ENDOSCOPIC ENDONASAL RESECTION OF ANTERIOR CRANIAL BASE MENINGIOMAS

Neurosurgery ◽  
2008 ◽  
Vol 63 (1) ◽  
pp. 36-54 ◽  
Author(s):  
Paul A. Gardner ◽  
Amin B. Kassam ◽  
Ajith Thomas ◽  
Carl H. Snyderman ◽  
Ricardo L. Carrau ◽  
...  
Keyword(s):  
Cerebrospinal Fluid Leak ◽  
Tumor Location ◽  
Cranial Base ◽  
Complete Resection ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Petroclival Meningiomas ◽  
Anterior Cranial Base ◽  
Fluid Leak

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.

Endoscopic Endonasal Approach for Resection of Cranial Base Chordomas

Neurosurgery ◽  
2012 ◽  
Vol 71 (3) ◽  
pp. 614-625 ◽  
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.

The endoscopic endonasal approach for cerebrospinal fluid leak repair in the elderly

2015 ◽  
Vol 132 ◽  
pp. 21-25 ◽  
Author(s):  
Enzo Emanuelli ◽  
Laura Milanese ◽  
Marta Rossetto ◽  
Diego Cazzador ◽  
Elena d’Avella ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Cerebrospinal Fluid Leak ◽  
The Elderly ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Fluid Leak

scholarly journals Concerns of cerebrospinal fluid leak in aggressive expanded endonasal endoscopic approach for craniopharyngiomas

2020 ◽  
Vol 10 (4) ◽  
pp. 154-156
Author(s):  
Marlon Ortiz Machín ◽  
Omar López Arbolay
Keyword(s):  
Cerebrospinal Fluid ◽  
Third Ventricle ◽  
Cerebrospinal Fluid Leak ◽  
Endoscopic Approach ◽  
Csf Leak ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Fluid Leak

Cerebrospinal fluid leak represents a frequent complication in Craniopharyngioma´s Endoscopic Endonasal Approach. A descriptive observational investigation was performed in 50 adult patients operated of Craniopharyngiomas by aggressive Expanded Endonasal Endoscopic Approach (EEEA) in “Hermanos Ameijeiras” Hospital since 2010 to 2019 using nasoseptal flap. The 14% of all patients develop CSF leak and 85,7 % of these cases had a great communication into third ventricle creating a cisternoventricular space. Was identified relation with tumor size, hypothalamic invasion and adhesion strength of tumour. Surgical cavity suffered hydrostatic and hydrodynamic pression than lead to CSF leak independent of multilayer reparation.

Resection of Anterior Cranial Base Meningiomas with Intra- and Extracranial Involvement via a Purely Endoscopic Endonasal Approach

ORL ◽  
2012 ◽  
Vol 74 (4) ◽  
pp. 199-207 ◽  
Author(s):  
Qiuhang Zhang ◽  
Zhenlin Wang ◽  
Hongchuan Guo ◽  
Feng Kong ◽  
Ge Chen ◽  
...  
Keyword(s):  
Cranial Base ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Anterior Cranial Base

EXPANDED ENDOSCOPIC ENDONASAL APPROACH FOR ANTERIOR CRANIAL BASE AND SUPRASELLAR LESIONS

Neurosurgery ◽  
2009 ◽  
Vol 64 (4) ◽  
pp. 677-689 ◽  
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.

Extrapolating the Limits of the Nasoseptal Flap With Pedicle Dissection to the Internal Maxillary Artery

2018 ◽  
Vol 16 (1) ◽  
pp. 37-44 ◽  
Author(s):  
Carlos D Pinheiro-Neto ◽  
Maria Peris-Celda ◽  
Tyler Kenning
Keyword(s):  
Cerebrospinal Fluid ◽  
Frontal Sinus ◽  
Cerebrospinal Fluid Leak ◽  
Cranial Base ◽  
Pedicled Flap ◽  
Maxillary Artery ◽  
Internal Maxillary Artery ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Anterior Cranial Base

Abstract BACKGROUND The nasoseptal flap is the main pedicled flap used for endoscopic cranial base reconstruction. For large anterior cranial base defects, the anterior edge is a concern for the nasoseptal flap reach. OBJECTIVE To present a surgical technique that completely releases the vascular pedicle of the nasoseptal flap from the sphenopalatine artery (SPA) foramen improving considerably the reach of the flap. METHODS A patient with left anterior cranial base fracture involving the posterior table of the frontal sinus, who presented with cerebrospinal fluid leak and contused brain herniation to the ethmoid and frontal sinuses. Unilateral endoscopic endonasal anterior cranial base reconstruction was performed with left sided nasoseptal flap. The nasoseptal flap pedicle was dissected and completely released from the SPA foramen. The flap was left attached only to the internal maxillary artery (IMAX) vascular bundle. RESULTS The flap covered the entire left anterior cranial base, from the planum sphenoidale to the posterior table of the frontal sinus. There was complete obliteration of the cerebrospinal fluid fistula postoperatively with resolution of the radiographic pneumocephalus and the patient's rhinorrhea. CONCLUSION The complete release of the nasoseptal flap pedicle from the SPA foramen is feasible and remarkably improves the reach of the flap. It also increases the reconstructive area of the flap since the entire septal mucosa can be used for reconstruction and the pedicle length is based exclusively upon the SPA/IMAX.

Endoscopic Endonasal Approaches to the Clivus with No Violation of the Nasopharynx: Surgical Anatomy and Clinical Illustration

2021 ◽  
Author(s):  
Carlos D. Pinheiro-Neto ◽  
Laura Salgado-Lopez ◽  
Luciano C.P.C. Leonel ◽  
Serdar O. Aydin ◽  
Maria Peris-Celda
Keyword(s):  
Posterior Fossa ◽  
Cerebrospinal Fluid Leak ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Surgical Anatomy ◽  
Csf Leak ◽  
Surgical Approaches ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

Abstract Background Despite the use of vascularized intranasal flaps, endoscopic endonasal posterior fossa defects remain surgically challenging with high rates of postoperative cerebrospinal fluid leak. Objective The aim of the study is to describe a novel surgical technique that allows complete drilling of the clivus and exposure of the craniovertebral junction with preservation of the nasopharynx. Methods Two formalin-fixed latex-injected anatomical specimens were used to confirm feasibility of the technique. Two surgical approaches were used: sole endoscopic endonasal approach and transnasion approach. The sole endonasal approach was used in a patient with a petroclival meningioma. Results In both anatomical dissections, the inferior clivectomy with exposure of the foramen magnum was achieved with a sole endoscopic endonasal approach. The addition of the transnasion approach helped to complete drilling of the inferior border of the foramen magnum and exposure of the arch of C1. Conclusion This study shows the anatomical feasibility of total clivectomy and exposure of the craniovertebral junction with preservation of the nasopharynx. A more favorable anatomical posterior fossa defect for the reconstruction is achieved with this technique. Further clinical studies are needed to assess if this change would impact the postoperative CSF leak rate.

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