The Supraorbital Endoscopic Approach for Tumors

Endoscopic endonasal approach for olfactory groove meningioma resection: Strategies and outcomes in a retrospective case series

OBJECTIVE

Though the endoscopic endonasal approach (EEA) is a widely accepted treatment for skull base tumors, the specific use of EEA for olfactory groove meningiomas (OGMs) is debated, with variable outcomes reported in the literature. We review the surgical results of OGM resections for one surgeon including the operative approach, surgical nuances, and outcomes, with a focus on factors relating to patient selection which favor EEA over transcranial approaches.

METHODS

We retrospectively reviewed thirteen cases of endoscopic endonasal resection of olfactory groove meningiomas. Patient characteristics, clinical characteristics, surgical outcomes, and complications were analyzed. Extent of resection was determined based on volumetric analysis of pre- and postoperative MRI.

RESULTS

Anatomic characteristics that render a tumor difficult to access fully are lateral extension beyond the mid-orbit and anterior extension to the falx. Simpson Grade I resection was achieved in 11/13 (84.6 %) cases. Mean pre-operative tumor volume was 8.99 cm3 (range 2.19-16.79 cm3), and 92 % of tumors were WHO grade I. We demonstrate 2 cases of smell preservation, possible with small unilateral tumors and tumors that are confined to either the anterior or posterior portion of the cribriform plate. The post-operative CSF leak rate was 7.7 %, without prophylactic lumbar CSF drainage. The mortality rate was 7.7 % (n = 1) after infectious complications following CSF leak.

CONCLUSIONS

Endoscopic endonasal resection of olfactory groove meningiomas is an effective and safe operative method with outcomes and complication rates comparable to transcranial approaches. Key considerations include careful patient selection and familiarity with technical nuances of endoscopic endonasal approach for this specific tumor type.

Microsurgical and endoscopic-assisted supraorbital keyhole approach for intra-suprasellar cysticercosis

Background

Treatment for intra/suprasellar cysticercosis can be challenging and may result in visual disturbances if not managed properly. Despite its limited knowledge, an effective surgical option exists to treat this condition. This article presents three cases of sellar cysticercosis, comprising one female and two male patients, managed with microsurgical supraorbital keyhole approach (mSKA) and endoscopic-assisted supraorbital keyhole approach (eaSKA).

Case Description

The first patient is a 35-year-old man with no prior medical history who suffered from memory deficits and visual disturbances due to a sellar cyst pushing the orbitofrontal gyrus treated with mSKA. The second case involved a 52-year-old man who experienced visual deficits caused by a rostral sellar cyst with posterior displacement of the pituitary gland treated with eaSKA. The third case was a 46-year-old woman who experienced decreased visual acuity and memory loss due to multifocal neurocysticercosis (NCC) with sellarsuprasellar cyst extension treated with mSKA. All case diagnoses were confirmed by neuropathology department.

Conclusion

The authors confidently suggest that the SKA is an effective surgical option and could be considered for removing sellar cystic lesions with suprasellar extension. With endoscopic assistance, it improves adequate neurovascular structure visualization.

The Supraorbital Eyebrow Approach in Pediatric Neurosurgery: Perspectives and Challenges of Frontal Keyhole Surgery

OBJECT

Supraorbital craniotomy via an eyebrow incision provides minimally invasive cosmetically favorable access to both orbital and intracranial pathologies. We describe the indication, surgical technique, and clinical course using this surgical approach in a cohort of patients from a single pediatric neurosurgery unit.

METHODS

In a retrospective analysis, we identified all surgical cases between January 2013 and April 2022 who underwent the supraorbital craniotomy via an eyebrow incision. Craniotomy was performed using piezosurgery ultrasonic bone incision. An interdisciplinary team of an orbital surgeon and a neurosurgeon performed the orbital surgeries. Clinical and surgical characteristics, perioperative data, possible complications, or redo surgeries as well as ophthalmologic status were assessed.

RESULTS

Clinical data of 37 interventions (cases) in 30 patients (age: 8 ± 6.5 years) were analyzed. The supraorbital craniotomy established access to the cranial, lateral, and central portions of the orbit (n = 11) and ipsilateral fronto-medial portions of the skull base (n = 26). Thirty cases suffered from tumor disease with heterogeneous histopathologic diagnoses, and in 13 cases, adjuvant therapy was required. The mean duration of surgery was 163 ± 95 min, and the mean time of hospital stay was 6.0 ± 2.8 days. In two cases (5.4%), the following complications were observed. One infection treated by puncture and antibiotics and one revision surgery was necessary due to loosening of osteosynthesis material. Postoperative visual function was stable compared to preoperative status after all interventions. After a mean follow-up time of 26 ± 25.9 months for oncologic cases the long term outcome was complete remission in 13, stable disease in 14, progressive disease in 1 and death in 2 patients.

CONCLUSION

The supraorbital eyebrow approach is feasible and safe in pediatric neurosurgical cases as a minimally invasive and cosmetic favorable technique and should be considered for intraorbital as well as ipsilateral intracranial lesions adjacent to the skull base. Interdisciplinary cooperation enables a broader spectrum of surgical options in orbital and complex, fronto-basal, skull base pathologies.

A Brief Explanation on Surgical Approaches for Treatment of Different Brain Tumors

The main goal of brain tumor surgery is to achieve gross total tumor resection without postoperative complications and permanent new deficits. However, when the lesion is located close or within eloquent brain areas, cranial nerves, and/or major brain vessels, it is imperative to balance the extent of resection with the risk of harming the patient, by following a so-called maximal safe resection philosophy. This view implies a shift from an approach-guided attitude, in which few standard surgical approaches are used to treat almost all intracranial tumors, to a pathology-guided one, with surgical approaches actually tailored to the specific tumor that has to be treated with specific dedicated pre- and intraoperative tools and techniques. In this chapter, the basic principles of the most commonly used neurosurgical approaches in brain tumors surgery are presented and discussed along with an overview on all available modern tools able to improve intraoperative visualization, extent of resection, and postoperative clinical outcome.

Supraorbital eyebrow approach: A single-center experience

Background

Keyhole neurosurgery is the notion of safely removing brain and skull base lesions through smaller and more precise openings that lessen collateral damage to the surrounding scalp, brain, blood vessels, and nerves. The traditional frontal and pterional approaches require large craniotomies and this predisposes patients to significant and avoidable morbidity. With the growing expectation for minimally invasive surgery, we present our experience with the supraorbital keyhole craniotomy for surgical lesions in the anterior cranial fossa and parasellar regions.

