Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients

Microsurgical versus endoscopic trans-sphenoidal approaches for clivus chordoma: a pooled and meta-analysis

Chordoma is a rare slow-growing neoplastic bone lesion. However, they show an invasive local growth and high recurrence rate, leading to an overall survival rate of 65% at 5 years and 35% at 10 years. We conducted a pooled and meta-analysis comparing recurrence rate, post-operative-complications, and survival in patients undergoing either microsurgical (MA) or endoscopic approaches (EA). Search of literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify surgical series of clivus chordomas published between January 1990 and March 2018 on Pubmed, Scopus, and Cochrane. Two different statistical analyses have been performed: a pooled analysis and a single-arm meta-analysis of overall recurrence rate and subgroup meta-analysis of complications in the subgroups open surgery and endoscopic surgery. After full-text screening, a total of 58 articles were included in the pooled analysis and 27 studies were included for the study-level meta-analysis. Pooled analysis-the extent of resection was the only association that remained significant (subtotal: HR = 2.18, p = 0.004; partial: HR = 4.40, p < 0.001). Recurrence was more prevalent among the surgical patients (45.5%) compared to endoscopic ones (23.7%). Meta-analysis-results of the cumulative meta-analysis showed an overall rate of recurrence of 25.6%. MA recurrence rate was 31.8% (99% CI 14-52.8), EA recurrence rate was 19.4% (5.4-39.2). CSF leak rate for the endoscopic group was 10.3% (99%CI 5-17.3) and 9.5% (99%CI 1.2-24.6) for the open surgery group. The partial removal versus total removal has an influence on recurrence rate (p < 0.001). MA recurrence rate was 31.8%; EA recurrence rate was 19.4%. The extent of resection is confirmed as a statistically significant factor affecting the risk for recurrence both with the pooled analysis and with the meta-analysis. Meta-analysis demonstrated that older patients tend to recur more than young patients, especially in surgical group.

Preoperative radiographic and clinical factors associated with the visualization of intraoperative cerebrospinal fluid during endoscopic transsphenoidal resection of pituitary adenomas

Background:

Intraoperative visualization of cerebrospinal fluid (CSF) during endoscopic endonasal resection of skull base tumors is the most common factor contributing to the development of postoperative CSF leaks. No previous studies have solely evaluated preoperative factors contributing to intraoperative CSF visualization. The purpose of this study was to identify preoperative factors predictive of intraoperative CSF visualization.

Methods:

Retrospective review of patients who underwent transsphenoidal resection of pituitary adenomas was conducted. Clinical and radiographic variables were compared for those who had CSF visualized to those who did not. Nominal logistic regression models were built to determine predictive variables.

Results:

Two hundred and sixty patients were included in the study. All significant demographic and radiographic variables on univariate analysis were included in multivariate analysis. Two multivariate models were built, as tumor height and supraclinoid extension were collinear. The first model, which considered tumor height, found that extension into the third ventricle carried a 4.60-fold greater risk of CSF visualization (P = 0.005). Increasing tumor height showed a stepwise, linear increase in risk; tumors >3 cm carried a 19.02-fold greater risk of CSF visualization (P = 0.003). The second model, which considered supraclinoid tumor extension, demonstrated that extension into the third ventricle carried a 4.38-fold increase in risk for CSF visualization (P = 0.010). Supraclinoid extension showed a stepwise, linear increase in intraoperative CSF risk; tumors with >2 cm of extension carried a 9.26-fold increase in risk (P = 0.017).

Conclusion:

Our findings demonstrate that tumor height, extension into the third ventricle, and extension above the clinoids are predictive of intraoperative CSF visualization.

Surgical management of craniopharyngiomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section

BACKGROUND AND OBJECTIVE

Craniopharyngiomas are locally aggressive neuroepithelial tumors infiltrating nearby critical neurovascular structures. The majority of published surgical series deal with childhood-onset craniopharyngiomas, while the optimal surgical management for adult-onset tumors remains unclear. The aim of this paper is to summarize the main principles defining the surgical strategy for the management of craniopharyngiomas in adult patients through an extensive systematic literature review in order to formulate a series of recommendations.

MATERIAL AND METHODS

The MEDLINE database was systematically reviewed (January 1970-February 2019) to identify pertinent articles dealing with the surgical management of adult-onset craniopharyngiomas. A summary of literature evidence was proposed after discussion within the EANS skull base section.

