Utility of Early Postoperative Imaging after Combined Endoscopic and Open Ventral Skull Base Surgery

2017 ◽  
Vol 31 (3) ◽  
pp. 186-189 ◽  
Author(s):  
Zachary S. Mendelson ◽  
Kristen A. Echanique ◽  
Meghan M. Crippen ◽  
Alejandro Vazquez ◽  
James K. Liu ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Skull Base ◽  
Clinical Symptoms ◽  
Skull Base Surgery ◽  
False Negative ◽  
True Negative ◽  
Endoscopic Endonasal ◽  
Postoperative Imaging ◽  
Significant Difference ◽  
Ventral Skull Base

Purpose Immediate postoperative imaging is frequently obtained after combined skull base surgery (SBS) with endoscopic endonasal and open transcranial approaches. The importance of early postoperative imaging for detecting complications in these patients is still debatable. In this study, we investigated the clinical utility of early postoperative imaging after combined SBS for determination of postoperative complications. Methods A retrospective chart analysis of 21 cases of combined SBS between 2009 and 2015 was performed. Data on postoperative computed tomography (CT) and magnetic resonance imaging (MR), and the hospital course were collected. We separated interpretations of postoperative imaging into two groups: (1) when using the radiologist's interpretation alone, and (2) when using the surgeon's knowledge of the case in conjunction with imaging. Results Forty-two postoperative scans were obtained (21 CT, 21 MR) within 48 hours of surgery. There was a significant statistical difference between imaging interpretation by surgeons and radiologists for CT interpretation only. For CT interpretation the true positive (TP), false positive (FP), true negative (TN), and false negative (FN) rates for radiologists (TP, 0/21; FP, 6/21; TN, 11/21; FN, 4/21) slightly deviated from surgeons' interpretation (TP, 1/21 [p = 0.9999]; FP, 0/21 [p = 0.0207]; TN, 17/21 [p = 0.1000]; FN, 3/21 [p = 1.000]). Rates for MRI interpretation by both groups were nearly identical, with no significant difference found. Overall, four patients experienced seven postoperative complications, which led to a complication rate of 19.0% (4/21). The patients exhibited clinical symptoms in all instances of postoperative complications that required further intervention. Conclusion The benefit of early postoperative imaging to detect complications after combined SBS was limited. In this cohort of patients, positive imaging findings' effects on patient management were dictated by the presence of supporting clinical symptoms.

Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

2014 ◽  
Vol 121 (4) ◽  
pp. 961-975 ◽  
Author(s):  
Matei A. Banu ◽  
Oszkar Szentirmai ◽  
Lino Mascarenhas ◽  
Al Amin Salek ◽  
Vijay K. Anand ◽  
...  
Keyword(s):  
Learning Curve ◽  
Skull Base ◽  
Skull Base Surgery ◽  
Postoperative Management ◽  
Csf Leak ◽  
Histopathological Diagnosis ◽  
Endoscopic Endonasal ◽  
Postoperative Imaging ◽  
Interhemispheric Fissure ◽  
Csf Leaks

Object Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS. Methods The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1–10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0–4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak. Results The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed “suspicious” pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as “benign” pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0–4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of “suspicious” pneumocephalus provides the best overall prediction for postoperative CSF leaks. Conclusions Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A “suspicious” pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of “suspicious” pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.

Sensitivity and specificity of intrathecal fluorescein and white light excitation for detecting intraoperative cerebrospinal fluid leak in endoscopic skull base surgery: a prospective study

2016 ◽  
Vol 124 (3) ◽  
pp. 621-626 ◽  
Author(s):  
Shaan M. Raza ◽  
Matei A. Banu ◽  
Angela Donaldson ◽  
Kunal S. Patel ◽  
Vijay K. Anand ◽  
...  
Keyword(s):  
Skull Base ◽  
Sensitivity And Specificity ◽  
Skull Base Surgery ◽  
False Negative ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Predictive Values ◽  
Endoscopic Skull Base Surgery ◽  
Csf Leaks

