Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series

Endonasal Suturing of Nasoseptal Flap to Nasopharyngeal Fascia Using the V-Loc™ Wound Closure Device: 2-Dimensional Operative Video

We present a case of cerebrospinal fluid (CSF) leak after endoscopic endonasal resection of a large clival chordoma in an obese patient. The leak was at the lower reconstruction at the craniocervical junction and had failed repositioning. Using the V-Loc™ wound closure device (Covidien, New Haven, Connecticut) to suture the nasoseptal flap to the nasopharyngeal fascia, a water-tight seal was created and, along with a lumbar drain, the patient healed successfully.CSF leak after an endoscopic endonasal approach (EEA) to intradural pathologies remains one of the more common complications.1-4 Various closure techniques have been developed5-8 with success in mitigating this risk, but all have their limitations and rely on multiple layers including vascularized flaps like the nasoseptal flap.9-11 Endonasal suturing of graft materials offers the advantage of creating a water-tight seal. We present the use of the V-Loc™ wound closure device (Covidien) to successfully seal a postoperative CSF leak. The absorbable V-Loc™ wound closure device does not require the surgeon to tie knots, which is the most challenging step in a deep, 2-dimensional corridor. The suture is barbed and is anchored by threading the needle through a prefabricated loop at the end of the suture which locks in place. Each throw of the suture through tissue maintains the suture line as the barbs catch the tissue and prevent retraction. After successful closure, the needle can simply be cut off.The V-Loc™ wound closure device (Covidien) is a safe and effective adjunct to reconstruction after endoscopic endonasal skull base surgery as it provides an option for graft/flap suturing.A written release from the patient whose name or likeness is submitted as part of this Work is on file.

Survey of endoscopic skull base surgery practice patterns among otolaryngologists

Background

Endoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences.

Methods

An anonymous 32‐item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi‐square, and Fisher exact tests.

Results

Seventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full‐time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice, P = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice (P = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high‐flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs (P < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2–8 weeks and positive airway pressure use for 2–6 weeks. Most respondents started saline irrigations 0–2 weeks postoperatively.

Conclusions

Based on responses from fellowship‐ and non‐fellowship‐trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS.

Level of Evidence

5

Reconstruction of Dural Defects in Endoscopic Transnasal Approaches for Intradural Lesions Using Multilayered Fascia with a Pressure-Control Spinal Drainage System

OBJECTIVE

Nasoseptal flap reconstruction is a widely accepted method for reducing cerebrospinal fluid (CSF) leakage after endoscopic transnasal surgeries (ETSs). However, this method is associated with nasal complications and is difficult to apply repeatedly in recurrent cases. Therefore, alternative methods are needed.

METHODS

Layers of autologous fascia lata were placed on the inside and outside of the dural defect to sufficiently cover it, and the grafts were compressed with an inflated balloon. A lumbar drainage system with a pressure-control valve was used for 72 hours postoperatively. We retrospectively analyzed data on patients with skull base lesions showing intracranial extensions that required wide opening of the ventral dura in ETS. Fifty cases (47 skull base tumors and 3 others) were included, 28 of which were recurrent cases.

RESULTS

In 21 cases (42%), the nasal septum was not intact because of the previous ETS. Seventeen patients (34%) had a history of radiotherapy and 9 (18%) had undergone multisession radiotherapies. None of the 50 patients required additional surgery for postoperative CSF rhinorrhea, and 2 had intermittent CSF leakage that resolved with prolonged lumbar drainage placement for a week. Previous multisession radiotherapy was the only significant risk factor for the need of prolonged drainage (P = 0.029).

CONCLUSIONS

The multilayer closure method with a pressure-control spinal drainage system is a simple, safe, and effective method for preventing postoperative CSF leakage, which can be readily applied to dural defects in any parts of the skull base regions and in patients with various conditions.

A Multilayered Technique for Repair of the Suboccipital Retrosigmoid Craniotomy

Objective  Our primary objective was to retrospectively review our single institution experience using an anatomic multilayered repair of the retrosigmoid suboccipital craniotomy. Our secondary objective was to review the existing body of literature on the repair of this craniotomy and compare our outcomes to previous results. Design  Retrospective review of 25 consecutive patients undergoing repair for the retrosigmoid craniotomy. Setting  University of California Davis Medical Center (2010-2016). Participants  A total of 25 consecutive patients who underwent retrosigmoid craniotomy and repair. Exclusion criteria included patients who were under the age of 18 years. Main Outcome Measures  Main outcomes included incidence of postoperative headache, cerebrospinal fluid leak, and wound infections. Results  Postoperative headache was reported in two patients in this series (8%). None of the patients in the series developed cerebrospinal fluid leak or wound infections. Mean follow-up period was 16 months. Conclusion  Our multilayered anatomic repair after retrosigmoid suboccipital craniotomy results in favorable clinical results and may help reduce the risks associated with this operation.

The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas

Background:

While effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and can result in a several-week period of postoperative crusting during re-mucosalization of the denuded nasal septum. Endoscopic transsphenoidal surgery for pituitary adenoma resection is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas. This flap is raised in all surgeries during the transnasal exposure using septal mucoperiosteum that would otherwise be discarded during the posterior septectomy performed in binostril approaches.

Methods:

We present a retrospective, consecutive case series of 43 patients undergoing endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure. Main outcome measures were extent of resection and postoperative CSF leak.

Results:

The mean extent of resection was 97.16 ± 1.03%. Radiographic measurement showed flap length to be adequate. While a defect in the diaphragma sellae and CSF leak were identified in 21 patients during surgery, postoperative CSF leak occurred in only one patient.

Conclusions:

The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly always successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. The flap is raised from mucoperiosteum lining the posterior nasal septum, which is otherwise resected during posterior septectomy. Because the anterior septal cartilage is not denuded, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap.

Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm

Background  Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives  The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods  The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results  Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3-581), nine remained with recurrent/persistent disease (23%). Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0-240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion  Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.

