Fully endoscopic transcranial removal of anterior fossa meningioma through the minipterional keyhole approach in case with marked frontal sinuous pneumatization: clinical case

Transcranial surgery of skull base meningiomas currently remains the main method of treatment. Transnasal removal is possible in a number of cases, but it is associated with the risk of postoperative CSF-leak as a result of insolvency of the reconstruction of the skull base defect. Minimally invasive (keyhole) accesses provide a tumor overview comparable to standard accesses in most cases. The anterior-medial part of the anterior cranial fossa and the olfactory fossa is not accessible to the direct view from the minipterional craniotomy. The use of angular endoscopic optics in combination with additional resection or thinning of the bones in the orbital roof provides an overview sufficient to remove the tumor, but manipulations in this area require the use of specific tools. Aspirators, dissectors and coagulators should have bends of different expressions. The application of the described technique is advisable only in certain specially selected cases.

Download Full-text

Spontaneous CSF rhinorrhoea from separate defects of the anterior and middle cranial fossa

The Journal of Laryngology & Otology ◽

10.1258/002221502760132674 ◽

2002 ◽

Vol 116 (7) ◽

pp. 546-547 ◽

Cited By ~ 7

Author(s):

U. Raghavan ◽

S. Majumdar ◽

N. S. Jones

Keyword(s):

Skull Base ◽

Middle Ear ◽

World Literature ◽

Intrathecal Injection ◽

Middle Cranial Fossa ◽

Csf Leak ◽

Csf Rhinorrhoea ◽

Cranial Fossa ◽

Skull Base Defect ◽

Tomography Scan

Multiple congenital dehiscence of the skull base is rare and can give rise to spontaneous CSF rhinorrhoea. A search of the world literature revealed only five reports of CSF leak with more than one concomitant skull base defect. When treating a patient with spontaneous CSF rhinorrhoea the possibility of its originating from the middle ear and eustachian tube should be considered. An intrathecal injection of fluorescein is useful in establishing the site of a CSF leak especially when a computed tomography scan (CT) or magnetic resonance image (MRI) has not localized the site. We discuss a case of a 72-year-old lady presenting with CSF rhinorrhoea, who had an anterior skull base defect localized with the help of intrathecal fluorescein and repaired surgically. Subsequent to this she had a further episode of CSF rhinorrhoea that originated from a middle-ear meningocele that was then repaired.

Download Full-text

Managing CSF Leak with Temporalis Muscle Flap for Challenging Skull Base Defect after Radiation Therapy

10.1055/s-0040-1702551 ◽

2020 ◽

Author(s):

Wei-Hsin Wang ◽

Ming-Ying Lan

Keyword(s):

Radiation Therapy ◽

Skull Base ◽

Muscle Flap ◽

Csf Leak ◽

Temporalis Muscle ◽

Temporalis Muscle Flap ◽

Skull Base Defect

Download Full-text

Residual and Recurrent Disease Following Endoscopic Endonasal Approach as a Reflection of Anatomic Limitation for the Resection of Midline Anterior Skull Base Meningiomas

Operative Neurosurgery ◽

10.1093/ons/opab244 ◽

2021 ◽

Author(s):

Pradeep Setty ◽

Juan C Fernandez-Miranda ◽

Eric W Wang ◽

Carl H Snyderman ◽

Paul A Gardner

Keyword(s):

Optic Nerve ◽

Skull Base ◽

Retrospective Chart Review ◽

Residual Tumor ◽

Average Diameter ◽

Anterior Skull Base ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Orbital Roof ◽

Skull Base Meningiomas

Abstract BACKGROUND Endoscopic endonasal approaches (EEAs) to anterior skull base meningiomas have grown in popularity, though anatomic limitations remain unclear. OBJECTIVE To show the anatomic limits of EEA for meningiomas. METHODS Retrospective chart review for all patients that underwent EEA for anterior skull base meningiomas from 2005 to 2014. RESULTS A total of 100 patients averaged follow-up of 46.9 mo (24-100 mo). A total of 35 patients (35%) had olfactory groove, 33 planum sphenoidale (33%), and 32 tuberculum sella (32%) meningiomas. The average diameter was 2.9 cm (0.5-8.1 cm). Vascular encasement was seen in 11 patients (11%) and calcification in 20 (20%). Simpson Grade 1 (SG1) resection was achieved in 64 patients (64%). Only calcification impacted degree of resection (40% SG1, P = .012). The most common residual was on the anterior clinoid dura (11 patients [11%]). Six (6%) had residual superior/lateral to the optic nerve. Residual tumor was adherent to the optic apparatus or arteries in 5 patients (5%) each, and 3 patients (3%) had residual lateral to the mid-orbit. Rates of residual decreased over time. A total of 11 patients (11%) had tumor recurrence (mean of 40 mo): 4 (4%) on the anterior clinoid, 2 (2%) each on the lateral orbital roof, adherent to optic apparatus and superolateral to the optic nerve, and 1 (1%) was at the anterior falx. CONCLUSION Anterior skull base meningiomas can effectively be approached via EEA in most patients; tumors extending to the anterior clinoid, anterior falx, or superolateral to the optic nerve or orbital roof, especially if calcified, may be difficult to reach via EEA.

