Surgical treatment of clival chordomas: the transsphenoidal approach revisited

1996 ◽  
Vol 85 (5) ◽  
pp. 784-792 ◽  
Author(s):  
Giulio Maira ◽  
Roberto Pallini ◽  
Carmelo Anile ◽  
Eduardo Fernandez ◽  
Fabrizio Salvinelli ◽  
...  
Keyword(s):  
Spinal Metastasis ◽  
Postoperative Radiotherapy ◽  
Primary Treatment ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Partial Removal ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Lower Clivus ◽  
Fine Print

✓ This is a report of 12 cases of clival chordomas that were surgically treated at the Catholic University Medical School, Rome, Italy, over a 7-year period. The study emphasizes the role of the transsphenoidal approach. The study group included seven men and five women whose ages ranged from 26 to 80 years (mean 49.8 years). Diplopia was the most common presenting symptom (eight cases). The tumor involved the upper and middle clivus in five cases, the middle clivus in five, and the lower clivus in two cases. One patient developed spinal metastasis. On histological examination, eight cases proved to be typical chordomas, three cases had a chondroid component, and one case of chordoma had atypical features. Immunohistological staining for vimentin and epithelial membrane antigen was positive in all cases. Follow-up periods ranged from 14 to 86 months (mean 40.2 months). The primary treatment consisted of surgery. Ten patients with chordomas of the upper and middle clivus underwent a total of 13 transsphenoidal procedures. Total tumor removal was achieved in seven cases, subtotal removal in two, and partial removal in one case. In the two cases of lower clival chordomas, total removal was accomplished in one and partial removal in the other. After total removal, no recurrence was noted at 14 to 86 months (mean 37.5 months). In the cases undergoing operation via a transsphenoidal approach, there was zero morbidity and one cerebrospinal fluid fistula that resolved without surgery. The tumor recurred in two patients after subtotal and partial removal, respectively. The authors opted to reoperate in cases of recurrence. Postoperative radiotherapy was administered in only two cases in which further surgery was not indicated because of medical reasons or because such a procedure was contrary to the patient's wishes. When mortality and morbidity rates of this group are compared to those of chordoma patients who were treated with extensive skull-base surgery, the results prompt a reappraisal of the transsphenoidal approach in the treatment of clival chordomas.

The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors

2005 ◽  
Vol 102 (5) ◽  
pp. 832-841 ◽  
Author(s):  
Joshua R. Dusick ◽  
Felice Esposito ◽  
Daniel F. Kelly ◽  
Pejman Cohan ◽  
Antonio DeSalles ◽  
...  
Keyword(s):  
Residual Tumor ◽  
Transsphenoidal Approach ◽  
Total Removal ◽  
Content Type ◽  
Patients Âgés ◽  
Extended Transsphenoidal Approach ◽  
Planum Sphenoidale ◽  
Dural Defects ◽  
Fine Print ◽  
Csf Leaks

Object. The extended transsphenoidal approach, which requires a bone and dural opening through the tuberculum sellae and posterior planum sphenoidale, is increasingly used for the treatment of nonadenomatous suprasellar tumors. The authors present their experiences in using the direct endonasal approach in patients with nonadenomatous suprasellar tumors. Methods. Surgery was performed with the aid of an operating microscope and angled endoscopes were used to assess the completeness of resection. Bone and dural defects were repaired using abdominal fat, collagen sponge, titanium mesh, and, in most cases, lumbar drainage of cerebrospinal fluid (CSF). Twenty-six procedures for tumor removal were performed in 24 patients (ages 9–79 years), including two repeated operations for residual tumor. Gross-total removal could be accomplished in only 46% of patients, with near-gross-total removal or better in 74% of 23 patients (five of eight with craniopharyngiomas, six of seven with meningiomas, five of six with Rathke cleft cysts, and one of two with a dermoid or epidermoid cyst); a patient with a lymphoma only underwent biopsy. Of 13 patients with tumor-related visual loss, 85% improved postoperatively. The complications that occurred included five patients (21%) with postoperative CSF leaks, one patient (4%) with bacterial meningitis; five patients (21%) with new endocrinopathy; and two patients (8%) who needed to undergo repeated operations to downsize suprasellar fat grafts. The only permanent neurological deficit was anosmia in one patient; there were no intracranial vascular injuries. Conclusions. The direct endonasal skull-base approach provides an effective minimally invasive means for resecting or debulking nonadenomatous suprasellar tumors that have traditionally been approached through a sublabial or transcranial route. Procedures in the supraglandular space can be performed effectively with excellent visualization of the optic apparatus while preserving pituitary function in most cases. The major challenge remains developing consistently effective techniques to prevent postoperative CSF leaks.