OBJECT The intraoperative detection of CSF leaks during endonasal endoscopic skull base surgery is critical to preventing postoperative CSF leaks. Intrathecal fluorescein (ITF) has been used at varying doses to aid in the detection of intraoperative CSF leaks. However, the sensitivity and specificity of ITF at certain dosages is unknown. METHODS A prospective database of all endoscopic endonasal procedures was reviewed. All patients received 25 mg ITF diluted in 10 ml CSF and were pretreated with dexamethasone and Benadryl. Immediately after surgery, the operating surgeon prospectively noted if there was an intraoperative CSF leak and fluorescein was identified. The sensitivity, specificity, and positive and negative predictive power of ITF for detecting intraoperative CSF leak were calculated. Factors correlating with postoperative CSF leak were determined. RESULTS Of 419 patients, 35.8% of patients did not show a CSF leak. Fluorescein-tinted CSF (true positive) was noted in 59.7% of patients and 0 false positives were encountered. CSF without fluorescein staining (false negative) was noted in 4.5% of patients. The sensitivity and specificity of ITF were 92.9% and 100%, respectively. The negative and positive predictive values were 88.8% and 100%, respectively. Postoperative CSF leaks only occurred in true positives at a rate of 2.8%. CONCLUSIONS ITF is extremely specific and very sensitive for detecting intraoperative CSF leaks. Although false negatives can occur, these patients do not appear to be at risk for postoperative CSF leak. The use of ITF may help surgeons prevent postoperative CSF leaks by intraoperatively detecting and confirming a watertight repair.

Long-term impact of pediatric endoscopic endonasal skull base surgery on midface growth

2019 ◽  
Vol 23 (4) ◽  
pp. 523-530 ◽  
Author(s):  
Wendy Chen ◽  
Paul A. Gardner ◽  
Barton F. Branstetter ◽  
Shih-Dun Liu ◽  
Yue Fang Chang ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Cranial Base ◽  
Early Surgery ◽  
Endoscopic Endonasal ◽  
Anterior Maxilla ◽  
Surgery Group ◽  
Significant Difference

OBJECTIVECranial base development plays a large role in anterior and vertical maxillary growth through 7 years of age, and the effect of early endonasal cranial base surgery on midface growth is unknown. The authors present their experience with pediatric endoscopic endonasal surgery (EES) and long-term midface growth.METHODSThis is a retrospective review of cases where EES was performed from 2000 to 2016. Patients who underwent their first EES of the skull base before age 7 (prior to cranial suture fusion) and had a complete set of pre- and postoperative imaging studies (CT or MRI) with at least 1 year of follow-up were included. A radiologist performed measurements (sella-nasion [S-N] distance and angles between the sella, nasion, and the most concave points of the anterior maxilla [A point] or anterior mandibular synthesis [B point], the SNA, SNB, and ANB angles), which were compared to age- and sex-matched Bolton standards. A Z-score test was used; significance was set at p < 0.05.RESULTSThe early surgery group had 11 patients, with an average follow-up of 5 years; the late surgery group had 33 patients. Most tumors were benign; 1 patient with a panclival arteriovenous malformation was a significant outlier for all measurements. Comparing the measurements obtained in the early surgery group to Bolton standard norms, the authors found no significant difference in postoperative SNA (p = 0.10), SNB (p = 0.14), or ANB (0.67) angles. The S-N distance was reduced both pre- and postoperatively (SD 1.5, p = 0.01 and p = 0.009). Sex had no significant effect. Compared to patients who had surgery after the age of 7 years, the early surgery group demonstrated no significant difference in pre- to postoperative changes with regard to S-N distance (p = 0.87), SNA angle (p = 0.89), or ANB angle (p = 0.14). Lesion type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group.CONCLUSIONSThough our cohort of patients with skull base lesions demonstrated some abnormal measurements in the maxillary-mandibular relationship before their operation, their postoperative cephalometrics fell within the normal range and showed no significant difference from those of patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

Straws Don't Suck: Are Straws Dangerous after Endoscopic Skull Base Surgery?

