101
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Dhandapani S, Singh H, Negm HM, Cohen S, Souweidane MM, Greenfield JP, Anand VK, Schwartz TH. Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas. J Neurosurg 2016; 126:418-430. [PMID: 27153172 DOI: 10.3171/2016.1.jns152238] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Sivashanmugam Dhandapani
- Departments of 1 Neurosurgery.,Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harminder Singh
- Departments of 1 Neurosurgery.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Hazem M Negm
- Departments of 1 Neurosurgery.,Department of Neurosurgery, Menoufia University, Shebeen El Kom, Egypt; and
| | - Salomon Cohen
- Departments of 1 Neurosurgery.,Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | | | | | - Theodore H Schwartz
- Departments of 1 Neurosurgery.,Otolaryngology, and.,Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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102
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Sankhla SK, Jayashankar N, Khan GM. Extended endoscopic endonasal transsphenoidal approach for retrochiasmatic craniopharyngioma: Surgical technique and results. J Pediatr Neurosci 2016; 10:308-16. [PMID: 26962333 PMCID: PMC4770639 DOI: 10.4103/1817-1745.174457] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: Surgical treatment of retrochiasmatic craniopharyngioma still remains a challenge. While complete removal of the tumor with preservation of the vital neurovascular structures is often the goal of the treatment, there is no optimal surgical approach available to achieve this goal. Transcranial and transsphenoidal microsurgical approaches, commonly used in the past, have considerable technical limitations. The extended endonasal endoscopic surgical route, obtained by removal of tuberculum sellae and planum sphenoidale, offers direct midline access to the retrochiasmatic space and provides excellent visualization of the undersurface of the optic chiasm. In this report, we describe the technical details of the extended endoscopic approach, and review our results using this approach in the surgical management of retrochiasmatic craniopharyngiomas. Methods: Fifteen children, including 9 girls and 6 boys, aged 8 to 15 years underwent surgery using extended endoscopic transsphenoidal approach between 2008 and 2014. Nine patients had a surgical procedure done previously and presented with recurrence of symptoms and regrowth of their residual tumors. Results: A gross total or near total excision was achieved in 10 (66.7%) patients, subtotal resection in 4 (26.7%), and partial removal in 1 (6.7%) patient. Postoperatively, headache improved in 93.3%, vision recovered in 77.3%, and the hormonal levels stabilised in 66.6%. Three patients (20%) developed postoperative CSF leaks which were managed conservatively. Three (20%) patients with diabetes insipidus and 2 (13.3%) with panhypopituitarism required long-term hormonal replacement therapy. Conclusions: Our early experience suggests that the extended endonasal endoscopic approach is a reasonable option for removal of the retrochiasmal craniopharyngiomas. Compared to other surgical approaches, it provides better opportunities for greater tumor removal and visual improvement without any increase in risks.
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Affiliation(s)
- Suresh K Sankhla
- Department of Neurosurgery, Nanavati Superspeciality Hospital, Mumbai, Maharashtra, India
| | - Narayan Jayashankar
- Department of ENT, Nanavati Superspeciality Hospital, Mumbai, Maharashtra, India
| | - Ghulam M Khan
- Department of Neurosurgery, Nanavati Superspeciality Hospital, Mumbai, Maharashtra, India
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103
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Metwali H, Gerganov V, Fahlbusch R. Optic nerve mobilization to enhance the exposure of the pituitary stalk during craniopharyngioma resection: early experience. J Neurosurg 2015; 125:683-8. [PMID: 26684781 DOI: 10.3171/2015.6.jns141847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Preservation of the pituitary stalk and its vasculature is a key step in good postoperative endocrinological outcome in patients with craniopharyngiomas. In this article, the authors describe the surgical technique of medial optic nerve mobilization for better inspection and preservation of the pituitary stalk. METHODS This operative technique has been applied in 3 patients. Following tumor exposure via a frontolateral approach, the pituitary stalk could be seen partially hidden under the optic nerve and the optic chiasm. The subchiasmatic and opticocarotid spaces were narrow, and tumor dissection from the pituitary stalk under direct vision was not possible. The optic canal was therefore unroofed, the falciform ligament was incised, and the lateral part of the tuberculum sellae was drilled medial to the optic nerve. The optic nerve could be mobilized medially to widen the opticocarotid triangle, which enhanced visualization of and access to the pituitary stalk. RESULTS By using the optic nerve mobilization technique, the tumor could be removed completely, and the pituitary stalk and its vasculature were preserved in all patients. In 2 patients, vision improved after surgery, while in 1 patient it remained normal, as it was before surgery. The hormonal status remained normal after surgery in 2 patients. In the patient with preoperative hormonal deficiencies, improvement occurred early after surgery and hormonal levels were normal after 3 months. No approach-related complications occurred. CONCLUSIONS This early experience shows that this technique is safe and could be used as a complementary step during microsurgery of craniopharyngiomas. It allows for tumor dissection from the pituitary stalk under direct vision. The pituitary stalk can thus be preserved without jeopardizing the optic nerve.