Surgical outcomes in 31 patients with craniopharyngiomas extending outside the suprasellar cistern: an evaluation of the frontobasal interhemispheric approach

2002 ◽  
Vol 96 (4) ◽  
pp. 704-712 ◽  
Author(s):  
Reizo Shirane ◽  
Ching-chan Su ◽  
Yasuko Kusaka ◽  
Hidefumi Jokura ◽  
Takashi Yoshimoto
Keyword(s):  
Visual Field ◽  
Total Removal ◽  
Partial Removal ◽  
Content Type ◽  
Interhemispheric Approach ◽  
Suprasellar Region ◽  
Initial Symptoms ◽  
Orbitozygomatic Approach ◽  
Fine Print

Object. Craniopharyngiomas frequently grow from remnants of the Rathke pouch, which is located on the cisternal surface of the hypothalamic region. These lesions can also extend elsewhere in the infundibulohypophyseal axis. The aim of this study was to establish the usefulness of the frontobasal approach made through a relatively small craniotomy window for the removal of tumors protruding from the sellar—suprasellar region into the third and basal cistern. Methods. Thirty-one patients who were surgically treated for craniopharyngiomas extending outside the sellar—suprasellar region were evaluated. The diagnoses were established in all cases by using magnetic resonance and computerized tomography imaging. The initial symptoms and signs were increased intracranial pressure in eight, vision impairment or visual field defect in 16, hypopituitarism in 17, and psychological disturbances in three cases. All patients underwent surgery via the frontobasal interhemispheric approach, and the average follow-up period was 30 months. Total removal of the lesion was achieved in 22 cases, six patients underwent subtotal resection, and three underwent partial removal due to tumor recurrence after previous surgeries performed with or without adjunctive radiotherapy. Major complications, including impairment of the cranial nerves, were not observed in the immediate postoperative period. One patient exhibited transient memory disturbance due to infarction of the perforating vessels; after 3 months this symptom was ameliorated. None of the patients died during long-term follow up; however, four of the 22 who underwent total removal and six of the nine patients who underwent subtotal or partial removal suffered recurrence. Of the 10 patients with recurrence, six experienced a small recurrence of the lesion (average 3 months postsurgery); after gamma knife surgery (GKS), the size of two of the lesions was unchanged and in four reoperation was performed due to tumor enlargement during the follow-up period. Ultimately, a total of eight patients (four with recurrence and four who had been treated with GKS) underwent reoperation, with gross-total removal via the same approach or combined with the orbitozygomatic approach in patients with very short optic nerves. In no patient was deterioration of visual acuity and visual field observed after surgery. Although all patients except four children and one adult were receiving some form of hormone replacement therapy, their endocrine status was stably controllable. Conclusions. In the authors' experience, the frontobasal interhemispheric approach, even made through a small craniotomy window, is a valid choice for the removal of craniopharyngiomas extending outside the sellar—suprasellar region. Via this approach, tumors can be removed without significant sequelae related to the surgical method, due to ease of preservation of the pituitary stalk, hypothalamic structures, and perforating vessels. This approach offers a safe and minimally invasive means of treating craniopharyngiomas.

