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Kohli G, Gabriel PJ, Brady M, Fang CH, Eloy JA, Liu JK. The role of endoscopic endonasal salvage surgery in recurrent or residual craniopharyngioma after a transcranial approach: a systematic review. Acta Neurochir (Wien) 2024; 166:120. [PMID: 38430312 DOI: 10.1007/s00701-024-05980-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/17/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND The management of craniopharyngiomas is challenging due to their high rate of recurrence following resection. Excision of recurrent tumors poses further surgical challenges due to loss of arachnoidal planes and adherence to anatomical structures. The endoscopic endonasal approach (EEA) offers a favorable alternative to transcranial approaches for primary craniopharyngiomas. However, the safety and efficacy of EEA for recurrent tumors, specifically after a prior transcranial approach, needs further investigation. METHODS We performed a systematic review using PubMed to develop a database of cases of recurrent craniopharyngiomas previously treated with a transcranial approach. RESULTS Fifteen articles were included in this review with a total of 75 cases. There were 50 males and 25 females with a mean age of 38 years (range 2-80). One prior transcranial surgery was done in 80.0% of cases, while 8.0% had two and 12.0% had more than two prior surgeries. Radiotherapy after transcranial resection was given in 18 cases (24.0%). Following EEA, vision improved in 60.0% of cases, and vision worsened in 8.6% of the cases. Of cases, 64.4% had pre-existing anterior hypopituitarism, and 43.8% had diabetes insipidus prior to EEA. New anterior hypopituitarism and diabetes insipidus developed in 24.6% and 21.9% of cases, respectively following EEA. Gross total resection (GTR) was achieved in 64.0%, subtotal resection in 32.0%, and partial resection in 4.0% revision EEA cases. GTR rate was higher in cases with no prior radiotherapy compared to cases with prior radiotherapy (72.0% vs 39.0%, p = 0.0372). The recurrence rate was 17.5% overall but was significantly lower at 10.0% following GTR (p = 0.0019). The average follow-up length was 41.2 months (range, 1-182 months). CONCLUSION The EEA can be utilized for resection of recurrent or residual craniopharyngiomas previously managed by a transcranial approach.
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Affiliation(s)
- Gurkirat Kohli
- Department of Neurological Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Phabinly J Gabriel
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Melanie Brady
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Christina H Fang
- Department of Otorhinolaryngology-Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jean Anderson Eloy
- Departments of Otolaryngology-Head and Neck Surgery, Neurological Surgery, And Ophthalmology and Visual Science Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Otolaryngology and Facial Plastic Surgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ, USA
| | - James K Liu
- Skull Base Institute of New Jersey, Neurosurgeons of New Jersey, NYU Langone Neurosurgery Network, Livingston, NJ, USA.
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ, USA.
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Webb KL, Pruter WW, Hinkle ML, Walsh MT. Comparing Surgical Approaches for Craniopharyngioma Resection Among Adults and Children: A Meta-analysis and Systematic Review. World Neurosurg 2023; 175:e876-e896. [PMID: 37062335 DOI: 10.1016/j.wneu.2023.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/10/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Craniopharyngioma treatment often necessitates surgical resection. Conventional approaches, such as transcranial and transsphenoidal approaches, are predominantly used. However, a recently adopted supraorbital approach may be more efficacious. Thus, this meta-analysis and systematic review aimed to compare the efficacy of the transcranial, transsphenoidal, and supraorbital approaches for resection and treatment of craniopharyngiomas. METHODS This study was performed following PRISMA guidelines. Analyses were performed according to study design: (1) analyses for studies comparing several surgical approaches; and (2) analyses of all included studies. Random effects meta-analysis models were used to pool odds ratios among studies comparing several approaches. Similarly, categorical meta-regression models were used to examine the effect of surgical approach as a covariate of outcome data for all studies. Statistics were performed using Comprehensive Meta-Analysis software (CMA 3.3, Biostat, Englewood, NJ) (significance set at P < 0.05). RESULTS Patients were well-matched for age, sex, and preoperative comorbidities between groups stratified by surgical approach. Analyses including 22 studies that compared several approaches demonstrated that the transsphenoidal group had a greater occurrence of postoperative visual improvement (P < 0.0001), lesser occurrence of visual deterioration (P < 0.0001), and lower tumor recurrence rate (P = 0.015) compared with the transcranial group. Only 2 studies compared the supraorbital approach to another approach, limiting analyses. Analyses including all studies demonstrated that the supraorbital group did not differ to either the transcranial or transsphenoidal group for any examined variables. CONCLUSIONS The present study suggests that the transsphenoidal approach is associated with improved clinical outcomes for craniopharyngioma resection. There are limited data regarding the supraorbital approach, warranting future investigation.
