Endoscopic Endonasal Supraoptic and Infraoptic Approaches for Complex “Parasuprasellar” Lesions: Surgical Anatomy, Technique Nuances, and Case Series

Surgical management of lesions involving the lateral area of the suprasellar region, including the lateral aspect of the planum sphenoidale and a tight junction region of the optic canal (OC), the anterior clinoid process (ACP), and the internal carotid artery (ICA) and its dural rings, is extremely challenging. Here, the authors introduce two novels endoscopic endonasal supraoptic (EESO) and endoscopic endonasal infraoptic (EEIO) approaches to access these regions, namely, “parasuprasellar” area. Surgical simulation of the EESO and EEIO approaches to the parasuprasellar area was conducted in 5 silicon-injected specimens. The same techniques were applied in 12 patients involving the parasuprasellar area.The EESO and EEIO approaches can be used independently or in combination, but are more often employed as a complement to the endoscopic endonasal midline approach and transcavernous approach. In clinical application, the EESO and EEIO approaches were successfully performed in 12 patients harboring tumors and multiple aneurysms involving the parasuprasellar area. Gross total and subtotal tumor resection were achieved in 9 patients and 1 patient, respectively. For two patients with multiple aneurysms, the lesions were clipped selectively according to location and size. Visual acuity improved in 7 patients, remained stable in 4, and deteriorated in only 1. No postoperative intracranial infection or ICA injury occurred in this series. The EESO and EEIO approaches can be combined with the current endoscopic endonasal midline approach and transcavernous approach to remove extensive pathologies involving the intrasellar, suprasellar, sphenoid, and cavernous sinuses and even bifurcation of the ICA.

Management of an Internal Carotid Artery Injury During Open Skull Base Surgery With a Crushed Muscle Patch – Technical Note and Lessons Learned

BACKGROUND Iatrogenic internal carotid artery (ICA) injury is a catastrophic complication in open skull base surgery. There is a lack of information regarding the most appropriate techniques on how to manage this complication. OBJECTIVE To highlight the difficulties encountered when an ICA injury arises intraoperatively and discuss the role and the potential pitfalls of the crushed muscle patch in the management of an ICA injury during open skull base surgery. METHODS In this technical video, we demonstrate the management of intraoperative ICA injury, which occurred during the resection of a diffuse planum sphenoidale meningioma via a left pterional craniotomy. RESULTS When isolation of the defect with temporary clips failed, we opted for a crushed muscle graft to plug the defect. Hemostasis was achieved, but because of prolonged pressure application and “overpacking,” the parent vessel was occluded. CONCLUSION The crushed muscle patch can be easily applied; however, care must be taken not to “overpack” and occlude the ICA.

Endoscopic Endonasal Supraoptic and Infraoptic Approaches for Complex “Parasuprasellar” Lesions: Surgical Anatomy, Technique Nuances, and Case Series

Purpose: Surgical management of lesions involving the lateral area of the suprasellar region, including the lateral aspect of the planum sphenoidale and a tight junction region of the optic canal (OC), the anterior clinoid process (ACP), and the internal carotid artery (ICA) and its dural rings, is extremely challenging. Here, the authors introduce two novel endoscopic endonasal supraoptic (EESO) and endoscopic endonasal infraoptic (EEIO) approaches to access these regions, namely, “parasuprasellar” area.Methods: Surgical simulation of the EESO and EEIO approaches to the parasuprasellar area was conducted in 5 silicon-injected specimens. The same techniques were applied in 12 patients involving the parasuprasellar area.Results: The EESO and EEIO approaches can be used independently or in combination, but are more often employed as a complement to the endoscopic endonasal midline approach and transcavernous approach. In clinical application, the EESO and EEIO approaches were successfully performed in 12 patients harboring tumors and multiple aneurysms involving the parasuprasellar area. Gross total and subtotal tumor resection was achieved in 9 patients and 1 patient, respectively. For two patients with multiple aneurysms, the lesions were clipped selectively according to location and size. Visual acuity improved in 7 patients, remained stable in 4, and deteriorated in only 1. No postoperative intracranial infection or ICA injury occurred in this series.Conclusion: The EESO and EEIO approaches can be combined with the current endoscopic endonasal midline approach and transcavernous approach to remove extensive pathologies involving the intrasellar, suprasellar, sphenoid, and cavernous sinuses and even bifurcation of the ICA.

Comparative Parameters of Occult and Multiple Brain Tumors In Human: The Implication for Therapy