RESULTS

The EANS task force formulated 13 recommendations and 4 suggestions. Treatment of these patients should be performed in tertiary referral centers. The endonasal approach is presently recommended for midline craniopharyngiomas because of the improved GTR and superior endocrinological and visual outcomes. The rate of CSF leak has strongly diminished with the use of the multilayer reconstruction technique. Transcranial approaches are recommended for tumors presenting lateral extensions or purely intraventricular. Independent of the technique, a maximal but hypothalamic-sparing resection should be performed to limit the occurrence of postoperative hypothalamic syndromes and metabolic complications. Similar principles should also be applied for tumor recurrences. Radiotherapy or intracystic agents are alternative treatments when no further surgery is possible. A multidisciplinary long-term follow-up is necessary.

Endoscopic endonasal approach to the mesial temporal lobe: anatomical study and clinical considerations for a selective amygdalohippocampectomy

BACKGROUND

Selective amygdalohippocampectomy (AH) is a surgical option for patients with medically intractable seizures from mesial temporal lobe pathology. The transcranial route is considered the best method to achieve this goal. However, the standard approach through the neocortex is still invasive. The risks can be minimized if the mesial temporal lobe is resected while preserving the lateral temporal lobe and the Meyer's loop. This study explores the feasibility of selective AH by endoscopic endonasal approach (EEA) in cadaveric specimens.

METHODS

The endoscopic anatomy of the mesial temporal lobe and the feasibility of a successful selective AH were studied in six hemispheres from three injected human cadavers. Quantitative analyses on the extent of resection and angles of exposure were performed based on CT and MRI studies of pre- and post-selective AH and measurements taken during dissections.

RESULTS

The EEA V1-V2 corridor provided a direct and logical line of access to the mesial temporal lobe, following its natural trajectory with no brain retraction and minimal exposure of the pterygopalatine fossa. The components of the mesial temporal lobe were resected just as selectively and easily as the transcranial route, but without compromising the structures of the lateral temporal lobe or the Meyer's loop.

CONCLUSIONS

The EEA V1-V2 corridor demonstrated its selective resectability and accessibility of the mesial temporal lobe in cadaveric specimens. The clinical value of this approach should be explored responsibly by a surgeon with both competent microsurgical skills and experiences in EEA.

Acellular dermal matrix as an alternative to autologous fascia lata for skull base repair following extended endoscopic endonasal approaches

BACKGROUND

Skull base reconstruction after extended endoscopic endonasal approaches (EEAs) can be challenging. In addition to the nasoseptal flap, which has been adopted by most centers, autologous fascia lata is also often utilized. Harvesting of fascia lata requires a separate thigh incision, may prolong recovery, and results in a visible scar. In principal, the use of non-autologous materials would be preferable to avoid a second incision and maintain the minimally invasive nature of the approach, assuming the CSF leak rate is not compromised.

OBJECTIVE

To assess the efficacy of acellular dermal matrix (ADM) as a non-autologous alternative to autologous fascia lata graft for watertight closure of the cranial base following EEAs.

METHODS

A retrospective chart review of extended EEAs performed before and after the transition from fascia lata to ADM was performed. Cases were frequency matched for approach, pathology, BMI, use of lumbar drainage, and tumor volume. Power analysis was performed to estimate the sample size needed to demonstrate non-inferiority.

RESULTS

ADM was used for watertight closure of the cranial base in 19 consecutive extended endoscopic endonasal approaches (16 gasket-seals and 3 buttons) with 1 postoperative CSF leak at the last follow-up (median 5.3, range 1.0-12.6 months). All patients had high-flow intraoperative leaks. The cohort included 8 meningiomas, 8 craniopharyngiomas, 2 chordomas, and 1 pituicytoma ranging in size from 0.2 to 37.2cm³ (median 5.5, IQR 2.8-13.3 cm³). In 19 historical controls who received fascia lata, there were 2 postoperative CSF leaks.

CONCLUSIONS

Preliminary results suggest that ADM provides a non-inferior non-autologous alternative to fascia lata for watertight gasket-seal and button closures following extended EEAs, potentially reducing or eliminating the need to harvest autologous tissue.