Methods

We retrospectively analyzed and evaluated all cases of neoplastic, vascular, trauma, and infective pathologies of the anterior fossa and parasellar regions treated using a keyhole approach, the supraorbital eyebrow (SOE) approach from January 2018 to June 2022. Treatment outcomes were evaluated based on pathology.

Results

A total of 50 patients underwent a SOE craniotomy during the study period (28 females and 22 males). Their average age ranged from 12 to 86 years, with a mean age of 47.4 years. All patients had anterior skull base and/or anterior frontal lobe pathologies: (23 tumors, 17 ruptured aneurysms, five traumatic frontal hematomas, three extradural empyema, one cerebral cavernous malformation, and one traumatic frontal skull base fracture with dural tear and CSF leak). Gross total tumor resection was achieved in 87% of cases (13 meningiomas of which six were giant, three gliomas, two craniopharyngiomas, and two cerebral metastases). Clip ligation occlusion rate for our aneurysm cases was 100% and intraoperative rerupture was observed in three cases. Mean ICU stay was 2.2 days for the entire series. The overall 30-day mortality rate for our series was 16% (eight deaths). This was highest in the ruptured aneurysm subgroup, with all 5 mortality cases in the aneurysmal subgroup presenting as World Federation of Neurological Surgeons (WFNS) grades ≥ III. 4 of the deaths were in WFNS IV and V patients. The most frequent perioperative complication was transient periorbital swelling which resolved within 7 days. It was observed in 18 of the 50 patients. The next common complications in descending frequency were eyebrow alopecia (three cases), supraorbital hypoesthesia (two cases), CSF leak (two cases), and surgical site infection (one case). There was one approach-related intraoperative complication secondary to carotid injury in a giant meningioma redo case. Conversion to a larger craniotomy was never necessary. Clinical outcome for our cases was evaluated according to the Modified Rankin Scale (mRS) at 3-month postsurgery. A good clinical outcome (mRS ≤ 2) was achieved for 78% of our patients.

Conclusion

The SOE approach craniotomy is an effective minimally invasive approach for various pathologies of the anterior cranial base and parasellar regions. With experience, giant tumors and complex vascular pathology can be addressed with this keyhole approach.

Combined Exoscopic and Endoscopic Two-Step Keyhole Approach for Intracranial Meningiomas

The advantages of neuroendoscopic surgery are the wide viewing angle and the freedom of an axis of view with minimal surgical trauma. With the advent of the exoscope, which has similar advantages to endoscopy, such as a small body and ergonomically superior heads-up surgery, it has become possible to add a field of view that is similar to that of microsurgery to endoscopic surgery. By taking advantage of the features of these scopes, we report the usefulness of the minimally invasive combined exoscopic and endoscopic two-step keyhole approach (EEKA) for various types of meningiomas. We reviewed data from 34 consecutive cases of EEKA for various types of intracranial meningiomas compared with that of conventional microsurgery. All of the tumors were resected as planned without severe complications. Significantly better outcome data were obtained in terms of the blood loss and the surgical time in the EEKA group, in addition to the craniotomy size. The well-illuminated fine vision in the deep corners by the endoscope enabled radical resection of the tumors with minimum burden on the patients. This technique has the potential for minimally invasive surgery in intracranial meningioma patients, including the older population.

Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases

OBJECTIVE

The authors' objective was to compare the indications, outcomes, and anatomical limits of supraorbital (SO) and mini-pterional (MP) craniotomies in patients with intra- and extraaxial brain tumors, and to assess approach selection, utility of endoscopy, and surgical field overlap.

METHODS

A retrospective analysis was conducted of all brain tumor patients who underwent an SO or MP approach. The analyzed characteristics included pathology, endoscopy use, extent of resection, length of stay (LOS), and complications. On the basis of preoperative MRI data, tumor heatmaps were constructed to compare surgical access provided by both routes, including coronal projection heatmaps for parasellar tumors.

RESULTS

From 2007 to 2020, 158 patients underwent 173 (84.8%) SO craniotomies and 30 patients underwent 31 (15.2%) MP craniotomies; 71 (34.8%) procedures were reoperations. Of these 204 operations, 110 (63.6%) SO and 21 (67.7%) MP approaches were for extraaxial tumors (meningiomas in 65% and 76.2%, respectively). Gliomas and metastases together represented 84.1% and 70% of intraaxial tumors accessed with SO and MP approaches, respectively. Overall, 56.1% of tumors accessed with the SO approach and 41.9% of those accessed with the MP approach were in the parasellar region. Axial projection heatmaps showed that SO access extended along the entire ipsilateral and medial contralateral anterior cranial fossa, parasellar region, ipsilateral sylvian fissure, medial middle cranial fossa, and anterior midbrain, whereas MP access was limited to the ipsilateral middle cranial fossa, sylvian fissure, lateral parasellar region, and posterior aspect of anterior cranial fossa. Coronal projection heatmaps showed that parasellar access extended further superiorly with the SO approach compared with that of the MP approach. Endoscopy was utilized in 98 (56.6%) SO craniotomies and 7 (22.6%) MP craniotomies, with further tumor resection in 48 (49%) and 5 (71.4%) cases, respectively. Endoscope-assisted tumor removal was clustered in areas that were generally at farther distances from the craniotomy or in angled locations such as the cribriform plate region where microscopic visualization is limited. Gross-total or near-total resection was achieved in 120/173 (69%) SO approaches and 21/31 (68%) MP approaches. Major complications occurred in 11 (6.4%) SO approaches and 1 (3.2%) MP approach (p = 0.49). The median LOS decreased to 2 days in the last 2 years of the study.

CONCLUSIONS

This clinical experience suggests the SO and MP craniotomies are versatile, safe, and complementary approaches for tumors located in the anterior and middle cranial fossae and perisylvian and parasellar regions. The SO route, used in 85% of cases, achieved greater overall reach than the MP route. Both approaches may benefit from expanded visualization with endoscopy.

Endoscope-controlled extended supraorbital keyhole approach through a modified eyebrow incision for a large dural-based solitary fibrous tumor of the frontal convexity: A technical note

Background:

The extended supraorbital approach through a modified eyebrow incision is a minimally invasive approach that has been recently described. It entails a lateral extension of the skin incision beyond the lateral end of the eyebrow and allows exposure of the proximal sylvian fissure with a superior degree of surgical freedom in the middle fossa and the parasellar region. In this technical note, we describe an endoscope-controlled extended supraorbital keyhole approach with modified eyebrow incision for excision of a large dural-based solitary fibrous tumor of the left frontal convexity.

