Endoscopic transnasal resection of anterior cranial fossa meningiomas

Object The extended transnasal approach, a recent surgical advancements for the ventral skull base, allows excellent midline access to and visibility of the anterior cranial fossa, which was previously thought to be approachable only via a transcranial route. The extended transnasal approach allows early decompression of the optic canals, obviates the need for brain retraction, and reduces neurovascular manipulation. Methods Between 2004 and 2007, 11 consecutive patients underwent transnasal resection of anterior cranial fossa meningiomas—4 olfactory groove (OGM) and 7 tuberculum sellae (TSM) meningiomas. Age at surgery, sex, symptoms, and imaging studies were reviewed. Tumor size and tumor extension were estimated, and the anteroposterior, vertical, and horizontal diameters were measred on MR images. Medical records, surgical complications, and outcomes of the patients were collected. Results A gross-total removal of the lesion was achieved in 10 patients (91%), and in 1 patient with a TSM only a near-total (> 90%) resection was possible. Four patients with preoperative visual function defect had a complete recovery, whereas 3 patients experienced a transient worsening of vision, fully recovered within few days. In 3 patients (2 with TSMs and 1 with an OGM), a postoperative CSF leak occurred, requiring a endoscopic surgery for skull base defect repair. Another patient (a case involving a TSM) developed transient diabetes insipidus. The operative time ranged from 6 to 10 hours in the OGM group and from 4.5 to 9 hours in the TSM group. The mean duration of the hospital stay was 13.5 and 10 days in the OGM and TSM groups, respectively. Six patients (3 with OGMs and 3 with TSMs) required a blood transfusion. Surgery-related death occurred in 1 patient with TSM, in whom the tumor was successfully removed. Conclusions The technique offers a minimally invasive route to the midline anterior skull base, allowing the surgeon to avoid using brain retraction and reducing manipulation of the large vessels and optic apparatus; hastens postoperative recovery; and improves patient compliance. Further assessment and refinement are required, particularly because of the potential risk of CSF leakage. Other studies and longer follow-up periods are necessary to ascertain the benefits of the technique.

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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.

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OLFACTORY GROOVE MENINGIOMAS – CLINICAL PRESENTATION, TREATMENT AND OUTCOMES

Journal of Surgical Sciences ◽

10.33695/jss.v2i1.104 ◽

2015 ◽

Vol 2 (1) ◽

pp. 34-48

Author(s):

Tabita Larisa Cazac ◽

Ioana Andreea Dărămuș ◽

B. C. Dumitrescu ◽

C. Toader

Keyword(s):

Visual Acuity ◽

Cribriform Plate ◽

Anterior Cranial Fossa ◽

External Carotid ◽

Olfactory Groove ◽

Mental Disturbances ◽

Cranial Fossa ◽

Frontal Sinuses ◽

Planum Sphenoidale ◽

Brain Retraction

Olfactory groove meningiomas are benign tumors, which arise in the midline of the anterior cranial fossa, over the cribriform plate and frontosphenoid suture. They represent approximately 10 percent of all intracranial meningiomas, more likely to occur in women in the fifth and sixth decades of life. They often involve the area from the grista galli to the posterior planum sphenoidale, and can be either simetric, bilateral or unilateral based on their midline origin. We report the case of a 45-year-old man who presented with an episode of loss of consciousness, progressive mental disturbances, impairment of visual acuity, anosmia and headache. Gadolinium-enhanced T1-weighted MR images showed a well-defined, hyperintense mass, located in the anterior cranial fossa, measuring 45/50/61 mm, with homogenous enhancement and a broad dural attachment to the cribriform plate, from crista galli to the planum sphenoidale. Preoperative Angiography revealed tumor vascularization from anterior and posterior ethmoidal arteries, branches of ophthalmic artery and branches of external carotid artery. The olfactory groove meningioma was successfully resected using a bifrontal approach with frontal sinuses opened in order to avoid brain retraction. Cranialization with pericranium of frontal sinuses was performed at the end of surgical procedure. Improvement of visual acuity was noted, mental disturbances and seizures remitted, but cerebrospinal leakage occurred, resolved via recranialization of frontal sinuses and lumbar punctions. The last postoperative computer-tomography investigation showed total surgical removal with no recurrence or residual tumor. Total tumor removal must be performed with coagulation of its arachnoid attachments and resection of hyperostotic bone in order to avoid recurrence, but with least brain retraction.