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Affiliation(s)
- Hussam Metwali
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Venelin Gerganov
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Rudolf Fahlbusch
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
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104
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Jeswani S, Nuño M, Wu A, Bonert V, Carmichael JD, Black KL, Chu R, King W, Mamelak AN. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study. J Neurosurg 2015; 124:627-38. [PMID: 26361276 DOI: 10.3171/2015.3.jns142254] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Craniopharyngiomas and similar midline suprasellar tumors have traditionally been resected via transcranial approaches. More recently, expanded endoscopic endonasal transsphenoidal approaches have gained interest. Surgeons have advocated for both approaches, and at present there is no consensus whether one approach is superior to the other. The authors therefore compared surgical outcomes between craniotomy and endoscopic endonasal transsphenoidal surgery (EETS) for suprasellar tumors treated at their institution. METHODS A retrospective review of patients undergoing resection of suprasellar lesions at Cedars-Sinai Medical Center between 2000 and 2013 was performed. Patients harboring suspected craniopharyngioma were selected for extensive review. Other pathologies or predominantly intrasellar masses were excluded. Cases were separated into 2 groups, based on the surgical approach taken. One group underwent EETS and the other cohort underwent craniotomy. Patient demographic data, presenting symptoms, and previous therapies were tabulated. Preoperative and postoperative tumor volume was calculated for each case based on MRI. Student t-test and the chi-square test were used to evaluate differences in patient demographics, tumor characteristics, and outcomes between the 2 cohorts. To assess for selection bias, 3 neurosurgeons who did not perform the surgeries reviewed the preoperative imaging studies and clinical data for each patient in blinded fashion and indicated his/her preferred approach. These data were subject to concordance analysis using Cohen's kappa test to determine if factors other than surgeon preference influenced the choice of surgical approach. RESULTS Complete data were available for 53 surgeries; 19 cases were treated via EETS, and 34 were treated via craniotomy. Patient demographic data, preoperative symptoms, and tumor characteristics were similar between the 2 cohorts, except that fewer operations for recurrent tumor were observed in the craniotomy cohort compared with EETS (17.6% vs 42.1%, p = 0.05). The extent of resection was similar between the 2 groups (85.6% EETS vs 90.7% craniotomy, p = 0.77). An increased rate of cranial nerve injury was noted in the craniotomy group (0% EETS vs 23.5% craniotomy, p = 0.04). Postoperative CSF leak rate was higher in the EETS group (26.3% EETS vs 0% craniotomy, p = 0.004). The progression-free survival curves (log-rank p = 0.99) and recurrence rates (21.1% EETS vs 23.5% craniotomy, p = 1.00) were similar between the 2 groups. Concordance analysis of cases reviewed by 3 neurosurgeons indicated that individual surgeon preference was the only factor that determined surgical approach (kappa coefficient -0.039, p = 0.762) CONCLUSIONS: Surgical outcomes were similar for tumors resected via craniotomy or EETS, except that more CSF leaks occurred in the EETS cohort, whereas more neurological injuries occurred in the craniotomy cohort. Surgical approach appears to mostly reflect surgeon preference rather than specific tumor characteristics. These data support the view that EETS is a viable alternative to craniotomy, providing a similar extent of resection with less neurological injury.
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Affiliation(s)
| | | | | | - Vivien Bonert
- Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Ray Chu
- Departments of 1 Neurosurgery
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105
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Wong RH, De Los Reyes K, Alikhani P, Sivakanthan S, van Gompel J, van Loveren H, Agazzi S. The Subtemporal Approach to Retroinfundibular Craniopharyngiomas: A New Look at an Old Approach. Oper Neurosurg (Hagerstown) 2015; 11:495-503. [PMID: 29506162 DOI: 10.1227/neu.0000000000000972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrochiasmatic, retroinfundibular craniopharyngiomas are surgically challenging tumors. Anterolateral, posterolateral, and endoscopic endonasal approaches represent the most commonly used techniques to access these tumors, but all require an extensive exposure time, and each has its own risks and limitations. The subtemporal approach is a well-known neurosurgical approach that is rarely described for craniopharyngiomas. OBJECTIVE To assess the feasibility, advantages, and disadvantages of a subtemporal approach for craniopharyngiomas. METHODS Five patients with retrochiasmatic craniopharyngiomas where the majority of the tumor extended behind the dorsal clival line underwent a subtemporal approach for resection. Extent of resection, degree of temporal lobe injury, visual and endocrine outcomes, and time to recurrence were analyzed. RESULTS Average tumor volume was 6.4 cm3. Near-total resection was achieved in 80% (4/5) and subtotal in 20% (1/5). All patients had stable or improved vision. There was 1 new permanent endocrine deficiency. Minimal temporal lobe edema was observed in 80% (4/5) of patients. Three patients required postoperative radiation. CONCLUSION The subtemporal approach represents a feasible approach for retrochiasmatic, retroinfundibular craniopharyngiomas when gross total resection is not mandatory. It provides rapid access to the tumor and a caudal-to-cranial visualization that promotes minimal manipulation of critical neurovascular structures, particularly the optic apparatus.
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Affiliation(s)
- Ricky H Wong
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Kenneth De Los Reyes
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Sananthan Sivakanthan
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | | | - Harry van Loveren
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
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106
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Prabhu V, Anand VK, Schwartz TH. Preservation of Pituitary Function after Endonasal Craniopharyngioma Surgery: Case Report and Review of the Literature. Cureus 2015; 7:e305. [PMID: 26430579 PMCID: PMC4578786 DOI: 10.7759/cureus.305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Craniopharyngiomas comprise approximately 3% of all intracranial tumors. Preservation of pituitary function after resection represents a significant challenge due to their location in the anterior skull base and aggressive local behavior. We report a case of a 79-year-old woman with a large suprasellar craniopharyngioma who presented with visual loss. MRI revealed a suprasellar cystic mass with mass effect on the optic chiasm and pituitary gland. Following endoscopic endonasal gross total resection of the tumor, the patient’s pituitary function returned to normal.
