The combined pterional and orbitocygomatic approach to extensive tumours of the lateral and latero-basal orbit and orbital apex

Management of Skull-Base Meningiomas With Extracranial Extensions: Clinical Features, Radiological Findings, Surgical Strategies, and Long-Term Outcomes

Objectives:

The aim of this research was to summarize the clinical and prognostic features of the skull-base meningiomas with extracranial extensions, and enhance the management of skull-base communicative meningiomas.

Methods

We retrospectively studied the medical records and analyzed the follow-up information of 53 patients who have done surgery for skull-base meningiomas with extracranial extensions in West China Hospital of Sichuan University from 2009 to 2020.

Results

The incidence of skull-base meningiomas with extracranial extensions was 0.74%. The average diagnosis age was 45.9 years, with a 1:3.1 men to women ratio. WHO grade I was seen in 84.9% of patients, and higher grades were found in 15.1%. Heterogeneous enhancement, high bone invasion rate, high incidence of peritumoral edema, and high dural tail sign rate were typical imaging features. Routine craniotomy and endoscopic endonasal approach were adopted, and gross total resection was performed in 62.3% of cases with 20.8% postoperative complication rates. The average follow-up time was 61.5 months, with a recurrence rate of 34.9%. By survival analysis, the extent of resection (p = 0.009) and the histological grade (p = 0.007) were significantly related to the prognosis. Adjuvant radiotherapy proved beneficial in patients with subtotal resection (p = 0.010) and high-grade meningiomas (p = 0.018).

Conclusions

Skull-base meningiomas with extracranial extensions were sporadic. According to the tumor location and communication way showed by the preoperative imaging, routine craniotomy or endoscopic endonasal approach with a reasonable skull-base repair strategy could be adopted to achieve the maximum tumor resection. Maximized resection, adjuvant radiotherapy, and low histological grade indicate a better prognosis.

Fronto-orbitozygomatic approach: functional and cosmetic outcomes in a series of 169 patients

OBJECTIVE Advantages of the fronto-orbitozygomatic (FOZ) approach have been reported extensively in the literature; nevertheless, restoration of normal anatomy and the esthetic impact of surgery are increasingly important issues for patients and neurosurgeons. The aim of this study was to analyze functional and cosmetic outcomes in a series of 169 patients with different pathologies who underwent surgery in which the FOZ approach was used. METHODS Between January 2000 and December 2014, 250 consecutive patients underwent surgery with an FOZ approach as the primary surgical treatment. Follow-up data were available for only 169 patients; 103 (60.9%) of these patients were female and 66 (39.1%) were male, and their ages ranged from 6 to 77 years (mean 46.9 years; SD 15.6 years). Mean follow-up time was 66 months (range 6-179 months; SD 49.5 months). Evaluation of clinical outcomes was performed with a focus on 4 main issues: surgical complications, functional outcome, cosmetic outcome, and patient satisfaction. The additional time needed to perform orbitotomy and orbital reconstruction was also evaluated. RESULTS The permanent postoperative complications included forehead hypesthesia (41.4%) and dysesthesia (15.3%), frontal muscle weakness (10.3%), exophthalmos (1.4%), enophthalmos (4.1%), diplopia (6.6%; 2% were related to surgical approach), and persistent periorbital and eyelid swelling (3%). Approximately 90% of the patients reported subjectively that surgery did not affect their quality of life or complained of only minor problems that did not influence their quality of life significantly. The mean time needed for orbitotomy and orbital reconstruction was approximately half an hour. CONCLUSIONS Comprehensive knowledge of the potential complications and overall clinical outcomes of the FOZ approach can be of great utility to neurosurgeons in balancing the well-known benefits of the approach with potential additional morbidities.

Total removal of a trigeminal schwannoma via the expanded endoscopic endonasal approach. Technical note

BACKGROUND

Because of their deep location surrounded by closed numerous neurovascular structures, skull base tumors of the cavernous sinus are still difficult to manage. Recently, the endoscopic endonasal approach commonly used for pituitary tumor resection has been "expanded" to the parasellar, infratemporal and orbital compartments with some advantages compared to the intracranial route.