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Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Wyatt W Pruter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Pang JC, Chung DD, Wang J, Abiri A, Lien BV, Himstead AS, Ovakimyan A, Kim MG, Hsu FPK, Kuan EC. Characteristics and Outcomes in Pediatric Versus Adult Craniopharyngiomas: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 92:1112-1129. [PMID: 36639856 DOI: 10.1227/neu.0000000000002346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/05/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Craniopharyngiomas account for 1.2% to 4.6% of all intracranial tumors. Although age at presentation is distributed bimodally, with a pediatric peak occurring between 5 and 15 years and an adult peak between 50 and 70 years, presentation, treatment, and outcome differences between these two craniopharyngioma populations have not been thoroughly characterized. OBJECTIVE To compare treatments and outcomes between adult and pediatric craniopharyngiomas. METHODS This is a systematic review and meta-analysis. Web of Science, MEDLINE, and Scopus databases were searched for primary studies reporting postoperative complications, functional outcomes, recurrence, and overall survival in patients with craniopharyngioma undergoing surgery. RESULTS The search yielded 1,202 unique articles, of which 106 (n=4,202 patients) met criteria for qualitative synthesis and 23 (n=735 patients) met criteria for meta-analysis. Compared with adult, pediatric craniopharyngiomas were less likely to present with visual defects (odds ratio [OR] 0.54, 95% CI 0.36-0.80) or cognitive impairment (OR 0.29, 95% CI 0.12-0.71) and more likely with headaches (OR 2.08, 95% CI 1.16-3.73). Children presented with significantly larger tumors compared with adults (standardized mean difference 0.68, 95% CI 0.38-0.97). Comparing functional outcomes, pediatric patients sustained higher rates of permanent diabetes insipidus (OR 1.70, 95% CI 1.13-2.56), obesity (OR 3.15, 95% CI 1.19-8.31), and cranial nerve and/or neurological defects (OR 4.87, 95% CI 1.78-13.31) than adults. No significant differences were found in rates of postoperative cerebrospinal fluid leak, overall or progression-free survival, or recurrence. CONCLUSION Adult and pediatric craniopharyngiomas seem to have fundamental differences in clinical presentation and functional outcomes. These patients frequently require multimodality treatment and are best managed with a multidisciplinary team and an individualized approach.
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Affiliation(s)
- Jonathan C Pang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Dean D Chung
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Jenny Wang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Andrew Ovakimyan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Michael G Kim
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
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Solari D, Mastantuoni C, Cavallo LM, Esposito F, Cappabianca P. Endoscopic endonasal treatment of craniopharyngiomas: current management strategies and future perspectives. J Neurosurg Sci 2023; 67:26-35. [PMID: 35301832 DOI: 10.23736/s0390-5616.21.05507-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Craniopharyngiomas are locally aggressive disembryogenetic tumors presenting mostly in childhood and late adulthood. They are often burdened by an unfavorable clinical course due to close relationships with nearby critical neurovascular structures and high risk of recurrences. The aim of our paper is to provide a systematic review of the literature regarding current strategies and future perspectives for the treatment of craniopharyngiomas, focusing on the role of endoscopic endonasal surgery. EVIDENCE ACQUISITION A comprehensive literature search of three databases (PubMed, Ovid Medline, and Ovid Embase) has been conducted to identify papers addressing the management strategies in adult and pediatric craniopharyngioma patients. EVIDENCE SYNTHESIS Twenty-two articles have been included, providing data for 560 adult and 215 pediatric patients. Mean follow-up was 40.29 months for the adult and 58.05 months for pediatric population. GTR rate was 60.97% and 82.52% in adult and pediatric patients, respectively. Adjuvant radiotherapy was delivered in 20.99% of adult and 8.25% of pediatric cases; 89% of adult patients and 94.11% of pediatric patients receiving radiotherapy had previously undergone NTR, STR or partial resection. The recurrence rate was 19.32% and 18.61% for adult and pediatric population, respectively. Recurrences occurred mostly in patients receiving incomplete resection without adjuvant radiotherapy (72.87% in adults and 51.28% in children); 86.69% and 87.12% of adult and pediatric patients reported improvement of their previous ophthalmologic deficit; 40% of the adult population and 41.86%% of pediatric patients worsened or developed endocrinological disturbances. CSF leak rate was 16.4% in adults and 13.95%% in children. CONCLUSIONS Modern policy of craniopharyngioma management is represented by the combination of a "maximum safe" allowed surgical removal plus radiotherapy. In this scenario, the endoscopic endonasal technique proved to be a valid approach for removing these lesions, providing satisfactory outcomes with lower morbidity.
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Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy -
| | - Ciro Mastantuoni
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Felice Esposito
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
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Yang J, Kim YH, Phi JH, Kim SK, Wang KC. Complications of Endoscopic Skull Base Surgery for Sellar and Parasellar Tumors in Pediatric Population; Neurosurgical Perspectives. Front Oncol 2022; 12:769576. [PMID: 35692769 PMCID: PMC9186047 DOI: 10.3389/fonc.2022.769576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Advances in surgical techniques based on in-depth anatomical knowledge of the skull base have broadened the indications for endoscopic skull base surgery (ESS) with the advantage of wide and direct surgical exposure while minimizing invasiveness. However, the low incidence of the indicated diseases and narrow surgical corridors in children have limited the popularization of ESS. In addition, surgical complications and preventive interventions are not yet well known. Therefore, we retrospectively investigated the complications and prevention methods of ESS in children with a comprehensive review. Methods We retrospectively analyzed the medical records of pediatric patients who underwent ESS for sellar and parasellar tumors at Seoul National University Children's Hospital from July 2010 to December 2020. Visual and endocrine status, extent of resection, complications, and recurrences were investigated depending on the pathology of the tumor. In addition, a comprehensive literature review regarding the complications of pediatric ESS was performed. Results A total of 98 patients were enrolled. The median age of the patients was 12 years, and 52 patients were male. Preoperative visual disturbance was found in 53 patients, anterior pituitary function deficit in 69, and diabetes insipidus in 32. Gross total resection was attempted in 67 patients and achieved in 62 (93%). Biopsy and cyst fenestration were the goals of surgery in 26 patients, and all were achieved as planned. Regarding outcomes, visual disturbance worsened in two patients (2%), endocrine status was aggravated in 34 (35%) patients, and new-onset diabetes insipidus occurred in 27 (41%) patients. The overall surgical complication rate (other than aggravation of visual or endocrine status) was 17%. Postoperative meningitis (12%) was the most common complication, followed by cerebrospinal fluid leakage (2%), vasospasm, hemorrhage and infarction. By pathological diagnosis, craniopharyngioma had the highest complication rate of 29%. All but one patient with postoperative hemorrhage showed no permanent deficits. Conclusion ESS in children is feasible and relatively safe. More attention and different postoperative management protocols are required in children to avoid complications, especially in craniopharyngiomas. However, the complications can be mostly managed conservatively without permanent neurologic deficits.