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Affiliation(s)
- Vishaal Prabhu
- Neurological Surgery, University of Rochester Medical Center
| | - Vijay K Anand
- Otolaryngology, New York-Presbyterian/Weill Cornell Medical Center
| | - Theodore H Schwartz
- Weill Cornell Brain and Spine Center, New York-Presbyterian/Weill Cornell Medical Center
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107
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Conger AR, Lucas J, Zada G, Schwartz TH, Cohen-Gadol AA. Endoscopic extended transsphenoidal resection of craniopharyngiomas: nuances of neurosurgical technique. Neurosurg Focus 2015; 37:E10. [PMID: 25270129 DOI: 10.3171/2014.7.focus14364] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Andrew R Conger
- Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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108
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Baldauf J, Hosemann W, Schroeder HWS. Endoscopic Endonasal Approach for Craniopharyngiomas. Neurosurg Clin N Am 2015; 26:363-75. [PMID: 26141356 DOI: 10.1016/j.nec.2015.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The endoscopic endonasal approach for craniopharyngiomas is increasingly used as an alternative to microsurgical transsphenoidal or transcranial approaches. It is a step forward in treatment, providing improved resection rates and better visual outcome. Especially in retrochiasmatic tumors, this approach provides better lesion access and reduces the degree of manipulations of the optic apparatus. The panoramic view offered by endoscopy and the use of angulated optics allows the removal of lesions extending far into the third ventricle avoiding microsurgical brain splitting. Intensive training is required to perform this surgery. This article summarizes the surgical technique, outcome, and complications.
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Affiliation(s)
- Jörg Baldauf
- Department of Neurosurgery, Ernst Moritz Arndt University, Sauerbruchstrasse, Greifswald 17475, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Ernst Moritz Arndt University, Walter-Rathenau-Strasse 43-45, Greifswald 17475, Germany
| | - Henry W S Schroeder
- Department of Neurosurgery, Ernst Moritz Arndt University, Sauerbruchstrasse, Greifswald 17475, Germany.
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109
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Klimo P, Venable GT, Boop FA, Merchant TE. Recurrent craniopharyngioma after conformal radiation in children and the burden of treatment. J Neurosurg Pediatr 2015; 15:499-505. [PMID: 25700121 DOI: 10.3171/2014.10.peds14384] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this paper the authors present their experience treating children with recurrent craniopharyngioma who were initially managed with surgery followed by conformal radiation therapy (CRT). METHODS A departmental oncology information system was queried to identify all children (< 18 years old) who received CRT for a craniopharyngioma between 1998 and 2010 (inclusive) and specifically those who experienced tumor progression. For each patient, the authors recorded the type of recurrence (solid, cystic, or both), the time interval to first progression and each subsequent progression, the associated treatment complications, and disease status at last follow-up evaluation. RESULTS Among the 97 patients that met criteria for entry into this study, 18 (18.6%) experienced tumor progression (9 cystic, 3 solid, 6 cystic and solid). The median time to first recurrence was 4.62 years (range 1.81-9.11 years). The subgroup included 6 female and 12 male patients with a median age of 7.54 years (range 3.61-13.83 years). Ten patients experienced first progression within 5 years of CRT. The 5- and 10-year treatment-free survival rates for the entire cohort were 89.0% (95% confidence interval [CI] 80.5%-93.9%) and 76.2% (95% CI 64%-85%), respectively. Seven patients had a single episode of progression and 11 had more than 1. The time interval between each subsequent progression was progressively shorter. The 18 patients underwent 38 procedures. The median follow-up duration for this group was 9.32 years (range 4.04-19.0 years). Three patients died, including 1 from perioperative complications. CONCLUSIONS Craniopharyngioma progression after prior irradiation is exceedingly difficult to treat and local control is challenging despite repeated surgical procedures. Given our results, gross-total resection may need to be the surgical goal at the time of first recurrence, if possible. Decompressing new cyst formation alone has a low rate of long-term success.
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Affiliation(s)
- Paul Klimo
- Semmes-Murphey Neurologic & Spine Institute
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110
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Schwartz TH. Editorial: Does chiasmatic blood supply dictate endonasal corridors? J Neurosurg 2015; 122:1163-4. [DOI: 10.3171/2014.6.jns141129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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111
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Patel KS, Raza SM, McCoul ED, Patrona A, Greenfield JP, Souweidane MM, Anand VK, Schwartz TH. Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas. J Neurosurg 2015; 123:571-80. [PMID: 25884258 DOI: 10.3171/2014.12.jns141591] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Theodore H Schwartz
- Departments of 1 Neurological Surgery.,Otolaryngology, and.,Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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112