Clinoidal meningiomas

1990 ◽  
Vol 73 (6) ◽  
pp. 840-849 ◽  
Author(s):  
Ossama Al-Mefty
Keyword(s):  
Cerebral Vessels ◽  
Sinus Surgery ◽  
Morbidity Rate ◽  
Total Removal ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Group Iii ◽  
Group I ◽  
Subtotal Removal ◽  
Fine Print

✓ Anterior clinoidal meningiomas are frequently grouped with suprasellar or sphenoid ridge meningiomas, masking their notorious association with a high mortality and morbidity rate, failure of total removal, and recurrence. To avoid injury to encased cerebral vessels, most surgeons are content with subtotal removal. Without total removal, however, recurrence is expected. Recent advances in cranial-base exposure and cavernous sinus surgery have facilitated radical total removal. The author reports 24 cases operated on with vigorous attempts at total removal of the tumor with involved dura and bone. This experience has distinguished three groups (I, II, and III) which influence surgical difficulties, the success of total removal, and outcome. These subgroups relate to the presence of interfacing arachnoid membranes between the tumor and cerebral vessels. The presence or absence of arachnoid membranes depends on the origin of the tumor and its relation to the naked segment of carotid artery lying outside the carotid cistern. Total removal was impossible in the three patients in Group I, with postoperative death occurring in one patient and hemiplegia in another. Total removal was achieved in 18 of the 19 patients in Group II, with one death from pulmonary embolism. In the two patients in Group III, total removal without complications was easily achieved.

Malignant transformation in benign cerebellar astrocytoma

1978 ◽  
Vol 49 (1) ◽  
pp. 111-118 ◽  
Author(s):  
George M. Kleinman ◽  
William C. Schoene ◽  
Thomas M. Walshe ◽  
Edward P. Richardson
Keyword(s):  
Malignant Transformation ◽  
Pilocytic Astrocytoma ◽  
Partial Removal ◽  
Content Type ◽  
Cerebellar Astrocytoma ◽  
Juvenile Pilocytic Astrocytoma ◽  
Pilocytic Astrocytomas ◽  
Infiltrative Growth Pattern ◽  
Fine Print

✓ The authors give follow-up information on Case 59 of Cushing's 1931 series of cerebellar astrocytomas. The patient died with a malignant cerebellar astrocytoma 48 years after partial removal of a previously benign astrocytoma at the same site. Including the present one, there have been only five reported cases in which this has occurred. Ordinarily, juvenile pilocytic astrocytomas are of extremely benign character, and it is well established that even with incomplete resections patients have survived for years without progression of the tumor. Not all of the cases so reported can be wholly accepted as representing malignant transformation of the tumor, but may instead be instances of recurrence of an inherently benign glioma since the presence of features such as endothelial hyperplasia or nuclear atypicality in a juvenile pilocytic astrocytoma does not warrant its being classified as malignant. Features truly suggestive of malignancy are hypercellularity, frequent mitoses, necrosis, and, in some instances, a diffusely infiltrative growth pattern; all of these features were found in the present case.

Craniopharyngioma in adults and children: a study of 122 surgical cases

2002 ◽  
Vol 97 (1) ◽  
pp. 3-11 ◽  
Author(s):  
Rémy Van Effenterre ◽  
Anne-Laure Boch
Keyword(s):  
Patient Survival ◽  
Postoperative Radiotherapy ◽  
Clinical Signs ◽  
Functional Results ◽  
Recurrence Risk ◽  
Tumor Removal ◽  
Content Type ◽  
Adults And Children ◽  
Fine Print