Suprasellar and recurrent pediatric craniopharyngiomas: expanding indications for the extended endoscopic transsphenoidal approach

OBJECTIVE The expanded endonasal endoscopic transsphenoidal approach has become increasingly used for craniopharyngioma surgery in the pediatric population, but questions still persist regarding its utility in younger children, in recurrent and irradiated tumors, and in masses primarily located in the suprasellar region. The narrow corridor, incomplete pneumatization, and fear of hypothalamic injury have traditionally relegated this approach to application in older children with mostly cystic craniopharyngiomas centered in the sella. The authors present a series of consecutive pediatric patients in whom the endonasal endoscopic approach was used to remove craniopharyngiomas from patients of varied ages, regardless of the location of the tumor and previous treatments or surgeries, to ascertain if the traditional concerns about limitations of this approach are worth reevaluating METHODS Eleven consecutive pediatric patients (age ≤ 18 years) underwent surgery via an endoscopic transsphenoidal approach at NewYork-Presbyterian/Weill Cornell Medical Center from 2007 to 2016. The authors recorded the location, consistency, and size of the lesion, assessed for hypothalamic invasion radiographically, calculated skull base measurements, and assessed parameters such as extent of resection, visual function, endocrinological function, weight gain, and return-to-school status. RESULTS The average age at the time of surgery was 7.9 years (range 4-17 years) and the tumor sizes ranged from 1.3 to 41.7 cm³. Five cases were purely suprasellar, 5 had solid components, 4 were reoperations, and 5 had a conchal sphenoid aeration. Nevertheless, gross-total resection was achieved in 45% of the patients and 50% of those in whom it was the goal of surgery, without any correlation with the location, tumor consistency, or the age of the patient. Near-total resection, subtotal resection, or biopsy was performed intentionally in the remaining patients to avoid hypothalamic injury. Anterior pituitary dysfunction occurred in 81.8% of the patients, and 63.3% developed diabetes insipidus . Two patients (18%) had a greater than 9% increase in body mass index. Visual function was stable or improved in 73%. All children returned to an academic environment, with 10 of them in the grade appropriate for their age. There was a single case of each of the following: CSF leak, loss of vision unilaterally, and abscess. CONCLUSIONS The endoscopic transsphenoidal approach is suitable for removing pediatric craniopharyngiomas even in young children with suprasellar tumors, conchal sphenoid sinus, recurrent tumors, and tumors with solid components. The extent of resection is dictated by intrinsic hypothalamic tumor invasiveness rather than the approach. The endoscopic transsphenoidal approach affords the ability to directly inspect the hypothalamus to determine invasion, which may help spare the patient from hypothalamic injury. Irrespective of approach, the rates of postoperative endocrinopathy remain high and the learning curve for the approach to a relatively rare tumor is steep.

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

OBJECTIVE Craniopharyngiomas arise from the pituitary stalk, and in adults they are generally located posterior to the chiasm extending up into the third ventricle. The extended endonasal approach (EEA) can provide an ideal corridor between the bottom of the optic chiasm and the top of the pituitary gland (chiasm-pituitary corridor [CPC]) for their removal. A narrow CPC in patients with a prefixed chiasm and a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and subtotal resection. METHODS A database of all patients treated in the authors' center (Weill Cornell Medical College, NewYork-Presbyterian Hospital) between July 2004 and August 2016 was reviewed. Patients with craniopharyngiomas who underwent EEA with the goal of gross-total resection (GTR) were included in the study. Patients with postfixed chiasm or limited available preoperative imaging were excluded. Using preoperative contrast-enhanced T1-weighted sagittal midline MR images, the authors calculated the CPC as well as the distance from the chiasm to the top of the tumor (CTOT). From these numbers, they calculated a ratio of the CPC to the CTOT as a measure of difficulty in removing the tumors through the EEA and called this ratio the corridor index (CI). The relationship between the CI and the ability to achieve GTR and visual outcome were measured. RESULTS Thirty-four patients were included in the study. The mean CPC was 10.1 mm (range 5.2-19.1 mm). The mean CTOT was 12.8 mm (range 0-28.3 mm). The median CI was 0.8; the CI ranged from 0.4 to infinity (for tumors with a CTOT of 0). Thirty-two patients had GTR (94.1%) and 2 had subtotal resection. The CPC value had no relationship with our ability to achieve GTR and no effect on visual or endocrine outcome. CONCLUSIONS EEA for craniopharyngioma is generally considered the first-line surgical approach. Although a narrow corridor between the top of the pituitary gland and the bottom of the chiasm may seem to be a relative contraindication to surgery for larger tumors, the authors' data do not bear this out. EEA appears to be a successful technique for the majority of midline craniopharyngiomas.

The Impact of Age on Long-Term Quality of Life After Endonasal Endoscopic Resection of Skull Base Meningiomas

BACKGROUND

Midline ventral skull base meningiomas may be amenable to an endonasal endoscopic approach, which has theoretical advantages and may help preserve quality of life (QOL) when compared with transcranial approaches.

OBJECTIVE

To investigate the effect of age on QOL following endonasal endoscopic surgery, given the documented impact of age on QOL outcomes following transcranial resection of midline ventral skull base meningiomas.

METHODS

We reviewed a prospectively acquired database of endonasal endoscopic surgery for meningiomas. Inclusion criteria included patients who had completed long-term postoperative (≥6 months follow-up) QOL questionnaires (Anterior Skull Base Questionnaire [ASBQ] and Sino-Nasal Outcome Test [SNOT-22]). Postoperative QOL scores were also compared with preoperative QOL in a patient subset.

RESULTS

Long-term QOL data were available in 34 patients. Average postoperative ASBQ and SNOT-22 scores were 3.39 and 23.0, respectively. Better QOL was statistically associated with age <55 (P = .02). In a subset of patients, preoperative and postoperative ASBQ and SNOT-22 scores were compared. Only SNOT-22 scores significantly increased from 15.9 + 20.8 to 25.9 + 19.5 (P = .04).

CONCLUSION

We report the first study specifically evaluating long-term QOL after endonasal endoscopic resection of skull base meningiomas. QOL was decreased postoperatively in patients aged ≥55.

ABBREVIATIONS

ASBQ, Anterior Skull Base QuestionnaireGTR, gross total resectionQOL, quality of lifeSNOT-22, 22-item Sino-Nasal Outcome Test.

Open Anterior Skull Base Reconstruction: A Contemporary Review

Skull base extirpative and reconstructive surgery has undergone significant changes due to technological and operative advances. While endoscopic resection and reconstruction will continue to advance skull base surgery for the foreseeable future, traditional open surgical approaches and reconstructive techniques are still contemporarily employed as best practices in certain tumors or patient-specific anatomical cases. Skull base surgeons should strive to maintain a working knowledge and technical skill set to manage these challenging cases where endoscopic techniques have previously failed, are insufficient from anatomical constraints, or tumor biology with margin control supersedes the more minimally invasive approach. This review focuses on the reconstructive techniques available to the open skull base surgeon as an adjunct to the endoscopic reconstructive options. Anatomic considerations, factors relating to the defect or patient, reconstructive options of nonvascular grafts, local and regional flaps, and free tissue transfer are outlined using the literature and author's experience. Future directions in virtual surgical planning and emerging technologies will continue to enhance open and endoscopic skull base surgeon's preparation, performance, and outcomes in this continually developing interdisciplinary field.