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The Corkscrew Technique – A Minimally Invasive, Trans-nasal Anterior Skull Base Reconstruction Using a Wedge-shaped Construct for Treatment of Cerebro-Spinal Fluid Leak

10.21203/rs.3.rs-707136/v1 ◽

2021 ◽

Author(s):

Yazid Samih Badarny ◽

Iddo Paldor ◽

Samih Badarny ◽

Ziv Gil ◽

Gill Sviri

Keyword(s):

Skull Base ◽

Lateral Displacement ◽

Standard Technique ◽

Fascia Lata ◽

Anterior Skull Base ◽

Spinal Fluid ◽

Csf Leak ◽

Transnasal Approach ◽

Skull Base Reconstruction ◽

Csf Leakage

Abstract Background : Cerebro-spinal fluid rhinorrhea may follow surgical and traumatic events, and may be spontaneous. Various techniques have been employed for reconstruction of the skull base following a CSF leak. Recent years have seen the development of endoscopic, transnasal techniques for reconstruction of the anterior skull base. We describe our experience with a novel corkscrew technique (CST), which entails harvesting a fascia lata graft, and placement of a wedge-shaped construct above the aperture in the skull base dura. This technique serves to prevent dislodgement of the construct extracranially, and lateral displacement of the construct away from the opening. Methods : We operated 28 cases of CSF leak, in 26 patients, with a transnasal endoscopic approach. Twelve were operated using the CST and 16 with standard technique (ST), with a mean follow-up of over 5 years.Results : The success rate in alleviating the leak was 91.7% in the CST group, and 87.5% in the ST group. Altogether, our complication rate was 8.3% in the CST group, and 37.5% in the ST group. None of the differences were statistically significant. Conclusions : We recommend the use of a wedge-shaped, fascia lata based construct for transnasal endoscopic repair of anterior skull base CSF leaks. Keywords: rhinorrhea, pituitary adenoma, CSF leakage, endoscopic transnasal approach, fascia lata.

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Traumatic Anterior Cranial Fossa CSF Leaks

Neurotrauma ◽

10.1093/med/9780190936259.003.0011 ◽

2019 ◽

pp. 93-102

Author(s):

Omaditya Khanna ◽

Tomas Garzon-Muvdi ◽

Hermes Garcia ◽

Richard F. Schmidt ◽

James J. Evans ◽

...

Keyword(s):

Skull Base ◽

Anterior Cranial Fossa ◽

Confirmatory Test ◽

Ct Cisternography ◽

Csf Rhinorrhea ◽

Csf Leakage ◽

Cranial Fossa ◽

Csf Diversion ◽

Magnetic Resonance Cisternography ◽

Csf Leaks

Traumatic CSF leaks are reported to complicate 10–30% of skull base fractures. CSF rhinorrhea or otorrhea may be clinically apparent but in patients with less obvious leaks, β‎2-transferrin evaluation is the most sensitive and specific confirmatory test to establish the diagnosis of CSF leakage. High-resolution CT effectively identifies the majority of skull base fractures and sites of CSF leakage. Adjunctive imaging modalities such as CT cisternography and magnetic resonance cisternography may be used for further evaluation. Most traumatic CSF leaks of the anterior cranial fossa resolve spontaneously with conservative management including bedrest, head elevation, and avoidance of activities that increase intracranial pressure. The risk of meningitis increases significantly with persistent CSF leakage beyond 1 week, and intervention in the form of CSF diversion or surgical closure of the leak should be pursued. Prophylactic antibiotics have not been shown to decrease the risk of meningitis in patients with traumatic CSF leaks.

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Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

Journal of Neurosurgery ◽

10.3171/jns.1999.90.4.0651 ◽

1999 ◽

Vol 90 (4) ◽

pp. 651-655 ◽

Cited By ~ 37

Author(s):

Marc S. Schwartz ◽

James I. Cohen ◽

Toby Meltzer ◽

Michael J. Wheatley ◽

Sean O. McMenomey ◽

...

Keyword(s):

Skull Base ◽

Free Flap ◽

Cranial Base ◽

Csf Leak ◽

Content Type ◽

Lateral Skull Base ◽

Csf Leakage ◽

Radial Forearm ◽

Microvascular Free Flap ◽

Fine Print

Object. Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage.Methods. Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation.Conclusions. Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to “low-volume” defects.