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Affiliation(s)
- Jeyul Yang
- Neuro-Oncology Clinic, National Cancer Center, Goyang, South Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul, South Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul, South Korea
| | - Kyu-Chang Wang
- Neuro-Oncology Clinic, National Cancer Center, Goyang, South Korea
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Feng Z, Li C, Cao L, Qiao N, Wu W, Bai J, Zhao P, Gui S. Endoscopic Endonasal Transsphenoidal Surgery for Recurrent Craniopharyngiomas. Front Neurol 2022; 13:847418. [PMID: 35481274 PMCID: PMC9035929 DOI: 10.3389/fneur.2022.847418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/22/2022] [Indexed: 11/28/2022] Open
Abstract
Object Although revision surgery for recurrent craniopharyngiomas is more challenging than primary surgery and often accompanies a higher risk of death and complications, endoscopic endonasal transsphenoidal surgery (EETS) is sometimes still an effective and reliable treatment option. In this study, we introduced the surgical outcomes of EETS for recurrent craniopharyngiomas and summarized the surgical experiences. Methods Between 2014 and 2018, 28 patients with recurrent craniopharyngiomas underwent 29 EETS in our department. We regarded the patient undergoing two EETS as two independent patients in statistical analysis. Of the 29 patients, 16 had undergone 1 previous surgery, 10 had undergone 2 previous surgeries, and the remaining 3 patients had undergone 3 surgeries. The extent of resection, visual and endocrine outcomes, and complications of all the patients were collected and analyzed. Results Gross total resection was accomplished in 16 patients (55.17%), subtotal resection in 11 patients (37.93%), and partial resection in 2 patients (6.9%). Among the 22 patients with preoperative visual acuity and visual field impairment, some degree of vision improvement was observed in 18 patients, 3 patients were without visual change, and perpetual deterioration of vision occurred in one patient. The remaining six patients had normal vision before and after surgery. Postoperative endocrine tests showed that, among five patients with normal preoperative pituitary hormone function, only one patient still had normal pituitary hormone function and the other four patients had one or more hypothalamic-pituitary axes involved. None of the patients with preoperative endocrine dysfunction had endocrine function improved. Diabetes insipidus was observed in six new cases postoperatively. Cerebrospinal fluid (CSF) leakage occurred in 1 patient. One patient had bacterial meningitis, which was cured with antibiotics and a lumbar drain. No serious morbidity and mortality occurred in all patients. Conclusions For recurrent craniopharyngiomas, a personalized treatment plan should be developed according to the tumor characteristics and the patient's situation. There is no omnipotent method to be used for all patients. The EETS still is a safe and effective way to treat recurrent craniopharyngiomas in appropriate patients.
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Affiliation(s)
- Zhenguang Feng
- Department of Neurosurgery, Tianjin First Center Hospital, Tianjin, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Qiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wentao Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiwei Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Songbai Gui
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Qiao N, Li C, Xu J, Ma G, Kang J, Jin L, Cao L, Liu C, Zhang Y, Gui S. Prognostic Utility of Optical Coherence Tomography for Visual Outcome After Extended Endoscopic Endonasal Surgery for Adult Craniopharyngiomas. Front Oncol 2022; 11:764582. [PMID: 35070970 PMCID: PMC8770264 DOI: 10.3389/fonc.2021.764582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Owing to the close vicinity of the optic chiasma, visual dysfunction is known as one of the most common surgical indications and postoperative complications in adult patients with craniopharyngiomas, probably leading to poor quality of life. Historically, very few consistent predictive factors associated with the visual outcome are identified, which may not be helpful for patient counseling and preoperative decision making. Recently, optical coherence tomography (OCT) serving as a novel high-resolution imaging technique can assess the retinal morphology by measuring the circumpapillary retinal nerve fiber layer (cpRNFL) and macular ganglion cell complex thickness. However, few studies have examined the prognostic utility of OCT parameters for visual outcome after surgery for craniopharyngiomas. This study aims to use the largest series to evaluate the association between OCT parameters and visual outcome after extended endoscopic endonasal surgery (EEES) for primary craniopharyngiomas in adults. MATERIAL AND METHODS From October 2018 to October 2020, one hundred and seventy eyes in 88 adult patients with newly confirmed craniopharyngiomas were retrospectively reviewed and pertinent prognostic factors were analyzed. RESULTS Gross total resection was performed in 82 (93.2%) patients. The median postoperative follow-up time was 10.9 months. Multiple logistic regression analysis showed that increased temporal cpRNFL thickness was associated with higher odds of visual acuity (VA) improvement and maintenance (OR = 1.070; 95% CI, 1.005-1.140; p = 0.035), and greater inferior cpRNFL thickness was significantly associated with visual field (VF) improvement and maintenance (OR = 1.034; 95% CI, 1.001-1.068; p = 0.046). Furthermore, tight adhesion between optic nerves and craniopharyngiomas was demonstrated as an independent adverse factor for either postoperative VA or VF (p = 0.048, p = 0.030, respectively). The ROC results further verified the robustness of the prediction model either in VA (AUC = 0.843; 95% CI, 0.734-0.952; p < 0.001) or VF (AUC = 0.849; 95% CI, 0.741-0.958; p < 0.001). CONCLUSION Preoperative OCT can effectively predict visual outcome after EEES for adult craniopharyngiomas. It can also serve as a reliable alternative to evaluate preoperative visual field defects, especially for patients with lower compliance. Tight adhesion was confirmed as an independent risk factor for postoperative visual outcome. The OCT-based multivariable prediction models developed in the present study may contribute to patient counseling on visual prognosis.