METHODS

The authors reported the case of a 49-year-old male presenting a large extradural tumor of the left cavernous sinus with extensions toward the orbit, sphenoid sinus and infratemporal fossa. His ophthalmological examination was normal, and the body CT scan revealed no primary neoplasm.

RESULTS

In this operative video, the approach is described step by step with surgical nuances. The endoscopy provided a close-up panoramic view and various angles of vision. Also, it avoided an invasive craniotomy, cerebral retraction and cranial nerves damages. Thus, it allowed the total removal of this tumor originating from the maxillary branch of the trigeminal nerve. The pathologic examination confirmed a schwannoma.

CONCLUSION

The expanded endoscopic endonasal approach provides an interesting corridor to cavernous sinus tumors with satisfactory control of extensions inferiorly toward the infratemporal fossa, anteriorly via the superior orbital fissure and medially within the sphenoid. Finally, the skull base surgeon has to master this anterior endoscopic route as well as all the other "open" transcranial skull base approaches to propose the best surgical route fitting the tumor characteristics.

Multisession Gamma Knife Radiosurgery for Orbital Apex Tumors

OBJECTIVE

This study was performed to analyze the outcome of multisession gamma knife radiosurgery (GKS) in benign tumors located at the orbital apex.

METHODS

Medical records of 23 patients who underwent multisession GKS for benign orbital apex tumors were reviewed retrospectively. Three patients were diagnosed by histology, and the other 20 patients were given the diagnoses on the basis of clinical and radiological findings. Diagnoses included cavernous hemangioma (8 cases), meningioma (8 cases), and schwannoma (7 cases). All patients were treated with 4 sessions of GKS with 12 hours of interval. Median marginal dose in each session was 5 Gy (range, 4.5-5.5 Gy) at the 50% isodose line (range, 50%-55%).

RESULTS

Mean clinical and imaging follow-up duration after treatment were 52.1 and 34.2 months, respectively. Tumor control was achieved in 22 patients (95.7%). Significant tumor shrinkage was observed in 17 patients (73.9%), and mean tumor volume reduction rate was 53.9%. Visual function was improved in 16 patients (69.6%) and stable in 4 patients (17.4%). Deterioration of visual acuity was reported by 3 patients (13.0%). Clinical and radiological response to multisession GKS was most excellent in cavernous hemangiomas with tumor control in all patients, and the mean tumor volume reduction rate was 68.3%.

CONCLUSIONS

Multisession GKS proved to be an effective and safe management strategy for benign orbital apex tumors. Response to treatment was different according to the pathology, and multisession GKS may be considered as the initial treatment of choice for specific pathology such as cavernous hemangioma.

Transorbital approach without craniotomy to orbital tumors with extradural intracranial extension

PURPOSE

To review indications and clinical outcomes in a series of orbitocranial tumors treated surgically through a transorbital extradural approach without craniotomy.

METHODS

In this retrospective case series, all patients who underwent surgery through a transorbital extradural approach without craniotomy for benign orbitocranial tumors involving the dura or extending into the anterior or middle cranial fossae were analyzed.

RESULTS

Twenty-seven patients (20 females and 7 males) were included. Median age was 47.0 years (range: 6-74 years) and median follow-up time was 43.5 months (range: 3-148 months). The median preoperative best-corrected visual acuity (logMAR) was improved from 0.35 (range: 0-2.6) to 0.1 (range: 0-2.6) at the last follow-up (p < 0.03). The mean ± SD preoperative exophthalmos significantly decreased from 20.4 ± 3.4 mm to 13.1 ± 3.5 mm at the last follow-up visit (p < 0.01). Four postoperative complications were noted and included one case each of ptosis, numbness, diplopia (transient for 6 months), and cranial nerve VI palsy (transient for 4 months).

CONCLUSIONS

The transorbital extradural approach provides access to the deep orbit and adjacent extradural cranial spaces. Benign orbital tumors that have eroded through the orbital roof, are located in the orbital apex abutting the anterior cavernous sinus and tumors requiring debulking are all processes that can be potentially approached through the transorbital extradural route. Compared to open craniotomy, the incision is smaller, the access more direct and specific risks of open craniotomy are reduced.