Background Brain cancer treatment is a difficult task, because of complex nature of physico-chemical properties of brain, central nervous system (cns) acting drugs and drug carriers. Methods In view of this, literatures were searched with a view to assessing comparative mathematical parameters of occult and multiple primary brain tumors and their therapeutic outcomes. A total of thirteen patients comprised of eight males and five females who had suffered either occult or multiple brain tumors were used for the study. Tumor parameters and their therapeutic prognoses were mathematically determined. The data were analyzed using a modified Kaplan-Meier method at 5 % level of significance. Results Findings have shown that occult tumors such as meningiosarcoma (65.4cm3), teratoma (268 cm3), solitary brain tumor (20.6–22.4 cm3) and gliosarcoma (31.1 cm3) as well as multiple primary brain tumors; meningioma/diffuse astrocytoma (47.7 cm3), glioblastoma multiforme/pituitary adenoma (164. 59 cm3) and planum sphenoidale meningioma/pituitary adenoma (26.52 cm3) are deadly. However solitary brain tumor (4.2 cm3), glioblastoma multiforme/pituitary adenoma (12.77 cm3) and multimeningioma/pituitary adenoma (0.70 cm3) have high survival rate. Generally tumor weight (4.2–144.0 g), tumor density (0.24–0.96), total population of tumor cells (9.5 x 108-2.5 x 1011, rate of tumor cell migration (1.10–48.0 cm2/yr) and tumor radius (0.55-4.0 cm) are relatively moderate to very high, signifying that occult brain tumors may generate faster and may be more difficult to treat chemotherapeutically, radiotherapeutically, immunologically and surgically. Brain tumors affect male and female of 2–79 years old. Conclusions The locations of tumors are parietal, temporal, frontal, thalamic, frontoparietal, stellar, and planum sphenoidale lobes. Both occult and multiple brain tumors are diagnosed when all forms of therapy would have been useless.

Meningiomas of the Planum Sphenoidale and Tuberculum Sella

Patients with meningiomas of the planum sphenoidale and tuberculum sella often present with insidious vision loss in one or both eyes as the only sign or symptom of their disease, although other sensory, oculomotor, and even endocrine abnormalities may be seen in a minority of cases. Incidentally discovered tumors also are common, as patients may undergo neuroimaging for unrelated symptoms or events. Depending on the size and orientation of the tumor, central vision loss from optic nerve compression may be a later sign, and loss of peripheral vision in one or both eyes may not be recognized until it has progressed to areas closer to fixation. A thorough neuroophthalmologic assessment including visual field testing will help to define the extent of optic pathway involvement. Both fundus examination and optical coherence tomography of the retinal nerve fiber layer and macular ganglion cell complex will aid in determining prognosis after treatment of the tumor. Orbital surgery rarely is indicated as primary therapy for meningiomas in this location, and surgical resection or debulking is usually pursued before consideration is given to radiation therapy. Because of the long-term risk of residual tumor growth or recurrence, neuroophthalmic surveillance along with serial neuroimaging is required for years after tumor resection and/or radiation therapy.

Olfactory Outcomes after Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas via a Transcranial Approach

Objectives Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery. Study Design A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center. Participants & Main Outcome Measures All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations). Results Twenty-two patients were included in the study analysis, (range = 27–76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up. Conclusion Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately.

Planum Sphenoidale Meningioma: A Rare Location of Skull Base Meningioma

Background: Meningioma is common primary central nervous system tumors. Twenty-five percent of all meningioma consist of skull base meningioma. Planum sphenoidale meningiomas are rare. Planum sphenoidale meningiomas can extend into adjacent areas. Approximately two thirds of patients complain of failing vision in one eye as the first symptom. Case Report: A 32-year-old woman presented with 6-month history of progressively worsening blurred of both of vision. She also complained her smell ability was reduced for 3 months. She had headache for 6 months. The pain was worsening in the morning. She is conscious. A neurologic examination revealed bilateral hyposmia and visual deficits but no weakness. Visus of oculo dextra was 1/300 and visus of oculo sinistra was no light perception. Magnetic resonance imaging (MRI) intravena contrast of brain revealed a large extra-axial mass measured ±6,2x5,9x6 cm centred on planum sphenoidale displacing both frontal lobes. She had an operation of tumor removal with cranio-orbito-zygotomy approach. The tumor, which measured ±7cmx7cmx6 cm, was succesfully removed completely. She gets improvement of smell ability and both visual postoperatively. The histopathology of the tumor revealed meningioma WHO grade I. Discussion: Planum sphenoidale meningiomas present a frequently encountered pathology of the anterior skull base. These meningiomas give rise to an early visual disturbance with relatively slow progression. Displacement of the olfactory tracts and optic chiasm occur when the meningioma extends into the paranasal sinuses and nasal cavity. Clinical presentation and diagnosis often occur in the late stage. Anosmia is one of common finding on physical examination. Postoperative improvement of visual symptoms depends on the preoperative duration of those symptoms.

Tuberculum Sellae Meningiomas: Outcome of Twenty-eight Cases after Surgery

Objective: To present this series of surgically treated tuberculum sellae meningiomas with particular regard to visual compromises Methods: A retrospective analysis was done on 28 patients (21 females) with meningiomas originating from the tuberculum sellae who underwent surgery between 2010 and 2019. The standard surgical approach of pterional craniotomy. Twelve meningiomas extended posteriorly onto the diaphragma sellae, 13 anteriorly to the planum sphenoidale, and 3 to the anterior clinoid process. 21 tumours involved the optic canal, one bilaterally. Follow up ranged from 6 to 12 months. Results: Total microscopic resection was achieved in 28 patients. Median tumour size was 3.2 cm. Postoperatively, visual acuity improved in 19 patients and deteriorated 3. Preoperative and postoperative visual acuity worsened with increasing duration of preoperative symptoms and with increasing age. Extension into the intraconal space was a negative predictor. Recurrence occurred in one cases. One patients died from causes unrelated to the tumour. Conclusions: In the majority of patients with tuberculum sellae meningiomas, total resection may be achieved through a pterional approach with minimal complications. Bang. J Neurosurgery 2020; 10(1): 39-44