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Affiliation(s)
- Ning Qiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Cell Biology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jing Xu
- Department of Ophthalmology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guofo Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lu Jin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunhui Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Cell Biology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Kopparapu S, Khalafallah AM, Botros D, Carey AR, Rodriguez FJ, Duan D, Rowan NR, Mukherjee D. Predictors of Postoperative Visual Outcome After Surgical Intervention for Craniopharyngiomas. World Neurosurg 2021; 148:e589-e599. [PMID: 33482413 DOI: 10.1016/j.wneu.2021.01.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/10/2021] [Accepted: 01/10/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Because of involvement of the optic apparatus, craniopharyngiomas frequently present with visual deterioration. Although visual improvement is a primary goal of surgical intervention, prediction models are lacking. METHODS We retrospectively reviewed all patients undergoing craniopharyngioma surgery at a single institution (2014-2019). Preoperative, intraoperative, and postoperative variables of interest were collected. Visual acuity and visual fields (VFs) were standardized into Visual Impairment Scores (VISs), defined by the German Ophthalmological Society. VIS ranged from 0 (normal vision) to 100 (complete bilateral blindness). Visual improvement/deterioration was defined as a postsurgical decrease/increase of ≥5 VIS points, respectively. RESULTS Complete ophthalmologic assessments were available for 61 operations, corresponding to 41 patients (age, 4-73 years). Vision improved after 28 operations (46%), remained stable after 27 (44%), and deteriorated after 6 (10%). In bivariate analysis, significant predictors of visual improvement included worse preoperative VIS (odds ratio [OR], 1.058; P < 0.001), worse preoperative VF mean deviation (OR, 1.107; P = 0.032), preoperative vision deficits presenting for longer than 1 month (OR, 6.050; P = 0.010), radiographic involvement of the anterior cerebral arteries (OR, 3.555; P = 0.019), and gross total resection (OR, 4.529; P = 0.022). The translaminar surgical approach was associated with visual deterioration (OR, 6.857; P = 0.035). In multivariate analysis, worse preoperative VIS remained significantly associated with postoperative visual improvement (OR, 1.060; P = 0.011). Simple linear correlation (R2=0.398; P < 0.001) suggests prediction of postoperative VIS improvement via preoperative VIS. CONCLUSIONS Patients with reduced preoperative vision, specific radiographic vascular involvement, and gross total resection showed increased odds of visual improvement, whereas the translaminar approach was associated with visual deterioration. Such characteristics may facilitate patient-surgeon counseling and surgical decision making.
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Affiliation(s)
- Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adham M Khalafallah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Botros
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew R Carey
- Department of Neuro-Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fausto J Rodriguez
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daisy Duan
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas R Rowan
- Department of Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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9
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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10
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Surgical management of craniopharyngiomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section. Acta Neurochir (Wien) 2020; 162:1159-1177. [PMID: 32112169 DOI: 10.1007/s00701-020-04265-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 02/17/2020] [Indexed: 12/19/2022]
Abstract
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.
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11
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Cavallo LM, Somma T, Solari D, Iannuzzo G, Frio F, Baiano C, Cappabianca P. Endoscopic Endonasal Transsphenoidal Surgery: History and Evolution. World Neurosurg 2020; 127:686-694. [PMID: 31266131 DOI: 10.1016/j.wneu.2019.03.048] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/05/2019] [Indexed: 12/30/2022]
Abstract
In previous decades, extensive and disfiguring transfacial and/or transcranial approaches were used to reach the sellar and parasellar areas. However, these surgical routes were burdened by severe complications and high mortality rates. Recently, the development of endoscopic endonasal techniques has revolutionized the surgical strategies for approaching the sella and adjacent areas and increased the development of transsphenoidal surgery. With these techniques, surgeons have been able to overcome the visual limitations of the open surgical approaches and access areas previously hidden from view. After the contributions of the Pittsburgh duo, Carrau and Jho, pioneers of pure endoscopic surgery, our school began to implement this technique, introducing technical innovations and variations, describing the anatomical details and defining new routes, and playing a key role in its widespread clinical application.
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Affiliation(s)
- Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Teresa Somma
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Gianpiero Iannuzzo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Federico Frio
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Cinzia Baiano
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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12
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Gauden AJ, Harley B, Pears C, Wickremesekera A, Parker A, Robinson S, Baguley C, Wormald PJ. A regional Australasian experience of extended endoscopic transsphenoidal surgery for craniopharyngioma: Progression of the mentoring model. J Clin Neurosci 2019; 68:188-193. [PMID: 31303398 DOI: 10.1016/j.jocn.2019.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 04/22/2019] [Accepted: 06/21/2019] [Indexed: 12/01/2022]
Abstract
Endoscopic endonasal transsphenoidal approaches to craniopharyngioma has become increasingly popular over the last 15 years. We present the results of our retrospective series of craniopharyngiomata resected by an endoscopic, endonasal approach at a low-volume service in Australasia. Between the years of 2009 and 2017, 11 patients underwent pure endoscopic endonasal transsphenoidal resection for a craniopharyngioma at our institutions. The medical records, histopathology, intraoperative findings and patient imaging were retrospectively assessed. 11 patients were included with 5 male and 6 female patients. The mean age was 32.0 years (range 14-68 years). Of this patient series a gross total resection of the tumour was achieved in 8 of 11 patients (73%). In the immediate postoperative phase, 10 of the 11 patients developed diabetes insipidus (91%). The pituitary stalk was formally not seen in 4 patients and all were treated with vasopressin. Of the 7 patients where the pituitary stalk was identified it was formally divided in 6 and preserved in 1 patient where the tumour was separate to the stalk. The endoscopic endonasal transsphenoidal approach for excision of craniopharyngioma, utilising and progressing the surgical mentoring model, can achieve adequate decompression of critical structures. Furthermore, our aggressive approach to divide and remove the involved pituitary stalk results in high rates of gross macroscopic resection with excellent long-term disease control with a greater risk of postoperative diabetes insipidus and panhypopituitarism.