Object. This work is devoted to a 25-year retrospective study of 122 cases of craniopharyngiomas in adults and children treated and followed by the same neurosurgeon (R.V.E.). In this homogeneous series, the aim was total microsurgical removal of the tumor, without postoperative radiotherapy. Methods. The operation was performed via a frontopterional approach in 112 cases and a transsphenoidal approach in 10 cases. The tumor removal was considered total in 59%, subtotal in 29%, and partial in 12%. The surgical mortality rate was 2.5%. Even when tumor removal was not complete, radiotherapy was not systematically administered; it was reserved for cases of recurrence. The authors have studied clinical signs, operative characteristics, and ophthalmological, endocrinological, and functional outcomes, as well as recurrence risk and long-term patient survival. The mean follow-up period was 7 years. The functional results in these patients were excellent in 85%, good in 9%, fair in 5% (usually because of ophthalmological sequelae), and poor in 1%. Tumors recurred in 29 patients, but the salvage treatment, by operation or radiotherapy, was successful in 83%. The actuarial patient survival rate was 92% after 5 years and 85% after 10 years. Conclusions. These results compared favorably with the data reported in the literature, suggesting that radical surgery of craniopharyngiomas allows good outcome in terms of survival, full recovery, and quality of life for both adults and children.

Total removal of large global meningiomas at the medial aspect of the sphenoid ridge

1971 ◽  
Vol 34 (1) ◽  
pp. 107-113 ◽  
Author(s):  
Albert W. Cook
Keyword(s):  
Optic Nerve ◽  
Middle Cerebral Artery ◽  
Operative Technique ◽  
Middle Meningeal Artery ◽  
Medial Aspect ◽  
Total Removal ◽  
Content Type ◽  
Meningeal Artery ◽  
Sphenoid Ridge ◽  
Fine Print

✓ An operative technique for total removal of large global meningiomas at the medial aspect of the sphenoid ridge is described, and experience with 11 patients reported. The technique involves extradural liberation of the dural and tumor attachments to the underlying bone, and extradural occlusion of the blood supply through bone and middle meningeal artery. Subsequent procedures are carried out sequentially in the parasellar area to free the optic nerve and carotid, in the subtemporal tentorial region to release tumor from neighboring structures, and in the Sylvian fissure to isolate the middle cerebral artery.

Late results of radical excision of craniopharyngiomas in children

1975 ◽  
Vol 42 (1) ◽  
pp. 86-90 ◽  
Author(s):  
Edward L. Katz
Keyword(s):  
High Mortality ◽  
Surgical Excision ◽  
Late Results ◽  
Radical Excision ◽  
Initial Operation ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Fine Print

✓ The results of radical surgical excision of craniopharyngiomas in children operated on by Dr. Donald Matson beginning in 1950 are presented. The patients are analyzed in regard to survival and quality of survival. While 22 of 34 children so treated at the initial operation are presently alive and tumor-free, high mortality and morbidity followed in cases where reoperation was performed. Properly treated endocrinological deficits need not be a serious problem, but persistent hyperosmolality carried a grave prognosis. No predictive criteria are yet available to determine which tumors are amenable to radical surgical excision.

Efficacy of multiple intraarterial papaverine infusions for improvement in cerebral circulation time in patients with recurrent cerebral vasospasm

2004 ◽  
Vol 100 (3) ◽  
pp. 414-421 ◽  
Author(s):  
James K. Liu ◽  
Michael S. Tenner ◽  
Oren N. Gottfried ◽  
Edwin A. Stevens ◽  
Joshua M. Rosenow ◽  
...  
Keyword(s):  
Cerebral Vasospasm ◽  
Cerebral Circulation ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Primary Treatment ◽  
Circulation Time ◽  
Control Group ◽  
Content Type ◽  
The Mean ◽  
Cerebral Circulation Time ◽  
Fine Print

