Usefulness of Imaging Fusion for Therapeutic Planning in Skull Base Lesions

2003 ◽  
Vol 16 (2) ◽  
pp. 299-305
Author(s):  
E. Puglielli ◽  
R. Galzio ◽  
A. Ricci ◽  
A. Splendiani ◽  
F. Iannessi ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Foramen Magnum ◽  
Mean Value ◽  
Trigeminal Schwannoma ◽  
Correct Definition ◽  
Skull Base Lesions ◽  
The Mean ◽  
Planum Sphenoidale ◽  
Skull Base Meningiomas

We propose critical considerations on the usefulness of CT, MRI, and fMRI imaging fusion for the treatment of skull base lesions evaluating 41 cases (24 meningiomas: six petroclival, seven clinoidal, four olfactory, two in the foramen magnum, two spheno-petro-clival, one in the planum sphenoidale, one in the posterior pyramid and one in the PCA; five acoustic schwannomas, three epidermoids, two pituitary adenomas, two craniopharingiomas, two posterior fossa aneurysms, one trigeminal schwannoma, one dermoid and one juvenile angiofibroma). Data were collected, fused, integrated and reconstructed by a dedicated Stealth-Station system for Neuronavigation. CT images were acquired on axial non-overlapping slices, 1–3 mm thick; MRI images were obtained with a 1.5 T system, same FOV and thickness. During surgery the Mean Fiducially Error measured at 6 cm depth and anatomical distortion due to CSF loss was evaluated. Neuronavigation was possible in all cases and successfully applied in preoperative planning and during surgical procedures. The Mean Fiducially Error at 6 cm was 1.7 mm. CSF loss during surgery produced modifications on planned anatomy in a mean value of 0.6 mm. In all cases, imaging fusion for pre and intra-operative neuronavigation provided great advantages in the choice of the best approach, placing of bone flap, correct definition of tumour boundaries and meningeal implant, relationship with functional areas, early identification and real-time correction of the surgical route with respect of deep normal or distorted anatomic or pathologic structures and their eventual encasement or involvement by the pathologic primary process. Neuronavigation appeared ideal for skull base meningiomas making surgical manoeuvres safer, more effective and less invasive. In skull base lesions, CSF loss appeared not significant due to the fact that posterior fossa structures are strictly connected to each other and to the bone, thus are poorly affected by surgical deliquoration. We propose the possible extension of imaging fusion technique with the aim of optimizing the target in radiotherapy for intracranial tumours.

Level I to III craniofacial approaches based on Barrow classification for treatment of skull base meningiomas: surgical technique, microsurgical anatomy, and case illustrations

2011 ◽  
Vol 30 (5) ◽  
pp. E5 ◽  
Author(s):  
Emel Avcı ◽  
Erinç Aktüre ◽  
Hakan Seçkin ◽  
Kutluay Uluç ◽  
Andrew M. Bauer ◽  
...  
Keyword(s):  
Surgical Technique ◽  
Skull Base ◽  
Surgical Anatomy ◽  
Microsurgical Anatomy ◽  
Middle Point ◽  
The Mean ◽  
The Right ◽  
Skull Base Meningiomas ◽  
Supraorbital Foramen ◽  
Ethmoidal Foramen

Object Although craniofacial approaches to the midline skull base have been defined and surgical results have been published, clear descriptions of these complex approaches in a step-wise manner are lacking. The objective of this study is to demonstrate the surgical technique of craniofacial approaches based on Barrow classification (Levels I–III) and to study the microsurgical anatomy pertinent to these complex craniofacial approaches. Methods Ten adult cadaveric heads perfused with colored silicone and 24 dry human skulls were used to study the microsurgical anatomy and to demonstrate craniofacial approaches in a step-wise manner. In addition to cadaveric studies, case illustrations of anterior skull base meningiomas were presented to demonstrate the clinical application of the first 3 (Levels I–III) approaches. Results Cadaveric head dissection was performed in 10 heads using craniofacial approaches. Ethmoid and sphenoid sinuses, cribriform plate, orbit, planum sphenoidale, clivus, sellar, and parasellar regions were shown at Levels I, II, and III. In 24 human dry skulls (48 sides), a supraorbital notch (85.4%) was observed more frequently than the supraorbital foramen (14.6%). The mean distance between the supraorbital foramen notch to the midline was 21.9 mm on the right side and 21.8 mm on the left. By accepting the middle point of the nasofrontal suture as a landmark, the mean distances to the anterior ethmoidal foramen from the middle point of this suture were 32 mm on the right side and 34 mm on the left. The mean distance between the anterior and posterior ethmoidal foramina was 12.3 mm on both sides; the mean distance between the posterior ethmoidal foramen and distal opening of the optic canal was 7.1 mm on the right side and 7.3 mm on the left. Conclusions Barrow classification is a simple and stepwise system to better understand the surgical anatomy and refine the techniques in performing these complex craniofacial approaches. On the other hand, thorough anatomical knowledge of the midline skull base and variations of the neurovascular structures is crucial to perform successful craniofacial approaches.

