Endoscopic rhino-neurosurgical approach for non-adenomatous sellar and skull base lesions

OBJECTIVE: Since endoscopic endonasal transsphenoidal surgery requires skills of both neurosurgeons and otorhinolaryngologists, and the nose is the primary corridor of approach, we favour the term `endoscopic rhino-neurosurgery` and report on our interdisciplinary experience treating non-adenomatous lesions with skull base extension. METHODS: Between 2004 and 2009, 58 patients with 21 different disease patterns underwent endoscopic rhino-neurosurgical procedures. Mean age was 39.9 years, 50% were female. Seven had undergone prior surgery. Clinically, 34.5% presented with visual field deficits and with nerve palsies. Preoperatively, 62.1% showed a normal pituitary function. RESULTS: Mean follow-up was 13.1 months. The surgical goal depended on type of lesion; the intended extent of resection was achieved in 81%. Recovery from visual field deficits occurred in 80%. Neither deteriorated nor new cranial nerve palsies were observed. A normal endocrinological function could be maintained in 94.4%. Permanent diabetes insipidus occurred in 7 patients. Surgical complications included cerebrospinal fluid (CSF) leaks in 6 patients and meningitis in 4. All complications were managed successfully. There was no surgery-related mortality. CONCLUSION: The endoscopic rhino-neurosurgical approach is applicable for a wide variety of lesions comprising sella and skull base. As our data prove, this technique can be performed with satisfying results in non-adenomatous lesions as well.

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Site-Specific Considerations in the Surgical Management of Skull Base Chondrosarcomas

Operative Neurosurgery ◽

10.1093/ons/opx171 ◽

2017 ◽

Vol 14 (6) ◽

pp. 611-619 ◽

Cited By ~ 5

Author(s):

Shaan M Raza ◽

Paul W Gidley ◽

Michael E Kupferman ◽

Ehab Y Hanna ◽

Shirley Y Su ◽

...

Keyword(s):

Skull Base ◽

Primary Outcome ◽

Extent Of Resection ◽

Subtotal Resection ◽

Related Factors ◽

Endoscopic Endonasal ◽

Factors Affecting ◽

Cavernous Sinus Invasion ◽

Soft Tissue Involvement ◽

Transcranial Approach

Abstract BACKGROUND Numerous approaches have been reported in the management of skull base chondrosarcomas. Data are lacking for surgical outcomes by the tumor site of origin. OBJECTIVE To provide insight into outcomes by site of origin and factors affecting resection in order to aid in surgical approach selection. METHODS A retrospective review was conducted of 49 patients with chondrosarcoma treated at our institution. Charts were reviewed for tumor- and treatment-related factors. Extent of resection was the primary outcome, while neurological function and surgical complications were secondary outcomes. Statistical analyses were performed assessing variables for their impact on the primary outcome. RESULTS The gross total resection rate for the overall cohort was 67.3%, and 97.8% of patients were either neurologically stable or improved postoperatively. A petroclival site of origin had lower rates of resection vs all other sites (P < .05). Histology and previous surgery did not predict outcome (P > .05), while previous radiotherapy and cavernous sinus invasion correlated with a subtotal resection (P < .05). In the petroclival cohort, clival, jugular tubercle, and soft tissue involvement correlated with a subtotal resection (P < .05). An endoscopic endonasal transpterygoid approach alone or combined with a transcranial approach yielded the highest resection rates for petroclival tumors (P < .05). CONCLUSION Chondrosarcomas pose unique challenges based on the site of origin and pattern of extension. While current surgical strategies appear to yield adequate results at a majority of skull base sites, petroclival tumors represent a particular cohort in which improvement is needed. Based on our analysis, strategies incorporating both endoscopic and transcranial skull base approaches are likely necessary to achieve optimal outcomes.