Bilaminar Chitosan Scaffold for Sellar Floor Repair in Transsphenoidal Surgery

Background

Endoscopic endonasal transsphenoidal surgery (EETS) is a standard technique used to approach sellar tumors. It is relatively safe, minimally invasive and carries a low risk of complications. However, one of the common complications reported with this technique is CSF leakage which causes morbidity, an increase in recovery time and hospital costs. This complication usually occurs from violation of the diaphragma sellae and a defect in the structures of the sellar floor or incomplete repair. In this article we report the first case with the use of a novel bilaminar chitosan scaffold which can be potentially used in the repair of the sellar floor, primarily aiming to the bony part of this structure.

Case Presentation

After a personalized design employing a tissue engineering strategy, we reconstructed the sellar floor in a 65-year-old woman who had undergone EETS for a pituitary adenoma with progressive bilateral visual loss. To repair the bony defect of the sellar floor, we used a novel bilaminar chitosan scaffold. The patient had an unremarkable postoperative course with no evidence of CSF leak. The polymer was well tolerated without toxicity, infection or complications. After 2 years of follow up the patient remains neurologically intact, and in good endocrinological status.

Conclusion

This is the first report of the use of this biomaterial and its biocompatibility in a clinical setting for the repair of the sellar floor during EETS. Our experience with chitosan bilaminar scaffold and in several preclinical studies in the literature have demonstrated good biocompatibility and effective bioengineered bone regeneration due to its excellent osteoconductive properties, this study pretends to be one landmark for further clinical research and larger case series with the use of this personalized tissue engineering materials in order to see they real efficacy to increase the surgeon armamentarium.

A Simple Onlay Sellar Reconstruction Does Not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients

Objective  A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design  Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting  The present study was conducted at a tertiary care center. Participants  In this study, pituitary adenoma patients were the participants. Outcome Measures  Main outcome measure of the study is postoperative CSF leak. Results  A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm ³ . No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 ( p  = 0.796), respectively. Conclusion  The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.

Continuous dural suturing for closure of grade 3 leaks after tumor removal via an endoscopic endonasal approach

Cerebrospinal fluid (CSF) leakage is a major complication after extended endonasal transsphenoidal surgery (EETSS), which is commonly used in the treatment of anterior skull base tumors. Dural suturing and graded reconstruction are promising techniques to further decrease the incidence of postoperative CSF (poCSF) leakage. The effect of continuous dural suturing in endoscopic surgery was investigated in this retrospective study. A total of 79 EETSS patients were included; the procedures were performed for subdural tumor removal by a single endoscopic neurosurgical team. Comparisons were applied between patients who did and did not undergo endoscopic dural suturing after tumor removal. Multivariate logistic regression analysis was performed to identify variables that significantly influenced the incidence of poCSF leakage. In all, 79 adult patients developed Esposito's grade 3 intraoperative high-flow CSF leakage. Ten patients (12.7%) experienced poCSF leakage. One of the 36 patients who underwent intraoperative dural suturing developed poCSF leakage, compared with nine of 43 patients who did not undergo dural suturing (p = 0.016). Regression analysis showed that dural suturing could significantly decrease the incidence of poCSF leakage (p = 0.049, OR 0.108, 95% CI 0.013-0.899). Prophylactic lumbar drainage could also help decrease the CSF leakage rate. Dural suturing under endoscopy is a promising and effective method for application in skull base reconstruction after subdural skull base tumor removal. With future progress, lumbar drainage and even nasoseptal flap placement could be replaced in certain groups of patients undergoing EETSS.

Infectious Complications of Expanded Endoscopic Transsphenoidal Surgery: A Retrospective Cohort Analysis of 100 Cases

Objective  To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS). Study Design  This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis. Results  A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33-56.47; p  = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected. Conclusion  CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.

Rathke's cleft cysts: a 6-year experience of surgery vs. observation with comparative volumetric analysis

BACKGROUND

Rathke's cleft cysts (RCCs) are common sellar lesions. Their management remains controversial, particularly when small or asymptomatic. Herein we review a consecutive series of RCC patients managed with surgery or observation.

METHODS

All patients with a new diagnosis of presumed RCC, based on MRI, from February 2012-March 2018 were retrospectively divided into observational and surgical cohorts based on an intent-to-treat model. The cohorts were compared for clinical presentation, and cyst volume. The observational cohort was followed for change in cyst size. The surgical cohort was followed for changes in endocrinopathy, visual symptoms, headache and recurrence.

