 with SO (median follow-up=3.1 years, range 0.9–6.1). Median age of PRT patients was 8.2 years at diagnosis (range 1.0–14.4) and 9.4 years at PRT (range 4.2–16.7). 13 PRT patients also received surgery: 53.8% biopsy, 30.8% subtotal resection, 15.4% gross total resection. Tumor sites included: 31.2% hypothalamic/suprasellar, 25.0% optic pathway, 18.8% temporal, 25.0% other. Median age of SO patients was 8.2 years at diagnosis (range 2.9–18.6). Surgical outcomes were: 75.0% gross total resection, 21.9% biopsy/other. There were no group differences in diagnosis age, tumor volume, or shunt history (all p>0.05). Both PRT and SO groups displayed stable cognitive functioning over time (all p>0.1). Slopes (i.e., change in scores over time) did not differ between groups (all p>0.1). Age at treatment was not associated with slope or performance at last follow-up in either group (all p>0.05). CONCLUSIONS We observed stable cognitive functioning, independent of age at treatment, following PRT for LGG. Outcomes were similar to patients receiving surgery only. Further examination in a larger sample is warranted.

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Transcavernous Resection of a Giant Extensive Chondrosarcoma with Endoscopic Assistance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1727124 ◽

2021 ◽

Author(s):

Walid Elshamy ◽

Burcak Soylemez ◽

Sima Sayyahmelli ◽

Nese Keser ◽

Mustafa K. Baskaya

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Skull Base ◽

Internal Carotid ◽

Gross Total Resection ◽

Petrous Apex ◽

Left Internal Carotid Artery ◽

Total Resection ◽

Complete Occlusion ◽

Grade Ii

AbstractChondrosarcomas are one of the major malignant neoplasms which occur at the skull base. These tumors are locally invasive. Gross total resection of chondrosarcomas is associated with longer progression-free survival rates. The patient is a 55-year-old man with a history of dysphagia, left eye dryness, hearing loss, and left-sided facial pain. Magnetic resonance imaging (MRI) showed a giant heterogeneously enhancing left-sided skull base mass within the cavernous sinus and the petrous apex with extension into the sphenoid bone, clivus, and the cerebellopontine angle, with associated displacement of the brainstem (Fig. 1). An endoscopic endonasal biopsy revealed a grade-II chondrosarcoma. The patient was then referred for surgical resection. Computed tomography (CT) scan and CT angiogram of the head and neck showed a left-sided skull base mass, partial destruction of the petrous apex, and complete or near-complete occlusion of the left internal carotid artery. Digital subtraction angiography confirmed complete occlusion of the left internal carotid artery with cortical, vertebrobasilar, and leptomeningeal collateral development. The decision was made to proceed with a left-sided transcavernous approach with possible petrous apex drilling. During surgery, minimal petrous apex drilling was necessary due to autopetrosectomy by the tumor. Endoscopy was used to assist achieving gross total resection (Fig. 2). Surgery and postoperative course were uneventful. MRI confirmed gross total resection of the tumor. The histopathology was a grade-II chondrosarcoma. The patient received proton therapy and continues to do well without recurrence at 4-year follow-up. This video demonstrates steps of the combined microsurgical skull base approaches for resection of these challenging tumors.The link to the video can be found at: https://youtu.be/WlmCP_-i57s.

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Transcavernous Approach for Gross Total Resection of a Dumbbell-Shaped Giant Trigeminal Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1729995 ◽

2021 ◽

Author(s):

Sima Sayyahmelli ◽

Emel Avci ◽

Burak Ozaydin ◽

Mustafa K. Başkaya

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Tumor Resection ◽

Mass Effect ◽

World Health ◽

Gross Total Resection ◽

Petrous Apex ◽

Total Resection ◽

Who Grade ◽

Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare nerve sheet tumors that represent the second most common intracranial site of occurrence after vestibular nerve origins. Microsurgical resection of giant dumbbell-shaped trigeminal schwannomas often requires complex skull base approaches. The extradural transcavernous approach is effective for the resection of these giant tumors involving the cavernous sinus.The patient is a 72-year-old man with headache, dizziness, imbalance, and cognitive decline. Neurological examination revealed left-sided sixth nerve palsy, a diminished corneal reflex, and wasting of temporalis muscle. Magnetic resonance imaging (MRI) showed a giant homogeneously enhancing dumbbell-shaped extra-axial mass centered within the left cavernous sinus, Meckel's cave, and the petrous apex, with extension to the cerebellopontine angle. There was a significant mass effect on the brain stem causing hydrocephalus. Computed tomography (CT) scan showed erosion of the petrous apex resulting in partial anterior autopetrosectomy (Figs. 1 and 2).The decision was made to proceed with tumor resection using a transcavernous approach. Gross total resection was achieved. The surgery and postoperative course were uneventful, and the patient woke up the same as in the preoperative period. MRI confirmed gross total resection of the tumor. The histopathology was a trigeminal schwannoma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence at 15-month follow-up.This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors.The link to the video can be found at https://youtu.be/TMK5363836M

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Pneumocephalus and CSF leak secondary to skull base fracture by pyrotechnical object: case report

Peruvian Journal of Neurosurgery ◽

10.53668/2021.pjns33175 ◽

2021 ◽

Vol 3 (3) ◽

Author(s):

Marcos Vilca ◽

◽

Carlos Palacios ◽

Sofía Rosas ◽

Ermitaño Bautista ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Pressure ◽

Skull Base ◽

Rare Complication ◽

Cerebrospinal Fluid Leak ◽

Standing Position ◽

Csf Leak ◽

Skull Base Fracture ◽

Timely Diagnosis ◽

The Right

Introduction: Pneumocephalus is mainly associated with traumatic injuries, being a rare complication but with high mortality rates; it behaves like a space-occupying lesion and increases intracranial pressure. The symptoms are not specific, but in the event of trauma it is necessary to suspect this entity to carry out a timely diagnosis and treatment, since being the product of the skull base fracture it can cause communication with the outside, and the appearance of cerebrospinal fluid (CSF) leak. Clinical Case: a 38-year-old male patient who suffers trauma from a pyrotechnic explosion near his right ear, when handling a pyrotechnic object (whistle) during the New Year, presenting severe pain, slight bleeding in the right ear, feeling faint and holocranial headache that increased in a standing position; likewise, he presents high-flow aqueous secretion (CSF) from the right ear. Brain and skull base tomography (CT) showed air in the intracranial cavity, fracture of the skull base, and the ossicles of the right middle ear. Conservative management was performed using rest and lumbar drainage, presenting a satisfactory evolution. Conclusion: Pneumocephalus is a frequent and expected complication of trauma with a skull base fracture. Its early and timely diagnosis using skull base CT is essential to define therapeutic measures. Accidents due to the misuse of pyrotechnics continue to be a relevant problem in our country. Knowing and disseminating its consequences can help raise awareness in the population. Keywords: Pneumocephalus, Skull Base, Intracranial Pressure, Cerebrospinal Fluid Leak. (Source: MeSH NLM)

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