Endoscopic endonasal approach for craniopharyngioma: the importance of the relationship between pituitary stalk and tumor

OBJECTIVE The endoscopic endonasal approach (EEA) is commonly used for the treatment of craniopharyngioma; therefore, it is essential to analyze outcomes in order to understand the benefits and drawbacks. The goal of this paper was to evaluate the clinical features and outcomes associated with this treatment approach. METHODS From July 2010 to March 2016, 82 adult craniopharyngioma patients underwent an EEA at the authors' institution. Of these cases, intraoperative records and immediate postoperative MR images were available for 68 patients. The patients underwent systemized endocrinological evaluation. Eighteen of 68 patients who underwent EEA for recurrence or regrowth of residual lesions after previous surgical management were excluded in the analysis of the anatomical tumor classification. The authors retrospectively analyzed preoperative clinical features and previous anatomical classifications, focusing on the relationship of the pituitary stalk and tumor, to determine predictive factors for the clinical outcome, such as the extent of resection, visual function, endocrinological function, recurrence rate, and complications. RESULTS The mean tumor size was 2.5 cm (3.1 cm for primary tumors and 1.9 cm for recurrent lesions). Gross-total resection (GTR) was achieved in 62 (91.1%) patients (48 [96.0%] patients with primary tumors and 14 [77.8%] patients with recurrent tumors). The rate of GTR was higher in the primary group than in the group with recurrence (p = 0.038). The overall pre- and postoperative visual impairment scale (VIS) scores were 40.8 and 22.1, respectively (50.9 and 14.3 in the primary group and 30.7 and 29.9 in patients with recurrence, respectively). The improvement rate in VIS score was higher in the primary group than in the recurrent group (p = 0.001). Endocrinological function was improved in 4 patients (5.9%) and deteriorated in 32 of 68 patients (47.1%). Tumor invasion into the center of the pituitary stalk affected the postoperative outcomes most significantly. Cognitive dysfunction was observed in 22 patients before surgery and improved in 20 patients (90.9%) after surgery. Hydrocephalus was found in 7 patients and resolved after surgery in all cases. CSF leakage occurred in 2 (2.9%) of 68 patients and was repaired by revision surgery in both patients. Ten patients without CSF leakage also received antibiotics for the treatment of meningitis. The infection rate was higher in the recurrent group. Postoperative endocrinological evaluation showed no deficits in 12 patients and panhypopituitarism in 55 patients. The remaining patient had growth hormone deficiency. Forty-three patients had new-onset diabetes insipidus, and 1 patient had persistent diabetes insipidus after surgery. There were 2 (2.9%) cases of recurrence during the mean 30.7-month follow-up period; one patient underwent radiosurgery and the other underwent reoperation. CONCLUSIONS The EEA resulted in excellent surgical outcomes and acceptable morbidity rates, regardless of the anatomical location of the tumor. Invasion of the craniopharyngioma into the center of the pituitary stalk has strong predictive power for postoperative endocrinological outcome.

Management of Skull Base Defects After Surgical Resection of Sinonasal and Ventral Skull Base Malignancies

Over the past 2 decades, there has been a significant increase in the resection of larger and more complex ventral skull base malignancies. The resection of these lesions has resulted in the creation of larger and more difficult to repair skull base defects. There are many available options for ventral skull base reconstruction. Despite the variety of reconstructive options, the key objective is to eliminate any communication between the intracranial space and the sinonasal cavity. This article discusses some of the more common techniques currently used for repair of these skull base defects.

Role of lumbar drains in contemporary endonasal skull base surgery: Meta-analysis and systematic review

BACKGROUND

Historically, lumbar drains (LD) have played a prominent role in endonasal skull base surgery. Over the past few decades, advancements in techniques have augmented our ability to successfully reconstruct complex skull base defects and often obviates the need for cerebrospinal fluid (CSF) diversion. Clarity on the appropriate use of LDs is needed.

OBJECTIVE

To examine the literature for the need for LDs in contemporary skull base reconstruction after resection of skull base tumors.

METHODS

A systematic literature review of English language articles by using PubMed and Ovid. Search terms included "lumbar drain," "CSF leak," and "endoscopic endonasal reconstruction." Articles were included when they pertained to adults, used current methods for reconstruction (i.e., multilayered repair or vascularized tissue), and addressed CSF leak rates secondary to endoscopic resection of skull base masses. All the studies discussed CSF leaks that resulted from traumatic-, idiopathic-, or sinus surgery-related iatrogenic causes were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.

RESULTS

A total of five articles met inclusion criteria. These comprised 376 endoscopic skull base tumor resection and reconstruction cases; 5.59% developed postoperative CSF leaks. A meta-analysis was conducted by incorporating three studies that met criteria based on testing for heterogeneity. The average odds ratio for postoperative CSF leak for patients who did not have an LD relative to patients who had an LD was 0.590 (95% confidence interval, 0.214-1.630). Given a p value of 0.30, the results demonstrated a lack of statistically significant improvement between patients who had an LD and patients who did not have an LD. Various details, such as the defect size and type of CSF leak, were not consistently reported among studies.

CONCLUSIONS

Available evidence for the use of LDs in skull base surgery is of poor quality. Analysis of the literature revealed heterogenous and varied reporting in the primary literature. Further studies that include randomized controlled trials are needed.

Lumbar Drains Decrease the Risk of Postoperative Cerebrospinal Fluid Leak Following Endonasal Endoscopic Surgery for Suprasellar Meningiomas in Patients With High Body Mass Index

BACKGROUND

Postoperative cerebrospinal fluid (CSF) leak is a persistent, albeit much less prominent, complication following endonasal endoscopic surgery. The pathology with highest risk is suprasellar meningiomas. A postoperative lumbar drain (LD) is used to decrease the risk of CSF leak but is not universally accepted.

OBJECTIVE

To compare the rates of postoperative CSF leak between patients with and without LD who underwent endonasal endoscopic surgical resection of suprasellar meningiomas.

METHODS

A consecutive series of newly diagnosed suprasellar meningiomas was drawn from a prospectively acquired database of endonasal endoscopic surgeries at our institution. An intraoperative, preresection LD was placed and left open at 5 cc/h for ∼48 h. In a subset of patients, the LD could not be placed. Rates of postoperative CSF leak were compared between patients with and without an LD.

RESULTS

Twenty-five patients underwent endonasal endoscopic surgical resection of suprasellar meningiomas. An LD could not be placed in 2 patients. There were 2 postoperative CSF leaks (8%), both of which occurred in the patients who did not have an LD (P = .0033). The average body mass index (BMI) of the patients in whom the LD could not be placed was 39.1 kg/m2, compared with 27.6 kg/m2 for those in whom the LD could be placed (P = .009). In the subgroup of obese patients (BMI &gt; 30 kg/m2), LD placement was protective against postoperative CSF leak (P = .022).

