Midline Meningiomas of the Anterior Skull Base: Surgical Outcomes and a Decision-Making Algorithm for Classic Skull Base Approaches

(1) Background: Midline meningiomas such as olfactory groove (OGMs), planum sphenoidale (PSMs), or tuberculum sellae meningiomas (TSMs) are challenging, and determining the appropriate approach is important. We propose a decision algorithm for choosing suitable transcranial approaches. (2) Methods: A retrospective chart review between 06/2007 and 01/2020. Clinical outcomes, radiographic findings, and postoperative complication rates were analyzed with respect to operative approaches. (3) Results: We included 88 patients in the analysis. Of these, 18.2% (16/88) underwent an interhemispheric approach, 72.7% (64/88) underwent a pterional/frontolateral/supraorbital approach, 2.3% (2/88) underwent a unilateral subfrontal approach, and 6.8% (6/88) underwent a bifrontal approach. All OGMs underwent median approaches, along with one PSM. All of the other PSMs and TSMs were resected via lateral approaches. The preoperative tumor volume was ∅20.2 ± 27.1 cm3. Median approaches had significantly higher tumor volume but also higher rates of Simpson I resection (75.0% vs. 34.4%). An improvement of visual deficits was observed in 34.1% (30/88). The adverse event rate was 17.0%. Median follow-up was 15.5 months (range 0–112 months). (4) Conclusions: Median approaches provides satisfying results for OGMs, lateral approaches enable sufficient exposure of the visual apparatus for PSMs and TSMs. In proposing a simple decision-making algorithm, the authors found that satisfactory outcomes can be achieved for midline meningiomas.

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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.

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Targeted sequencing of SMO and AKT1 in anterior skull base meningiomas

Journal of Neurosurgery ◽

10.3171/2016.8.jns161076 ◽

2017 ◽

Vol 127 (2) ◽

pp. 438-444 ◽

Cited By ~ 15

Author(s):

Matthew R. Strickland ◽

Corey M. Gill ◽

Naema Nayyar ◽

Megan R. D'Andrea ◽

Christian Thiede ◽

...

Keyword(s):

Skull Base ◽

Tumor Volume ◽

Anterior Skull Base ◽

Targeted Sequencing ◽

Genomic Research ◽

High Yield ◽

Small Subset ◽

Mutation Status ◽

Olfactory Groove ◽

Skull Base Meningiomas

OBJECTIVEMeningiomas located in the skull base are surgically challenging. Recent genomic research has identified oncogenic SMO and AKT1 mutations in a small subset of meningiomas.METHODSThe authors performed targeted sequencing in a large cohort of patients with anterior skull base meningiomas (n = 62) to better define the frequency of SMO and AKT1 mutations in these tumors.RESULTSThe authors found SMO mutations in 7 of 62 (11%) and AKT1 mutations in 12 of 62 (19%) of their cohort. Of the 7 meningiomas with SMO mutations, 6 (86%) occurred in the olfactory groove. Meningiomas with an SMO mutation presented with significantly larger tumor volume (70.6 ± 36.3 cm3) compared with AKT1-mutated (18.2 ± 26.8 cm3) and wild-type (22.7 ± 23.9 cm3) meningiomas, respectively.CONCLUSIONSCombined, these data demonstrate clinically actionable mutations in 30% of anterior skull base meningiomas and suggest an association between SMO mutation status and tumor volume. Genotyping of SMO and AKT1 is likely to be high yield in anterior skull base meningiomas with available surgical tissue.

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Nuances of Olfactory Groove Meningioma Surgery: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab233 ◽

2021 ◽

Author(s):

Michael A Mooney ◽

Walid Ibn Essayed ◽

Ossama Al-Mefty

Keyword(s):

