The microsurgical treatment of cranio-orbital tumors assisted by intraoperative electrophysiologic monitoring and neuronavigation

A novel classification for guiding the surgical approach for cranio-orbital lesions: a single institution case series of 45 cases and a literature review

We aim to share our experience of the removal of cranio-orbital lesions (COLs) and propose a novel classification to guide the tailored approach selection. We retrospectively reviewed 45 consecutive patients with COLs who underwent surgery performed by the same neurosurgeon between November 2010 and November 2022. The surgical approach was selected according to the anatomical region classification of the COLs. For lesions limited to space A (lateral superior orbital fissure, SOF), the pterion or extended pterion approach (PA or EPA) was used. For lesions limited to space B (extraconal compartment medial SOF, and cavernous sinus CS) and C (intraconal compartment, medial SOF, and CS), the pretemporal transcavernous approach (PTCA) was used. For lesions limited to space D (intraconal compartment and optic canals), the subfrontal approach (SA) was used. For lesions extending into the infratemporal fossa (ITF), the cranio-orbito-zygomatic approach (COZA) was used. For lesions involving pterygopalatine fossa (PPF), the endoscopic transnasal approach (ETNA) was used. We analyzed the clinical manifestations, imaging data, surgical approaches, surgical outcomes, neurological outcomes, and follow-up data. Gross total resection was performed in 35 patients (35/45, 77.8%). SA, PA, EPA, PTCA, COZA, and ETNA were performed in 9, 9, 10, 10, 6, and 1 case(s), respectively. Progression of the residual tumor was observed in 6 cases (1 adenoid cystic carcinoma and 5 meningiomas). Surgical approach selection plays a vital role in patient prognosis. This novel classification based on the involvement of anatomic space could help surgeons select an appropriate approach to remove the COLs.

Exposure of the Cavernous Sinus via the Endoscopic Transorbital and Endoscopic Endonasal Approaches: A Comparative Study

OBJECTIVE

To compare the endoscopic transorbital approach (ETOA) and endoscopic endonasal approach (EEA) in terms of cavernous sinus (CS) exposure.

METHODS

Four cadaveric heads (8 sides) were dissected. The CS was accessed using the EEA and ETOA. Stereotactic measurements of the length of the main structures exposed, angles of attack, depths of surgical corridor, and areas of exposure were obtained and compared between the approaches. An illustrative case is also presented.

RESULTS

The endoscopic transorbital approach (ETOA) exposed the lateral and superior compartments of the CS without obstruction by the internal carotid artery (ICA). The EEA exposed all compartments after mobilizing the ICA. Both approaches enabled similar exposure of the cranial nerves. The depth of surgical corridor was significantly shorter with the ETOA (P < 0.01). The areas of lateral compartment exposure were similar. As the number of instruments placed into the surgical channel increased, the available angles of attack with the ETOA became smaller and were smaller than those of the EEA. In the clinical case presented, the tumor was successfully removed without complications.

CONCLUSIONS

The ETOA has the advantages of a sterile surgical channel, short operation time, little patient trauma, short surgical corridor, large exposure area, and interdural pathway; moreover, it allows dissection through the interdural space without entering the neurovascular compartment of the CS. Although the space for manipulation of instruments is limited, the ETOA is suitable for treating selected tumors in the superior and lateral compartments of the CS.

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.

Surgical Techniques and the Choice of Operative Approach for Cranioorbital Lesions

Objectives  Cranioorbital lesions present a great challenge for neurosurgeons and ophthalmologists. There is no consensus on the choice of surgical approach. The aims of this study were to investigate 49 cases of cranioorbital lesions and evaluate surgical approaches and outcomes. Patients and Methods  A retrospective study was done on 49 patients (51 operations) from 2009 to 2018. Information about the lesion was used to decide whether the supraorbital eyebrow approach (SEA) or pterional approach (PA) was performed. Results  Twenty-eight patients had surgical resection using SEA, 21 patients received PA, each group included one case of recurrence, who underwent reoperation via the same approach. SEA provided better cosmetic satisfaction, and a shorter incision than PA ( p  < 0.05). There was no significant difference in total resection rates, visual outcomes, recovery of ptosis, and other new surgical-related complications between SEA group and PA group ( p  > 0.05). Forty-nine cases of proptosis (94.1%, 49/51) were improved. Thirty-three patients (33/37, 89.2%) who underwent follow-up for longer than 12 weeks had a modified Rankin Scale (mRS) score ≤ 3. Conclusion  Surgery is the preferred treatment for cranioorbital lesions, but total resection is difficult. SEA may be a more minimally invasive option for some more limited lesions superior to optic nerve. PA may be more reasonable for the lesion with obvious hyperostosis and more extensive lesions.

Cranio-Orbital Tumors: Clinical Results and A Surgical Approach

Objectives:

In this study, we aimed to share the surgical approaches and clinical experiences of cranio-orbital tumors, which are surgically difficult anatomies.

Methods:

A total of 22 orbital tumors with extraorbital-transcranial pathology between January 2004 and December 2017 were retrospectively reviewed. Information was obtained from hospital, operation and outpatient records for this study. Preoperative demographic data, ophthalmologic examination findings, clinical and radiological findings were recorded. All patients had cranial magnetic resonance and cranial computerised tomography examinations at this time. The location of the tumor, its size and its relation to neighboring structures were recorded in the light of these examinations.