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Endoscopic endonasal resection of skull base meningiomas: the significance of a “cortical cuff” and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14321 ◽

2014 ◽

Vol 37 (4) ◽

pp. E7 ◽

Cited By ~ 17

Author(s):

Osaama H. Khan ◽

Vijay K. Anand ◽

Theodore H. Schwartz ◽

Keyword(s):

Skull Base ◽

Brain Edema ◽

Extent Of Resection ◽

Gross Total Resection ◽

Surgical Experience ◽

Total Resection ◽

Endoscopic Endonasal ◽

Case Selection ◽

Skull Base Meningiomas ◽

Group 1

Object This paper describes a consecutive series of skull base meningiomas resected using an endoscopic endonasal approach through various corridors at a single institution over 7 years. The impact of case selection and experience, the presence of a cortical cuff between the tumor and surrounding vessels, and brain edema on morbidity and rates of gross-total resection (GTR) were examined. Methods A retrospective review of a series of 46 skull base meningiomas from a prospective database was conducted. The series of cases were divided by location: olfactory groove (n = 15), tuberculum and planum (n = 20), sellar/cavernous (n = 9) and petroclival (n = 2). Gross-total resection was never intended in the sellar/cavernous tumors, which generally invaded the cavernous sinus. Clinical charts, volumetric imaging, and pathology were reviewed to assess the extent of resection and complications. Cases were divided based on a time point in which surgical technique and case selection improved into Group 1 (surgery prior to June 2008; n = 21) and Group 2 (surgery after June 2008; n = 25) and into those with and without a cortical cuff and with and without brain edema. Results Improved case selection had the greatest impact on extent of resection. For the entire cohort, rates of GTR went from 38% to 76% (p = 0.02), and for cases in which GTR was the intent, the rates went from 63% to 84% (not significant), which was mostly driven by the planum and tuberculum meningiomas, which went from 75% to 91.7 % (nonsignificant difference). The presence of a cortical cuff and brain edema had no impact on outcomes. There were 3 CSF leaks (6.5%) but all were in Group 1. Hence, CSF leak improved from 14.2% to 0% with surgical experience. Lessons learned for optimal case selection are discussed. Conclusions Surgical outcome for endonasal endoscopic resection of skull base meningiomas depends mostly on careful case selection and surgical experience. Imaging criteria such as the presence of a cortical cuff or brain edema are less important.

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Clinical outcomes of an endoscopic transclival and transpetrosal approach for primary skull base malignancies involving the clivus

Journal of Neurosurgery ◽

10.3171/2016.12.jns161920 ◽

2018 ◽

Vol 128 (5) ◽

pp. 1454-1462 ◽

Cited By ~ 10

Author(s):

Yong Hwy Kim ◽

Chiman Jeon ◽

Young-Bem Se ◽

Sang Duk Hong ◽

Ho Jun Seol ◽

...

Keyword(s):

Prognostic Factors ◽

Skull Base ◽

Clinical Outcomes ◽

Univariate Analysis ◽

Extent Of Resection ◽

Subtotal Resection ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Tumor Laterality

OBJECTIVEThe endoscopic endonasal approach for treating primary skull base malignancies involving the clivus is a formidable task. The authors hypothesized that tumor involvement of nearby critical anatomical structures creates hurdles to endoscopic gross-total resection (GTR). The aim of this study was to retrospectively review the clinical outcomes of patients who underwent an endoscopic endonasal approach to treat primary malignancies involving the clivus and to analyze prognostic factors for GTR.METHODSBetween January 2009 and November 2015, 42 patients underwent the endoscopic endonasal approach for resection of primary skull base malignancies involving the clivus at 2 independent institutions. Clinical data; tumor locations within the clivus; and anatomical involvement of the cavernous or paraclival internal carotid artery, cisternal trigeminal nerve, hypoglossal canal, and dura mater were investigated to assess the extent of resection. Possible prognostic factors affecting GTR were also analyzed.RESULTSOf the 42 patients, 37 were diagnosed with chordomas and 5 were diagnosed with chondrosarcomas. The mean (± SD) preoperative tumor volume was 25.2 ± 30.5 cm3 (range 0.8–166.7 cm3). GTR was achieved in 28 patients (66.7%) and subtotal resection in 14 patients (33.3%). All tumors were classified as upper (n = 17), middle (n = 17), or lower (n = 8) clival tumors based on clival involvement, and as central (24 [57.1%]) or paramedian (18 [42.9%]) based on laterality of the tumor. Univariate analysis identified the tumor laterality (OR 6.25, 95% CI 1.51–25.86; p = 0.011) as significantly predictive of GTR. In addition, the laterality of the tumor was found to be a statistically significant predictor in multivariate analysis (OR 41.16, 95% CI 1.12–1512.65; p = 0.043).CONCLUSIONSAn endoscopic endonasal approach can provide favorable clinical and surgical outcomes. However, the tumor laterality should be considered as a potential obstacle to total removal.

