scholarly journals Septal transposition: a novel technique for preservation of the nasal septum during endoscopic endonasal resection of olfactory groove meningiomas

2014 ◽  
Vol 37 (4) ◽  
pp. E6 ◽  
Author(s):  
Marc R. Rosen ◽  
Mindy R. Rabinowitz ◽  
Christopher J. Farrell ◽  
Madeleine R. Schaberg ◽  
James J. Evans ◽  
...  
Keyword(s):  
Nasal Septum ◽  
Cranial Base ◽  
Septal Perforation ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Anterior Cranial Base ◽  
Nasal Septal Flap ◽  
Early Tumor ◽  
Brain Retraction ◽  
Wide Exposure

Endonasal resection of olfactory groove meningiomas allows for several advantages over transcranial routes, including a direct approach to the bilateral anterior cranial base and dura mater, early tumor devascularization, and avoidance of brain retraction. Although considered minimally invasive, the endoscopicapproach to the cribriform plate typically requires resection of the superior nasal septum, resulting in a large superior septal perforation. The septal transposition technique improves preservation of sinonasal anatomy through the elimination of a septal perforation while allowing for wide exposure to the midline anterior cranial base and harvest of a nasal septal flap. Herein, the authors describe a 39-year-old female who presented with a progressively enlarging olfactory groove meningioma. An endoscopic endonasal resection with a septal transposition technique was performed. On follow-up, the nasal cavity had completely normal anatomy with preservation of the turbinatesand nasal septum. The authors conclude that septal transposition is a useful technique that allows wide exposure of the anterior cranial base with maximal preservation of normal nasal anatomy and avoidance of a large septal perforation.

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.

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.

The Role of 3D tractography in Skull Base Surgery: Technological Advances, Feasibility, and Early Clinical Assessment with Anterior Skull Base Meningiomas

2020 ◽  
Author(s):  
Srikant S. Chakravarthi ◽  
Melanie B. Fukui ◽  
Alejandro Monroy-Sosa ◽  
Lior Gonen ◽  
Austin Epping ◽  
...  
Keyword(s):  
Skull Base ◽  
Cranial Nerve ◽  
Skull Base Surgery ◽  
Three Dimensional ◽  
Qualitative Assessment ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Volume Functional ◽  
Signal Abnormality ◽  
Anterior Cranial Base

Abstract Objective The aim of this study is to determine feasibility of incorporating three-dimensional (3D) tractography into routine skull base surgery planning and analyze our early clinical experience in a subset of anterior cranial base meningiomas (ACM). Methods Ninety-nine skull base endonasal and transcranial procedures were planned in 94 patients and retrospectively reviewed with a further analysis of the ACM subset. Main Outcome Measures (1) Automated generation of 3D tractography; (2) co-registration 3D tractography with computed tomography (CT), CT angiography (CTA), and magnetic resonance imaging (MRI); and (3) demonstration of real-time manipulation of 3D tractography intraoperatively. ACM subset: (1) pre- and postoperative cranial nerve function, (2) qualitative assessment of white matter tract preservation, and (3) frontal lobe fluid-attenuated inversion recovery (FLAIR) signal abnormality. Results Automated 3D tractography, with MRI, CT, and CTA overlay, was produced in all cases and was available intraoperatively. ACM subset: 8 (44%) procedures were performed via a ventral endoscopic endonasal approach (EEA) corridor and 12 (56%) via a dorsal anteromedial (DAM) transcranial corridor. Four cases (olfactory groove meningiomas) were managed with a combined, staged approach using ventral EEA and dorsal transcranial corridors. Average tumor volume reduction was 90.3 ± 15.0. Average FLAIR signal change was –30.9% ± 58.6. 11/12 (92%) patients (DAM subgroup) demonstrated preservation of, or improvement in, inferior fronto-occipital fasciculus volume. Functional cranial nerve recovery was 89% (all cases). Conclusions It is feasible to incorporate 3D tractography into the skull base surgical armamentarium. The utility of this tool in improving outcomes will require further study.

scholarly journals Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique

2014 ◽  
Vol 37 (4) ◽  
pp. E10 ◽  
Author(s):  
Andrew R. Conger ◽  
Joshua Lucas ◽  
Gabriel Zada ◽  
Theodore H. Schwartz ◽  
Aaron A. Cohen-Gadol ◽  
...  
Keyword(s):  
Third Ventricle ◽  
Tumor Resection ◽  
Direct Access ◽  
Complication Rates ◽  
Endoscopic Endonasal ◽  
Transnasal Surgery ◽  
Recovery Times ◽  
Early Tumor ◽  
Ventral Skull Base ◽  
Brain Retraction

Endoscopic approaches to the midline ventral skull base have been extensively developed and refined for resection of cranial base tumors over the past several years. As these techniques have improved, both the degree of resection and complication rates have proven comparable to those for transcranial approaches, while visual outcomes may be better via endoscopic endonasal surgery and hospital stays and recovery times are often shorter. Yet for all of the progress made, the steep learning curve associated with these techniques has hampered more widespread implementation and adoption. The authors address this obstacle by coupling a thorough description of the technical nuances for endoscopic endonasal craniopharyngioma resection with detailed illustrations of the important steps in the operation. Traditionally, transsphendoidal approaches to craniopharyngiomas have been restricted to lesions mostly confined to the sella. However, recently, endoscopic endonasal resections are more frequently employed for extrasellar and purely third ventricle craniopharyngiomas, whose typical retrochiasmatic location makes them ideal candidates for endoscopic transnasal surgery. The endonasal endoscopic approach offers many advantages, including direct access to the long axis of the tumor, early tumor debulking with minimal manipulation of the optic apparatus, more precise visualization of tumor planes, particularly along the undersurface of the chiasm and the roof of the third ventricle, and a minimal-access corridor that obviates the need for brain retraction. Although much emphasis has been placed on technical tenets of exposure and “how to get there,” this article focuses on nuances of tumor resection “when you are there.” Three operative videos illustrate our discussion of technical tenets.

