Endoscopic Endonasal Craniofacial Surgery for Recurrent Skull Base Meningiomas Involving the Pterygopalatine Fossa, the Infratemporal Fossa, the Orbit, and the Paranasal Sinus

Combined Endoscopic Transorbital and Transmaxillary-Pterygoid Approach for a Recurrent Spheno-Orbital Meningioma: 2-Dimensional Operative Video

Spheno-orbital meningiomas are challenging invasive tumors, involving different cranial regions, requiring multiple surgical approaches and often with an unfavorable biological behavior characterized by multiple recurrences and possible escape from standard treatments. 1 We present a case of a 57-year-old woman, already undergone a transcranial approach, an endoscopic transorbital surgery, and a radiosurgical treatment for a spheno-orbital meningioma. She presented a further tumoral recurrence, involving the orbit and the infratemporal and pterygopalatine fossa, and we proposed a combined fully endoscopic multistaged approach. The patient consented to the procedure and to the publication of his/her image. We adopted the endoscopic transorbital and the endoscopic transmaxillary-pterygoid corridors for the different portions of the tumor, followed by radiation therapy with carbon ions, achieving a large tumor resection with no progression at 12-month follow-up and without complications or neurological sequelae. This treatment strategy gave us the possibility to fully manage the tumoral extension with 2 innovative minimally invasive surgical procedures, which resulted well-tolerated and favored the prompt patient recovery and quality-of-life preservation, leaving the meningioma remnant to the external radiation therapy. 2-6 Our case emphasizes the possibilities given by the endoscopic approaches to manage at 360° the multiregional extensions of a spheno-orbital meningioma, demonstrating how such direct and extracranial corridors could allow the surgeon to remove these tumors, with no brain retraction or manipulation and limited functional or neurological sequelae. 7,8

Recurrent Meningothelial Meningioma With Multiple Extensions: A Complex Case Study

This case report presents a comprehensive analysis of a 67-year-old patient diagnosed in 2017 with meningothelial meningioma, focusing on the challenges of managing such tumors and their neurological implications. Meningiomas, being the most common benign intracranial neoplasms, have a notable research gap regarding their association with seizures and motor deficits. This patient, who had a history of depressive disorder, persistent cephalalgia syndrome, and ataxic gait, initially presented with symptoms including ataxic gait, confusion, and headache. Imaging revealed a large, hyperdense right frontal meningioma with a significant mass effect. Following surgical resection, the patient experienced notable neurological improvement. However, in 2023, the patient re-presented with bradypsychia, bradykinesia, and memory disorders, indicating a recurrent meningioma. This case exemplifies the recurrence and complex management of meningiomas, particularly in elderly patients, and highlights the importance of individualized treatment strategies. Surgical resection remains the primary treatment approach, supplemented by radiotherapy in cases of recurrence or incomplete resection. The case underscores the need for advancements in therapeutic approaches to mitigate recurrence risks and enhance patient outcomes in meningioma management. This is especially pertinent given the tumor's predilection for older females and its varied neurological manifestations, such as ataxic gait and seizures.

Long-term Outcomes of Non-vascularized Multilayer Fascial Closure Technique for Dural Repair in Endoscopic Transnasal Surgery: Efficacy, Durability, and Limitations

OBJECTIVE

Non-vascularized multilayer fascial closure technique (NMFCT) can be used instead of nasoseptal flap reconstruction for dural repair in endoscopic transnasal surgery (ETS); however, due to the lack of blood supply, its long-term durability and possible limitations need to be clarified.

METHODS

This was a retrospective study on patients who underwent ETS with intraoperative cerebrospinal fluid (CSF) leakage. We assessed the postoperative and delayed CSF leakage rates and the associated risk factors.

RESULTS

Among 200 ETSs with intraoperative CSF leakage, 148 (74.0%) ETSs were performed for skull base pathologies other than pituitary neuroendocrine tumor. The mean follow-up period was 34.4 months. Esposito grade 3 leakage was confirmed in 148 (74.0%) cases. NMFCT was used either with (67 [33.5%]) or without (133 [66.5%]) lumbar drainage. There were 10 cases (5.0%) of postoperative CSF leakage that necessitated reoperation. In 4 other cases (2.0%), CSF leakage was suspected but lumbar drainage alone successfully restored the condition. Multivariate logistic regression analyses revealed that posterior skull base location (P < 0.01, odds ratio 11.5, 95% CI 1.99-2.17 × 102) and craniopharyngioma pathology (P = 0.03, odds ratio 9.4, 95% CI 1.25-1.92 × 102) were significantly associated with postoperative CSF leakage. No delayed leakage occurred during the observation period except for 2 patients who underwent multiple radiotherapies.

CONCLUSIONS

NMFCT is a reasonable alternative with long-term durability, though vascularized flap may be a better choice for cases in which vascularity of the surrounding tissues is significantly impaired due to interventions including multiple radiotherapies.

Tumors Involving the Infratemporal Fossa: A Systematic Review of Clinical Characteristics and Treatment Outcomes

BACKGROUND

Infratemporal fossa (ITF) tumors represent various pathologies and are seldom described in the literature, reflecting their rarity. Here we review the literature on tumors invading ITF and describe patient characteristics, treatment strategies, and clinical outcomes.

METHODS

Relevant articles were retrieved from PubMed, Scopus, and Cochrane. A systematic review and meta-analysis were conducted on the clinical presentation, treatment protocols, and clinical outcomes.