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Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

Journal of Neurosurgery ◽

10.3171/2018.4.jns18366 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1625-1631 ◽

Cited By ~ 2

Author(s):

Takayuki Ishikawa ◽

Kazuhito Takeuchi ◽

Yuichi Nagata ◽

Jungsu Choo ◽

Teppei Kawabata ◽

...

Keyword(s):

Skull Base ◽

Transsphenoidal Surgery ◽

Skull Base Surgery ◽

Sella Turcica ◽

High Flow ◽

Anterior Skull Base ◽

Csf Leak ◽

Dural Defect ◽

Csf Leakage ◽

Dural Suturing

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

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Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

Neurosurgical FOCUS ◽

10.3171/2012.5.focus1255 ◽

2012 ◽

Vol 32 (6) ◽

pp. E7 ◽

Cited By ~ 61

Author(s):

James K. Liu ◽

Richard F. Schmidt ◽

Osamah J. Choudhry ◽

Pratik A. Shukla ◽

Jean Anderson Eloy

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Base ◽

High Flow ◽

Csf Leak ◽

Reconstruction Technique ◽

Dural Defect ◽

Nasoseptal Flap ◽

Endoscopic Skull Base Surgery ◽

Csf Leakage

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

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Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

Journal of Neurosurgery ◽

10.3171/2011.12.jns111474 ◽

2012 ◽

Vol 116 (4) ◽

pp. 749-754 ◽

Cited By ~ 32

Author(s):

Wouter I. Schievink ◽

Marc S. Schwartz ◽

M. Marcel Maya ◽

Franklin G. Moser ◽

Todd D. Rozen

Keyword(s):

Skull Base ◽

Intracranial Hypotension ◽

Spontaneous Intracranial Hypotension ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Spinal Imaging ◽

Radiological Data ◽

Single Instance ◽

Csf Leakage ◽

Csf Leaks

Object Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. Methods Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period. Results Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. Conclusions There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

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Classification and Microvascular Flap Selection for Anterior Cranial Fossa Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1649520 ◽

2018 ◽

Vol 34 (08) ◽

pp. 590-600 ◽

Cited By ~ 1

Author(s):

James Vargo ◽

Wojciech Przylecki ◽

Paul Camarata ◽

Brian Andrews

Keyword(s):

Skull Base ◽

Free Flap ◽

Cerebrospinal Fluid Leak ◽

Anterior Cranial Fossa ◽

Microvascular Reconstruction ◽

Autologous Reconstruction ◽

Muscle Flaps ◽

Defect Groups ◽

Microvascular Flap ◽

Cranial Fossa

Background Microvascular reconstruction of the anterior cranial fossa (ACF) creates difficult challenges. Reconstructive goals and flap selection vary based on the defect location within the ACF. This study evaluates the feasibility and reliability of free tissue transfer for salvage reconstruction of low, middle, and high ACF defects. Methods A retrospective review was performed. Reconstructions were anatomically classified as low (anterior skull base), middle (frontal bar/sinus), and high (frontal bone/soft tissue). Subjects were evaluated based on pathologic indication and goal, type of flap used, and complications observed. Results Eleven flaps in 10 subjects were identified and anatomic sites included: low (n = 5), middle (n = 3), and high (n = 3). Eight of 11 reconstructions utilized osteocutaneous flaps including the osteocutaneous radial forearm free flap (OCRFFF) (n = 7) and fibula (n = 1). Other reconstructions included a split calvarial graft wrapped within a temporoparietal fascia free flap (n = 1), latissimus myocutaneous flap (n = 1), and rectus abdominis myofascial flap (n = 1). All 11 flaps were successful without microvascular compromise. No complications were observed in the high and middle ACF defect groups. Two of five flaps in the low defect group using OCRFFF flaps failed to achieve surgical goals despite demonstrating healthy flaps upon re-exploration. Complications included persistent cerebrospinal fluid leak (n = 1) and pneumocephalus (n = 1), requiring flap repositioning in one subject and a second microvascular flap in the second subject to achieve surgical goals. Conclusion In our experience, osteocutaneous flaps (especially the OCRFFF) are preferred for complete autologous reconstruction of high and middle ACF defects. Low skull base defects are more difficult to reconstruct, and consideration of free muscle flaps (no bone) should be weighed as an option in this anatomic area.

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