Stereotactic fractionated radiotherapy for cavernous venous malformations (hemangioma) of the orbit

PURPOSE

Cavernous malformations (hemangioma) of the orbit, when symptomatic, can often be treated successfully with complete surgical excision. However, when they involve local structures in their capsule, are situated in the orbital apex, or extend through the superior orbital fissure, the risks of surgery increase significantly. In such cases, alternative treatment modalities can be explored. In this study, the authors report on the use of fractionated stereotactic radiotherapy (SFRT) for the treatment of surgically complicated cavernous malformations.

METHODS

In this retrospective cohort study, the authors reviewed the clinical and radiologic records of 5 patients treated with SFRT over the past 5 years.

RESULTS

Patients ranged in age from 30 to 65 years, and 3 out of 5 were female. Two cases involved the cavernous sinus, one involved the ophthalmic artery, one involved the posterior ciliary artery, and the last traversed the superior orbital fissure. Four had significant visual field defects. Each was treated with SFRT. A total dose of 4000 cGy divided into 20,200 cGy fractions was applied for 3 cases, while 2 other cases were treated with total doses of 4563 and 4959 cGy divided into 28 × 162 cGy and 29 × 171 cGy fractions, respectively. Rapid resolution of visual field defect was noted by 3 months, and overall tumor shrinkage was on average 60% (range: 32-79%). Follow-up was on average 23.4 months (range: 5-50 months). No complications of treatment were noted.

CONCLUSIONS

For symptomatic cavernous malformations demonstrating anatomical position that may increase risk of surgical excision, SFRT is an effective and safe method to control lesion size and improve visual function.

Transnasal transsphenoid approach: a minimally invasive approach for removal of cavernous haemangiomas located at inferomedial part of orbital apex

Ten patients complaining of visual impairment, proptosis or ocular pain, were selected for transnasal transsphenoid microsurgical approach to address cavernous haemangiomas located at inferomedial part of orbital apex. Via this approach, the contents of orbital apex were clearly illuminated and exposed as large as the surgical removal required. All tumours were identified under frameless image-guided neuronavigation and removed completely without any complications and recurrence in a mean of 12.2 months follow-up. It is concluded that a transnasal transsphenoid microsurgical approach is a minimally invasive surgery for cavernous haemangiomas located at inferomedial part of orbital apex.

Treatment of deep vascular orbital malformations

OBJECTIVE

In this article, we discuss the clinical features and endovascular and/or surgical treatment of deep vascular orbital malformations.

METHODS

We report on our treatment of 58 cases of vascular malformations of the orbit between 1991 and 2008.

RESULTS

Arterial low flow lesions, such as cavernomas (n=44) were the most common finding. These were treated by complete excision. High flow lesions such as angiomas were less common (n=4). These were treated by the endovascular and/or surgical approach. Venous flow lesions appear as distensible lesions (n=3) or non-distensible anomalies (n=4). Deep venous lesions (n=7) should be treated if they cause severe pain, progressive proptosis, motility disturbances or visual deterioration. No flow lesions include lymphangiomas (n=3). Surgery may be helpful in specific cases with intracystic haemorrhage and progressive proptosis. Patients with severe visual deterioration do not improve, whereas all other symptoms are potentially reversible.

CONCLUSIONS

Treatment of vascular malformations is required in case of progression of symptoms. In cases of visual deterioration, we generally favour early treatment. The least invasive surgical approach, tailored to the individual patient, should be chosen.

The supraorbital approach--a minimally invasive approach to the superior orbit

BACKGROUND

We present a minimally invasive approach to the superior orbit via an eyebrow incision with a small osteotomy, minimal orbital rim resection and small frontal craniotomy.

METHODS

This approach was used in 20 patients with a well-defined intra-and extraconal lesion superior to the optic nerve, who underwent surgery between 2000 and 2007.

RESULTS

This approach is purely extradural with minimal brain and orbital retraction. The size of the lesion was not a limiting factor. Sensory deficits in the territory of the supraorbital nerve resolved within 7 months on average.

CONCLUSION

This approach presents a combination of an extra-and transcranial approach, which is indicated in all orbital lesions superior to the optic nerve. The clinical and cosmetic results are excellent.