Skull Base ◽

Frontal Lobe ◽

Tumor Resection ◽

Fat Graft ◽

Complication Rates ◽

Olfactory Groove ◽

Simpson Grade ◽

Number Of Patients ◽

Olfactory Groove Meningioma ◽

Meningioma Surgery

Abstract Olfactory groove meningiomas frequently present as large or giant-size tumors associated with marked frontal lobe edema and significant frontal lobe dysfunction. Simpson grade I removal was rare in early reports due to their invasion of the ethmoid sinuses and skull base bone,1 which resulted in high recurrence rates.2,3 Indeed, recurrence occurred in the most celebrated case of olfactory groove meningioma.4,5 To achieve Simpson grade I removal (tumor, dura, bone), protect the frontal lobes from additional injury, and provide the best chance for recovery, we demonstrate a few nuances for olfactory groove meningioma surgery: Utilizing a skull base approach with a low dural opening, the frontal veins are preserved, and the frontal lobe is protected from retraction, manipulation, and venous injury. By the time of diagnosis, although the patient's olfaction is often absent, there still remains a role to preserve at least 1 olfactory tract, which might yield some preservation in a limited number of patients. Emphasis has been rightly made on the preservation of the A2 segments, which can be dissected using microsurgical technique. Lastly, multilayer reconstruction of the skull base is required, using an inlay graft, resting on a vascularized pericranial flap, and occlusion of the sinuses with a fat graft. The endonasal endoscopic approach has fallen out of favor due to limitations for complete tumor resection and higher complication rates.6 We present a case of a relatively small olfactory groove meningioma in a 36-yr-old male with partial olfactory loss. The patient consented for surgery. Images at 2:07, 2:29, and 2:54 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission. Image at 8:31 public domain by age.

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Embolization of Skull Base Meningiomas and Feeding Vessels Arising From the Internal Carotid Circulation

Neurosurgery ◽

10.1227/neu.0b013e3181fe2de9 ◽

2011 ◽

Vol 68 (1) ◽

pp. 162-169 ◽

Cited By ~ 37

Author(s):

James S. Waldron ◽

Michael E. Sughrue ◽

Steven W. Hetts ◽

Sean P. Wilson ◽

Steven A. Mills ◽

...

Keyword(s):

Decision Making ◽

Skull Base ◽

Internal Carotid ◽

Preoperative Embolization ◽

Complication Rates ◽

Feeding Artery ◽

Skull Base Tumors ◽

Feeding Vessels ◽

Skull Base Meningiomas ◽

Carotid Circulation

Abstract BACKGROUND: Practice patterns regarding the preoperative embolization of skull base tumors vary widely among institutions and are driven by surgeon preference and concerns about safety. OBJECTIVE: We present a recent experience at our institution with a specific focus on procedural decision-making, embolization of vessels arising from the internal carotid circulation, and complication rates. METHODS: During a 7.5-year period, 262 meningiomas were referred for embolization. of which 119 (45%) originated from the skull base. Tumors were categorized by location, feeding artery origin, and arteries embolized. Complication rates were reviewed. RESULTS: Sixty-four of 119 patients with skull base tumors (54%) underwent embolization of at least 1 feeding artery. Feeding arteries arose from the external carotid artery (ECA) circulation in 26 (22%), the internal carotid artery (ICA) circulation in 30 (25%), a combination of ECA/ICA/Vert in 54 (45%), and had only pial supply in 10 (8%). In total, 15 of 85 (18%) ICA feeding vessels were embolized. This included 9 of 28 vessels from the meningohypopheseal trunk, 3 of 4 vessels from the anterior temporal artery, 1 of 35 vessels from the ophthalmic artery, 1 of 8 vessels directly from the ICA, and 1 of 5 vessels from the inferolateral trunk. Complete devascularization occurred in 6 of 64 patients; subtotal devascularization was seen in 58 of 64. The overall angiographic complication rate for all meningiomas embolized in the study period was 2.5% (5/199). None of the complications occurred in the skull base group. CONCLUSION: Preoperative embolization of skull base meningiomas and ICA feeding vessels can be done with low complication rates when intraprocedural decision-making favors complication avoidance over complete devascularization.

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Minimally Invasive Approaches to Anterior Skull Base Meningiomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1716671 ◽

2020 ◽

Author(s):

Scott C. Seaman ◽

Muhammad S. Ali ◽

Anthony Marincovich ◽

Luyuan Li ◽

Jarrett E. Walsh ◽

...