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Yadav YR, Nishtha Y, Vijay P, Shailendra R, Yatin K. Endoscopic endonasal trans-sphenoid management of craniopharyngiomas. Asian J Neurosurg 2015; 10:10-6. [PMID: 25767569 PMCID: PMC4352621 DOI: 10.4103/1793-5482.151502] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction: Craniopharyngiomas treatment has been challenging because of their anatomical location. The endoscopic endonasal (EE) trans-sphenoidal approach is indicated in sellar, supra sellar, selected intraventricular lesions in adults and children. We are reporting our initial experience of 44 patients managed by EE approach. Materials and Methods: This is a retrospective study of 44 craniopharyngiomas. The goal of surgery was gross-total resection in all cases. All patients underwent pre- and post-operative comprehensive ophthalmological and endocrinological evaluation. Lumbar drain at the start of the operation was used in all cases with tumor larger than 3 cm maximum diameter. Binostril technique vascularized nasoseptal flap and multilayer closure of the dural defect were used. Wide sphenoidotomy, posterior ethmoidectomy, tuberculum selle, and planum removal were performed in all cases. Perioperative antibiotic prophylaxis was used for 72 h. Results: There were 44 patients of age ranging from 8 to 65 (mean: 42) years. Diameter of the tumor varied from 3.1 cm to 6.6 cm (average: 4.3 cm). Visual and pituitary dysfunctions were observed in 44 and 33, respectively, before surgery. Vision improvement, gross-total removal, cerebrospinal fluid (CSF) leak and recurrence were observed in 34, 26, four and six patients, respectively. Average follow-up was 19 months. Conclusion: Endoscopic endonasal trans-sphenoidal approach for craniopharyngioma is safe and effective alternative to transcranial approach in selected patients. Although this technique is associated with effective tumor removal and improved visual outcome, CSF leak, and endocrine dysfunctions remain a major challenge.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Yadav Nishtha
- Department of Radiodiagnosis and Imaging All India Institute of Medical Science, New Delhi, India
| | - Parihar Vijay
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Ratre Shailendra
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Kher Yatin
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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113
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Gu Y, Zhang X, Hu F, Yu Y, Xie T, Sun C, Li W. Suprachiasmatic translamina terminalis corridor used in endoscopic endonasal approach for resecting third ventricular craniopharyngioma. J Neurosurg 2015; 122:1166-72. [PMID: 25723303 DOI: 10.3171/2015.1.jns132842] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The translamina terminalis corridor was used in the transcranial anterior route to treat third ventricular craniopharyngioma (TVC), which presents a challenge to neurosurgeons. The endoscopic endonasal approach (EEA) has recently been used to treat craniopharyngiomas. However, there are few reports of the EEA being used to treat TVC. The authors' novel surgical approach of treating selected TVC by the endoscopic endonasal route via the suprachiasmatic translamina terminalis (STLT) corridor is described. METHODS In this single-center study, the EEA via the STLT corridor was used to resect TVC with great upper and anterior extension causing bulged lamina terminalis, and TVC with a residual upper compartment, after routine infrachiasmatic transmetastalk corridor resection. RESULTS The STLT corridor was used in 3 patients. Gross-total resection was achieved in all cases. One patient achieved visual improvement, and the other 2 patients showed partial visual improvement. Leakage of CSF occurred in 1 patient. Postoperative hormone replacement therapy was required in all patients. CONCLUSIONS The STLT corridor is a complementary minimally invasive corridor used in the EEA for treating selected TVC. The STLT alone or combined with infrachiasmatic transmetastalk corridors should be selected depending on the size of suprachiasmatic and infrachiasmatic space.
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Affiliation(s)
- Ye Gu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University
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114
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Third Ventricle Craniopharyngiomas. World Neurosurg 2014; 82:1023-5. [DOI: 10.1016/j.wneu.2014.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/14/2014] [Indexed: 11/19/2022]
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115
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Ivan ME, Iorgulescu JB, El-Sayed I, McDermott MW, Parsa AT, Pletcher SD, Jahangiri A, Wagner J, Aghi MK. Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery. J Clin Neurosci 2014; 22:48-54. [PMID: 25439754 DOI: 10.1016/j.jocn.2014.08.009] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 08/01/2014] [Indexed: 11/27/2022]
Abstract
Postoperative cerebrospinal fluid (CSF) leak is a serious complication of transsphenoidal surgery, which can lead to meningitis and often requires reparative surgery. We sought to identify preoperative risk factors for CSF leaks and meningitis. We reviewed 98 consecutive expanded endoscopic endonasal surgeries performed from 2008-2012 and analyzed preoperative comorbidities, intraoperative techniques, and postoperative care. Univariate and multivariate analyses were performed. The most common pathologies addressed included pituitary adenoma, Rathke cyst, chordoma, esthesioneuroblastoma, meningioma, nasopharyngeal carcinoma, and squamous cell carcinoma. There were 11 CSF leaks (11%) and 10 central nervous system (CNS) infections (10%). Univariate and multivariate analysis of preoperative risk factors showed that patients with non-ideal body mass index (BMI) were associated with higher rate of postoperative CSF leak and meningitis (both p<0.01). Also, patients with increasing age were associated with increased CSF leak (p = 0.03) and the length of time a lumbar drain was used postoperatively was associated with infection in a univariate analysis. In addition, three of three endoscopic transsphenoidal surgeries combined with open cranial surgery had a postoperative CSF leak and CNS infection rate which was a considerably higher rate than for transsphenoidal surgeries alone or surgeries staged with open cases (p<0.01 and p=0.04, respectively) In this series of expanded endoscopic transsphenoidal surgeries, preoperative BMI remains the most important preoperative predictor for CSF leak and infection. Other risk factors include age, intraoperative CSF leak, lumbar drain duration, and cranial combined cases. Risks associated with complex surgical resections when combining open and endoscopic approaches could be minimized by staging these procedures.
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Affiliation(s)
- Michael E Ivan
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M7, San Francisco, CA 94143-0112, USA; Center for Minimally Invasive Skull Base Surgery, University of California, San Francisco, CA, USA.