Object. Cerebral vasospasm that is caused by aneurysmal subarachnoid hemorrhage and that is refractory to maximal medical management can be treated with selective intraarterial papaverine infusions. The effects of single papaverine treatments on cerebral circulation time are well known. The purpose of this study was to assess the efficacy of multiple, repeated papaverine infusions on the cerebral circulation time in patients with recurrent vasospasm. Methods. A retrospective study was conducted in 17 patients who received multiple intraarterial papaverine infusions in 91 carotid artery (CA) territories for the treatment of cerebral vasospasm. Cerebral circulation times were measured from the first angiographic image, in which peak contrast was seen above the supraclinoid internal CA, to the peak filling of cortical veins. Glasgow Outcome Scale (GOS) scores assessed 12 months after discharge were reviewed. Cerebral circulation times in 16 CA territories were measured in a control group of 11 patients. Seventeen patients received a total of 91 papaverine treatments. Prolonged cerebral circulation times improved after 90 (99%) of 91 papaverine treatments. The prepapaverine mean cerebral circulation time was 6.54 seconds (range 3.35–27 seconds) and the immediate postpapaverine mean cerebral circulation time was 4.19 seconds (range 2.1–12.6 seconds), an overall mean decrease of 2.35 seconds (36%, p < 0.001). Recurrent vasospasm reflected by prolonged cerebral circulation times continued to improve with subsequent papaverine infusions. Repeated infusions were just as successful quantitatively as the primary treatment (mean change 2.06 seconds). The mean cerebral circulation time in the control group was 5.21 seconds (range 4–6.8 seconds). In five patients a dramatic reversal of low-attenuation changes was detected on computerized tomography scans. The mean GOS score at 12 months after discharge was 3.4. Conclusions. The preliminary results indicate that multiple intraarterial papaverine treatments consistently improve cerebral circulation times, even with repeated infusions in cases of recurrent vasospasm.

Primary intramedullary spinal cord germinoma

1996 ◽  
Vol 84 (6) ◽  
pp. 1060-1061 ◽  
Author(s):  
Akira Miyauchi ◽  
Katsumi Matsumoto ◽  
Eiji Kohmura ◽  
Teruo Doi ◽  
Kazuhiko Hashimoto ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Central Nervous System ◽  
Nervous System ◽  
Conus Medullaris ◽  
Rare Occurrence ◽  
Partial Removal ◽  
Intramedullary Spinal Cord ◽  
Content Type ◽  
Disease Free ◽  
Fine Print

✓ Primary central nervous system germinoma usually presents as an extraaxial intracerebral mass. The authors report the rare occurrence of an intramedullary spinal cord germinoma at the conus medullaris in a 24-year-old man, which was treated by partial removal and radiation therapy. The tumor was highly radiosensitive and the patient remains disease free 15 months posttreatment.

Interhemispheric approach for the surgical removal of thalamocaudate arteriovenous malformations

1987 ◽  
Vol 66 (3) ◽  
pp. 345-351 ◽  
Author(s):  
Robert A. Solomon ◽  
Bennett M. Stein
Keyword(s):  
Corpus Callosum ◽  
Arteriovenous Malformations ◽  
Surgical Removal ◽  
Cerebral Arteriovenous Malformations ◽  
Total Removal ◽  
Recurrent Hemorrhage ◽  
Content Type ◽  
Interhemispheric Approach ◽  
Parinaud’S Syndrome ◽  
Fine Print

✓ A series of 250 surgically treated cerebral arteriovenous malformations (AVM's) is presented, in which 22 lesions were located primarily in the thalamus and caudate nucleus. A standardized interhemispheric approach through the posterior corpus callosum and into the atrium of the lateral ventricle was utilized for the surgical removal of these AVM's. Total removal was confirmed by angiography in 18 patients; removal was subtotal in four cases. There were no deaths in this group of patients. Disturbances of recent memory pre- and postoperatively were seen in half of the patients, but most of these deficits were temporary. Other complications included: postoperative homonymous hemianopsia (six cases), transient hemiparesis (three cases), hemisensory loss (two cases), Parinaud's syndrome (one case), and recurrent hemorrhage 2 years after surgery (one case). All 22 patients returned to their previous occupations and are leading independent lives. The results of this experience indicate that thalamocaudate AVM's can be effectively treated by resection.

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