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Affiliation(s)
- A J Gauden
- Department of Neurosurgery, Wellington Hospital, New Zealand; Department of Neurosurgery, Royal Melbourne Hospital, Australia.
| | - B Harley
- Department of Neurosurgery, Wellington Hospital, New Zealand
| | - C Pears
- Department of Neurosurgery, Wellington Hospital, New Zealand
| | | | - A Parker
- Department of Neurosurgery, Wellington Hospital, New Zealand
| | - S Robinson
- Department of Otolaryngology, Wellington Hospital, New Zealand
| | - C Baguley
- Department of Otolaryngology, Wellington Hospital, New Zealand
| | - P J Wormald
- Department Otolaryngology, Royal Adelaide Hospital, Australia
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13
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The Evolution of Endoscopic Skull Base Surgery Outcomes: Defining the Edge of the Envelope. World Neurosurg 2019. [DOI: 10.1016/j.wneu.2019.01.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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14
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Schwartz TH, Morgenstern PF, Anand VK. Lessons learned in the evolution of endoscopic skull base surgery. J Neurosurg 2019; 130:337-346. [PMID: 30717035 DOI: 10.3171/2018.10.jns182154] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVEEndoscopic skull base surgery (ESBS) is a relatively recent addition to the neurosurgical armamentarium. As with many new approaches, there has been significant controversy regarding its value compared with more traditional approaches to ventral skull base pathology. Although early enthusiasm for new approaches that appear less invasive is usually high, these new techniques require rigorous study to ensure that widespread implementation is in the best interest of patients.METHODSThe authors compared surgical results for ESBS with transcranial surgery (TCS) for several different pathologies over two different time periods (prior to 2012 and 2012-2017) to see how results have evolved over time. Pathologies examined were craniopharyngioma, anterior skull base meningioma, esthesioneuroblastoma, chordoma, and chondrosarcoma.RESULTSESBS offers clear advantages over TCS for most craniopharyngiomas and chordomas. For well-selected cases of planum sphenoidale and tuberculum sellae meningiomas, ESBS has similar rates of resection with higher rates of visual improvement, and more recent results with lower CSF leaks make the complication rates similar between the two approaches. TCS offers a higher rate of resection with fewer complications for olfactory groove meningiomas. ESBS is preferred for lower-grade esthesioneuroblastomas, but higher-grade tumors often still require a craniofacial approach. There are few data on chondrosarcomas, but early results show that ESBS appears to offer clear advantages for minimizing morbidity with similar rates of resection, as long as surgeons are familiar with more complex inferolateral approaches.CONCLUSIONSESBS is maturing into a well-established approach that is clearly in the patients' best interest when applied by experienced surgeons for appropriate pathology. Ongoing critical reevaluation of outcomes is essential for ensuring optimal results.
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Affiliation(s)
- Theodore H Schwartz
- Departments of1Neurological Surgery and
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
- 3Department of Neuroscience, Weill Cornell Medical College, New York, New York
| | | | - Vijay K Anand
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
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15
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Younus I, Forbes JA, Ordóñez-Rubiano EG, Avendano-Pradel R, La Corte E, Anand VK, Schwartz TH. Radiation therapy rather than prior surgery reduces extent of resection during endonasal endoscopic reoperation for craniopharyngioma. Acta Neurochir (Wien) 2018; 160:1425-1431. [PMID: 29802559 DOI: 10.1007/s00701-018-3567-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 05/15/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Radiation therapy is often advocated for residual or recurrent craniopharyngioma following surgical resection to prevent local recurrence. However, radiation therapy is not always effective and may render tumors more difficult to remove. If this is the case, patients may benefit more from reoperation if gross total resection can be achieved. Nevertheless, there is little data on the impact of radiation on reoperations for craniopharyngioma. In this study, we sought to analyze whether a history of previous radiation therapy (RT) affected extent of resection in patients with recurrent craniopharyngiomas subsequently treated with reoperation via endoscopic endonasal approach (EEA). METHODS The authors reviewed a prospectively acquired database of EEA reoperations of craniopharyngiomas over 13 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior author. The operations were separated into two groups based on whether the patient had surgery alone (group A) or surgery and RT (group B) prior to recurrence. RESULTS A total of 24 patients (16 male, 8 female) who underwent surgery for recurrent craniopharyngioma were identified. The average time to recurrence was 7.64 ± 4.34 months (range 3-16 months) for group A and 16.62 ± 12.1 months (range 6-45 months) for group B (p < 0.05). The average tumor size at recurrence was smaller in group A (1.85 ± 0.72 cm; range 0.5-3.2) than group B (2.59 ± 0.91 cm; range 1.5-4.6; p = 0.00017). Gross total resection (GTR) was achieved in 91% (10/11) of patients in group A and 54% (7/13) of patients in group B (p = 0.047). There was a near significant trend for higher average Karnofsky performance status (KPS) score at last follow-up for group A (83 ± 10.6) compared with group B (70 ± 16.3, p = 0.056). CONCLUSIONS While RT for residual or recurrent craniopharyngioma may delay time to recurrence, ability to achieve GTR with additional surgery is reduced. In the case of recurrent craniopharyngioma, if GTR can be achieved, consideration should be given to endonasal reoperation prior to the decision to irradiate residual or recurrent tumor.