Methods:

An endoscope-controlled extended supraorbital keyhole approach with modified eyebrow incision was performed to excise a large extra-axial mass attached to the dura of the left frontal convexity and extends from the superior temporal line up to the midline in a 34-year-old male patient presented with 1-year history of headache, dizziness, and blurred vision.

Results:

The patient had an uneventful postoperative course with gross total excision of the lesion and satisfying cosmetic appearance. Histopathological examination revealed a Grade 1 solitary fibrous tumor.

Conclusion:

We demonstrated the feasibility of the endoscope-controlled extended supraorbital keyhole approach through a modified eyebrow incision for excision of tumors that abut the inner table of the frontal calvarial bone, extend highly above the skull base level, or extend medially reaching the midline. The approach is very versatile and allows a great exposure for a category of lesions deemed not perfectly suitable for the classic supraorbital keyhole approach.

Keyhole supraorbital eyebrow approach for the resection of a tuberculum sellae meningioma with intraoperative endoscopic assistance

Background:

Tuberculum sellae meningiomas represent approximately 5–10% of intracranial meningiomas.[2] Although benign, they are associated with substantial morbidity, especially visual disturbance. At present, there are three main treatment options for patients with tuberculum sellae meningiomas: observational, with serial imaging follow; microsurgical resection; and stereotactic radiosurgery. The advantages of the supraorbital eyebrow craniotomy are the direct visualization of the anterior cranial fossa, anterior circulation, and the optical apparatus, reducing the extent of brain retraction, and the absence of risks of temporalis muscle hypotrophy and posterior chewing discomfort. Conversely, minor drawbacks are a steeper learning curve related to a narrower surgical corridor than a standard frontotemporal approach and the minimal risk of supraorbital nerve injury.[1,3]

Case Description:

The authors report the case of a 42-year-old female who presented with acute-onset vision loss and only finger counting in her left eye associated with headache. Magnetic resonance imaging (MRI) showed a suprasellar extra-axial T1 enhancing mass with encasement of the left optic nerve and paraclinoid internal carotid artery and mass effect on the optic chiasm. A keyhole supraorbital eyebrow approach assisted with a microinspection tool was performed for tumor resection and optic nerve decompression. A Simpson Grade 2 tumor resection was achieved, and histopathology revealed a WHO Grade-I tuberculum sellae meningioma. The patient’s presentation, rationale, key surgical steps, and outcome are discussed, and informed consent for surgery and video recording was obtained.

Conclusion:

This surgical video illustrates the use of a keyhole supraorbital eyebrow approach assisted with a microinspection endoscopic tool for the resection of a tuberculum sellae meningioma. The tumor size, extension, and preoperative clinical status determine the optimal surgical corridor in tuberculum sellae meningioma. The keyhole supraorbital eyebrow approach allows safe and direct access to anterior cranial fossa lesions.

Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis

BACKGROUND

Supraorbital eyebrow keyhole craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor resection and aneurysm clipping. The purpose of this study is to provide a contemporary review on the outcomes related to this approach and to determine whether they vary with the type of pathology and the addition of an endoscope.

METHODS

PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used.

RESULTS

A total of 2629 manuscripts were identified. of those, 124 studies (8241 surgical cases) met the inclusion criteria. Mean total complication rate was 26.7 ± 25.7% and the mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross total tumor resection or complete aneurysm clipping, was achieved in 83.6 ± 21.5% of the cases. Vascular pathologies were associated with greater technical success, lower total complications, and longer length of hospital stay compared with tumor cases (P < 0.05 for all). For vascular cases, addition of the endoscope yielded lower technical success (P = 0.001) and lower complication rate (P = 0.041). The use of the endoscope for tumor pathologies did not affect technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate (P > 0.05).

CONCLUSIONS

The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate for both vascular and tumor pathologies.

Endoscopic-assisted surgical approach for butterfly glioma surgery

PURPOSE

Gliomas that spread along the white matter tracts of the corpus callosum to both hemispheres have traditionally been considered surgically challenging largely due to the relative complexity of safely achieving complete resections. We present a series of endoscopic-assisted resections of butterfly gliomas with post-operative radiological assessment of EOR and clinical outcome data.

METHODS

Retrospective review of patients who underwent surgical resection of a butterfly glioma from 2007 to 2020. Butterfly gliomas were defined as gliomas, which appeared to arise from the corpus callosum with significant bilateral extension. All records were retrospectively reviewed with operative/clinical outcomes and complications recorded.

RESULTS

70 patients who underwent an endoscopic-assisted transcortical or interhemispheric approach for butterfly glioma resection met inclusion criteria. A unilateral transcortical approach was used in 86% of cases and an interhemispheric approach in 14%. The endoscope enhanced the visualization of the contralateral hemisphere and allowed for resection of tumor, not reached by standard microscopic visualization, in 100% of cases. 90% of resections resulted in greater than a 95% resection rate. Neurological deficits mostly consisted of motor (10%) and memory (6%) deficits and were most common with posterior tumors of the splenium.

CONCLUSION

The endoscopic-assisted transcortical or interhemispheric approach for butterfly glioma resection is effective in achieving a greater than 95% resection with minimal complications. An angled approach allows careful maneuvering around complex anatomic structures and difficult corners, and should be examined further for its clinical benefits in a prospective manner.

Neurosurgical Approaches to Brain Tissue Harvesting for the Establishment of Cell Cultures in Neural Experimental Cell Models

In recent decades, cell biology has made rapid progress. Cell isolation and cultivation techniques, supported by modern laboratory procedures and experimental capabilities, provide a wide range of opportunities for in vitro research to study physiological and pathophysiological processes in health and disease. They can also be used very efficiently for the analysis of biomaterials. Before a new biomaterial is ready for implantation into tissues and widespread use in clinical practice, it must be extensively tested. Experimental cell models, which are a suitable testing ground and the first line of empirical exploration of new biomaterials, must contain suitable cells that form the basis of biomaterial testing. To isolate a stable and suitable cell culture, many steps are required. The first and one of the most important steps is the collection of donor tissue, usually during a surgical procedure. Thus, the collection is the foundation for the success of cell isolation. This article explains the sources and neurosurgical procedures for obtaining brain tissue samples for cell isolation techniques, which are essential for biomaterial testing procedures.