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Neuro-ophthalmological function of patients with pineal region tumors approached transtentorially in the semisitting position

Journal of Neurosurgery ◽

10.3171/jns.1992.76.5.0746 ◽

1992 ◽

Vol 76 (5) ◽

pp. 746-751 ◽

Cited By ~ 52

Author(s):

Jules M. Nazzaro ◽

William T. Shults ◽

Edward A. Neuwelt

Keyword(s):

Visual Field ◽

Postoperative Period ◽

Visual Fields ◽

Occipital Lobe ◽

Pineal Region ◽

Motor Dysfunction ◽

Homonymous Hemianopsia ◽

Pineal Region Tumors ◽

Cranial Nerve Palsies ◽

Visual Field Deficits

✓ To optimize orientation and operative exposure for aggressive resection, the authors approached pineal region tumors transtentorially with the patient in a semisitting position. In the current report, 12 consecutive patients were evaluated to document operative ocular morbidity referable to the brain stem as well as visual deficits secondary to occipital lobe retraction. Before craniotomy, ophthalmological findings related to dorsal midbrain dysfunction were evident in four of the 10 patients who had previously undergone ventricular shunting. The other patients developed a partial or complete Parinaud's syndrome in the early postoperative period and some suffered additional deficits such as cranial nerve palsies. These deficits improved to varying degrees in all patients. Although each had full visual fields preoperatively, an absolute or incomplete left homonymous hemianopsia developed in the immediate postoperative period. Such visual field deficits fully resolved over a variable period of time in 10 of the 12 patients. One patient has a permanent left homonymous hemianopsia, while another has a left homonymous paracentral scotoma. Eight patients were able to return to preoperative pursuits. While ocular abnormalities related to dorsal midbrain dysfunction are most probably independent of operative approach, visual field deficits attributable to occipital lobe retraction were common in patients after a occipital transtentorial approach performed in the semisitting position. Reading difficulties associated with ocular motor dysfunction due to dorsal midbrain involvement represent the principal long-term neuro-ophthalmological complaint of patients who have undergone pineal region surgery.

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Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010–2018

Journal of Neurosurgery ◽

10.3171/2020.11.jns202494 ◽

2021 ◽

pp. 1-12

Author(s):

Douglas A. Hardesty ◽

Alaa Montaser ◽

Daniel Kreatsoulas ◽

Varun S. Shah ◽

Kyle K. VanKoevering ◽

...

Keyword(s):

Postoperative Complications ◽

Skull Base ◽

Perioperative Complications ◽

Lessons Learned ◽

Neurosurgical Procedures ◽

High Grade ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Single Institution ◽

Endoscopic Endonasal

OBJECTIVE The endoscopic endonasal approach (EEA) has evolved into a mainstay of skull base surgery over the last two decades, but publications examining the intraoperative and perioperative complications of this technique remain scarce. A prior landmark series of 800 patients reported complications during the first era of EEA (1998–2007), parallel to the development of many now-routine techniques and technologies. The authors examined a single-institution series of more than 1000 consecutive EEA neurosurgical procedures performed since 2010, to elucidate the safety and risk factors associated with surgical and postoperative complications in this modern era. METHODS After obtaining institutional review board approval, the authors retrospectively reviewed intraoperative and postoperative complications and their outcomes in patients who underwent EEA between July 2010 and June 2018 at a single institution. RESULTS The authors identified 1002 EEA operations that met the inclusion criteria. Pituitary adenoma was the most common pathology (n = 392 [39%]), followed by meningioma (n = 109 [11%]). No patients died intraoperatively. Two (0.2%) patients had an intraoperative carotid artery injury: 1 had no neurological sequelae, and 1 had permanent hemiplegia. Sixty-one (6.1%) cases of postoperative cerebrospinal fluid leak occurred, of which 45 occurred during the original surgical hospitalization. Transient postoperative sodium dysregulation was noted after 87 (8.7%) operations. Six (0.6%) patients were treated for meningitis, and 1 (0.1%) patient died of a fungal skull base infection. Three (0.3%) patients died of medical complications, thereby yielding a perioperative 90-day mortality rate of 0.4% (4 deaths). High-grade (Clavien-Dindo grade III–V) complications were identified after 103 (10%) EEA procedures, and multivariate analysis was performed to determine the associations between factors and these more serious complications. Extradural EEA was significantly associated with decreased rates of these high-grade complications (OR [95% CI] 0.323 [0.153–0.698], p = 0.0039), whereas meningioma pathology (OR [95% CI] 2.39 [1.30–4.40], p = 0.0053), expanded-approach intradural surgery (OR [95% CI] 2.54 [1.46–4.42], p = 0.0009), and chordoma pathology (OR [95% CI] 9.31 [3.87–22.4], p < 0.0001) were independently associated with significantly increased rates of high-grade complications. CONCLUSIONS The authors have reported a large 1002-operation cohort of EEA procedures and associated complications. Modern EEA surgery for skull base pathologies has an acceptable safety profile with low morbidity and mortality rates. Nevertheless, significant intraoperative and postoperative complications were correlated with complex intradural procedures and meningioma and chordoma pathologies.