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Affiliation(s)
- Iyan Younus
- Weill Cornell Medical College, New York, NY, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Edgar G Ordóñez-Rubiano
- Department of Neurological Surgery, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital de San José, Bogota, Colombia
| | | | - Emanuele La Corte
- Foundation IRCCS Neurological Institute Carlo Besta, University of Milan and Department of Neurosurgery, Milan, Italy
| | - Vijay K Anand
- Department of Otolaryngology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Theodore H Schwartz
- Department of Otolaryngology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
- Department of Neurosurgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
- Department of Neuroscience, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
- Departments of Neurological Surgery, Otolaryngology and Neuroscience, Department of Neurosurgery, Anterior Skull Base and Pituitary Surgery, Epilepsy Research Laboratory, Weill Cornell Medicine, 525 East 68th St., Box no. 99, New York, NY, 10065, USA.
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16
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Kim KH, Kim YH, Dho YS, Kim JH, Hong SD, Choi JW, Seol HJ, Nam DH, Lee JI, Park CK, Kong DS. Is Low-Lying Optic Chiasm an Obstacle to an Endoscopic Endonasal Approach for Retrochiasmatic Craniopharyngiomas? (Korean Society of Endoscopic Neurosurgery -003). World Neurosurg 2018. [PMID: 29524705 DOI: 10.1016/j.wneu.2018.02.178] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Despite advances in endoscopic techniques, retrochiasmatic craniopharyngiomas (CPs) are difficult to remove completely, because the low-lying optic chiasm often provides an obstacle to an endoscopic endonasal approach. This study aimed to identify the endoscopic surgical outcomes of the retrochiasmatic CP and resolve the issues related to low-lying optic chiasm. METHODS We reviewed 154 consecutive patients with CP who underwent endonasal endoscopic resection from February 2009 to April 2017 at 2 independent institutions. The topographic relationship of the tumor with the third ventricle, stalk, and optic chiasm and clinical outcomes were investigated. RESULTS Retrochiasmatic CPs were found in 142 of 154 patients (92.2%). The median follow-up time was 25 months. Gross total resection and near-total resection were achieved in 113 patients (79.6%) and 21 patients (13.8%), respectively. Postoperative cerebrospinal fluid leaks were found in 16 patients (11.3%). Low-lying and high-lying chiasms were found in 44 patients (31.0%) and 98 patients (69.0%), respectively. Low-lying chiasm did not affect clinical outcomes including the extent of resection. Patients with low-lying chiasm showed a marginal trend for postoperative visual deterioration. The ventricular growth pattern representing the origin of the tumor and previous surgery were significantly associated with the position of the optic chiasm (P = 0.007 and 0.001, respectively). CONCLUSIONS An endoscopic endonasal approach is an effective surgical approach for retrochiasmatic CP, even in tumors with low-lying chiasm. However, a thorough and careful dissection is necessary to prevent visual deterioration.
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Affiliation(s)
- Kyung Hwan Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun-Sik Dho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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17
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Tang B, Xiao L, Xie S, Huang G, Wang Z, Zhou D, Zeng E, Hong T. Extended endoscopic endonasal approach for recurrent or residual symptomatic craniopharyngiomas. Clin Neurol Neurosurg 2018. [PMID: 29522935 DOI: 10.1016/j.clineuro.2018.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Removal of recurrent or residual symptomatic craniopharyngiomas is more challenging than the primary surgery. The extended endoscopic endonasal (EEE) approach has been proposed an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas currently. In this study, we summarized the operative experience and described the feasibility and advantages of this technique in recurrent or residual symptomatic craniopharyngiomas. PATIENTS AND METHODS A retrospective review of 15 patients (9 males and 6 females) whom underwent EEE approach between April 2012 and February 2017, were included in this study. The lesions included 8 purely suprasellar craniopharyngiomas (2 extraventricular, 6 intraextraventricular), 3 both intra- and suprasellar craniopharyngiomas, and 4 intrasellar craniopharyngiomas. The mean preoperative (that is, EEE approach) tumor volume was 10.54 cm3. The mean follow-up period was 23.1 months (range, 8-54). All patients were analyzed in terms of the treatment effect, complictions and follow-up results. RESULTS Total removal of tumors was achieved in 12 patients (80.0%) and subtotal removal in 3 cases (20.0%). The pituitary stalks were identified in 11 patients during operations and secured in 8 patients. Postoperative visual acuity was improved in 10 cases, and normalization of the impairment was achieved in 3 patients. There were no significant differences between pre and postoperative endocrine function, except in one patient with normal preoperative pituitary hormone function who suffered postoperative hypopituitarism. Postoperative diabetes insipidus (DI) occurred in 14 patients including 6 patients who had long-term DI and others reporting transient postoperative DI. No cerebrospinal fluid (CSF) leak was identified. There were no deaths or major complications. Obesity developed in 2 patients, with no deaths and recurrent cases during follow-up period. CONCLUSION The pure EEE approach is a safe, effective alternative for treatment of recurrent or residual symptomatic craniopharyngiomas owing to its advantages including wide-angle view, close observation and elimination of brain retraction. Larger studies with further follow-up is needed to assess the long-term efficacy of this minimal access approach.