Keyhole Supraorbital-Eyebrow Approach for Resection of an Olfactory Groove Meningioma with Intraoperative Endoscopic Assistance

The authors present the case of a 52-year-old male with a history of new-onset seizures who presented in status epilepticus. Computed tomography and magnetic resonance imaging demonstrated an olfactory groove mass. A keyhole supraorbital-eyebrow approach assisted with a microinspection tool was performed for tumor resection.^1-5 A Simpson grade 2 tumor resection was achieved, and histopathology revealed a World Health Organization grade I olfactory groove meningioma. Postoperative and follow-up course has been unremarkable, with early postoperative imaging demonstrating no residual tumoral mass. The operative video highlights the advantages of using the microinspection tool for the visualization of deep lesions.

Usefulness of T2 Relaxation Time for Quantitative Prediction of Meningioma Consistency

BACKGROUND

Meningioma consistency is one of the most critical factors affecting the difficulty of surgery. Although many studies have attempted to predict meningioma consistency via magnetic resonance imaging findings, no definitive method has been established, because most have been based on qualitative evaluations. Therefore, the present study examined the potential of the T2 relaxation time (T2 value), a tissue-specific quantitative parameter, for assessment of meningioma consistency.

METHODS

Eighteen surgically treated meningiomas in 16 patients were included in the present study. Preoperatively, the T2 values of all meningiomas were calculated pixel by pixel, and a T2 value distribution map was generated. A total of 27 tumor specimens (multiple specimens were procured if heterogeneous) were taken from these meningiomas, with each localization identified intraoperatively using image guidance. The consistency of the specimens was measured with a durometer, originally a device for measuring the hardness of material such as elastic rubber, and their water content was subsequently measured using wet and dry measurements.

RESULTS

A significant correlation was found between the T2 values of the matched locations identified by image guidance intraoperatively and the consistency measured using the durometer (r = -0.722; P < 0.01) and the water content (r = 0.621; P = 0.01). In addition, the water content correlated significantly with the durometer consistency (r = -0.677; P < 0.01).

CONCLUSIONS

The T2 values could be a reliable quantitative predictor of meningioma consistency, and the T2 value distribution map, which elucidated the internal structure of the tumor in detail, could provide helpful information for surgical resection.

Minimally invasive surgical treatment of intracranial meningiomas in elderly patients (≥ 65 years): outcomes, readmissions, and tumor control

OBJECTIVE

Increased lifespan has led to more elderly patients being diagnosed with meningiomas. In this study, the authors sought to analyze and compare patients ≥ 65 years old with those < 65 years old who underwent minimally invasive surgery for meningioma. To address surgical selection criteria, the authors also assessed a cohort of patients managed without surgery.

METHODS

In a retrospective analysis, consecutive patients with meningiomas who underwent minimally invasive (endonasal, supraorbital, minipterional, transfalcine, or retromastoid) and conventional surgical treatment approaches during the period from 2008 to 2019 were dichotomized into those ≥ 65 and those < 65 years old to compare resection rates, endoscopy use, complications, and length of hospital stay (LOS). A comparator meningioma cohort of patients ≥ 65 years old who were observed without surgery during the period from 2015 to 2019 was also analyzed.

RESULTS

Of 291 patients (median age 60 years, 71.5% females, mean follow-up 36 months) undergoing meningioma resection, 118 (40.5%) were aged ≥ 65 years and underwent 126 surgeries, including 20% redo operations, as follows: age 65-69 years, 46 operations; 70-74 years, 40 operations; 75-79 years, 17 operations; and ≥ 80 years, 23 operations. During 2015-2019, of 98 patients referred for meningioma, 67 (68%) had surgery, 1 (1%) had radiosurgery, and 31 (32%) were observed. In the 11-year surgical cohort, comparing 173 patients < 65 years versus 118 patients ≥ 65 years old, there were no significant differences in tumor location, size, or outcomes. Of 126 cases of surgery in 118 elderly patients, the approach was a minimally invasive approach to skull base meningioma (SBM) in 64 cases (51%) as follows: endonasal 18, supraorbital 28, minipterional 6, and retrosigmoid 12. Endoscope-assisted surgery was performed in 59.5% of patients. A conventional approach to SBM was performed in 15 cases (12%) (endoscope-assisted 13.3%), and convexity craniotomy for non-skull base meningioma (NSBM) in 47 cases (37%) (endoscope-assisted 17%). In these three cohorts (minimally invasive SBM, conventional SBM, and NSBM), the gross-total/near-total resection rates were 59.5%, 60%, and 91.5%, respectively, and an improved or stable Karnofsky Performance Status score occurred in 88.6%, 86.7%, and 87.2% of cases, respectively. For these 118 elderly patients, the median LOS was 3 days, and major complications occurred in 10 patients (8%) as follows: stroke 4%, vision decline 3%, systemic complications 0.7%, and wound infection or death 0. Eighty-three percent of patients were discharged home, and readmissions occurred in 5 patients (4%). Meningioma recurrence occurred in 4 patients (3%) and progression in 11 (9%). Multivariate regression analysis showed no significance of American Society of Anesthesiologists physical status score, comorbidities, or age subgroups on outcomes; patients aged ≥ 80 years showed a trend of longer hospitalization.

CONCLUSIONS

This analysis suggests that elderly patients with meningiomas, when carefully selected, generally have excellent surgical outcomes and tumor control. When applied appropriately, use of minimally invasive approaches and endoscopy may be helpful in achieving maximal safe resection, reducing complications, and promoting short hospitalizations. Notably, one-third of our elderly meningioma patients referred for possible surgery from 2015 to 2019 were managed nonoperatively.

Minimally Invasive Subfrontal Approach: How to Make it Safe and Effective from the Olfactory Groove to the Mesial Temporal Lobe

BACKGROUND

 Different surgical approaches have been developed to manage lesions of the anterior and middle skull base areas. Frontal, pterional, bifrontal, and fronto-orbito-zygomatic approaches are traditionally used to reach these regions. With advancements in the neurosurgical field, skull opening should be simple and as minimally invasive as possible, tailored on the surgical corridor to the target. The supraorbital approach and the "keyhole" concept have been introduced and popularized by Axel Perneczky starting from 1998 and are now considered a part of everyday practice. The extended possibilities of this surgical route, considering the reachable targets and surgical limits, are described and systematically analyzed, including a description of the salient surgical anatomy, presenting different illustrative cases.

METHODS AND RESULTS

 Different illustrative cases are presented and discussed to underline the potentials and limits of the minimally invasive subfrontal approach (MISFA) and the possibilities to tailoring the craniotomy on the basis of the targets: extra-axial lesions with different localizations (anterior roof of the orbit, olfactory groove, tuberculum sellae, medial third of the sphenoid wing, anterior and posterior clinoid process), deeper intra-axial lesions (gyrus rectus, medial temporal lobe-uncus-amygdala-anterior hippocampus), and vascular lesions (anterior communicating aneurysm). Each case has been preoperatively planned considering the anatomical and radiologic features and using virtual simulation software to tailor the best possible corridor to reach the surgical target.