CONCLUSION

The inability to place an LD in patients with obesity is a risk factor for postoperative CSF leak. An LD may be useful to prevent postoperative CSF leak, particularly in patients with elevated BMI.

Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients

OBJECTIVE Planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas cause visual symptoms due to compression of the optic chiasm. The treatment of choice is surgical removal with the goal of improving vision and achieving complete tumor removal. Two options exist to remove these tumors: the transcranial approach (TCA) and the endonasal endoscopic approach (EEA). Significant controversy exists regarding which approach provides the best results and whether there is a subset of patients for whom an EEA may be more suitable. Comparisons using a similar cohort of patients, namely, those suitable for gross-total resection with EEA, are lacking from the literature. METHODS The authors reviewed all cases of PS and TS meningiomas that were surgically removed at Weill Cornell Medical College between 2000 and 2015 (TCA) and 2008 and 2015 (EEA). All cases were shown to a panel of 3 neurosurgeons to find only those tumors that could be removed equally well either through an EEA or TCA to standardize both groups. Volumetric measurements of preoperative and postoperative tumor size, FLAIR images, and apparent diffusion coefficient maps were assessed by 2 independent reviewers and compared to assess extent of resection and trauma to the surrounding brain. Visual outcome and complications were also compared. RESULTS Thirty-two patients were identified who underwent either EEA (n = 17) or TCA (n = 15). The preoperative tumor size was comparable (mean 5.58 ± 3.42 vs 5.04 ± 3.38 cm³ [± SD], p = 0.661). The average extent of resection achieved was not significantly different between the 2 groups (98.80% ± 3.32% vs 95.13% ± 11.69%, p = 0.206). Postoperatively, the TCA group demonstrated a significant increase in the FLAIR/edema signal compared with EEA patients (4.15 ± 7.10 vs -0.69 ± 2.73 cm³, p = 0.014). In addition, the postoperative diffusion-weighted imaging signal of cytotoxic ischemic damage was significantly higher in the TCA group than in the EEA group (1.88 ± 1.96 vs 0.40 ± 0.55 cm³, p =0.008). Overall, significantly more EEA patients experienced improved or stable visual outcomes compared with TCA patients (93% vs 56%, p = 0.049). Visual deterioration was greater after TCA than EEA (44% vs 0%, p = 0.012). While more patients experienced postoperative seizures after TCA than after EEA (27% vs 0%, p = 0.038), there was a trend toward more CSF leakage and anosmia after EEA than after TCA (11.8% vs 0%, p = 0.486 and 11.8% vs 0%, p = 0.118, respectively). CONCLUSIONS In this small single-institution study of similarly sized and located PS and TS meningiomas, EEA provided equivalent rates of resection with better visual results, less trauma to the brain, and fewer seizures. These preliminary results merit further investigation in a larger multiinstitutional study and may support EEA resection by experienced surgeons in a subset of carefully selected PS and TS meningiomas.

Endoscopic endonasal approach to the ventral brainstem: anatomical feasibility and surgical limitations

OBJECTIVE Sporadic cases of endonasal intraaxial brainstem surgery have been reported in the recent literature. The authors endeavored to assess the feasibility and limitations of endonasal endoscopic surgery for approaching lesions in the ventral portion of the brainstem. METHODS Five human cadaveric heads were used to assess the anatomy and to record various measurements. Extended transsphenoidal and transclival approaches were performed. After exposing the brainstem, white matter dissection was attempted through this endoscopic window, and additional key measurements were taken. RESULTS The rostral exposure of the brainstem was limited by the sella. The lateral limits of the exposure were the intracavernous carotid arteries at the level of the sellar floor, the intrapetrous carotid arteries at the level of the petrous apex, and the inferior petrosal sinuses toward the basion. Caudal extension necessitated partial resection of the anterior C-1 arch and the odontoid process. The midline pons and medulla were exposed in all specimens. Trigeminal nerves were barely visible without the use of angled endoscopes. Access to the peritrigeminal safe zone for gaining entry into the brainstem is medially limited by the pyramidal tract, with a mean lateral pyramidal distance (LPD) of 4.8 ± 0.8 mm. The mean interpyramidal distance was 3.6 ± 0.5 mm, and it progressively decreased toward the pontomedullary junction. The corticospinal tracts (CSTs) coursed from deep to superficial in a craniocaudal direction. The small caliber of the medulla with very superficial CSTs left no room for a safe ventral dissection. The mean pontobasilar midline index averaged at 0.44 ± 0.1. CONCLUSIONS Endoscopic endonasal approaches are best suited for pontine intraaxial tumors when they are close to the midline and strictly anterior to the CST, or for exophytic lesions. Approaching the medulla is anatomically feasible, but the superficiality of the eloquent tracts and interposed nerves limit the safe entry zones. Pituitary transposition after sellar opening is necessary to access the mesencephalon.

Bolstering the Nasoseptal Flap Using Sphenoid Sinus Fat Packing: A Technical Case Report

BACKGROUND

Resection of extensive skull base lesions often necessitates relatively large dural openings and arachnoid, resulting in skull base defects with the potential for a postoperative cerebrospinal fluid leak. A nasoseptal flap (NSF) is a vascularized graft that has greatly diminished the incidence of cerebrospinal fluid leak. Annealing of flaps against the ventral skull base can be tenuous within the first few days after surgery. We report the use of sphenoid sinus fat packing as a buttress to support the nasoseptal flap during skull base reconstruction.

CASE DESCRIPTION

A 37-year-old man presented with pan-hypopituitarism, bitemporal hemianopsia, and imaging consistent with a craniopharyngioma. He underwent an endoscopic endonasal approach with resection of the planum and tuberculum sphenoidale for resection of this mass. An NSF was harvested, and a combination of suprasellar fat packing, tensor fasciae lata graft, and Porex plate along with the flap were used to reconstruct the skull base. Postoperatively, he precipitously experienced copious rhinorrhea necessitating surgical re-exploration. A redundant segment of the NSF had retracted into the sphenoid sinus, and was no longer supported against the ventral skull base. We repositioned the NSF and used sphenoid sinus fat packing to help support the graft against the ventral skull base. A postoperative computed tomographic scan demonstrated a clear delineation between the vascularized graft and the fat packing, confirming proper positioning of the flap.

CONCLUSION

Sphenoid sinus fat packing can be an important technical adjunct in bolstering the nasoseptal flap against the ventral skull base in the tenuous early perioperative period.