2020 ◽  
Author(s):  
Erin K. Reilly ◽  
Judd H. Fastenberg ◽  
Mindy R. Rabinowitz ◽  
Colin T. Huntley ◽  
Maurits S. Boon ◽  
...  
Keyword(s):  
Nasal Cavity ◽  
Skull Base ◽  
Negative Pressure ◽  
Skull Base Surgery ◽  
Pressure Measurements ◽  
Average Pressure ◽  
Endoscopic Endonasal ◽  
Endoscopic Skull Base Surgery ◽  
Significant Difference ◽  
Pressure Dynamics

Abstract Objective Patients undergoing endoscopic endonasal surgery have historically been restricted from using straws postoperatively, due to the concern that this activity generates negative pressure. The objective of this study is to evaluate the pressure dynamics in the sinonasal cavity associated with the use of a straw. Methods Intracranial pressure catheters were placed in the nasal cavity of 20 healthy individuals. Pressure measurements were then recorded while participants drank liquids of different viscosities from a cup and from a straw. Measurements were recorded with and without subjects occluding their nose to simulate postoperative nasal obstruction. Results The average pressure in the nasal cavity while drinking water from a cup was −0.86 cmH2O, from a straw was −1.09 cmH2O, and while occluding the nose and using a straw was −0.81 cmH2O. The average pressure in the nasal cavity while drinking a milkshake from a cup was −0.98 cmH2O, from a straw was −1.88 cmH2O, and while occluding the nose and using a straw was −1.37 cmH2O. There was no statistically significant difference in pressure measurements when comparing either task or consistency (p > 0.05). Conclusion Straw use is not associated with the generation of significant negative pressure in the nasal cavity. The pressure generated when drinking from a straw is not significantly different from that of drinking from a cup. This data suggest that straw use may be safe for patients following endoscopic skull base surgery, but further investigation is warranted.

138 Endoscopic Endonasal Skull Base Surgery in Pediatric Patients and Impact on Midface Growth

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 232-232
Author(s):  
Wendy Chen ◽  
Shih-Dun Liu ◽  
Barton F Branstetter ◽  
Yue-Fang Chang ◽  
Lindsay A Schuster ◽  
...  
Keyword(s):  
Skull Base ◽  
Pediatric Patients ◽  
Skull Base Surgery ◽  
Score Test ◽  
Growth Period ◽  
Cranial Base ◽  
Tumor Type ◽  
Endoscopic Endonasal ◽  
Significant Difference ◽  
Maxilla And Mandible

Abstract INTRODUCTION Cranial base development plays a large role in anterior and vertical maxillary growth through age 7, and the effect of early endonasal cranial base surgery on midface growth is unknown. We present our experience with pediatric endoscopic endonasal surgery and long-term midface growth. METHODS This is a retrospective review (2000-2016). Pediatric patients were grouped by age at first endoscopic endonasal skull base surgery (<7 yo and >7 yo). Included patients had both pre- and post-operative (>1 yr) imaging. Radiologists performed measurements (Sella-Nasion distance and angles from S-N to maxilla and mandible (SNA, SNB, ANB)), which were compared to age- and sex-matched Bolton standards. Z score test was used; significance was set at P < 0.05. RESULTS >The <7 yo group had 11 patients, averaging follow-up of 5 yrs; the >7 yo group had 33 patients. Most tumors were benign; one patient with a panclival AVM was a significant outlier for all measurements. Comparing the <7 yo group to Bolton standard norms, there was no significant difference in post-operative SNA (P = 0.10), SNB (P = 0.14), or ANB (0.67). SN distance was reduced both pre- and post-operatively (SD = 1.5, P = 0.01 and P = 0.009). Sex had no significant effect. Compared to patients who had surgery in the >7 yo group, the <7 yo group demonstrated no significant difference in pre- to post-operative changes with regard to S-N (P = 0.87), SNA (P = 0.89), and ANB (P = 0.14). Tumor type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group. CONCLUSION Though our cohort of patients with skull base tumors demonstrate some abnormal measurements before their operation, their post-operative cephalometrics fall within normal standard deviations and generally have no significant difference compared to patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

Expanded endoscopic endonasal transcribriform approach for resection of anterior skull base olfactory schwannoma