scholarly journals The role of the basal cisterns in the development of posterior fossa skull base meningiomas

2016 ◽  
Vol 30 (3) ◽  
pp. 321-329
Author(s):  
Ioan Stefan Florian ◽  
Gheorghe Ungureanu ◽  
Alexandru Florian
Keyword(s):  
Brain Tumors ◽  
Skull Base ◽  
Posterior Fossa ◽  
Present Report ◽  
Intimate Relation ◽  
Vascular Structures ◽  
Skull Base Meningiomas ◽  
Basal Cisterns

Abstract Meningiomas account for more than 30% of all intracranial brain tumors, with 25% of them originating somewhere along the skull base and about 20% of these located in the posterior fossa. The intimate relation of these tumors with neural and vascular structures make them difficult to treat, both surgically and nonsurgically. Their treatment is further hampered by the lack of definitive recommendations, which is partially due to the fact that there is no general accepted model of classification. The present report proposes a new concept of classification of posterior fossa skull base meningiomas, one that takes into account the intimate relation of these tumors with arachnoid structures, simplifies the overcrowded landscape of their systematization and can be extended to oher skull base locations.

Radiosurgery for large-volume (> 10 cm3) benign meningiomas

2010 ◽  
Vol 112 (5) ◽  
pp. 951-956 ◽  
Author(s):  
Jonathan M. Bledsoe ◽  
Michael J. Link ◽  
Scott L. Stafford ◽  
Paul J. Park ◽  
Bruce E. Pollock
Keyword(s):  
Skull Base ◽  
Large Volume ◽  
Tumor Control ◽  
Skull Base Tumors ◽  
Who Grade ◽  
Average Tumor Volume ◽  
The Mean ◽  
Skull Base Meningiomas ◽  
Supratentorial Tumors

Object Stereotactic radiosurgery (SRS) has proven to be a safe and effective treatment for many patients with intracranial meningiomas. Nevertheless, the morbidity associated with radiosurgery of larger meningiomas is poorly understood. Methods The authors performed a retrospective review of 116 patients who underwent SRS for meningiomas (WHO Grade I) > 10 cm3 between 1990 and 2007, with a minimum follow-up of 12 months. Patients with atypical or malignant meningiomas and those who received prior radiotherapy were excluded. The average tumor volume was 17.5 cm3 (range 10.1–48.6 cm3); the average tumor margin dose was 15.1 Gy (range 12–18 Gy); and the mean follow-up duration was 70.1 months (range 12–199 months). Results Tumor control was 99% at 3 years and 92% at 7 years after radiosurgery. Thirty complications after radiosurgery were noted in 27 patients (23%), including 7 cases of seizures, 6 cases of hemiparesis, 5 cases of trigeminal injury, 4 cases of headaches, 3 cases of diplopia, 2 cases each of cerebral infarction and ataxia, and 1 case of hearing loss. Patients with supratentorial tumors experienced a higher complication rate compared with patients with skull base tumors (44% compared with 18%) (hazard ratio 2.9, 95% CI 1.3–6.7, p = 0.01). Conclusions The morbidity associated with SRS for patients with benign meningiomas > 10 cm3 is greater for supratentorial tumors compared with skull base tumors. Whereas radiosurgery is relatively safe for patients with large-volume skull base meningiomas, resection should remain the primary disease management for the majority of patients with large-volume supratentorial meningiomas.

scholarly journals Cerebral bypass surgery for skull base lesions: technical notes incorporating lessons learned over two decades

2008 ◽  
Vol 24 (2) ◽  
pp. E11 ◽  
Author(s):  
Ketan R. Bulsara ◽  
Toral Patel ◽  
Takanori Fukushima
Keyword(s):  
Skull Base ◽  
Bypass Surgery ◽  
Case Series ◽  
Senior Author ◽  
Lessons Learned ◽  
Morbidity Rate ◽  
Skull Base Lesions ◽  
Cavernous Carotid Artery ◽  
Skull Base Meningiomas ◽  
Cerebral Bypass