| | - J Bryan Iorgulescu
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M7, San Francisco, CA 94143-0112, USA
| | - Ivan El-Sayed
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA, USA; Center for Minimally Invasive Skull Base Surgery, University of California, San Francisco, CA, USA
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M7, San Francisco, CA 94143-0112, USA; Center for Minimally Invasive Skull Base Surgery, University of California, San Francisco, CA, USA
| | - Andrew T Parsa
- Department of Neurological Surgery, Northwestern University, Chicago, IL, USA
| | - Steven D Pletcher
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA, USA; Center for Minimally Invasive Skull Base Surgery, University of California, San Francisco, CA, USA
| | - Arman Jahangiri
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M7, San Francisco, CA 94143-0112, USA
| | - Jeffrey Wagner
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M7, San Francisco, CA 94143-0112, USA; Center for Minimally Invasive Skull Base Surgery, University of California, San Francisco, CA, USA
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M7, San Francisco, CA 94143-0112, USA; Center for Minimally Invasive Skull Base Surgery, University of California, San Francisco, CA, USA
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116
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Kim SK, Kim YH, Park CK, Kim DG, Jung HW. Extended endoscopic endonasal approach for recurrent or residual adult craniopharyngiomas. Acta Neurochir (Wien) 2014; 156:1917-22. [PMID: 24947753 DOI: 10.1007/s00701-014-2150-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/27/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the effectiveness of the extended endoscopic endonasal transsphenoidal approach (TSA) for recurrent or residual craniopharyngiomas, focusing on the extent of tumor resection and complications resulting from surgery at a single institution. METHODS Twelve adult patients (six men and six women) underwent extended endoscopic endonasal TSA for a recurrent or residual craniopharyngioma after a previous surgical intervention at a single institution by a single surgeon. The mean number of surgeries patients had undergone before TSA was 1.3 (range, 1-3). The mean period between patients' most recent surgery and extended TSA was 55.9 months (range, 1-184). The mean preoperative (that is, pre-extended TSA) tumor volume was 2.87 cm³. The mean follow-up period was 15.8 months (range, 4-32). We reviewed clinical and radiological features in each case, focusing on the degree of tumor resection as well as endocrinological and ophthalmological outcomes. RESULTS Gross total resection was achieved in ten patients (83.3 %), and the mean resection rate was 87 % in the other two cases. There were no significant differences between pre- and postoperative endocrine function, except in one patient who suffered postoperative panhypopituitarism resulting in pituitary stalk resection, which was necessary because of obvious tumor involvement. Three patients suffered transient diabetic insipidus (DI). With respect to ophthalmological outcomes, three patients showed improvement, two others showed decline, and the remainder showed no significant changes. CONCLUSION The extended endoscopic endonasal transsphenoidal approach is an effective and safe surgical approach for treating recurrent or residual craniopharyngioma.
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Affiliation(s)
- Sung Kwon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
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117
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ELKammash TH, Enaba MM, Awadalla AM. Variability in sphenoid sinus pneumatization and its impact upon reduction of complications following sellar region surgeries. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2014.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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118
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Banu MA, Szentirmai O, Mascarenhas L, Salek AA, Anand VK, Schwartz TH. Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks. J Neurosurg 2014; 121:961-75. [PMID: 24995788 DOI: 10.3171/2014.5.jns132028] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Matei A Banu
- Departments of Neurological Surgery, Brain and Spine Center
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119
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Learned KO, Adappa ND, Lee JYK, Newman JG, Palmer JN, Loevner LA. MR imaging evolution of endoscopic cranial defect reconstructions using nasoseptal flaps and their distinction from neoplasm. AJNR Am J Neuroradiol 2014; 35:1182-9. [PMID: 24457820 DOI: 10.3174/ajnr.a3853] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endoscopic endonasal approach is the procedure of choice for the resection of ventral skull base neoplasms, with defect closure requiring multilayer reconstruction. This study evaluates the temporal MR imaging evolution of nasoseptal flaps and free grafts used in endoscopic skull base reconstruction. MATERIALS AND METHODS Sixty-nine follow-up brain MRIs of 22 patients who had endoscopic skull base reconstruction using 26 nasoseptal flaps combined with 8 collagen-matrix dural grafts, 10 fascia lata grafts, and 10 intracranial fat grafts were retrospectively reviewed. Temporal changes in signal intensity, enhancement, thickness, and the configuration of reconstructive layers were evaluated. Tissue with signal intensity or enhancement different from that of normal evolving reconstructive layers at the surgical bed was evaluated, and its association with clinically confirmed tumor was assessed with the Fisher exact test. RESULTS All normal reconstructive layers were retracted to cranial defects and showed maturation of imaging features within 2-6 months. The immediate postoperative T2-isointensity to brain and enhancement of nasoseptal flaps persisted, but the flap thickness was reduced by 20%-30% (average thickness, 4.5 ± 1.3 mm); additionally, the C shape and vascular pedicle of the nasoseptal flaps became indistinct, but the flap location remained unchanged. The initial appearance of the nonenhancing fascia lata with variable T2 signal intensity became enhancing with increasing T2-hypointensity and a graft-thickness reduction of ≥50% (average thickness, 3.5 ± 1.6 mm). All fat grafts showed progressive resorption. In 6 patients, abnormal tissue represented residual or recurrent tumor (P = .0001). CONCLUSIONS Maturation and stability of multilayer endoscopic skull base reconstructions on MR imaging occurs within 2-6 months postoperatively. Understanding of the normal imaging evolution of endoscopic skull base reconstructions is essential to distinguish them from neoplasms.
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Affiliation(s)
- K O Learned
- From the Departments of Radiology (K.O.L., L.A.L.)
| | - N D Adappa
- Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - J G Newman
- Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - J N Palmer
- Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - L A Loevner
- From the Departments of Radiology (K.O.L., L.A.L.)Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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120
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Cavallo LM, Frank G, Cappabianca P, Solari D, Mazzatenta D, Villa A, Zoli M, D'Enza AI, Esposito F, Pasquini E. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg 2014; 121:100-13. [PMID: 24785324 DOI: 10.3171/2014.3.jns131521] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas. METHODS The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated. RESULTS The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3-246 months). CONCLUSIONS The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.