2012 ◽  
Vol 32 (Suppl1) ◽  
pp. E3 ◽  
Author(s):  
James K. Liu ◽  
Jean Anderson Eloy
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Tumor Resection ◽  
Cranial Base ◽  
Anterior Skull Base ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Anterior Cranial Base ◽  
Ventral Skull Base ◽  
Brain Retraction

Anterior skull base (ASB) schwannomas are extremely rare and can often mimic other pathologies involving the ASB such as olfactory groove meningiomas, hemangiopericytomas, esthesioneuroblastomas, and other malignant ASB tumors. The mainstay of treatment for these lesions is gross-total resection. Traditionally, resection for tumors in this location is performed through a bifrontal transbasal approach that can involve some degree of brain retraction or manipulation for tumor exposure. With the recent advances in endoscopic skull base surgery, various ASB tumors can be resected successfully using an expanded endoscopic endonasal transcribriform approach through a “keyhole craniectomy” in the ventral skull base. This approach represents the most direct route to the anterior cranial base without any brain retraction. Tumor involving the paranasal sinuses, medial orbits, and cribriform plate can be readily resected. In this video atlas report, the authors demonstrate their step-by-step techniques for resection of an ASB olfactory schwannoma using a purely endoscopic endonasal transcribriform approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/NLtOGfKWC6U.

Endoscopic ventral skull base surgery: Is early postoperative imaging warranted for detecting complications?

2014 ◽  
Vol 125 (5) ◽  
pp. 1072-1076 ◽  
Author(s):  
Lucia Diaz ◽  
Leila J. Mady ◽  
Zachary S. Mendelson ◽  
James K. Liu ◽  
Jean Anderson Eloy
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Postoperative Imaging ◽  
Ventral Skull Base

scholarly journals Extended Endoscopic Endonasal Surgery to Ventral Skull Base Lesions

QJM ◽  
2020 ◽  
Vol 113 (Supplement_1) ◽  
Author(s):  
A S Montaser ◽  
M S Ismail ◽  
O Y Hammad ◽  
Z Y Fayed ◽  
D M Prevedello
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Direct Access ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Invasive Approach ◽  
Skull Base Lesions ◽  
The Mean ◽  
Ventral Skull Base

Abstract Introduction In the last two decades, Endoscopic endonasal approaches (EEAs) have undergone a significant evolution with a major shift from a transsellar approach to a variety of approaches that can directly access the midline and paramedian ventral skull base. Once the technical feasibility of any surgical approach is established; its safety (assessed through complications), and treatment outcomes (assessed through long-term follow-up) should be addressed. Aim of the Study To assess the feasibility, safety, and efficacy of EEA as a minimally invasive approach to ventral skull base lesions. Methodology and Materials this is a prospective observational study of group of 30 patients with ventral skull base lesions that were managed via endoscopic endonasal approaches. All patients’ clinical data, radiographic evaluations, procedural detail, complications, and follow-up data were recorded and analyzed. Results The mean age of patients was 50.8 years (range: 18-74 years), with a male:female ration of 1:1.72. The most commonly encountered pathological entities in the cohort was meningiomas (43.3%), pituitary adenomas (23.3%). and craniopharyngiomas (13.3%). Postoperative CSF leak was observed in 6.6% of cases and was managed successfully. There were no cases with postoperative infection in the cohort. Other procedure-related complications include transient diabetes insipidus (10%), pneumocephaly (3.3%), Syndrome of inappropriate ADH secretion (3.3%). Gross total resection was achieved in 93.3% of cases. Improvement of preoperative symptoms was recorded in 89.2% of cases. The mean follow-up duration was 17.8 ± 2.7 months. Conclusion EEAs provide direct access and better visualization to the ventral skull base without brain retraction and with minimal neurovascular manipulation, leading to less morbidity and mortality. EEA can be considered a feasible, safe, and effective tool on the armamentarium of skull base surgery. EEAs should not be considered as a replacement to the traditional transcranial approaches; rather. EEAs are deemed as a complementary route and a potential alternative to conventional skull base surgery in select cases.

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