Direct Endonasal Approach with Partial Upper Posterior Septectomy. A "Rescue Flap" Technique Modification

Objective Report a modification of the "rescue flap" technique using a direct endonasal approach with a partial superior septectomy for approaching pituitary tumors developed in our institution. Design Prospective study. Setting Hospital Universitario "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León. Main Outcome Measures Since April 2015, we have performed 19 cases employing a direct endonasal approach with partial superior septectomy. Results and a technical note are described below. Results Nineteen patients were included in this report. Six patients presented transoperatory cerebrospinal fluid (CSF) leak, so a nasoseptal rescue flap was harvested. No patients developed postoperative CSF leak in this group. Two patients were submitted to a second surgical procedure. Nasoseptal flap was harvested without complications. In both patients, the size of the flap was enough to cover the dural defect and avoid CSF leak. Conclusion Direct endonasal approach with a partial posterior septectomy allows enough exposition of the sphenoidal sinus while preserving the nasoseptal septum with the possibility of a successful rescue flap when needed.

Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair: A Meta-analysis

Objective

Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well-established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta-analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea.

Data Sources

A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015).

Review Method

A meta-analysis was performed according to PRISMA guidelines.

Results

A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drainage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10).

Conclusions

There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postoperative CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.

Endoscopic Endonasal Management of Craniopharyngioma

Craniopharyngioma is a rare clinical entity that poses a significant management challenge given their location and propensity to recur. As part of a minimally disruptive treatment paradigm, the expanded endonasal approach has the potential to improve rates of resection, improve postoperative visual recovery, and minimize surgical morbidity. This article updates the otolaryngologic community on the basic principles and techniques regarding the incorporation of the endoscopic, endonasal approach in the management paradigm of craniopharyngioma.

Reconstruction of Skull Base Defects

"Endoscopic endonasal skull base surgery has dramatically changed and expanded over recent years due to significant advancements in instrumentation, techniques, and anatomic understanding. With these advances, the need for more robust skull base reconstructive techniques was vital. In this article, reconstructive options ranging from acellular grafts to vascular flaps are described, including the strengths, weaknesses, and common uses."

Comprehensive Postoperative Management After Endoscopic Skull Base Surgery

To maximize outcomes from endoscopic skull base surgery, careful early postoperative management is critically important. Standardized postoperative regimens are lacking. The type of reconstruction and presence and type of cerebrospinal fluid leak dictate management. If a leak is encountered intraoperatively, patients should avoid maneuvers that increase intracranial pressures for at least 1 month. Early postoperative care focuses on minimizing and managing nasal crusting. This article reviews the evidence in the literature on postoperative management, complications, and quality of life after surgery, and outlines our experience in the management of patients after endoscopic skull base surgery.

Cerebrospinal fluid leaks in extended endoscopic transsphenoidal surgery: covering all the angles

Following extended endoscopic transsphenoidal approach (EETSA), cerebrospinal fluid (CSF) leak rate has been reported in the range of 5-50 %. Novel closure techniques, such as the nasoseptal flap and other multilayered repairs improved the outcomes significantly but took most of our focus. Little attention, however, was given to other aspects of the equation such as nasal support-to support the heavy weight of such repairs-and lumbar drains. These are important because they diminish the forces acting on both sides of the repair, hence covering all the angles. We reviewed data of 98 consecutive patients who underwent an EETSA between 1999 and 2014. We analyzed the rates of CSF leak throughout the years and with every modification added to our closure technique. Common pathologies encountered were invasive adenomas, meningiomas, chordomas, and craniopharyngiomas. CSF leak occurred overall in five patients (5.1 %). The nasoseptal flap decreased the rate of CSF leak but not significantly (P = 0.112), while placing a nasal trumpet to support our repair resulted in significant decrease in CSF leak rate (P = 0.0013). In the last 2 years of our series, when all modifications took place and all angles were covered, there was one leak in 35 cases (2.8 %). A protocol that covers all the angles by a good multilayered repair (regardless of its type and materials) while diminishing the forces acting on both sides of the repair leads to a minimal rate of CSF leak. No principle alone is effective individually.

The use of a three-dimensional endoscope for different skull base tumors: results of a preliminary extended endonasal surgical series

BACKGROUND

The evolution of skull base surgery over the past decade has been influenced by advancement in visualization technology. Recently, as a result of such improvements, three-dimensional (3-D) scopes have been widely used during endoscopic endonasal approaches. In the present study, we describe the use of 3-D stereoscopic endoscope for the treatment of a variety of skull base lesions.

METHODS

From January 2010 to June 2015, a 3-D endoscopic endonasal approach (4 and 4.9 mm, 0°, and 30° rigid endoscopes) was performed in 70 patients with the following lesions: 42 large extrasellar pituitary macroadenomas, seven tuberculum sellae meningiomas, seven clivus chordomas, five craniopharyngiomas, three fibrous dysplasia of the clivus, three sinonasal malignancies, one orbital lymphangioma, one trigeminal neurinoma, one primary suprasellar lymphoma.

RESULTS

Total tumor removal was obtained in 50 patients (71.4 %) while in 14 (20 %), subtotal removal was possible in six (8.6 %) only partial removal was achieved. Overall complications included diabetes insipidus in eight patients (11.4 %), hypopituitarism in seven patients (10 %), CSF leak in five patients (7.1 %), cranial nerve injury in two patients (2.8 %), panhypopituitarism in two patients (2.8 %), meningitis in one (1.4 %) and one postoperative central retinal artery occlusion (1.4 %). There was no mortality in the series. The mean follow-up time was 39 months (range, 6-72 months).

CONCLUSIONS

In our experience, the 3-D endoscope represents a critical development in visualization, thus enabling improved hand-eye coordination and depth perception, which are mandatory for the management of complex intradural neurovascular structures during tumor removal surgery.

Extended endoscopic endonasal approach to clival and paraclival tumors: Indications and limits

OBJECTIVE

To report our experience with the Extended endoscopic endonasal approach (EEEA) for clival and paraclival tumors.

DESIGN

Retrospective analysis of a consecutive series of patients.

RESULTS

Eleven patients were considered: 3 chordomas, 3 meningiomas, 3 metastatic lesions, one chondroma and one chondrosarcoma. Gross total resection (GTR) was achieved in all chordomas and in chondromas with patients free of disease at the last follow-up. The chondrosarcoma was first operated on using a transfacial approach and endoscopy was performed for local progression with subtotal resection. The meningiomas were treated by a combination of transcranial and endoscopic approach due to their extension. The resection was subtotal and the residue treated by radiosurgery. Two patients with rhinopharyngeal carcinoma underwent palliative debulking. One metastatic melanoma that underwent GTR experienced remission. Two patients had postoperative cranial nerve palsy. No other complications were observed.

CONCLUSIONS

EEEA allows a direct access to the skull base. Through a minimal access, it limits the incidence of neurological morbidities. For midline epidural clival tumors, EEEA allows a total excision. It also offers an excellent access to the clival component of intradural lesions. A combined approach permits good tumor control with minimal complications.

Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas

OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m² over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more impacted by tumor volume and prior radiation. Reoperations should be offered to patients with recurrent craniopharyngiomas and may be preferable to radiation in patients in whom GTR or NTR can be achieved.

Principles in Skull Base Reconstruction following Expanded Endoscopic Approaches

OBJECTIVES

This study aims to describe the types of anterior skull base defects following expanded endoscopic approaches (EEA) and to outline the techniques involved in the repair of these defects.

DESIGN

We retrospectively analyzed 63 cases of endoscopic skull base reconstruction (ESBR) following tumor excision, done from September 2011 to January 2015. These tumors consisted of 14 pituitary adenomas, 20 craniopharyngiomas, and 29 other miscellaneous tumors. The classification of skull base defects by Tabaee et al and the classification of cerebrospinal fluid (CSF) leaks by Esposito et al were considered during the ESBR. Recurrence of CSF leak was considered as failure of reconstruction.

RESULTS

The 63 skull base defects included in this study occurred following EEA for tumor excision. Failure of reconstruction occurred in 6 six patients. All were successfully repaired, however, three patients in this series died due to tumor-related complications.

CONCLUSION

The adherence to the general principles of reconstruction, appreciating the subtle differences in the nature of the various defects and the ability to adopt different strategies are the prerequisites for the successful closure of skull base defects.

A new multilayer reconstruction using nasal septal flap combined with fascia graft dural suturing for high-flow cerebrospinal fluid leak after endoscopic endonasal surgery

This study aimed to evaluate the usefulness and reliability of a new endoscopic multilayer reconstruction using nasal septal flap (NSF) to prevent high-flow cerebrospinal fluid leak after endoscopic endonasal surgery. This study was a retrospective review on 97 patients who underwent multilayer reconstructions using NSF combined with fascia graft dural suturing after endoscopic endonasal surgery between July 2012 and March 2014. Patients were divided into two groups, third ventricle opening group and nonopening group, based on the presence of a direct connection between the third ventricle and the paranasal sinus after tumor removal. Furthermore, we compared this procedure with our previous reconstruction after resection of craniopharyngioma. Finally, we checked the patients who had postoperative prolonged discomfort of the nasal cavity for over a year. Postoperative cerebrospinal fluid (CSF) leak occurred in three patients (3.1 %): one from the third ventricle opening group and the remaining two from the nonopening group. External lumbar drain was performed after surgery in only seven patients (7.2 %). The incidence of postoperative CSF leak was similar in both groups, whereas the rate of craniopharyngioma in the third ventricle opening group was significantly higher. The incidence of postoperative CSF leak after resection of craniopharyngioma was not statistically significant but obviously higher in the previous group (12.2 %) compared with that in the present group (2.3 %). Twelve patients (12.4 %) had postoperative nasal discomfort of the nasal cavity for over a year. Multilayer reconstruction using NSF combined with fascia graft dural suturing is a more reliable method for preventing postoperative high-flow CSF leakage after endoscopic endonasal surgery even if there is a direct connection between the third ventricle and the paranasal sinus. However, we should pay close attention especially to prolonged discomfort of the nasal cavity after harvesting NSF.

Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations

BACKGROUND

Management strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely because of limited evidence-based guidance.

METHODS

A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014 to examine 5 endoscopic repair techniques and 8 perioperative management strategies for CSF rhinorrhea. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process.

RESULTS

We reviewed 67 studies examining 13 practices pertinent to the management of CSF rhinorrhea, reaching a highest aggregate grade of evidence of B. The literature does not support the routine use of prophylactic antibiotics or lumbar drainage. Various endoscopic repair materials show similar success rates; however, larger defects may benefit from vascularized grafts. There were no relevant studies to address postoperative activity restrictions.

CONCLUSION

Despite relatively low levels of evidence, recommendations for the management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal clinical management approaches.

Cranial Base Repair Using Suturing Technique Combined with a Mucosal Flap for Cerebrospinal Fluid Leakage During Endoscopic Endonasal Surgery

OBJECTIVE

To evaluate a cranial base repair method using the dural suturing technique in combination with a mucosal flap in the endoscopic endonasal approach.

METHODS

We analyzed 190 patients (mean age, 52.3 years; age range, 3-86 years) who underwent 194 endoscopic endonasal approaches. The degree of intraoperative cerebrospinal fluid (CSF) leakage was graded based on previously published criteria: grade 0, absent; grade 1, small; grade 2, moderate; and grade 3, large. Cranial base repair using the dural suturing technique was performed according to the grade of CSF leakage: grades 1 and 2, autologous fat graft anchored by dural suturing covered with a sphenoid sinus mucosal flap, and grade 3, multilayered, inlay sutured and onlay nonsutured fascial grafts covered with a nasoseptal flap.

RESULTS

Intraoperative CSF leakage was observed in 125 of 194 cases (64.4%). The degree of CSF leakage was grade 0 in 69 cases, grade 1 in 51 cases, grade 2 in 30 cases, and grade 3 in 44 cases. A postoperative CSF leak was encountered in 2 of 125 repaired cases (1.6%). Both cases with CSF leak involved grade 3 CSF leak (4.5%), and both were successfully treated with lumbar drainage.

CONCLUSION

Our graded cranial base repair method using the dural suturing technique is simple and reliable.

Endoscope-assisted endonasal versus supraorbital keyhole resection of olfactory groove meningiomas: comparison and combination of 2 minimally invasive approaches

OBJECTIVE

Although the endonasal endoscopic approach has been applied to remove olfactory groove meningiomas, controversy exists regarding the efficacy and safety of this approach compared with more traditional transcranial approaches. The endonasal endoscopic approach was compared with the supraorbital (eyebrow) keyhole technique, as well as a combined "above-and-below" approach, to evaluate the relative merits of each approach in different situations.

METHODS

Nineteen cases were reviewed and divided according to operative technique into 3 different groups: purely endonasal (6 cases); supraorbital eyebrow (microscopic with endoscopic assistance; 7 cases); and combined endonasal endoscopic with either the bicoronal or eyebrow microscopic approach (6 cases). Resection was judged on postoperative MRI using volumetric analysis. Tumors were assessed based on the Mohr radiological classification and the presence of the lion's mane sign.

RESULTS

The mean age at surgery was 61.4 years. The mean tumor volume was 19.6 cm(3) in the endonasal group, 33.5 cm(3) in the supraorbital group, and 37.8 cm(3) in the combined group. Significant frontal lobe edema was identified in 10 cases (52.6%). The majority of tumors were either Mohr Grade II (moderate) (42.1%) or Grade III (large) (47.4%). Gross-total resection was achieved in 50% of the endonasal cases, 100% of the supraorbital eyebrow cases with endoscopic assistance, and 66.7% of the combined cases. The extent of resection was 87.8% for the endonasal cases, 100% for the supraorbital eyebrow cases, and 98.9% for the combined cases. Postoperative anosmia occurred in 100% of the endonasal and combined cases and only 57.1% of the supraorbital eyebrow cases. Excluding anosmia, permanent complications occurred in 83.3% of the cases in the endoscopic group, 0% of the cases in the supraorbital eyebrow group, and 16.7% of cases in the combined group (p = 0.017). There were 3 tumor recurrences: 2 in the endonasal group and 1 in the combined group.