CONCLUSIONS

 The MISFA is a safe multicorridor approach that can be used efficiently to manage lesions of the anterior and middle skull base areas with extremely low approach-related morbidity.

Endoscopic Endonasal and Supraorbital Removal of Tuberculum Sellae Meningiomas: Anatomic Guides and Operative Nuances for Keyhole Approach Selection

BACKGROUND

With growing worldwide endoscopy experience, endonasal and supraorbital removal of tuberculum sellae meningiomas (TSM) has increased.

OBJECTIVE

To describe anatomic factors for guiding approach selection and outcomes.

METHODS

Retrospective analysis of patients undergoing endonasal or supraorbital TSM resection: approach criteria, clinical outcomes, acute magnetic resonance imaging (MRI) fluid-attenuated inversion-recovery (FLAIR)/T2 changes.

RESULTS

From 2008 to 2020, 33 patients (mean age 55 ± 11 yr) were identified: 20 (61%) had endonasal and 13 (39%) supraorbital removal. Comparing endonasal and supraorbital approaches, mean tumor volume (3.7 ± 3.5 cm3 vs 7.7 ± 8.5 cm3, P = .07); percent tumor above planum (42% vs 65%, P = .02), and lateral tumor beyond supraclinoid internal carotid arteries (1.4 ± 2.0 mm vs 4.0 ± 3.2 mm, P = .006) were greater for supraorbital route. Sellar depth was greater for endonasal route tumors (12.2 ± 2.6 mm vs 9.3 ± 2.4 mm, P = .003). Endoscopy, used in 10/13(77%) supraorbital cases, was helpful in additional tumor removal in 4/10(40%). Gross total removal and mean volumetric tumor resection were 16/20(80%) and 97.5% by endonasal, and 5/13(39%) and 96% by supraorbital route. Vision improved in 12/17 (71%) endonasal, 6/8 (75%) supraorbital operations, and worsened in 1 (3%) supraorbital case. Endonasal approach with optic canal decompression increased over study period: 15/20 (75%) endonasal patients vs 1/13(8%) supraorbital (P < .001). Postoperative FLAIR/T2 MRI changes occurred in 2/12 supraorbital and 0/20 endonasal cases.

CONCLUSION

In our experience, both endonasal and supraorbital routes are safe and effective for TSM removal. Greater tumor extension below planum and medial optic canal invasion favor endonasal route, while larger size and lateral extension favor supraorbital route. Given high frequency of TSM growth into optic canals and better access for medial optic canal tumor removal, endonasal route may be preferred for most TSMs.

Meningiomas of the Planum Sphenoidale and Tuberculum Sella

Patients with meningiomas of the planum sphenoidale and tuberculum sella often present with insidious vision loss in one or both eyes as the only sign or symptom of their disease, although other sensory, oculomotor, and even endocrine abnormalities may be seen in a minority of cases. Incidentally discovered tumors also are common, as patients may undergo neuroimaging for unrelated symptoms or events. Depending on the size and orientation of the tumor, central vision loss from optic nerve compression may be a later sign, and loss of peripheral vision in one or both eyes may not be recognized until it has progressed to areas closer to fixation. A thorough neuroophthalmologic assessment including visual field testing will help to define the extent of optic pathway involvement. Both fundus examination and optical coherence tomography of the retinal nerve fiber layer and macular ganglion cell complex will aid in determining prognosis after treatment of the tumor. Orbital surgery rarely is indicated as primary therapy for meningiomas in this location, and surgical resection or debulking is usually pursued before consideration is given to radiation therapy. Because of the long-term risk of residual tumor growth or recurrence, neuroophthalmic surveillance along with serial neuroimaging is required for years after tumor resection and/or radiation therapy.

Transpalpebral Approach for Microsurgical Removal of Tuberculum Sellae Meningiomas

Background:

The evolution of skull base approaches associated with individualization of surgical corridor and minimizing the collateral damage. Achieving the radical removal of tumor and preserving the neurological status of the patient is possible, both with the traditional approaches and keyhole approaches. Our work presents experience using the transpalpebral approach (TPA) for microsurgical removal of tuberculum sellae meningioma (TSM).

Materials and Methods:

A total of 15 patients with meningiomas underwent microsurgical removal of TSM through TPA. Ten patients were women and five were men. The standard preoperative diagnostic protocol includes magnetic resonance imaging with contrast enhancement, brain computed tomography for neuronavigation. We assess surgical complications, functional and cosmetic outcomes, and surgical parameters, including the time of surgery and intraoperative blood loss.

Results:

Visual impairment was finding in 100% patients, including slight decrease of vision (46,7%, seven patients), partial vision field loss (six patients, 40%), and serious visual impairment (two patients 13.3%). Visual improvement was noted in ten cases (66.7%), there was no improvement in four cases (26.7%), and one case (6.6%) had transient visual worsening for 4 days and slow improvement in 1 month. Headache disappeared in three patients (50%). There were no cases of cerebrospinal fluid leak. Transient frontal hypoesthesia was noted in all patients (100%) without permanent deficit. Transient palsy of the frontal muscle was noted in four patients for 4–6 months. Histological examination revealed WHO Grade I meningioma in 14 cases and in 1 case WHO Grade II meningioma. No deaths were identified in follow-up at 12 months. The average value of the Modified Rankin Scale was 1.4. The mean length of stay in hospital was 5.

Conclusion:

TPA is technically difficult and requires some experience to work in deep structures in a small surgical corridor. This technique can be good alternative to traditional fronto-lateral, supraorbital keyhole craniotomies, and endoscopic endonasal approaches.

Supraorbital keyhole approach: Pure endoscopic and endoscope-assisted perspective

OBJECTIVE

To assess the assumed advantages of pure endoscopic and endoscope-assisted methods for the supraorbital keyhole approach. The aim is to demonstrate visibility and accessibility of the pure endoscope approach as a possible standard approach for the supraorbital keyhole approach.

PATIENTS AND METHODS

We performed eight dissections on four cadaver heads using an operating microscope, an endoscope, and neuronavigation. The visibility and accessibility of the anterior and middle cranial fossae regions were compared for each. Special structures were defined to assess their preservation in both approaches. We used pure endoscopy on the eight sides and with a microscope on those same eight sides. Accessibility was quantified for key structures using linear measurements taken with the navigation system. In addition, we present clinical cases in which an endoscope-assisted supraorbital approach was employed.