Object Despite advancements in endovascular neurosurgery, there remains an important role for cerebral bypass surgery in the treatment of skull base lesions. The authors describe their replacement cerebral bypass surgery techniques incorporating lessons learned over 2 decades. Methods The authors performed a retrospective review of cerebral bypass surgery performed by the senior author for skull base lesions between 1986 and 2006. One hundred patients had adjunct bypass surgery for skull base lesions. Results The bypass surgeries performed are conceptually divided into Skull Base Bypass I, II, and III. The majority of lesions requiring bypass surgery were giant cavernous carotid artery aneurysms or skull base meningiomas. There were no deaths in this case series. There was a 7% morbidity rate. Conclusions The ability to perform this surgery is an important adjunct in the armamentarium of skull base/cerebrovascular neurosurgeons.

scholarly journals Extracranial ligation of ethmoidal arteries before resection of giant olfactory groove or planum sphenoidale meningiomas: 3 illustrative cases with a review of the literature on surgical techniques

2013 ◽  
Vol 35 (6) ◽  
pp. E13 ◽  
Author(s):  
Sunil Manjila ◽  
Efrem M. Cox ◽  
Gabriel A. Smith ◽  
Mark Corriveau ◽  
Nipun Chhabra ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Techniques ◽  
Anterior Skull Base ◽  
Preoperative Embolization ◽  
Imaging Data ◽  
Olfactory Groove ◽  
Surgical Ligation ◽  
Ethmoidal Arteries ◽  
Planum Sphenoidale ◽  
Skull Base Meningiomas

Object There are several surgical techniques for reducing blood loss—open surgical and endoscopic—prior to resection of giant anterior skull base meningiomas, especially when preoperative embolization is risky or not technically feasible. The authors present examples of an institutional experience using surgical ligation of the anterior and posterior ethmoidal arteries producing persistent tumor blush in partially embolized tumors. Methods The authors identified 12 patients who underwent extracranial surgical ligation of ethmoidal arteries through either a transcaruncular or a Lynch approach. Of these, 3 patients had giant olfactory groove or planum sphenoidale meningiomas. After approval from the institution privacy officer, the authors studied the medical records and imaging data of these 3 patients, with special attention to surgical technique and outcome. The variations of ethmoidal artery foramina pertaining to this surgical approach were studied using preserved human skulls from the Hamann-Todd Osteological Collection at the Museum of Natural History, Cleveland, Ohio. Results The extracranial ligation was performed successfully for control of the ethmoidal arteries prior to resection of hypervascular giant anterior skull base meningiomas. The surgical anatomy and landmarks for ethmoidal arteries were reviewed in anthropology specimens and available literature with reference to described surgical techniques. Conclusions Extracranial surgical ligation of anterior, and often posterior, ethmoidal arteries prior to resection of large olfactory groove or planum sphenoidale meningiomas provides a safe and feasible option for control of these vessels prior to either open or endoscopic resection of nonembolized or partially embolized tumors.

scholarly journals Fractionated Gamma Knife radiosurgery for skull base meningiomas: a single-institution experience

2019 ◽  
Vol 46 (6) ◽  
pp. E8 ◽  
Author(s):  
Krishna C. Joshi ◽  
Alankrita Raghavan ◽  
Baha’eddin Muhsen ◽  
Jason Hsieh ◽  
Hamid Borghei-Razavi ◽  
...  
Keyword(s):  
Skull Base ◽  
Gamma Knife ◽  
Tumor Volume ◽  
Gamma Knife Radiosurgery ◽  
Cranial Neuropathy ◽  
High Dose ◽  
Perilesional Edema ◽  
The Mean ◽  
Skull Base Meningiomas