Results:

The lateral approach was performed in 12 cases. The lateral approach was performed with frontotemporal craniotomy. Because of the lateral inferior location of the tumor in three of 12 cases, zygoma osteotomy was added to classical osteotomy. In 10 cases, the anterior approach was applied and the frontal craniotomy was found sufficient in seven cases. In three cases subfrontal craniotomy was added to classical craniotomy.

Conclusion:

The findings obtained in this study suggest that high resection rates can be achieved with appropriate surgical intervention in orbital tumors requiring a transcranial surgical approach. The most important factor in surgical planning is the location of the tumor. The size of the tumor and the expectation of the percentage of surgical removal are the other important factors. In our series, it has reached high excision ratio in most cases with low complication rate, good visual field and eye movements results.

Cranial nerve monitoring in endoscopic endonasal surgery of skull base tumors (observing of 23 cases)

Background

Preservation of anatomic integrity and function of the cranial nerves during the removal of skull base tumors is one of the most challenging procedures in endoscopic endonasal surgery. It is possible to use intraoperative mapping and identification of the cranial nerves in order to facilitate their preservation.

The purpose of this study was to evaluate the effectiveness of intraoperative trigger electromyography in prevention of iatrogenic damage to the cranial nerves.

Methods

Twenty three patients with various skull base tumors (chordomas, neuromas, pituitary adenomas, meningiomas, cholesteatomas) underwent mapping and identification of cranial nerves during tumor removal using the endoscopic endonasal approach in Department of Neurooncology of Federal State Autonomous Institution “N.N. Burdenko National Medical Research Center of Neurosurgery” of the Ministry of Health of the Russian Federation from 2013 to 2018. During the surgical interventions, mapping and identification of the cranial nerves were carried out using electromyography in triggered mode. The effectiveness of the method was evaluated based on a comparison with a control group (41 patients).

Results

In the main group of patients, 44 nerves were examined during surgery using triggered electromyography. During the study, the III, V, VI, VII, and XII cranial nerves were identified intraoperatively. Postoperative cranial nerve deficiency was observed in 5 patients in the study group and in 13 patients in the control group. The average length of hospitalization was 9 days.

Conclusion

We did not receive statistically significant data supporting the fact that intraoperative identification of cranial nerves using trigger electromyography reduces the incidence of postoperative complications in the form of cranial nerve deficits (p = 0.56), but the odds ratio (0.6) suggests a less frequent occurrence of complications in the study group.

Based on our experience, the trigger electromyography methodology appears quite promising and requires further research.

Tricetin suppresses human oral cancer cell migration by reducing matrix metalloproteinase-9 expression through the mitogen-activated protein kinase signaling pathway

Tricetin is a flavonoid derivative and a potent anti-inflammatory and anticancer agent. However, the molecular mechanism underlying the effects of tricetin on human oral cancer cell migration remains unclear. The cell migration and invasion abilities of three oral cancer cell lines (SCC-9, HSC-3, and OECM-1) were analyzed using Boyden chamber migration assays. Our results demonstrated that tricetin attenuates 12-O-tetradecanoylphorbol-13-acetate-induced SCC-9, HSC-3, and OECM-1 cell invasiveness and migration by reducing matrix metalloproteinase (MMP)-9 enzyme activity. The reverse transcription polymerase chain reaction and luciferase reporter assay revealed that tricetin downregulates the mRNA expression and promoter activity of MMP-9. In addition, Western blot analysis revealed that tricetin significantly reduced the levels of phosphorylated c-Jun N-terminal kinase (JNK) 1/2 and p38 levels but not those of extracellular signal-regulated kinase 1/2. In conclusion, this study demonstrated that tricetin suppresses MMP-9 enzymatic activity by downregulating the p38/JNK1/2 pathway and might be a beneficial chemopreventive agent.

Usefulness of intraoperative electromyographic monitoring of oculomotor and abducens nerves during skull base surgery

BACKGROUND

Intraoperative neurophysiologic monitoring of the extraocular cranial nerve (EOCN) is not commonly performed because of technical difficulty and risk, reliability of the result and predictability of the postoperative function of the EOCN.

METHODS

We performed oculomotor nerve (CN III) and abducens nerve (CN VI) intraoperative monitoring in patients with skull base surgery by recording the spontaneous muscle activity (SMA) and compound muscle action potential (CMAP). Two types of needle electrodes of different length were percutaneously inserted into the extraocular muscles with the free-hand technique. We studied the relationships between the SMA and CMAP and postoperative function of CN III and CN VI.

RESULTS

A total of 23 patients were included. Nineteen oculomotor nerves and 22 abducens nerves were monitored during surgery, respectively. Neurotonic discharge had a positive predictive value of less than 50% and negative predictive value of more than 80% for postoperative CN III and CN VI dysfunction. The latency of patients with postoperative CN III dysfunction was 2.79 ± 0.13 ms, longer than that with intact CN III function (1.73 ± 0.11 ms). One patient had transient CN VI dysfunction, whose CMAP latency (2.54 ms) was longer than that of intact CN VI function (2.11 ± 0.38 ms). There was no statistically significant difference between patients with paresis and with intact function.

CONCLUSIONS

The method of intraoperative monitoring of EOCNs described here is safe and useful to record responses of SMA and CMAP. Neurotonic discharge seems to have limited value in predicting the postoperative function of CN III and CN VI. The onset latency of CMAP longer than 2.5 ms after tumor removal is probably relevant to postoperative CN III and CN VI dysfunction. However, a definite quantitative relationship has not been found between the amplitude and stimulation intensity of CMAP and the postoperative outcome of CN III and CN VI.