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Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data

Journal of Neurosurgery ◽

10.3171/2020.4.jns20475 ◽

2020 ◽

pp. 1-13 ◽

Cited By ~ 1

Author(s):

Brett E. Youngerman ◽

Matei A. Banu ◽

Mina M. Gerges ◽

Eseosa Odigie ◽

Abtin Tabaee ◽

...

Keyword(s):

Risk Factors ◽

Extent Of Resection ◽

Outcome Data ◽

Incomplete Resection ◽

Term Outcome ◽

Endoscopic Endonasal ◽

Long Term Outcome ◽

Prior Surgery ◽

The Relationship

OBJECTIVEThe endoscopic endonasal approach (EEA) has gained increasing popularity for the resection of suprasellar meningiomas (SSMs). Appropriate case selection is critical in optimizing patient outcome. Long-term outcome data are lacking. The authors systematically identified preoperative factors associated with extent of resection (EOR) and determined the relationship between EOR and long-term recurrence after EEA for SSMs.METHODSIn this retrospective cohort study, the authors identified preoperative clinical and imaging characteristics associated with EOR and built on the recently published University of California, San Francisco resectability score to propose a score more specific to the EEA. They then examined the relationship between gross-total resection (GTR; 100%), near-total resection (NTR; 95%–99%), and subtotal resection (STR; < 95%) and recurrence or progression with Kaplan-Meier survival analysis.RESULTSA total of 51 patients were identified. Radiographic GTR was achieved in 40 of 47 (85%) patients in whom it was the surgical goal. Significant independent risk factors for incomplete resection were prior surgery (OR 25.94, 95% CI < 2.00 to 336.49, p = 0.013); tumor lateral to the optic nerve (OR 13.41, 95% CI 1.82–98.99, p = 0.011); and complete internal carotid artery (ICA) encasement (OR 15.12, 95% CI 1.17–194.08, p = 0.037). Tumor size and optic canal invasion were not significant risk factors after adjustment for other variables. A resectability score based on the multivariable model successfully predicted the likelihood of GTR; a score of 0 had a positive predictive value of 97% for GTR, whereas a score of 2 had a negative predictive value of 87.5% for incomplete resection. After a mean follow-up of 40.6 ± 32.4 months (mean ± SD), recurrence was 2.7% after GTR (1 patient with atypical histology), 44.4% after NTR, and 80% after STR (p < 0.0001). Vision was stable or improved in 93.5% and improved in 67.4% of patients with a preoperative deficit. There were 5 (9.8%) postoperative CSF leaks, of which 4 were managed with lumbar drains and 1 required a reoperation.CONCLUSIONSThe EEA is a safe and effective approach to SSMs, with favorable visual outcomes in well-selected cases. The combination of postoperative MRI-based EOR with direct endoscopic inspection can be used in lieu of Simpson grade to predict recurrence. GTR dramatically reduces recurrence and can be achieved regardless of tumor size, proximity or encasement of the anterior cerebral artery, or medial optic canal invasion. Risk factors for incomplete resection include prior surgery, tumor lateral to the optic nerve, and complete ICA encasement.