RESULTS

Our measurements have been reported for each side in the formalin-fixed heads as the mean ± SD (in mm) from the bone margin to selected regions. Moreover, image analysis was performed using ImageJ software to compare selected surface area measurements between the endoscope and microscope images on each side for all cadaveric available specimens. There were no significant statistical differences between visualization of the selected areas. This means that by visual analysis both endoscopic and microscopic images can provide the surgeon nearly the same visibility and accessibility of a selected region.

CONCLUSION

A pure endoscopic method can be used to conduct the supraorbital keyhole approach when the endoscope is used as a primary tool. Our recommendation is to use the measurements described in this study for preoperative planning of the keyhole approach. We believe that with advances in neuro-endoscope technology, and instrumentations, the endoscopic approach may replace the microscopic approach in the near future.

Minimally Invasive Resection of Brain Metastases

BACKGROUND

Minimally invasive resection of brain metastases aims to maximize resection while minimizing brain trauma.

METHODS

Patients with 1 or more metastases that underwent resection following neuro-oncology multidisciplinary meeting discussion from September 2014 to October 2018, with pre- and postoperative magnetic resonance imaging, were included. All patients including posterior fossa metastases or multiple metastases were positioned supine. Hair was not shaved. Volumetric postcontrast T1 magnetic resonance imaging was used for incision planning and neuronavigation. The craniotomy site was tailored to tumor depth according to keyhole principles and ranged between 2 and 5 cm. Intraoperative monitoring and awake mapping were carried out in selected cases.

RESULTS

Out of 320 consecutive patients with brain metastases, 44 patients were identified as suitable for minimally invasive resection. Nine patients had no postoperative imaging and were excluded. There were 38 metastases in 35 patients. There were 18 cerebellar metastases, 10 frontal, 3 parietal, 3 occipital, 2 temporal, 1 intraventricular, and 1 basal ganglia. Median length of stay was 3 days (range, 1-24). Average tumor volume was 54.7 cm³ (range, 10-240 cm³). Endoscopic assistance was used in 4 patients. Median performance status improved from 2 to 1 (range, preoperative: 0-4; postoperative: 0-2). Median survival was 14.7 months.

CONCLUSIONS

Minimally invasive resection of brain metastasis is safe and effective, and in selected cases confers advantages compared with standard techniques.

Extended Supraorbital Approach with Modified Eyebrow Incision: Technical Note

BACKGROUND

The extended supraorbital approach through a modified eyebrow incision is a minimally invasive variant of the frontotemporal or pterional approach that enriches a neurosurgeon's armamentarium for the treatment of pathologies lateral to the anterior clinoid process, by advancing laterally with frontal facial nerve branches monitoring. To demonstrate the steps of the approach, we studied 2 formalin-fixed and artery/vein silicone-injected adult cadaveric heads, and reviewed 1 of the 3 clinical cases operated on to illustrate the applicability of the approach.

CLINICAL PRESENTATION

A 56-year-old woman presented with a history of seizures and a complaint of headache that started 2 months ago. She underwent an examination with brain magnetic resonance imaging that showed a dural-based lesion at the medial third of the lesser wing of sphenoid (which is consistent with meningioma). The patient underwent craniotomy with an extended supraorbital approach through a modified eyebrow incision that allowed Simpson grade II removal to be performed and good aesthetic outcome to be achieved.

CONCLUSIONS

The extended supraorbital approach through a modified eyebrow incision is a minimally invasive approach that can add to a neurosurgeon's armamentarium and be used with microscopy, assisted by endoscope, or both to reach the anterior and middle cranial fossae.

Lessons learned in the evolution of endoscopic skull base surgery

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.

Supraorbital Keyhole Approach: Lessons Learned from 106 Operative Cases

OBJECTIVE

The supraorbital keyhole approach through an eyebrow incision has been a potentially less invasive approach as an alternative to the standard pterional craniotomy. We aimed to review procedures for anterior and middle cranial fossa lesions and identify lessons learned from addressing various pathologies through this approach.

METHODS

We retrospectively reviewed 106 consecutive patients who underwent this approach. We documented patients' age, sex, pathology, clinical results, extent of tumor resection, complications, use of endoscope, and cosmetic results.

RESULTS

Our series addressed a variety of pathologies. Male patients accounted for 55% of the cohort and mean age was 51.7 (2-79) years. Notably, 52% of patients underwent resection of extra-axial masses. Gross total resection was achieved in 74.4% of intra-axial lesions according to postoperative imaging. Two (1.9%) patients developed transient ptosis. One (0.9%) patient developed an allergic reaction to titanium. No cerebrospinal fluid fistula or rhinorrhea occurred. Three patients developed temporary diabetes insipidus after resection of parasellar lesions (2 craniopharyngiomas and 1 pituitary adenoma). In 14 patients with olfactory groove meningiomas, 6 (42.8%) suffered from absence or diminished olfaction postoperatively, and 2 (14.2%) developed postoperative anosmia. Five (38.5%) patients underwent a subsequent resection of recurrent glial tumors. Four weeks postoperatively, 95% of patients demonstrated acceptable cosmetic results. Cosmetic results for 6 (5%) patients were unavailable.

CONCLUSIONS

The supraorbital keyhole approach may be safely used for various lesions within the anterior and middle cranial fossa. The effectiveness and limitations of this approach and possible complications are discussed. This is a valuable approach for selected patients.

Utility of calcium phosphate cement cranioplasty following supraorbital approach for tumor resection

OBJECTIVE

We have previously documented the utility of calcium phosphate cement cranioplasty following retromastoid craniectomy. In this study, we aimed to demonstrate its efficacy following a supraorbital approach for tumor resection.

METHODS

A retrospective analysis of a prospectively maintained database was conducted of eight patients (7 female, 1 male) with anterior cranial fossa meningiomas resected via a supraorbital approach followed by cranioplasty involving adjunctive or sole use of calcium phosphate cement.

RESULTS

Cranioplasty was achieved in all patients. No patient developed an incisional leak. The cohort had a mean follow-up of approximately 3.1 months (range: 0.5-7 months) in which time no further complications were noted. No patients developed post-surgical infections.

CONCLUSION

In our experience, a low incidence of infection or CSF leaks has been noted after the use of calcium phosphate cement retromastoid cranioplasty. Extending this technique to supraorbital craniotomies may minimize incisional CSF leak.