Keyword(s):

Visual Acuity ◽

Minimally Invasive ◽

Skull Base ◽

Retrospective Chart Review ◽

Anterior Skull Base ◽

Direct Access ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Skull Base Meningiomas ◽

Csf Leaks

Abstract Objective Anterior skull base meningiomas include olfactory groove, planum sphenoidale, and tuberculum sellae lesions. Traditionally, standard craniotomy approaches have been used to access meningiomas in these locations. More recently, minimally invasive techniques including supraorbital and endonasal endoscopic approaches have gained favor; however there are limited published series comparing the use of these two techniques for these meningiomas. Using our patent database, we identified patients who underwent these two approaches, and conducted a retrospective chart review to compare outcomes between these two techniques. Methods A total of 32 patients who underwent minimally invasive approaches were identified: 20 supraorbital and 11 endoscopic endonasal. Radiographic images, presenting complaints and outcomes, were analyzed retrospectively. The safety of each approach was evaluated. Results The mean extent of resection through a supraorbital approach was significantly greater than that of the endoscopic endonasal approach, 88.1 vs. 57.9%, respectively (p = 0.016). Overall, preoperative visual acuity and anopsia deficits were more frequent in the endonasal group that persisted postoperatively (visual acuity: p = 0.004; anopsia: p = 0.011). No major complications including cerebrospinal fluid (CSF) leaks or wound-related complications were identified in the supraorbital craniotomy group, while the endonasal group had two CSF leaks requiring lumbar drain placement. Length of stay was shorter in the supraorbital group (3.4 vs. 6.1 days, p < 0.001). Conclusion Anterior skull base meningiomas can be successfully managed by both supraorbital and endoscopic endonasal approaches. Both approaches provide excellent direct access to tumor in carefully selected patients and are safe and efficient, but patient factors and symptoms should dictate the approach selected.

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Endoscopic Reconstruction of Large Anterior Skull Base Defects using Acellular Dermal Allograft

American Journal of Rhinology ◽

10.2500/ajr.2007.21.3080 ◽

2007 ◽

Vol 21 (5) ◽

pp. 615-618 ◽

Cited By ~ 69

Author(s):

Ross M. Germani ◽

Richard Vivero ◽

Islam R. Herzallah ◽

Roy R. Casiano

Keyword(s):

Skull Base ◽

Retrospective Chart Review ◽

Defect Size ◽

Anterior Skull Base ◽

Complication Rates ◽

Graft Material ◽

Dural Defect ◽

Endoscopic Repair ◽

Endoscopic Reconstruction ◽

Acellular Dermal

Background Endoscopic repair of small- to medium-sized anterior skull base (ASB) defects using bone, cartilage, fascia, fibrin glue, lipolized dura, and, more recently, acellular dermal allograft have all been described with equal efficacy. The purpose of this study was to review our experience with the use of acellular dermis as the sole graft material in endoscopic reconstruction of large ASB defects. Methods A retrospective chart review of all patients who underwent endoscopic repair of ASB defects at the University of Miami between the years of 2001 and 2006 was conducted. Fifty-six patients were identified who met these criteria. All repairs were performed by a transnasal, endoscopic approach. Outcome measures included success of graft take and incidence of major and minor complications. Dural defect size was defined as small (<0.4 cm), intermediate (0.4–2.0 cm), and large (>2.0 cm). Results AlloDerm (AlloDerm. LifeCell Corp. Woodlands, TX) was used as the primary graft material in 30/55 (55%) cases; 16/55 (29%) of the repaired defects were classified as large. Graft success was 97% in the AlloDerm group and 92% in the non-AlloDerm group. The incidence of major and minor complications in the AlloDerm group was 0 and 3.3%, respectively. In the non-AlloDerm group, the incidence of major and minor complications was 4 and 12%, respectively. There were no statistical differences in the complication rates based on the type of repair or defect size. Conclusion Alloderm can be used successfully to repair ASB defects, including large defects that are >2 cm in size with little or no morbidity.