CONCLUSIONS

The supraorbital eyebrow approach, with endoscopic assistance, leads to a higher extent of resection and lower rate of complications than the purely endonasal endoscopic approach. The endonasal endoscopic approach by itself may be suitable for a small percentage of cases. The combined above-and-below approaches are useful for large tumors with invasion of the ethmoid sinuses.

Endoscopic endonasal clip ligation of cerebral aneurysms: an anatomical feasibility study and future directions

OBJECTIVE

The expansion of endovascular procedures for obliteration of cerebral aneurysms highlights one of the drawbacks of clip ligation through the transcranial route, namely brain retraction or brain transgression. Sporadic case reports have emerged over the past 10 years describing endonasal endoscopic clip ligation of cerebral aneurysms. The authors present a detailed anatomical study to evaluate the feasibility of an endoscopic endonasal approach for application of aneurysm clips.

METHODS

Nine human cadaveric head specimens were used to evaluate operative exposures for clip ligation of aneurysms in feasible anterior and posterior circulation locations. Measurements of trajectories were completed using a navigation system to calculate skull base craniectomy size, corridor space, and the surgeon's ability to gain proximal and distal control of parent vessels.

RESULTS

In each of the 9 cadaveric heads, excellent exposure of the target vessels was achieved. The transplanum, transtuberculum, and transcavernous approaches were used to explore the feasibility of anterior circulation access. Application of aneurysm clips was readily possible to the ophthalmic artery, A1 and A2 segments of the anterior cerebral artery, anterior communicating artery complex, and the paraclinoid and paraclival internal carotid artery. The transclival approach was explored, and clips were successfully deployed along the proximal branches of the vertebrobasilar system and basilar trunk and bifurcation. The median sizes of skull base craniectomy necessary for exposure of the anterior communicating artery complex and basilar tip were 3.24 cm(2) and 4.62 cm(2), respectively. The mean angles of surgical corridors to the anterior communicating artery complex and basilar tip were 11.4° and 14°, respectively. Although clip placement was feasible on the basilar artery and its branches, the associated perforating arteries were difficult to visualize, posing unexpected difficulty for safe clip application, with the exception of ventrolateral-pointing aneurysms.

CONCLUSIONS

The authors characterize the feasibility of endonasal endoscopic clip ligation of aneurysms involving the paraclinoid, anterior communicating, and basilar arteries and proximal control of the paraclival internal carotid artery. The endoscopic approach should be initially considered for nonruptured aneurysms involving the paraclinoid and anterior communicating arteries, as well as ventrolateral basilar trunk aneurysms. Clinical experience will be mandatory to determine the applicability of this approach in practice.

Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique

Endoscopic approaches to the midline ventral skull base have been extensively developed and refined for resection of cranial base tumors over the past several years. As these techniques have improved, both the degree of resection and complication rates have proven comparable to those for transcranial approaches, while visual outcomes may be better via endoscopic endonasal surgery and hospital stays and recovery times are often shorter. Yet for all of the progress made, the steep learning curve associated with these techniques has hampered more widespread implementation and adoption. The authors address this obstacle by coupling a thorough description of the technical nuances for endoscopic endonasal craniopharyngioma resection with detailed illustrations of the important steps in the operation. Traditionally, transsphendoidal approaches to craniopharyngiomas have been restricted to lesions mostly confined to the sella. However, recently, endoscopic endonasal resections are more frequently employed for extrasellar and purely third ventricle craniopharyngiomas, whose typical retrochiasmatic location makes them ideal candidates for endoscopic transnasal surgery. The endonasal endoscopic approach offers many advantages, including direct access to the long axis of the tumor, early tumor debulking with minimal manipulation of the optic apparatus, more precise visualization of tumor planes, particularly along the undersurface of the chiasm and the roof of the third ventricle, and a minimal-access corridor that obviates the need for brain retraction. Although much emphasis has been placed on technical tenets of exposure and "how to get there," this article focuses on nuances of tumor resection "when you are there." Three operative videos illustrate our discussion of technical tenets.

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

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.

Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas

OBJECT

Craniopharyngiomas are benign parasellar tumors for which surgical removal, although potentially curative, often leads to morbidity with resulting decreases in quality of life (QOL). The endonasal endoscopic approach is a minimal-access technique for removing these tumors and may reduce postoperative morbidity. The QOL following this method for resection of craniopharyngiomas has not been documented.

METHODS

The authors reviewed a database of consecutive endonasal endoscopic surgeries done at Weill Cornell Medical College. Adult patients with histologically proven craniopharyngiomas were included who had completed either only postoperative (> 9 months) or both pre- and postoperative QOL forms, the Anterior Skull Base Quality of Life (ASBQ) questionnaire, and the 22-Item Sinonasal Outcome Test (SNOT-22). Rates of gross-total resection (GTR), complications, and visual and endocrine function were collected. Retrospective independence (Wen score) was also assigned. A contemporaneous group of patients undergoing endonasal endoscopic pituitary macroadenoma resection was used as a control.

RESULTS

This study included 33 procedures performed in 31 patients. The average postoperative ASBQ score was 3.35 and the SNOT-22 score was 19.6. Better QOL was associated with GTR and postoperative radiation. Worse QOL was associated with persistent visual defects, hypopituitarism, tumor recurrence, increase in body mass index, and worsening Wen score. In a subset of 10 patients, both pre- and postoperative (> 9 months) QOL scores were obtained. Both ASBQ and SNOT-22 scores showed stability and a trend toward improvement, from 2.93 ± 0.51 to 2.96 ± 0.47 (ASBQ) and 23.7 ± 10.8 to 18.4 ± 11.6 (SNOT-22). Compared with 62 patients undergoing endoscopic pituitary macroadenoma resection, patients with craniopharyngiomas had worse postoperative QOL on the ASBQ (3.35 vs 3.80; p = 0.023) and SNOT-22 (19.6 vs 13.4; p = 0.12).

CONCLUSIONS

This report of validated site-specific QOL following endoscopic surgery for craniopharyngiomas shows an overall maintenance of postoperative compared with preoperative QOL. Better QOL could be seen in patients with GTR and radiation therapy, and worse QOL was found in patients with visual or endocrine deficits. Nevertheless, patients with craniopharyngiomas still had worse QOL than those undergoing similar surgery for pituitary macroadenomas, confirming the worse prognosis of craniopharyngiomas even when removed via a minimally invasive approach. These measures should serve as benchmarks for comparison with open transcranial approaches to similar tumors.