Outcomes After Transcranial and Endoscopic Endonasal Approach for Tuberculum Meningiomas-A Retrospective Comparison

BACKGROUND

Degree of resection and visual outcome are the main concerns in the surgical resection of tuberculum sellae meningioma (TSM). In addition to the transcranial approach (TCA), the endoscopic endonasal approach (EEA) has been used increasingly. However, the controversy regarding the optimal surgical approach is not clearly resolved.

METHODS

We compared the surgical outcomes of each approach for TSMs from 44 patients receiving EEA and 40 patients receiving TCA in 2 institutions between 2004 and 2015. We analyzed the surgical outcomes and affecting factors for the relapse of tumor and visual outcome.

RESULTS

Gross total resection rates and relapse-free survival were not different between the 2 groups; however, the locations of residual or recurred tumor definitely differed. All recurrences in the TCA group were in the sella turcica, whereas residual tumors in EEA group were mainly located at lateral or superior to the clinoid process. The complete or partial improvement rate of visual function in the EEA group was 97.7%, but 9 patients (23.7%) in the TCA group experienced visual deterioration after surgery. EEA and younger age (<55 years) were associated with favorable visual outcome. Cerebrospinal fluid leakage occurred in only one case in the EEA group.

CONCLUSIONS

Surgical approaches do not affect the gross total resection rates, but the locations of residual tumor or recurrence differ according to surgical approaches. EEA is superior to TCA in visual outcome. At least in pure TSMs, the trend seems to be shifting in favor of EEA, considering the huge difference in visual outcome.

Supraorbital Keyhole Approach to the Sella and Anterior Skull Base via a Forehead Wrinkle Incision

OBJECTIVE

To evaluate safety and effectiveness of supraorbital keyhole approach to the sella and anterior skull base via a forehead wrinkle incision.

METHODS

We analyzed and reclassified forehead wrinkle types in 100 recruited healthy individuals. Twenty patients with different intracranial lesions in the sella and anterior skull base areas were selected for surgery using the supraorbital keyhole approach via a forehead wrinkle incision by forehead wrinkle type. All clinical patient records were retrospectively reviewed.

RESULTS

Based on the feasibility of the surgical approach, the forehead wrinkles in Chinese individuals were categorized into 2 types: horizontal linear and nonlinear. Gross total removal of the lesions was achieved in 90% of the cases using this approach. All patients had excellent cosmetic results. Except for 2 patients with poor prognoses, a high level of comfort and satisfaction with the forehead wrinkle incisions was obtained based on the scale scores of pain from scars and headaches and satisfaction with the cosmetic results. No permanent approach-related complications occurred.

CONCLUSIONS

The supraorbital keyhole approach via a forehead wrinkle incision was safe and effective. This approach provided a sufficient visual field for lesion resection and satisfactory cosmetic results for patients.

Combined Minimally Invasive Supraciliary and Transfacial Approach for Large Tumors with Skull Base and Sinonasal Involvement

BACKGROUND

Tumors invading both the anterior skull base and the sinonasal area have traditionally been accessed via largely invasive open craniofacial approaches. Minimally invasive extended endoscopic endonasal approaches have recently become increasingly available but have anatomical limitations and require incremental experience and thus high patient volume. Our objective was to assess the applicability of a novel combination of the minimally invasive supraciliary incision and the limited maxillofacial osteotomy as a combined surgical approach for large tumors invading both the anterior skull base and the sinonasal area.

METHODS

The well-established technique of supraciliary incision with a 2.5 × 3.0-cm craniotomy was combined for the first time with limited facial translocation approach.

RESULTS

This series involves 11 cases (female/male ratio 4:7; ranging in age from 6 to 61 years). Intracranial tumor propagation with intranasal and ethmoidal extension was detected in all patients. The pathologic diagnoses included adenocarcinomas, esthesioneuroblastoma, rhabdomyosarcoma, sinonasal papilloma, meningioma, and neurofibroma. The postoperative approach-related mortality rate was zero. No case of cerebrospinal fluid leak was detected. The 3-year survival rate was 70%.

CONCLUSIONS

The limited transfacial approach in combination with a supraciliary extension is associated with minimal mortality and morbidity and facilitates gross total tumor removal. We highly recommend this approach for the surgical treatment of large tumors invading both the anterior skull base and the sinonasal area, especially for those being out of indication for extended endoscopic endonasal surgery.

Transfrontal-Sinus-Subcranial Approach to Olfactory Groove Meningiomas: Surgical Results and Clinical and Functional Outcome in a Consecutive Series of 21 Patients

BACKGROUND

The transfrontal-sinus-subcranial approach (TFSSA) allows for direct exposure and removal of olfactory groove meningiomas (OGMs), without any brain retraction. Compared with other skull base approaches (e.g., fronto-orbitobasal, transbasal, subcranial, fronto-orbitozygomatic, and one-and-half approach), it could offer the same advantages but is less invasive.

OBJECTIVE

We report the results in a series of 21 consecutive patients with OGMs and operated on through TFSSA, to propose a viable alternative approach.

METHODS

Mean maximum tumor diameter was 45.9 ± 3.4 mm (range, 25-70 mm). The aim of surgery was Simpson grade I removal. Surgical, clinical, and functional outcomes were reported. Mean follow-up was 87 ± 7 months (range, 36-176 months).

RESULTS

In all patients, magnetic resonance imaging after surgery confirmed complete tumor removal. The recurrence-free survival rate was 100% and 85.7% at 5 and 10 years, respectively. Surgery-related mortality and major morbidity were 0% and 4.8%, respectively. Risk of anosmia significantly correlates with meningioma size (P < 0.001) and smell sense was preserved only in patients with tumors less than 4 cm in maximum diameter (4/7; 57.1%). A significant improvement of Mini Mental Standard Examination score was recorded at follow-up (P < 0.001) and no patients worsened their cognitive profile. Visual function improved in 7/8 (87.5%). Karnofsky Performance Scale score after surgery significantly increased (P < 0.001). According to the Glasgow Outcome Score, good outcome was achieved in 20 patients (95.2%).

CONCLUSIONS

Based on reported results, TFSSA allows complete tumor removal with good outcome and low complication rate. It may be proposed as a safe and effective approach to treat large and giant OGMs.

A Review of the Literature on the Transciliary Supraorbital Keyhole Approach

BACKGROUND

Conventional craniotomy approaches involve substantial soft tissue manipulation that can cause complications. The transciliary supraorbital keyhole approach was developed to avoid these complications. The aim of this review is to evaluate the safety and the effectiveness of the transciliary supraorbital keyhole approach.

METHODS

We searched the PubMed/Medline database for full-text publications from 1996 onward containing data on 100 or more cases of aneurysm clipping or tumor resection by the transciliary supraorbital keyhole approach. The primary outcome was the incidence of approach-related complications. The secondary outcomes were the aneurysm occlusion rate and the extent of tumor resection.