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Lessons learned in the evolution of endoscopic skull base surgery

Journal of Neurosurgery ◽

10.3171/2018.10.jns182154 ◽

2019 ◽

Vol 130 (2) ◽

pp. 337-346 ◽

Cited By ~ 13

Author(s):

Theodore H. Schwartz ◽

Peter F. Morgenstern ◽

Vijay K. Anand

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Lessons Learned ◽

Lower Grade ◽

Complication Rates ◽

Best Interest ◽

Olfactory Groove ◽

Endoscopic Skull Base Surgery ◽

New Approaches ◽

Early Results

OBJECTIVEEndoscopic skull base surgery (ESBS) is a relatively recent addition to the neurosurgical armamentarium. As with many new approaches, there has been significant controversy regarding its value compared with more traditional approaches to ventral skull base pathology. Although early enthusiasm for new approaches that appear less invasive is usually high, these new techniques require rigorous study to ensure that widespread implementation is in the best interest of patients.METHODSThe authors compared surgical results for ESBS with transcranial surgery (TCS) for several different pathologies over two different time periods (prior to 2012 and 2012–2017) to see how results have evolved over time. Pathologies examined were craniopharyngioma, anterior skull base meningioma, esthesioneuroblastoma, chordoma, and chondrosarcoma.RESULTSESBS offers clear advantages over TCS for most craniopharyngiomas and chordomas. For well-selected cases of planum sphenoidale and tuberculum sellae meningiomas, ESBS has similar rates of resection with higher rates of visual improvement, and more recent results with lower CSF leaks make the complication rates similar between the two approaches. TCS offers a higher rate of resection with fewer complications for olfactory groove meningiomas. ESBS is preferred for lower-grade esthesioneuroblastomas, but higher-grade tumors often still require a craniofacial approach. There are few data on chondrosarcomas, but early results show that ESBS appears to offer clear advantages for minimizing morbidity with similar rates of resection, as long as surgeons are familiar with more complex inferolateral approaches.CONCLUSIONSESBS is maturing into a well-established approach that is clearly in the patients’ best interest when applied by experienced surgeons for appropriate pathology. Ongoing critical reevaluation of outcomes is essential for ensuring optimal results.

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Development of an electronic conversation aid to support shared decision making for children with acute otitis media

JAMIA Open ◽

10.1093/jamiaopen/ooab024 ◽

2021 ◽

Vol 4 (2) ◽

Author(s):

Jana L Anderson ◽

e Silva Lucas Oliveira J ◽

Juan P Brito ◽

Ian G Hargraves ◽

Erik P Hess

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Otitis Media ◽

Acute Otitis Media ◽

Medical Knowledge ◽

Complication Rates ◽

Shared Decision ◽

Web Based ◽

Quality Issue ◽

The Impact

Abstract Objective The overuse of antibiotics for acute otitis media (AOM) in children is a healthcare quality issue in part arising from conflicting parent and physician understanding of the risks and benefits of antibiotics for AOM. Our objective was to develop a conversation aid that supports shared decision making (SDM) with parents of children who are diagnosed with non-severe AOM in the acute care setting. Materials and Methods We developed a web-based encounter tool following a human-centered design approach that includes active collaboration with parents, clinicians, and designers using literature review, observations of clinical encounters, parental and clinician surveys, and interviews. Insights from these processes informed the iterative creation of prototypes that were reviewed and field-tested in patient encounters. Results The ear pain conversation aid includes five sections: (1) A home page that opens the discussion on the etiologies of AOM; (2) the various options available for AOM management; (3) a pictograph of the impact of antibiotic therapy on pain control; (4) a pictograph of complication rates with and without antibiotics; and (5) a summary page on management choices. This open-access, web-based tool is located at www.earpaindecisionaid.org. Conclusions We collaboratively developed an evidence-based conversation aid to facilitate SDM for AOM. This decision aid has the potential to improve parental medical knowledge of AOM, physician/parent communication, and possibly decrease the overuse of antibiotics for this condition.