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Affiliation(s)
- Bin Tang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Limin Xiao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Shenhao Xie
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Guanlin Huang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Zhigang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Dongwei Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Erming Zeng
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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18
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Moussazadeh N, Prabhu V, Bander ED, Cusic RC, Tsiouris AJ, Anand VK, Schwartz TH. Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a case-matched single-institution analysis. Neurosurg Focus 2017; 41:E7. [PMID: 27903116 DOI: 10.3171/2016.9.focus16299] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The authors compared clinical and radiological outcomes after resection of midline craniopharyngiomas via an endoscopic endonasal approach (EEA) versus an open transcranial approach (TCA) at a single institution in a series in which the tumors were selected to be equally amenable to gross-total resection (GTR) with either approach. METHODS A single-institution retrospective review of previously untreated adult midline craniopharyngiomas was performed. Lesions were evaluated by 4 neurosurgeons blinded to the actual approach used to identify cases that were equally amenable to GTR using either an EEA or TCA. Radiological and clinical outcome data were assessed. RESULTS Twenty-six cases amenable to either approach were identified, 21 EEA and 5 TCA. Cases involving tumors that were resected via a TCA had a trend toward larger diameter (p = 0.10) but were otherwise equivalent in preoperative clinical and radiological characteristics. GTR was achieved in a greater proportion of cases removed with an EEA than a TCA (90% vs 40%, respectively; p = 0.009). Endoscopic resection was associated with superior visual restoration (63% vs 0%; p < 0.05), a decreased incidence of recurrence (p < 0.001), lower increase in FLAIR signal postoperatively (-0.16 ± 4.6 cm3 vs 14.4 ± 14.0 cm3; p < 0.001), and fewer complications (20% vs 80% of patients; p < 0.001). Significantly more TCA patients suffered postoperative cognitive loss (80% vs 0; p < 0.0001). CONCLUSIONS An EEA is a safe and effective approach to suprasellar craniopharyngiomas amenable to GTR. For this select group of cases, the EEA may provide higher rates of GTR and visual improvement with fewer complications compared with a TCA.
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Shi X, Zhou Z, Wu B, Zhang Y, Qian H, Sun Y, Yang Y, Yu Z, Tang Z, Lu S. Outcome of Radical Surgical Resection for Craniopharyngioma with Hypothalamic Preservation: A Single-Center Retrospective Study of 1054 Patients. World Neurosurg 2017; 102:167-180. [PMID: 28254603 DOI: 10.1016/j.wneu.2017.02.095] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/19/2017] [Accepted: 02/20/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A retrospective review of the surgical outcome for patients with craniopharyngioma (CP) treated in a single neurosurgical center with surgical resection using visualization to ensure hypothalamic preservation. METHODS The study included 1054 patients. Before 2003, a pterional cranial approach was preferred for 78% of patients; after 2004, the unifrontal basal interhemispheric approach was performed in 79.1% of patients. RESULTS Complete tumor resection was achieved in 89.6% of patients; vision improved in 47.1% of patients who had preoperative vision impairment. However, diabetes insipidus worsened in 70.4% of patients and new-onset diabetes insipidus occurred in 29.7% of the remaining patients. Pituitary stalk preservation occurred in 48.9% of cases. There were 89.6% of patients with total tumor removal; 13.3% of patients showed tumor recurrence within an average of 2.8 years. Of 69 follow-up patients with a subtotal or partial resection, 94.2% showed tumor recurrence within an average of 4.3 months. Of the total patients, 82.3% fully recovered. CONCLUSIONS This study has shown that radical surgical resection of CP using microsurgical excision can be effective with a good patient outcome without more limitations on each individual tumor of distinct features despite the impact of recent endoscopic techniques on CP surgery. The surgical approach depends on a direct and wider visualization of CP located in the midline with preserving hypothalamic structures by identifying some hypothalamic landmark structures. After surgery, most patients can resume their normal activities even after aggressive tumor removal, although patients require postoperative hormonal replacement.
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Affiliation(s)
- Xiang'en Shi
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China.
| | - Zhongqing Zhou
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Bin Wu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yongli Zhang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Hai Qian
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yuming Sun
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yang Yang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zaitao Yu
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zhiwei Tang
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Shuaibin Lu
- Department of Neurosurgery, Fu Xing Hospital, Capital Medical University, Beijing, China
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20
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Turel MK, Tsermoulas G, Gonen L, Klironomos G, Almeida JP, Zadeh G, Gentili F. Management and outcome of recurrent adult craniopharyngiomas: an analysis of 42 cases with long-term follow-up. Neurosurg Focus 2017; 41:E11. [PMID: 27903122 DOI: 10.3171/2016.9.focus16315] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The treatment of recurrent and residual craniopharyngiomas is challenging. In this study the authors describe their experience with these tumors and make recommendations on their management. METHODS The authors performed an observational study of adult patients (≥ 18 years) with recurrent or residual craniopharyngiomas that were managed at their tertiary center. Retrospective data were collected on demographics and clinical, imaging, and treatment characteristics from patients who had a minimum 2-year follow-up. Descriptive statistics were used and the data were analyzed. RESULTS There were 42 patients (27 male, 15 female) with a mean age of 46.3 ± 14.3 years. The average tumor size was 3.1 ± 1.1 cm. The average time to first recurrence was 3.6 ± 5.5 years (range 0.2-27 years). One in 5 patients (8/42) with residual/recurrent tumors did not require any active treatment. Of the 34 patients who underwent repeat treatment, 12 (35.3%) had surgery only (transcranial, endoscopic, or both), 9 (26.5%) underwent surgery followed by adjuvant radiation therapy (RT), and 13 (38.2%) received RT alone. Eighty-six percent (18/21) had a gross-total (n = 4) or near-total (n = 14) resection of the recurrent/residual tumors and had good local control at last follow-up. One of 5 patients (7/34) who underwent repeat treatment had further treatment for a second recurrence. The total duration of follow-up was 8.6 ± 7.1 years. The average Karnofsky Performance Scale score at last follow-up was 80 (range 40-90). There was 1 death. CONCLUSIONS Based on this experience and in the absence of guidelines, the authors recommend an individualized approach for the treatment of symptomatic or growing tumors. This study has shown that 1 in 5 patients does not require repeat treatment of their recurrent/residual disease and can be managed with a "scan and watch" approach. On the other hand, 1 in 5 patients who had repeat treatment for their recurrence in the form of surgery and/or radiation will require further additional treatment. More studies are needed to best characterize these patients and predict the natural history of this disease and response to treatment.