RESULTS

Of 90 patients (mean age 36.7 ± 19.4 years; 68% female), 60% (n = 54) were in the observational cohort and 40% (n = 36) in the surgical cohort. Average follow-up was 13 ± 23 months in the observational cohort and 24 ± 19 months in the surgical group. In comparing the cohorts, mean ages were similar with more women in the surgical group (81% vs. 56%, p = 0.04). Most patients in the observational cohort had incidentally-discovered RCCs (n = 50, 88%) as opposed to the surgical cohort (n = 6, 17%). The surgical cohort had higher rates of headache (89% vs 26%, p < 0.001), endocrinopathy (36% vs 0%, p < 0.001), and visual dysfunction (19% vs 0%, p = 0.001). Mean cyst volume and maximal cyst dimensions were greater in the surgical cohort (0.94 ± 0.77 cm³ and 14.2 ± 4.1 mm), compared to the observational cohort (0.1 ± 0.14 cm³ and 6.4 ± 3 mm), (p < 0.001). Among the 53% (n = 30/54) of patients in the observational group with follow-up, 3 (10%) had spontaneous RCC shrinkage, 1 (3%) had modest asymptomatic growth (at 10 months from initial MRI), and 87% had stable cyst size. Of the 36 patients recommended to have surgery, 89% (n = 32) did so. Post-operatively, complete or partial resolution of headache, endocrinopathy and visual dysfunction were documented in 90% (n = 28/30), 75% (n = 10/12), and 100% (n = 7/7), respectively. On follow-up MRI, 8 (22%) patients had some cyst reaccumulation, of whom 3 (8%) were symptomatic and underwent uneventful reoperation. No major complications such as hematoma, CSF leak, new endocrinopathy or visual deficits occurred.

CONCLUSION

From this consecutive series, a majority (60%) of RCCs do not appear to warrant surgical intervention and have a low risk of cyst progression. However, surgical cyst removal appears to be indicated and safe for patients with larger, symptomatic RCCs. Simple cyst drainage has a high rate of improvement in pituitary gland function, visual function and headache resolution with low complication rates and symptomatic recurrence risk. These findings stress the importance of careful case selection and potential utility of volumetric assessment for patients with RCCs.

Strategy and Technique of Endonasal Endoscopic Bony Decompression and Selective Tumor Removal in Symptomatic Skull Base Meningiomas of the Cavernous Sinus and Meckel's Cave

BACKGROUND

Parasellar meningiomas involving the cavernous sinus and Meckel's cave pose a management challenge because of invasion around neurovascular structures and the pituitary gland. The management options range from aggressive resection to focused radiotherapy alone. We present a strategy for these tumors that includes endonasal bony decompression, partial tumor removal, and stereotactic radiotherapy (SRT) in select cases.

METHODS

The tumor location, previous treatments, cranial neuropathies, pituitary dysfunction, tumor control rates, use of stereotactic radiosurgery, SRT, and complications were retrospectively evaluated.

RESULTS

Twenty patients (age range, 43-81 years; 65% women; 90% with World Health Organization grade I; median follow-up, 57 months; 14 without previous debulking and RT; 6 with previous debulking and RT) underwent endonasal bony decompression and partial tumor removal. The most common tumor locations were cavernous sinus (95%), Meckel's cave (95%), sella (75%), petroclival (60%), and optic canal/orbit (30%). Three patients with large meningiomas underwent staged transcranial and endonasal debulking. Of the 14 patients without previous debulking and RT, 11 had undergone postoperative SRT, with tumor shrinkage in 3 (27%). At the last follow-up examination, for these 14 patients and the 6 patients who had undergone previous surgery and RT, tumor control was 100% and 33% (P < 0.001) and the cranial neuropathies had improved in 57% and 33%, respectively. Major complications occurred in 2 patients: a permanent sixth cranial nerve palsy and cerebrospinal fluid leakage requiring reoperation.

CONCLUSIONS

Endonasal bony decompression and selective tumor removal, followed by SRT, appears to be a reasonable treatment option for most previously untreated parasellar meningiomas. For patients who have undergone previous debulking and RT, new targeted treatment strategies are needed.