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

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

The Surgical Treatment of Posttraumatic Skull Base Defects with Cerebrospinal Fluid Leak

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1606555 ◽

2017 ◽

Vol 79 (02) ◽

pp. 205-216 ◽

Cited By ~ 1

Author(s):

Ashish Thapa ◽

Bing-Xi Lei ◽

Mei-Guang Zheng ◽

Zhong-Jun Li ◽

Zheng-Hao Liu ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Surgical Treatment ◽

Skull Base ◽

Surgical Approach ◽

Common Factors ◽

Csf Leak ◽

Surgical Approaches ◽

Skull Base Defect ◽

The Common ◽

Skull Base Defects

Objectives The objective was to explore further the surgical treatment of posttraumatic skull base defects with cerebrospinal fluid (CSF) leak and to identify the most common factors affecting the surgical treatment of posttraumatic skull base defect with CSF leak retrospectively. Materials and Methods This study included 144 patients with head trauma having skull base defect with CSF leak who had been surgically treated at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from 1998 to June 2016. There were 113 (78.5%) males and 31 (21.5%) females, with age ranging from 1 to 78 years and mean age of 26.58 ± 14.95 years. We explored the surgical approaches for the treatment of the skull base defect and the graft materials used and also measured the association among surgical approaches; location, size, and type of skull base defects; presence or absence of associated intracranial pathologies; postoperative complications; outcome; age; Glasgow outcome score (GOS) at discharge; and days of hospital stay. Results The location, size, and types of skull base defect and the presence of associated intracranial pathologies were the common factors identified not only for choosing the appropriate surgical approach but also for choosing the materials for defect repair, timing of the surgery, and the method used for the defect as well as leak repair. The statistically significant correlation with p < 0.001 was found in this study. Conclusion From this study, we could conclude that size, location, and types of the defect and the presence of associated intracranial injuries were the common factors that affected the surgical treatment of posttraumatic skull base defect with CSF leak. Hence, the importance of careful evaluation of these factors is essential for proper selection of the surgical approach and for avoiding unnecessary hassles.

Download Full-text

Excavating Meningoencephaloceles: A Newly Recognized Entity

American Journal of Rhinology and Allergy ◽

10.2500/ajra.2017.31.4413 ◽

2017 ◽

Vol 31 (2) ◽

pp. 127-134 ◽

Cited By ~ 1

Author(s):

Patricia A. Loftus ◽

Sarah K. Wise ◽

Pedram Daraei ◽

Kristen Baugnon ◽

John M. DelGaudio

Keyword(s):

Ct Scan ◽

Skull Base ◽

Operating Room ◽

Tertiary Care ◽

Distinct Type ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Skull Base Defect ◽

Skull Base Defects ◽

Csf Leaks

Background Spontaneous cerebrospinal fluid (CSF) leaks are largely attributed to idiopathic intracranial hypertension and typically present as skull base defects with or without prolapse of intracranial contents. However, in our practice, we have encountered a distinct type of spontaneous CSF leak that presents in a different manner. Objective To discuss a newly-classified, difficult to treat, subset of spontaneous CSF leaks that present as excavation of the bone of the skull base in a tunnel- or canal-like fashion by a meningocele or meningoencephalocele instead of as a localized area of bony dehiscence. Methods A retrospective review was performed at a tertiary care rhinology practice to identify a subset of CSF leak patients with an excavating/canal-like skull base defect visualized radiographically on computed tomography (CT) scan or magnetic resonance imaging and/or endoscopically in the operating room. Results The cohort of patients consisted of 7 females and 1 male with an average age of 53.6 years and a self-reported race of 4:3:1 African-American: Caucasian-Indian. All patients presented with CSF rhinorrhea. The most common leak site was the cribriform and upper septum. Six of the 8 patients had multiple defects and/or progression of their skull base defects, and 5 patients required multiple and/or repeat repairs in the operating room. Seven of the 8 patients underwent a cisternogram because the excavating nature of the leaks made it difficult to identify the specific leak site on high-resolution CT scan alone. Conclusion In spontaneous CSF leaks that are difficult to identify or recur soon after a proper repair, an excavating pattern should be considered. Failure to recognize this type of leak and all of its tributaries, to fully unroof the excavated bone to completely resect the meningocele, and to visualize and close the site of origin will likely result in failure and recurrence of CSF leak.

Download Full-text