scholarly journals Endoscopic endonasal resection of midline cranial base tumors

2018 ◽  
Vol 19 (2) ◽  
pp. 7-17
Author(s):  
Enrico De Divitiis ◽  
Felice Esposito ◽  
Paolo Cappabianca ◽  
Luigi M. Cavallo ◽  
Oreste De Divitiis ◽  
...  
Keyword(s):  
Skull Base ◽  
Cranial Base ◽  
Transsphenoidal Approach ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Visual Deficits ◽  
Extended Transsphenoidal Approach ◽  
Anterior Cranial Base ◽  
Subtotal Removal

Objective: The advent of the endoscope in transsphenoidalsurgery has permitted to expand the indications of such approach also for the treatment of on tumors located in supra, para, retro and infrasellar regions, enabling the neurosurgeon to work under direct visual control in a minimally invasive way. Since 2004 we have started to use the extended endonasal transsphenoidal approach for a variety of lesions involving the midline skull base and, in particular, the suprasellar area, the cavernous sinus and the retroclival prepontine region. Methods: Over a 36-month period, sixty-four procedures have been performed. The series consisted of 29 males and 35 females, aged from 24 to 80 years (median 49.8 years). The mean follow-up was of 18 months (ranging from 3 to 36 months). Among the patients with midline lesions, who were 90.6 % of the total, seven patients had a pituitary adenoma, sixteen patients were affected by a craniopharyngioma, six patients had a suprasellar Rathke’s cleft cyst, seven subjects had a tuberculum sellae meningioma, four had an olfactorygroove meningioma, and six a clival tumor. Other lesions ofthe midline skull base were, 1 chiasmatic astrocytoma, 1 neuroendocrine tumor, 4 post-traumatic cerebro-spinal fluid rhinorrhea, and one optic nerve glioma. Three other patients had anterior cranial base meningoencephaloceles. Results: Overall, gross total removal of the lesion was achieved in 30/49 tumoral lesions (61.2%); subtotal removal was achieved in 12/49 cases (24.5%). The three cases of meningoencephaloceles were all successfully treated. Among the patients with preoperative visual deficits, most of them fully recovered or improved and only two worsened in one eye. Major complications consisted in 2 deaths (one not directly related with the surgical procedure), 6 postoperative CSF leak (one complicated with bacterial meningitis), one ICA injury, and 6 cases of permanent diabetes insipidus.Conclusion: The extended transsphenoidal approach tothe supra and parasellar lesions seems Endoscopy; Transsphenoidal surgery; Extended approach; Parasellar; Tumors; Anterior skull base. A promising minimally invasivetechnique for the removal of lesions affecting these areas,once thought to be suitable only of the transcranial routes.Concerning the lesion removal and the recurrence rate compared with the transcranial routes, it is too early to pose a definitive word, since the follow-up is still too short.

THREE-DIMENSIONAL AND 2-DIMENSIONAL ENDOSCOPIC EXPOSURE OF MIDLINE CRANIAL BASE TARGETS USING EXPANDED ENDONASAL AND TRANSCRANIAL APPROACHES

Neurosurgery ◽  
2009 ◽  
Vol 65 (6) ◽  
pp. 1116-1130 ◽  
Author(s):  
Jonathan Roth ◽  
Ameet Singh ◽  
Gurston Nyquist ◽  
Justin F. Fraser ◽  
Antonio Bernardo ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Improve Patient Safety ◽  
Cranial Nerves ◽  
Three Dimensional ◽  
Abducens Nerve ◽  
Cranial Base ◽  
Endoscopic Endonasal ◽  
3 Dimensional ◽  
Fresh Cadaver ◽  
Wide Exposure

Abstract OBJECTIVE Endoscopic endonasal approaches provide an access method to the midline cranial base. To integrate these approaches into neurosurgical practice, the extent of their anatomic exposure must be compared with that provided by more traditional transcranial approaches. METHODS Ten fresh cadaver heads were studied. Both endonasal and transcranial approaches to the midline cranial base were performed. The midline cranial base was divided into several areas, and the relative exposure provided by each approach was described and presented in both 2-dimensional and 3-dimensional images. Limitations and advantages of each approach are discussed. RESULTS The endonasal approaches achieved a direct and wide exposure of the midline extracranial and intracranial cranial base anatomy. The main lateral limitations of the endonasal approaches were the optic nerves, lateral cavernous sinus, vidian nerve, internal carotid artery, abducens nerve in Dorello's canal, jugular tubercle, and hypoglossal canals. Limitations of the transcranial approaches were the neurovascular structures which lie in the operative corridor and create narrow working spaces. CONCLUSION The endonasal approaches achieve a direct and wide exposure of the midline cranial base bilaterally. Lateral exposure, beyond the cranial nerves and carotid artery, are challenging. Transcranial approaches are limited by the narrow corridors provided by the cranial nerves, and they do not visualize the contralateral paramedian cranial base very well. Three-dimensional endoscopes augment the spatial orientation and may improve patient safety and the learning curve for endoscopic approaches to the midline cranial base.

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