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Influenza With an Infiltrate: Investigating the New Community-Acquired Pneumonia Guidelines

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.884 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s302-s302

Author(s):

Amanda Barner ◽

Lou Ann Bruno-Murtha

Keyword(s):

Demographic Data ◽

Retrospective Chart Review ◽

Vaccination Rate ◽

Community Acquired Pneumonia ◽

Teaching Hospitals ◽

Antibiotic Prescribing ◽

Supporting Evidence ◽

Radiographic Findings ◽

Significant Difference ◽

The Impact

Background: The Infectious Diseases Society of America released updated community-acquired pneumonia (CAP) guidelines in October 2019. One of the recommendations, with a low quality of supporting evidence, is the standard administration of antibiotics in adult patients with influenza and radiographic evidence of pneumonia. Procalcitonin (PCT) is not endorsed as a strategy to withhold antibiotic therapy, but it could be used to de-escalate appropriate patients after 48–72 hours. Radiographic findings are not indicative of the etiology of pneumonia. Prescribing antibiotics for all influenza-positive patients with an infiltrate has significant implications for stewardship. Therefore, we reviewed hospitalized, influenza-positive patients at our institution during the 2018–2019 season, and we sought to assess the impact of an abnormal chest x-ray (CXR) and PCT on antibiotic prescribing and outcomes. Methods: We conducted a retrospective chart review of all influenza-positive admissions at 2 urban, community-based, teaching hospitals. Demographic data, vaccination status, PCT levels, CXR findings, and treatment regimens were reviewed. The primary outcome was the difference in receipt of antibiotics between patients with a negative (<0.25 ng/mL) and positive PCT. Secondary outcomes included the impact of CXR result on antibiotic prescribing, duration, 30-day readmission, and 90-day mortality. Results: We reviewed the medical records of 117 patients; 43 (36.7%) received antibiotics. The vaccination rate was 36.7%. Also, 11% of patients required intensive care unit (ICU) admission and 84% received antibiotics. Moreover, 109 patients had a CXR: 61 (55.9%) were negative, 29 (26.6%) indeterminate, and 19 (17.4%) positive per radiologist interpretation. Patients with a positive PCT (OR, 12.7; 95% CI, 3.43–60.98; P < .0007) and an abnormal CXR (OR, 7.4; 95% CI, 2.9–20.1; P = .000003) were more likely to receive antibiotics. There was no significant difference in 30-day readmission (11.6% vs 13.5%; OR, 0.89; 95% CI, 0.21–3.08; P = 1) and 90-day mortality (11.6% vs 5.4%; OR, 2.37; 95% CI, 0.48–12.75; P = .28) between those that received antibiotics and those that did not, respectively. Furthermore, 30 patients (62.5%) with an abnormal CXR received antibiotics and 21 (43.7%) had negative PCT. There was no difference in 30-day readmission or 90-day mortality between those that did and did not receive antibiotics. Conclusions: Utilization of PCT allowed selective prescribing of antibiotics without impacting readmission or mortality. Antibiotics should be initiated for critically ill patients and based on clinical judgement, rather than for all influenza-positive patients with CXR abnormalities.Funding: NoneDisclosures: None

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Free Flap Reconstruction of the Anterior Skull Base: A Systematic Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1718909 ◽

2021 ◽

Author(s):

Rajan P. Dang ◽

Abhinav R. Ettyreddy ◽

Zain Rizvi ◽

Michelle Doering ◽

Angela L. Mazul ◽

...

Keyword(s):

Systematic Review ◽

Skull Base ◽

Free Flap ◽

High Reliability ◽

Anterior Skull Base ◽

Microvascular Reconstruction ◽

Complication Rates ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Comprehensive Search

Abstract Objectives Given the limitations in the available literature, the precise indications, techniques, and outcomes of anterior skull base free flap reconstruction remain uncertain. The objective of this study was to perform a systematic review of published literature and evaluate indications, methods, and complications for anterior skull base free flap reconstruction. Methods A systematic review of the literature was performed using a set of search criteria to identify patients who underwent free flap reconstruction of the anterior skull base. Articles were reviewed for inclusion based on relevance, with the primary outcome being surgical complications. Results After a comprehensive search, 406 articles were obtained and 16 articles were ultimately found to be relevant to this review—79 patients undergoing free flap reconstruction were identified. Overall complication rates were 17.7% (95% confidence interval [CI]: 16.6–33.1%) for major complications and 19.0% (95% CI: 17.8–35.5%) for minor complications. Conclusion Microvascular reconstruction of the anterior skull base is feasible with high reliability reported in the literature.

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