Banked Fascia Lata in Sellar Dura Reconstruction after Endoscopic Transsphenoidal Skull Base Surgery

Objectives Cerebrospinal fluid (CSF) leakage is an undesirable complication of transsphenoidal skull base surgery. The issue of the most appropriate sellar dura repair remains unresolved, although a multilayer technique using autologous fascia lata is widely used. We describe the novel application of a homologous banked fascia lata graft as an alternative to an autologous one in the reconstruction of sellar dura defects in endoscopic transsphenoidal surgery. Design The clinical records of patients who underwent endoscopic transsphenoidal surgery at our department from June 2012, when we started using homologous fascia lata, up to July 2014 were reviewed retrospectively. The data concerning diagnosis, reconstruction technique, and surgical outcome were analyzed. Results We treated 16 patients successfully with banked fascia lata. Twelve patients presented intraoperative CSF leakage, and four patients were treated for postoperative rhinoliquorrhea. Banked fascia lata was used in a single-to-multilayer technique, depending on the anatomical features of the defect and of the sellar floor. No complications or failures in sella reconstruction occurred. Conclusion A banked fascia lata graft proved reliable and safe in providing an effective sellar dura reconstruction. Used in a multilayer strategy, it should be considered a viable alternative to an autologous fascia lata graft.

Fascia patchwork closure for endoscopic endonasal skull base surgery

With the development of endoscopic technology and surgery, resection of midline skull base tumors has been achieved using endoscopic endonasal skull base (EESB) approaches. EESB approaches reportedly have a greater risk of postoperative cerebrospinal fluid (CSF) leakage. Recently, the introduction of the nasoseptal flap (NSF) decreased dramatically the incidence of CSF leakage, but the use of an NSF increases the risk of disturbing the function of the nose. Here, we report our new technique called "fascia patchwork closure" for closure after EESB surgery and its outcome. All 48 cases involved midline skull base tumors resected via EESB approaches. Of them, 32 cases were closed by the fascia patchwork technique after tumor resection, and there was no incidence of CSF leakage. Moreover, 6 of the 32 cases were closed without the use of an NSF, indicating that the fascia patchwork closure approach is effective as part of a multilayer closure for the prevention of CSF leakage. The establishment and popularization of this technique might result in the further development of EESB surgery and also an improvement of postoperative nasal function.

Perforation of a nasoseptal flap does not increase the rate of postoperative cerebrospinal fluid leak

BACKGROUND

The nasoseptal flap (NSF) has been shown to be a valuable addition to the reconstructive armamentarium of the endoscopic skull-base surgeon. We aimed to evaluate the rate of postoperative cerebrospinal fluid (CSF) leak after use of a NSF that had a small tear during harvest.

METHODS

After Institutional Review Board (IRB) approval, we analyzed our database of patients undergoing skull-base resection. We included all patients who had a NSF reconstruction, septoplasty, and/or spur on preoperative computed tomography (CT) imaging. We then evaluated video of each procedure to determine if a tear occurred in the NSF during harvest. Patient records were reviewed to determine if a postoperative CSF leak occurred.

RESULTS

We evaluated video of 21 patients who underwent a skull-base resection, were reconstructed with a NSF, and had either a septoplasty or evidence of a septal spur on CT imaging. Of these 21 cases, 11 small tears occurred during harvest of the NSF flap and none of the patients with a torn NSF had a postoperative CSF leak.

CONCLUSION

Our series shows a 0% postoperative CSF leak rate in patients undergoing skull-base reconstruction with a NSF that was torn during harvest. Small tears in the NSF do not seem to affect postoperative CSF leak rates.

Split-calvarial osteopericranial flap for reconstruction following endoscopic anterior resection of cranial base

OBJECTIVES/HYPOTHESIS

To conceive and critically evaluate an adaptation of the split calvarial osteopericranial flap for reconstruction following endoscopic endonasal resection of the anterior skull base.

STUDY DESIGN

Cadaveric anatomic study.

METHODS

Five cadavers were embalmed with methanol, and vasculature was injected with latex. Endoscopic endonasal resection of the anterior skull base was performed, followed by reconstruction with a unilateral osteopericranial flap and a contralateral conventional pericranial flap.

RESULTS

Rigid reconstruction was achieved in all specimens. Osteoplastic flap harvest was made more reliable by drilling the diploe below the graft with a curved bur. Dimensions of the bony flap were ideally shorter and wider than the defect, allowing for flap inset and rigid support by the orbits without compromise of the flap vascular supply. Endoscopic inset of the flap is feasible via nasion-frontal osteotomy and inlay technique.

CONCLUSION

Rigid anterior skull base reconstruction via split calvarial osteopericranial flap is adaptable to current endoscopic techniques. This provides more anatomic reconstruction than current methods and may lead to decreased complication rates following anterior skull base resection.

Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

OBJECTIVES

Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS.

METHODS

The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1-10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0-4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak.

RESULTS

The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed "suspicious" pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as "benign" pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0-4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of "suspicious" pneumocephalus provides the best overall prediction for postoperative CSF leaks.

CONCLUSIONS

Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A "suspicious" pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of "suspicious" pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.

Combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap multilayered reconstruction technique for high-flow cerebrospinal fluid leaks after endonasal endoscopic skull base surgery

OBJECTIVE

To assess the efficacy of the combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap (VP-NSF) multilayered reconstruction technique for high-flow cerebrospinal fluid (CSF) leaks resulting from endonasal endoscopic skull base surgery.

METHODS

From October 2009-June 2011, a VP-NSF multilayered reconstruction technique was used (single technique group) for patients with intraoperative high-flow CSF leaks; from July 2011-February 2013, a combination of a gasket seal closure and a VP-NSF multilayered reconstruction technique was used (combined technique group). A lumbar drain was placed after the operation. The rates of postoperative CSF leaks and repair-related complications in the 2 groups were analyzed.

RESULTS

The single technique group comprised 18 patients with a mean follow-up of 31.7 months; there were 5 postoperative CSF leaks (27.7%). The combined technique group comprised 15 patients with a mean follow-up of 13.6 months; no CSF leaks occurred (P < 0.05). The rate of intracranial infection in the single technique group was significantly higher than in the combined technique group.

CONCLUSIONS

The combined use of a gasket seal closure and a VP-NSF multilayered reconstruction technique for high-flow CSF leaks after endonasal endoscopic skull base surgery may significantly reduce the rates of postoperative CSF leaks and intracranial infections. Lumbar drainage after the operation is a necessary auxiliary method.