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Affiliation(s)
- Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Naples
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121
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Cavallo LM, Cappabianca P. Craniopharyngiomas: Infradiaphragmatic and Supradiaphragmatic Type and Their Management in Modern Times. World Neurosurg 2014; 81:683-4. [DOI: 10.1016/j.wneu.2013.03.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 03/21/2013] [Indexed: 12/01/2022]
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122
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Raza SM, Schwartz TH. How to achieve the best possible outcomes in the management of retroinfundibular craniopharyngiomas? World Neurosurg 2014; 82:614-6. [PMID: 24650490 DOI: 10.1016/j.wneu.2014.03.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 03/12/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Shaan M Raza
- Departments of Neurosurgery, Otolaryngology, Neurology, and Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Departments of Neurosurgery, Otolaryngology, Neurology, and Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
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123
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Unilateral Basal interhemispheric approach through the sphenoid sinus to retrochiasmatic and intrasellar craniopharyngiomas: surgical technique and results. World Neurosurg 2014; 82:799-805. [PMID: 24530454 DOI: 10.1016/j.wneu.2014.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 01/23/2014] [Accepted: 02/08/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE In the treatment of craniopharyngioma, complete surgical removal offers the best chance of cure and recurrence prevention. The basal interhemispheric approach involves problems with difficulty resecting tumors in the retrochiasmatic space located behind the optic chiasm and inability to resect, under direct view, tumors extending into the sella turcica. We report our approach via the sphenoid sinus devised to resolve these problems. METHODS A unilateral basal interhemispheric approach is planned for tumor resection. In cases in which the prechiasmatic space is too narrow to be utilized or the tumor has extended into the sella turcica, the prechiasmatic space is expanded by shaving the sphenoid surface and the tuberculum sellae. If the tumor inside the sella turcica needs to be removed, the anterior wall of the sella turcica also is shaved to permit tumor resection. RESULTS This technique was applied to 7 cases in total (in 3 cases to achieve prechiasmatic space expansion and in 4 cases for intrasellar tumor resection). Gross total removal was achieved in 6 cases and subtotal removal in 1. Of the 6 cases with preoperative visual field defects, 5 showed alleviation of these defects. The 5 patients with partial hypopituitarism developed complete panhypopituitarism postoperatively. All 7 patients have not suffered from postoperative cerebrospinal fluid leakage and meningitis. CONCLUSIONS This approach allowed a working space to be secured even in cases with a narrow prechiasmatic space, allowing tumor freeing from the lower plane of the optic nerve and safe resection of the intrasellar tumor.
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Ali ZS, Bailey RL, Daniels LB, Vakhshori V, Lewis DJ, Hossain AT, Sitterley KY, Lee JYK, Storm PB, Heuer GG, Stein SC. Comparative effectiveness of treatment options for pediatric craniopharyngiomas. J Neurosurg Pediatr 2014; 13:178-88. [PMID: 24313659 DOI: 10.3171/2013.11.peds1320] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT No clear treatment guidelines for pediatric craniopharyngiomas exist. The authors developed a decision analytical model to evaluate outcomes of 4 surgical approaches for craniopharyngiomas in children, including attempted gross-total resection (GTR), planned subtotal removal plus radiotherapy, biopsy plus radiotherapy, and endoscopic resections of all kinds. METHODS Pooled data, including the authors' own experience, were used to create evidence tables, from which incidence, relative risks, and summary outcomes in quality-adjusted life years (QALYs) were calculated for the 4 management strategies. RESULTS Quality-adjusted life years at the 5-year follow-up were 2.3 ± 0.1 for attempted GTR, 2.9 ± 0.2 for planned subtotal removal plus radiotherapy, 3.9 ± 0.2 for biopsy plus radiotherapy, and 3.7 ± 0.2 for endoscopic resection (F = 17,150, p < 0.001). Similarly, QALYs at 10-year follow-up were 4.5 ± 0.2 for attempted GTR, 5.7 ± 0.5 for planned subtotal removal plus radiotherapy, and 7.8 ± 0.5 for biopsy plus radiotherapy (F = 6,173, p < 0.001). On post hoc pairwise comparisons, the differences between all pairs compared were also highly significant (p < 0.001). Since follow-up data at 10 years are lacking for endoscopic cases, this category was excluded from 10-year comparisons. CONCLUSIONS Biopsy with subsequent radiotherapy is the preferred approach with respect to improved overall quality of life. While endoscopic approaches also show promise in preserving quality of life at five-year follow-up, there are not sufficient data to draw conclusions about this comparison at 10 years.
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Affiliation(s)
- Zarina S Ali
- Department of Neurosurgery, University of Pennsylvania; and
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Han S, Tie X, Qin X, Wang Y, Wu A. Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks? Acta Neurochir (Wien) 2014; 156:123-30; discussion 130-1. [PMID: 24142197 DOI: 10.1007/s00701-013-1905-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 09/27/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Large suprasellar craniopharyngiomas are surgically challenging. The aim of our study was to explore the therapeutic efficacy of the frontobasal interhemispheric approach for these lesions. METHODS Twenty-nine consecutive adult patients with large suprasellar craniopharyngiomas (diameter >4 cm) who underwent the frontobasal interhemispheric approach were retrospectively evaluated. Surgical and clinical outcomes were analyzed. RESULTS Gross total removal was achieved in 23 cases (79.3%) and subtotal removal in 6 cases (20.7%). The mean follow-up period was 76.5 ± 33.2 months (range, 12-132 months). Twenty-four patients (82.7%) had improvement of the visual impairment score (VIS) after surgery. VIS was unchanged in five patients (17.3%), and no patients experienced visual deterioration. Among 23 patients who had preoperative hypopituitarism, 8 (34.8%) had an improvement. Postoperative new or aggravated hypopituitarism was observed in four patients (13.8%). Permanent diabetes insipidus was observed in ten patients (34.4%). Postoperative anosmia occurred in two earlier cases (6.9%). There was no intracranial infection or cerebrospinal fluid fistula. At last follow-up, >9% BMI gain was observed in 34.5% of patients, and 65.5% of patients returned to work. Four patients (13.8%) suffered recurrence. CONCLUSION Although the frontobasal interhemispheric approach has some disadvantages, it provides ideal access to the suprasellar region and the third ventricle with limited brain retraction. The surgically visible angle is adequate; thus, vital structures can be better protected. For large suprasellar craniopharyngiomas, the benefits of this approach can outweigh its potential risks.