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Endoscopic Endonasal Minimal Access Approach to the Clivus: Case Series and Technical Nuances

Operative Neurosurgery ◽

10.1227/01.neu.0000383130.80179.41 ◽

2010 ◽

Vol 67 (3) ◽

pp. ons150-ons158 ◽

Cited By ~ 19

Author(s):

Justin F. Fraser ◽

Gurston G. Nyquist ◽

Nicholas Moore ◽

Vijay K. Anand ◽

Theodore H. Schwartz

Keyword(s):

Skull Base ◽

Case Series ◽

Extent Of Resection ◽

Csf Leak ◽

Minimal Access ◽

Endoscopic Endonasal ◽

Vein Thrombosis ◽

Lumbar Drain ◽

Deep Vein

Abstract BACKGROUND: The endoscopic endonasal transclival approach is a novel minimal-access method of managing clival pathology. Limited cases have been published. OBJECTIVE: To summarize our clinical experience with this approach and discuss technical nuances. METHODS: We retrospectively reviewed a prospective database of 250 endoscopic, endonasal skull base surgeries. Patients in whom a transclival approach was performed were identified. Extent of resection, complications, and clinical outcome were analyzed. RESULTS: Seventeen patients underwent 21 procedures. Pathology included chordoma, meningioma, hemangiopericytoma, enterogenous cyst, epidermoid, and metastasis. Lumbar drain was placed intraoperatively in 9 cases and maintained for goal. The risk of postoperative CSF leak was 4.8% for all procedures, 9.1% for procedures with large skull base defect, and 0% if a gasket-seal closure was achieved. A nasoseptal flap was used in 2 patients. There was one perioperative infarct, one case of deep vein thrombosis, and one postoperative pulmonary embolus. Mean follow-up was 8.5 months. All but one patient with preoperative cranial nerve deficits improved at last follow-up. All patients were free of disease progression at last follow-up. CONCLUSIONS: The endonasal endoscopic transclival approach provides a minimal-access approach to the ventral midline posterior fossa skull base. The risk of CSF leak is low if appropriate closure techniques are applied.

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Critical Appraisal of Minimally Invasive Keyhole Surgery for Intracranial Meningioma

10.21203/rs.3.rs-1208627/v1 ◽

2022 ◽

Author(s):

Jai Deep Thakur ◽

Regin Jay Mallari ◽

Alex Corlin ◽

Samantha Yawitz ◽

Amalia Eisenberg ◽

...

Keyword(s):

Minimally Invasive ◽

Extent Of Resection ◽

Csf Leak ◽

Intracranial Meningioma ◽

Complication Rates ◽

Endoscopic Endonasal ◽

Keyhole Surgery ◽

Prior Surgery ◽

Subtotal Removal ◽

Traditional Approaches

Abstract Purpose Minimally invasive meningioma removal through transcranial and endoscopic endonasal keyhole routes remain controversial. Herein we detail results of keyhole meningioma removal defined as use of a minimally invasive “retractorless” approach for which a traditional larger approach is often used instead. Methods Retrospective analysis from 2008-2021 of consecutive patients undergoing keyhole meningioma removal through one of six approaches: extent of resection, complications, endoscopy use, MRI FLAIR/T2 changes. Surgical goal was maximal safe removal including conservative(subtotal) removal for some invasive locations. Results Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30(15.5%) prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal(n=74,35%), supraorbital(n=73,34%), retromastoid(n=38,18%), mini-pterional(n=20,9%), suboccipital(n=4,2%), and contralateral transfalcine(n=4,2%). Primary outcomes: Gross total/near total(>90%) resection: 125(59%); (5% for petroclival, cavernous sinus/Meckel’s cave, spheno-cavernous locations vs 77% other locations). Complications included: permanent neurological worsening12(6%); CSF leak 2(1%); meningitis 2(1%); no patients sustained DVT, PE, MI, or 30-day mortality. Median LOS was 3 days with 94% discharged home and 96% with favorable 90-day KPS. Secondary outcomes: Small persistent FLAIR/T2 changes: 11(5.2%) patients. Endoscopy use: 87/139(63%) of craniotomies, facilitating additional tumor removal in 55%. Tumor progression was observed in 26(13%) patients(mean follow-up 42±36 months). Conclusion This analysis suggests keyhole meningioma removal can be associated with reasonable resection rates, low complication rates, short hospitalizations and high 90-day performance scores. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid complications. With careful patient selection and requisite experience, these approaches may be considered alternatives to traditional approaches.

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