OBJECTIVEGamma Knife radiosurgery (GKRS) has been successfully used for the treatment of intracranial meningiomas given its steep dose gradients and high-dose conformality. However, treatment of skull base meningiomas (SBMs) may pose significant risk to adjacent radiation-sensitive structures such as the cranial nerves. Fractionated GKRS (fGKRS) may decrease this risk, but until recently it has not been practical with traditional pin-based systems. This study reports the authors’ experience in treating SBMs with fGKRS, using a relocatable, noninvasive immobilization system.METHODSThe authors performed a retrospective review of all patients who underwent fGKRS for SBMs between 2013 and 2018 delivered using the Extend relocatable frame system or the Icon system. Patient demographics, pre- and post-GKRS tumor characteristics, perilesional edema, prior treatment details, and clinical symptoms were evaluated. Volumetric analysis of pre-GKRS, post-GKRS, and subsequent follow-up visits was performed.RESULTSTwenty-five patients met inclusion criteria. Nineteen patients were treated with the Icon system, and 6 patients were treated with the Extend system. The mean pre-fGKRS tumor volume was 7.62 cm3 (range 4.57–13.07 cm3). The median margin dose was 25 Gy delivered in 4 (8%) or 5 (92%) fractions. The median follow-up time was 12.4 months (range 4.7–17.4 months). Two patients (9%) experienced new-onset cranial neuropathy at the first follow-up. The mean postoperative tumor volume reduction was 15.9% with 6 patients (27%) experiencing improvement of cranial neuropathy at the first follow-up. Median first follow-up scans were obtained at 3.4 months (range 2.8–4.3 months). Three patients (12%) developed asymptomatic, mild perilesional edema by the first follow-up, which remained stable subsequently.CONCLUSIONSfGKRS with relocatable, noninvasive immobilization systems is well tolerated in patients with SBMs and demonstrated satisfactory tumor control as well as limited radiation toxicity. Future prospective studies with long-term follow-up and comparison to single-session GKRS or fractionated stereotactic radiotherapy are necessary to validate these findings and determine the efficacy of this approach in the management of SBMs.

scholarly journals Preoperative embolization of skull base meningiomas: current indications, techniques, and pearls for complication avoidance

2018 ◽  
Vol 44 (4) ◽  
pp. E5 ◽  
Author(s):  
Nam Yoon ◽  
Aatman Shah ◽  
William T. Couldwell ◽  
M. Yashar S. Kalani ◽  
Min S. Park
Keyword(s):  
Blood Loss ◽  
Skull Base ◽  
Vascular Anatomy ◽  
Vascular Supply ◽  
Preoperative Embolization ◽  
Endovascular Techniques ◽  
Potential Benefits ◽  
Skull Base Lesions ◽  
Skull Base Meningiomas ◽  
Decrease Blood Loss

Skull base meningiomas are technically challenging tumors to treat because of their deep vascular supply that can preclude early devascularization during resection. Preoperative embolization of these arterial feeders is thought to decrease blood loss and facilitate resection; however, given the complex and varied anatomy of these skull base lesions, preoperative embolization is not without risk. It is essential for both endovascular and skull base neurosurgeons to understand these risks in light of the potential benefits. The authors review the vascular anatomy of skull base meningiomas, indications for preoperative devascularization, endovascular techniques, and published results regarding embolization of these lesions.

scholarly journals Introduction: surgical management of skull base meningiomas

2017 ◽  
Vol 43 (videosuppl2) ◽  
pp. Intro ◽  
Author(s):  
Gabriel Zada ◽  
Mustafa K Başkaya ◽  
Mitesh V. Shah
Keyword(s):  
Skull Base ◽  
Wide Spectrum ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Surgical Approaches ◽  
Cerebrospinal Fluid Leakage ◽  
Endoscopic Endonasal ◽  
Tuberculum Sellae ◽  
Skull Base Meningiomas

Meningiomas represent the most common primary intracranial neoplasm treated by neurosurgeons. Although multimodal treatment of meningiomas includes surgery, radiation-based treatments, and occasionally medical therapy, surgery remains the mainstay of treatment for most symptomatic meningiomas. Because of the intricate relationship of the dura mater and arachnoid mater with the central nervous system and cranial nerves, meningiomas can arise anywhere along the skull base or convexities, and occasionally even within the ventricular system, thereby mandating a catalog of surgical approaches that neurosurgeons may employ to individualize treatment for patients. Skull base meningiomas represent some of the most challenging pathology encountered by neurosurgeons, on account of their depth, invasion, vascularity, texture/consistency, and their relationship to bony anatomy, cranial nerves, and blood vessels. Resection of complex skull base meningiomas often mandates adequate bony removal to achieve sufficient exposure of the tumor and surrounding region, in order to minimize brain retraction and optimally identify, protect, control, and manipulate sensitive neurovascular structures. A variety of traditional skull base approaches has evolved to address complex skull base tumors, of which meningiomas are considered the paragon in terms of both complexity and frequency.In this supplemental video issue of Neurosurgical Focus, contributing authors from around the world provide instructional narratives demonstrating resection of a variety of skull base meningiomas arising from traditionally challenging origins, including the clinoid processes, tuberculum sellae, dorsum sellae, petroclival region, falco-tentorial region, cerebellopontine angle, and foramen magnum. In addition, two cases of extended endoscopic endonasal approaches for tuberculum sellae and dorsum sellae meningiomas are presented, representing the latest evolution in accessing the skull base for selected tumors. Along with key pearls for safe tumor resection, an equally important component of open and endoscopic skull base operations for meningiomas addressed by the contributing authors is the reconstruction aspect, which must be performed meticulously to prevent delayed cerebrospinal fluid leakage and/or infections. This curated assortment of instructional videos represents the authors’ optimal treatment paradigms pertaining to the selection of approach, setup, exposure, and principles to guide tumor resection for a wide spectrum of complex meningiomas.