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Affiliation(s)
- Mazda K Turel
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Georgios Tsermoulas
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lior Gonen
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - George Klironomos
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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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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Yang J, Zhang F, Xu A, Li H, Ding Z. Comparison of surgical exposure and maneuverability associated with microscopy and endoscopy in the retrolabyrinthine and transcrusal approaches to the retrochiasmatic region: a cadaveric study. Acta Neurochir (Wien) 2016; 158:703-710. [PMID: 26860600 DOI: 10.1007/s00701-016-2733-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The retrolabyrinthine and transcrusal approaches (RLA and TCA, respectively) are the two most often used posterior transpetrosal approaches that are used to treat lesions in the retrochiasmatic region. Endoscopes are increasingly used in neurosurgical practice. To determine whether a difference exists between the two transpetrosal approaches in the retrochiasmatic region, we evaluated and compared the exposure and maneuverability associated with the microscope and the endoscope in these approaches. METHODS Seven formalin-fixed cadaveric heads were dissected bilaterally through the two approaches: four for evaluation and three injected with colored latex for photography. The retrochiasmatic region was divided into four sub-compartments: the compartment before the infundibulum, which was further divided into two parts, (1) the ipsilateral and (2) the contralateral compartments; (3) the retroinfundibulum compartment; (4) the third ventricle. After each approach, exposure and maneuverability of the structures in these four compartments obtained by microscopy and endoscopy were scored under a guidance of a numerical grading system for further comparison. RESULTS The TCA provided better exposure and maneuverability at the retrochiasmatic region than the RLA in both the microscopy model [scores of 39.75 ± 2.12 and 32.38 ± 2.56 respectively (p < 0.05)] and the endoscopy model [scores of 82.13 ± 3.40 and 43.75 ± 1.67 respectively (p < 0.05)]. CONCLUSIONS The TCA is better than the RLA at offering exposure and manipulation to structures in the retrochiasmatic region, especially in patients whose lesion is located high into the third ventricle and/or expanded into the contralateral part. Endoscopes may be helpful in TCA in terms of exposing and maneuvering structures in the contralateral and interpeduncle fossa areas. However, in RLA, not enough room is available for simultaneously maneuvering an endoscope and a surgical instrument.
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Zheng JP, Song M, Zhan XX, Li CZ, Zong XY, Zhang YZ. Anatomical partition of the clival region and adjacent structures via extended endoscopic endonasal approach. Clin Neurol Neurosurg 2015; 139:129-37. [PMID: 26448399 DOI: 10.1016/j.clineuro.2015.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/27/2015] [Accepted: 09/22/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To explore the anatomy of the ventral clivus and adjacent structure in the endoscopic surgery through the anterior approach, particularly in accurate locating lesions in transnasal endoscopic surgery. PATIENTS AND METHODS A total of 9 formalin-fixed adult cadaver heads were injected with red and blue latex to observe the arteries and veins, respectively. The relationships between various parts of internal carotid artery (ICA) and anatomic structures of clivus were investigated, followed by the measurement of the posterior pharyngeal wall, anterior wall and posterior wall of clivus, cerebral dura mater, subdural space and adjacent regions to determine their correlations, as well as the clivus and adjacent structures. RESULTS The clivus structure was divided into the bone segment, the ICA segment and subdural segment for anatomic division according to the anatomic landmarks in the anatomic process. The clivus can be classified in a shape of '' with the ICA, including the middle superior region, middle inferior region, bilateral lateral superior and lateral inferior regions. CONCLUSION The ICA is closely related to the ventral clivus and adjacent structure, which can be used as the basis of anatomic division via anterior approach.
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Affiliation(s)
- Jia-Ping Zheng
- Department of Neurosurgery Center, Aviation General Hospital of China Medical University, Beijing 100012, China
| | - Ming Song
- Department of Neurosurgery, Sanbo Brain Hospital Affiliated with Capital Medical University, Beijing 100093, China
| | - Xiang-Xin Zhan
- Department of Neurosurgery, Juxian Hospital of Traditional Chinese Medicine, Shandong Rizhao 276500, China
| | - Chu-Zhong Li
- Beijing Neurosurgical Institute, 6 Tiantan Xili, Beijing 100050, China
| | - Xu-Yi Zong
- Department of Neurosurgery, Beijing Tiantan Hospital, 6 Tiantan Xili, Beijing 100050, China
| | - Ya-Zhuo Zhang
- Beijing Neurosurgical Institute, 6 Tiantan Xili, Beijing 100050, China.
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