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Affiliation(s)
- Sheng Han
- Department of Neurosurgery, The First Hospital of China Medical University, Nanjing street 155, Heping District, Shenyang, 110001, China
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Endoscopic Endonasal Approaches for Benign Tumors Involving the Skull Base. CURRENT OTORHINOLARYNGOLOGY REPORTS 2013. [DOI: 10.1007/s40136-013-0026-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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127
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Patel KS, Komotar RJ, Szentirmai O, Moussazadeh N, Raper DM, Starke RM, Anand VK, Schwartz TH. Case-specific protocol to reduce cerebrospinal fluid leakage after endonasal endoscopic surgery. J Neurosurg 2013; 119:661-8. [DOI: 10.3171/2013.4.jns13124] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Endoscopic transsphenoidal surgery is expanding in acceptance, yet postoperative CSF leak rates remain a concern. This study presents the Cornell closure protocol, which has yielded significantly lower postoperative CSF leak rates compared with prior reports, as an algorithm that can be used by centers having difficulty with CSF leak.
Methods
A single closure algorithm for endoscopic surgery has been used since January 2010 at Weill Cornell Medical College. A prospective database noting intraoperative CSF leak, closure technique, and postoperative CSF leak was reviewed. The authors used a MEDLINE search to identify similar studies and compared CSF leak rates to those of patients treated using the Cornell algorithm.
Results
The retrospective study of a prospectively acquired database included 209 consecutive patients. In 84 patients (40%) there was no intraoperative CSF leak and no postoperative CSF leak. In the 125 patients (60%) with an intraoperative CSF leak, 35 of them with high-flow leaks, there were 0 (0%) postoperative CSF leaks.
Conclusions
It is possible to achieve a CSF leak rate of 0% by using this closure protocol. With proper experience, endoscopic skull base surgery should not be considered to have a higher CSF leak rate than open transcranial or microscopic transsphenoidal surgery.
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Affiliation(s)
| | - Ricardo J. Komotar
- 2Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida; and
| | | | | | - Daniel M. Raper
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M. Starke
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Theodore H. Schwartz
- 1Departments of Neurosurgery,
- 4Otolaryngology, and
- 5Neurology and Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Simal-Julián JA, Miranda-Lloret P, Pancucci G, Evangelista-Zamora R, Pérez-Borredá P, Sanromán-Álvarez P, Perez-de-Sanromán L, Botella-Asunción C. [Endonasal skull base endoscopy]. Neurocirugia (Astur) 2013; 24:210-5. [PMID: 23831339 DOI: 10.1016/j.neucir.2013.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 05/09/2013] [Accepted: 05/12/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVE The endoscopic endonasal techniques used in skull base surgery have evolved greatly in recent years. Our study objective was to perform a qualitative systematic review of the likewise systematic reviews in published English language literature, to examine the evidence and conclusions reached in these studies comparing transcranial and endoscopic approaches in skull base surgery. MATERIAL AND METHODS We searched the references on the MEDLINE and EMBASE electronic databases selecting the systematic reviews, meta-analyses and evidence based medicine reviews on skull based pathologies published from January 2000 until January 2013. We focused on endoscopic impact and on microsurgical and endoscopic technique comparisons. RESULTS Full endoscopic endonasal approaches achieved gross total removal rates of craniopharyngiomas and chordomas higher than those for transcranial approaches. In anterior skull base meningiomas, complete resections were more frequently achieved after transcranial approaches, with a trend in favour of endoscopy with respect to visual prognosis. Endoscopic endonasal approaches minimised the postoperative complications after the treatment of cerebrospinal fluid (CSF) leaks, encephaloceles, meningoceles, craniopharyngiomas and chordomas, with the exception of postoperative CSF leaks. CONCLUSIONS Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in skull base surgery.
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Gras-Cabrerizo JR, Muñoz-Hernández F, Montserrat-Gili JR, Tresserras-Ribo P, de Juan-Delago M, Webb SM, Aulinas-Masó A, Martín-Huerta B, Molet-Teixidó J, Quer-Agustí M, Massegur-Solench H. Endoscopic Surgery in the Skull Base Unit: Experience in the First 72 Cases. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013. [DOI: 10.1016/j.otoeng.2013.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gras-Cabrerizo JR, Muñoz-Hernández F, Montserrat-Gili JR, Tresserras-Ribo P, de Juan-Delago M, Webb SM, Aulinas-Masó A, Martín-Huerta B, Molet-Teixidó J, Quer-Agustí M, Massegur-Solench H. Integración de la cirugía endoscópica en una unidad de base de cráneo: experiencia en los primeros 72 casos. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013; 64:169-75. [DOI: 10.1016/j.otorri.2012.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/10/2012] [Accepted: 10/30/2012] [Indexed: 10/27/2022]
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Cappabianca P, Di Somma A, de Notaris M. Rerum magistra experientia est: the evolution of modern endoscopic endonasal skull base surgery and reconstruction techniques. World Neurosurg 2013; 82:e67-9. [PMID: 23542388 DOI: 10.1016/j.wneu.2013.03.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 03/21/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Paolo Cappabianca
- Department of Neurosciences & Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.