scholarly journals Skull Base Angle Morphometry in South Indian Population with Review on Terminology

2021 ◽  
Author(s):  
Veeramani Raveendranath ◽  
Prafulla Kumar Dash ◽  
Krishnan Nagarajan ◽  
Thangaraj Kavitha ◽  
Srinidhi Swathi
Keyword(s):  
Skull Base ◽  
Adult Population ◽  
Mean Value ◽  
South Indian Population ◽  
Basal Angle ◽  
South Indian ◽  
Significant Difference ◽  
Coefficient Corrélation ◽  
Males And Females ◽  
The Mean

Abstract Introduction Basal angle, Boogaard’s angle, and clival angle are frequently used in diagnosing the craniometric angle malformations either on radiography or now more on MRI. But anatomic and clinical studies have used varied terms for these parameters. We aimed to look for these parameters among a normal south Indian adult population to standardize the measurements and their terminology. Materials and Methods One hundred MRI images (50 males and 50 female) were studied retrospectively. MRI images that were reported as normal by neuroradiologist were taken up for the study. Mean and the standard deviation of males and females were calculated for basal angle, Boogaard’s angle, and clival angle, separately. Unpaired t-test was used to analyze the significant difference (p < 0.05) between the genders. The intraclass coefficient correlation was used to analyze the interobserver variability. Results The mean value of basal angle in males and females are 113°and 114°, respectively. The mean value of Boogaard’s angle in males and females are 120°and 121°, respectively. The mean value of clival angle in males and females are 157°and 155°, respectively. There was no statistically significant difference (p > 0.05) between males and females in all three angles. Conclusion Knowledge about the normal angles will be an important tool in understanding the normal and abnormal skull base. Since the type of skull varies in accordance with race, the normal craniometric angle also varies in accordance with race. The present study tried to standardize the parameters of normal skull base angles for appropriate correction of the anomalies and uniform usage of terminology.

scholarly journals Pediatric multicompartmental trigeminal schwannoma: illustrative case

2021 ◽  
Vol 1 (20) ◽  
Author(s):  
Alexander P. Landry ◽  
Vincent C. Ye ◽  
Kerry A. Vaughan ◽  
James M. Drake ◽  
Peter B. Dirks ◽  
...  
Keyword(s):  
Skull Base ◽  
Infratemporal Fossa ◽  
Middle Cranial Fossa ◽  
Surgical Approaches ◽  
Illustrative Case ◽  
Trigeminal Schwannoma ◽  
Skull Base Lesions ◽  
Cranial Fossa ◽  
Extradural Approach

BACKGROUND Trigeminal schwannoma (TS) is an uncommon and histologically benign intracranial lesion that can involve any segment of the fifth cranial nerve. Given its often impressive size at diagnosis and frequent involvement of critical neurovascular structures of the skull base, it represents a challenging entity to treat. Pediatric TS is particularly rare and presents unique challenges. Similarly, tumors with extension into multiple compartments (e.g., middle cranial fossa, posterior cranial fossa, extracranial spaces) are notoriously difficult to treat surgically. Combined or staged surgical approaches are typically required to address them, with radiosurgical treatment as an adjunct. OBSERVATIONS The authors presented the unusual case of a 9-year-old boy with a large, recurrent multicompartmental TS involving Meckel’s cave, the cerebellopontine angle, and the infratemporal fossa. Near-total resection was achieved using a frontotemporal-orbitozygomatic craniotomy with a combined interdural and extradural approach. LESSONS The case report adds to the current literature on multicompartmental TSs in children and their management. The authors also provided a simplified classification of TS that can be generalized to other skull base tumors. Given a lack of precedent, the authors intended to add to the discussion regarding surgical management of these rare and challenging skull base lesions.

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