Orbital Decompression as an Alternative Management Strategy for Patients with Benign Tumors Located at the Orbital Apex

PURPOSE

Tumors located in the intraconal portion of the orbital apex, especially those inferior to the optic nerve, can be difficult to access surgically, carrying a significant risk of ocular morbidity. The purpose of this study was to investigate outcomes in 5 patients with benign-appearing but symptomatic tumors located in the intraconal portion of the orbital apex in which orbital decompression was performed as an alternative management strategy to resection.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Five patients were diagnosed with a compressive optic neuropathy secondary to a benign-appearing tumor at the orbital apex.

INTERVENTION

Each patient underwent surgical decompression of the affected orbit. None of the patients had the tumor biopsied or resected.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (VA), pupillary responses, visual fields (VFs), color vision, and orbital imaging.

RESULTS

Each of the patients demonstrated improvement in visual function, as measured by VA, VFs, and, in some cases, color vision. One patient required a second orbital decompression for recurrent optic neuropathy 4 years after the initial decompression. Complications included ptosis and enophthalmos in 2 patients and diplopia in the extreme right gaze in 1 patient.

CONCLUSIONS

Orbital decompression is a therapeutic option for patients with compressive optic neuropathies from benign orbital apex tumors, offering potential improvement in optic nerve function while sparing morbidity from attempts at surgical resection.

Surgical management of meningiomas involving the optic nerve sheath

Object. The management of optic nerve sheath meningiomas (ONSMs) remains controversial but includes surgery, radiotherapy, and plain observation. Surgery is often thought to result in postoperative blindness. The authors report on a large series of patients surgically treated for ONSM, with an emphasis on the visual outcome.

Methods. Seventy-three patients with ONSMs who had undergone surgery between 1991 and 2002 were retrospectively analyzed. The standard surgical approach consisted of pterional craniotomy, intradural (54 patients) or extradural (10 patients) unroofing of the optic canal, or a combined procedure (seven patients). Thirty-two tumors demonstrated extension through the optic canal. Twenty-nine tumors reached the chiasm or contralateral side.

Patients with intraorbital flat tumors should undergo radiotherapy instead of surgery. Those with a large intraorbital mass and no useful vision should undergo surgery. Tumors extending intracranially through the optic canal are amenable to decompression of the optic canal and resection of the intracranial portion.

The follow-up period was a mean 45.4 months (range 6–144 months). Ten patients underwent postoperative radiotherapy. Visual acuity was not significantly influenced by surgery but did become worse with a longer duration of preoperative symptoms and a longer follow-up period. A tumor location in the optic canal was another negative factor. Radiotherapy preserved vision in five of 10 cases.

Conclusions. The loss of vision in patients with ONSM is only a matter of time. In patients with good vision the role of radiotherapy becomes more important. Surgery is recommended for intracranial tumors to prevent contralateral extension.

Surgical treatment of orbital cavernomas

BACKGROUND

There are numerous descriptions for the operative techniques applied in orbital lesions. We present a systematic overview of the surgical approaches, as determined by the location and extension of orbital cavernomas.

METHODS

In our study, 37 patients (12 m, 25 f, aged 21-74 years, mean 51.22 years) underwent surgical removal of their orbital cavernoma at our clinic between 1988 and 2002.

RESULTS

In ten cases the cavernoma was located in the lateral part of the intraconal space and a lateral orbitotomy was performed. Nine cavernomas were located more inferiorly and a transconjunctival approach was used. Seven cavernomas involving the optic canal, orbital apex and superior orbital fissure were operated on via an ipsilateral intradural approach. Four cavernomas of the superior orbital fissure or of the laterobasal intraconal space were approached extradurally. In one patient, a combined extra- intradural pterional operation was performed. Four patients with a lesion located medially in the posterior intraconal space were operated on via a contralateral pterional approach. One superior, medial, intraconal cavernoma was approached supraorbitally. In one cavernoma with direct contact to the sinus a transantral approach was used. The postoperative visual acuity improved in 14 of 19 cases with visual impairment, but in none with primary visual loss. Proptosis resolved completely in 21 of 27 patients. Ocular motility recovered in four of six patients, two patients with involvement of the superior orbital fissure presented with new oculomotor palsy postoperatively.

CONCLUSIONS

The location of the cavernoma determines the recommended surgical approach. Because of their tendency to lead to irreversible loss of visual acuity due to the mass effect, we favor early surgery after the onset of symptoms.