RESULTS

Eight publications met the eligibility criteria. All publications were of the retrospective case-series or case-cohort type without any independent assessment of outcomes. The risk of bias at the individual study level may thus have influenced any conclusions drawn from the overall study population, which included 2783 patients with 3085 lesions (2508 aneurysms and 577 tumors). Approach-related complications included 3.3% cerebrospinal fluid collection or leak, 4.3% permanent and 1.6% temporary supraorbital hypesthesia, 2.9% permanent and 1% temporary facial nerve palsy, and 1% wound healing disturbance or wound infection. Complete aneurysm clipping was achieved in 97% of cases. Complete tumor resection in 90% of cases. The overall surgical revision rate was 2.5%. The esthetic outcome was typically reported as highly acceptable.

CONCLUSIONS

This approach may represent a safe, effective, and less invasive alternative to conventional craniotomies in experienced hands and for a well-selected subset of patients. However, higher-level evidence is needed to confirm this hypothesis.

Role of Endoscopic Skull Base and Keyhole Surgery for Pituitary and Parasellar Tumors Impacting Vision

Significant advances over the last 2 decades in imaging technology, instrumentation, anatomical knowledge, and reconstructive techniques have resulted in the endonasal endoscopic approach becoming an integral part of modern skull base surgery. With growing use and greater experience, surgical outcomes continue to incrementally improve across many skull base pathologies, including those tumors that impact vision and ocular motility. The importance of the learning curve and use of a multi-disciplinary approach is critical to maximizing success, minimizing complications, and enhancing quality of life in these patients. Realizing the limits of the endonasal route and reasonable use of transcranial approaches such as the supraorbital eyebrow craniotomy, it may br appropriate to consider nonsurgical therapy including various forms of radiotherapy [corrected] and medical treatment options.

The evolving role of the oculoplastic surgeon in skull base surgery

PURPOSE OF REVIEW

Classical orbital approaches in skull base surgery have involved large incisions with extensive bone removal resulting in prolonged recovery with associated morbidity and mortality. The purpose of this review is to explore recent advances in skull base surgery that are applicable to the orbital surgeon.

RECENT FINDINGS

Transnasal endoscopic surgery provides access to the medial 180 degrees of the orbit. Access to the lateral 180 degrees may be obtained using transmaxillary and transcranial techniques. Transorbital approaches and multiport techniques further expand the reach of the skull base surgeon. These minimally invasive techniques are supplanting the classical pterional, frontotemporal, frontotemporal orbitozygomatic, frontal, and subfrontal approaches.

SUMMARY

The role of the orbital surgeon in skull base surgery is changing. Transnasal and transcranial approaches to orbital disorders using minimally invasive techniques are becoming more common. In addition, transorbital access to the skull base, paranasal sinuses, and anterior and middle cranial fossa is offering new opportunities for the orbital surgeon.

The expanding role of the endonasal endoscopic approach in pituitary and skull base surgery: A 2014 perspective

BACKGROUND

The past two decades have been the setting for remarkable advancement in endonasal endoscopic neurosurgery. Refinements in camera definition, surgical instrumentation, navigation, and surgical technique, including the dual surgeon team, have facilitated purely endonasal endoscopic approaches to the majority of the midline skull base that were previously difficult to access through the transsphenoidal microscopic approach.

METHODS

This review article looks at many of the articles from 2011 to 2014 citing endonasal endoscopic surgery with regard to approaches and reconstructive techniques, pathologies treated and outcomes, and new technologies under consideration.

RESULTS

Refinements in approach and closure techniques have reduced the risk of cerebrospinal fluid leak and infection. This has allowed surgeons to more aggressively treat a variety of pathologies. Four main pathologies with outcomes after treatment were identified for discussion: pituitary adenomas, craniopharyngiomas, anterior skull base meningiomas, and chordomas. Within all four of these tumor types, articles have demonstrated the efficacy, and in certain cases, the advantages over more traditional microscope-based techniques, of the endonasal endoscopic technique.

CONCLUSIONS

The endonasal endoscopic approach is a necessary tool in the modern skull base surgeon's armamentarium. Its efficacy for treatment of a wide variety of skull base pathologies has been repeatedly demonstrated. In the experienced surgeon's hands, this technique may offer the advantage of greater tumor removal with reduced overall complications over traditional craniotomies for select tumor pathologies centered near the midline skull base.

The supraorbital eyebrow approach in children: clinical outcomes, cosmetic results, and complications

OBJECT

The supraorbital eyebrow approach utilizes an eyebrow skin incision to fashion a supraorbital craniotomy for exposure of the subfrontal corridor. This provides anterolateral access to surgical lesions in the anterior cranial fossa, parasellar regions, brainstem, and medial temporal lobe. With use of the endoscope, further areas can be accessed. This approach has been applied effectively in adults, but questions remain about its use in children-specifically with regard to adequate working space, effectiveness for achieving the desired results, cosmesis, and complications.

METHODS

The authors conducted a retrospective review of more than 450 cases involving patients of all ages who had undergone a supraorbital eyebrow approach performed by the senior author (C.T.) from 1995 to 2013. Only cases involving patients younger than 18 years with a minimum follow-up of 6 weeks were included in this study. All inpatient and outpatient records were retrospectively reviewed and clinical/operative outcomes, cosmetic results, and complications were recorded. In the present article, the authors briefly describe the surgical approach and highlight any differences in applying it in children.

RESULTS

Fifty-four pediatric patients who had undergone a supraorbital eyebrow approach met inclusion criteria. The pathological conditions consisted mostly of tumors or other resectable lesions. In a total of 51 resectable lesions, 44 surgeries resulted in a gross-total (100%) resection and 7 cases resulted in subtotal (50%-99%) resection. The endoscope assisted and expanded visualization or provided access to areas not reached by standard microscopic visualization in all cases. Cosmetic outcomes were excellent. In all cases, the incisional scar was barely visible at 6 weeks. In 3 cases a minor bone defect was observed on the forehead. Given the small size of the frontal sinus in children, no frontal sinus breaches occurred. Additionally, no CSF leak or wound infection was identified.

CONCLUSIONS

The supraorbital eyebrow approach is extremely effective in achieving desired results in properly selected cases in patients of all pediatric age ranges, from infants to teenagers. There is sufficient working space for the endoscope and all instruments, allowing for endoscopic assistance and bimanual surgical technique. Cosmetic results are excellent, and complications related to the approach are minimal.