| | - Alberto Di Somma
- Department of Neurosciences & Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Matteo de Notaris
- Division of Neurosurgery, Hospital Clinic de Barcelona, Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine Universitat de Barcelona, Barcelona, Spain
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Schwartz TH. An eyebrow for an eyebrow and a nose for a nose. World Neurosurg 2013; 82:e97-9. [PMID: 23523681 DOI: 10.1016/j.wneu.2013.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 03/14/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
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Bedrosian JC, McCoul ED, Raithatha R, Akselrod OA, Anand VK, Schwartz TH. A prospective study of postoperative symptoms in sinonasal quality-of-life following endoscopic skull-base surgery: dissociations based on specific symptoms. Int Forum Allergy Rhinol 2013; 3:664-9. [PMID: 23520019 DOI: 10.1002/alr.21161] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 11/19/2012] [Accepted: 01/01/2013] [Indexed: 01/25/2023]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is a minimal access approach to cranial base pathology; however, it significantly disrupts the intranasal mucosa and intranasal structures, the long-term effects of which are still being studied. We prospectively assessed postoperative changes in sinonasal QOL symptoms following ESBS. METHODS Eighty-five patients were prospectively assessed with the Anterior Skull Base Questionnaire (ASBQ), a validated QOL instrument, preoperatively and up to 1 year postoperatively at each subsequent office visit. A subset of these data was analyzed to assess the effect of endoscopic pituitary surgery on postoperative taste, smell, appetite, nasal secretions, and vision. RESULTS ESBS patients were divided into 2 cohorts: those undergoing pituitary adenoma surgery and those undergoing ESBS for all other pathologies. Preoperative smell (3.11 vs 3.76, p = 0.03) and taste (3.04 vs 3.69, p = 0.03) were significantly lower in the nonpituitary group. Within the pituitary group both taste (3.69 vs 2.95, p = 0.03) and smell (3.76 vs 2.61, p ≤ 0.001) were significantly decreased by 6 weeks postoperatively. However, by 12 months both taste and smell scores returned to baseline. Vision scores improved by 3 weeks postoperatively with durable results at 1 year (2.80 vs 3.33, p = 0.04 vs 3.59, p = 0.03, respectively). Within the nonpituitary group, smell was decreased at 3 weeks, but was not significantly changed at any other time points. CONCLUSION Our study indicates a dissociation between the nasal and visual QOL after ESBS. While nasal QOL transiently decreases, visual QOL progressively improves. These data should not be lumped together for the purposes of statistical analysis.
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Affiliation(s)
- Jeffrey C Bedrosian
- Department of Otolaryngology-Head and Neck Surgery, New York-Presbyterian Hospital and Weill Medical College of Cornell University, New York, NY, USA
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Abstract
Craniopharyngiomas are rare benign sellar region tumors, which are diagnosed either in childhood or adolescence due to local mass effects on visual pathways, pituitary and hypothalamus, or because of an increased intracranial pressure resulting from obstructive hydrocephalus. The neurosurgeons challenge is to achieve tumor control without aggravating the symptoms. There are essentially two different surgical philosophies. Although only gross tumor resection has been proven to provide cure, the accompanying surgical hazard is substantial. Thus, less aggressive operations with partial or subtotal tumor resection or drainage of cystic portions followed by irradiation may relieve the patient's symptoms and benefit the patient more than a heroic tumor resection-since to date several variants of radiation therapy are available which also serve to control tumor progression. In the present brief review, the surgical techniques and outcomes of operations in craniopharyngiomas with special focus on the resulting morbidity and mortality are summarized.
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Affiliation(s)
- Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Yadav Y, Sachdev S, Parihar V, Namdev H, Bhatele P. Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma. J Neurosci Rural Pract 2012. [PMID: 23188987 PMCID: PMC3505326 DOI: 10.4103/0976-3147.102615] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.
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Affiliation(s)
- Yr Yadav
- Department of Neurosurgery and Radiodiagnosis NSCB Medical College and MP MRI Jabalpur, Madhya Pradesh, India
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de Divitiis E. Endoscopic endonasal transsphenoidal surgery: from the pituitary fossa to the midline cranial base. World Neurosurg 2012. [PMID: 23182736 DOI: 10.1016/j.wneu.2012.11.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Enrico de Divitiis
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.
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Attia M, Patel KS, Kandasamy J, Stieg PE, Spinelli HM, Riina HA, Anand VK, Schwartz TH. Combined cranionasal surgery for spheno-orbital meningiomas invading the paranasal sinuses, pterygopalatine, and infratemporal fossa. World Neurosurg 2012; 80:e367-73. [PMID: 23072879 DOI: 10.1016/j.wneu.2012.10.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 10/09/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy of combining an endonasal endoscopic skull-base approach and repair with a transcranial orbitozygomatic approach for spheno-orbital meningiomas (SOMs). METHODS Three patients with recurrent SOMs underwent combined orbitozygomatic and endonasal endoscopic surgery. In 2 patients both procedures were done in 1 operation and in 1 patient the endonasal surgery was done 2.5 months after the craniotomy. Extent of resection, complications, morbidity, and mortality were evaluated. RESULTS Gross total resection was achieved in 1 patient and near total resection in the other 2 patients with tumor left in the cavernous sinus and parapharyngeal space. Two patients suffered cranial neuropathy from the transcranial surgery and the other developed a pseudomeningocele. There were no complications from the endonasal surgery. Patients having combined single setting cranionasal surgery were discharged on day 6 and 8, whereas the patient having only the endonasal component on a later date was discharged on day 2. CONCLUSIONS A combined cranionasal approach involving transcranial orbitozygomatic and endonasal endoscopic approaches is an effective 2-stage surgery for resecting SOMs invading into the sinuses and paranasal compartments. The ability to perform a multilayer closure involving a vascularized nasoseptal flap additionally decreases the risk of postoperative cerebrospinal fluid leak.
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Affiliation(s)
- Moshe Attia
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
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