RESULT

A total of 27 articles containing 106 patients with ITF tumors (median tumor size: 24.3 cm³ [interquartile range, 15.2-42 cm³]) were included (median age: 46 years [interquartile range, 32-55 years]; 59.4% were males]). Of the confirmed tumor pathology data, schwannomas (n = 24; 26.1%) and meningiomas (n = 13; 14.1%) were the most common tumors. Facial hypoesthesia (n = 22; 18.5%), auricular/preauricular pain (n = 20; 16.8%), and headaches (n = 11; 9.2%) were the most common presenting symptoms. Of patients who had surgical resection (n = 97; 95.1%), 70 (73.7%) had transcranial surgery (TCS) and 25 (26.3%) had endoscopic endonasal surgery (EES). Among available details on the extent of resection (n = 84), gross-total resection (GTR) was achieved in 62 (73.8%), and 5 (6.0%) had biopsy only. Thirty-five (33.0%) patients had postoperative complications. Among cases with available data on reconstruction techniques (n = 8), four (50%) had adipofascial antero-lateral thigh flap, three (37.5%) had latissimus dorsi free flap, and one (12.5%) had antero-lateral thigh flap. Fourteen (13.2%) patients had adjuvant chemotherapy, and sixteen (15.1%) had adjuvant radiotherapy. During a median follow-up time of 28 months (IQR, 12.25-45.75 months), 15 (14.2%) patients had recurrences, and 18 (17.0%) patients died. The median overall survival (OS) time was 36 months (95% confidence interval: 29-41 months), and the 5-year progression-free survival (PFS) rate was 61%.

CONCLUSION

Various tumor types with different biological characteristics invade the ITF. The present study describes patient demographics, clinical presentation, management, and outcomes. Depending on the tumor type and patient condition, patient-tailored management is recommended to optimize treatment outcomes.

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.

Pterygovaginal artery as a target of embolization before endoscopic skull base surgery

BACKGROUND

The pterygovaginal artery (PtVA), a recurrent branch of the internal maxillary artery (IMA), can be a feeder of skull base tumors. Preoperative embolization can help endoscopic resection of hypervascular lesions, which is performed under a narrow surgical space with restricted instrumental maneuverability.

METHODS

We performed preoperative embolization in five cases with hypervascular skull base lesions supplied by the PtVA, four of which were resected via endoscopic endonasal approach. In two cases, selective PtVA embolization through the distal IMA was successfully conducted.

RESULTS

In all the cases, intraoperative bleeding during endoscopic resection was easily controlled. The medial and lateral origins of the PtVA from the IMA were demonstrated by cone-beam CT images reconstructed from three-dimensional rotational angiography, and anastomoses around the eustachian tube and soft palate were visualized by superselective angiography.

CONCLUSIONS

The PtVA embolization can be an effective strategy before endoscopic skull base tumor resection. When embolizing through the PtVA, clinicians should be aware of its anatomical variations and dangerous anastomoses. Understanding the surrounding angioarchitecture by angiographic techniques helps ensure safe embolization.

Angio-anatomical study of the pterygovaginal artery based on cone-beam computed tomography

PURPOSE

To investigate the anatomical characteristics and clinical implications of the pterygovaginal artery (PtVA), a recurrent branch from the distal internal maxillary artery (IMA), which courses through the pterygovaginal canal that connects the pterygopalatine fossa and nasopharynx.

METHODS

Eighty-two patients with 90 sides of cone-beam computed tomography (CBCT) reconstructed from rotational angiography of the external or common carotid artery with a field of view covering the pterygopalatine fossa were retrospectively reviewed. The origin from the IMA, branching type, distribution, and anastomoses was evaluated. The underlying lesions were 36 hypervascular lesions with possible supply from PtVA (17 cavernous sinus arteriovenous fistulas (AVFs), 6 anterior condylar AVFs, and 13 nasopharyngeal, parasellar, or paraclival tumors) and 46 other diseases.

RESULTS

PtVA was identified in 75 sides (83%). It originated from the pterygopalatine segment of the IMA in 45 sides (60%) and from the pterygoid segment in 30 sides (40%). It arose independently (77%), sharing the common trunk with the Vidian artery (15%) or with other branches. It ran posteromedially through the pterygovaginal canal to supply the mucosa over the nasopharyngeal roof, the choanae, and the pharyngeal ostium of the eustachian tube. It anastomosed with the ascending pharyngeal artery (n=37), the accessory meningeal artery (n=7), and the mandibular artery from the petrous internal carotid artery (n=2). It served as a feeder of osseous AVFs and skull base tumors.

CONCLUSION

PtVA was often identified by CBCT even in normal anatomy. Its detailed angio-anatomy could be evaluated in the presence of parasellar or paraclival hypervascular lesions.

Endoscopic transmastoid posterior petrosal approach for locally aggressive tumors in the petrous part of the temporal bone involving the internal auditory canal, jugular foramen, and hypoglossal canal

OBJECTIVE

The posterior petrosal approach is an established surgical method offering wide access to skull base lesions through mastoid air cells. The authors describe their experience with the endoscopic transmastoid "posterior petrosal" approach (EPPAP) for skull base tumors involving the internal auditory canal (IAC), jugular foramen, and hypoglossal canal.

METHODS

The EPPAP was performed for 7 tumors (3 chordomas, 2 chondrosarcomas, 1 schwannoma, and 1 solitary fibrous tumor). All surgical procedures were performed under endoscopic visualization with mastoidectomy. The compact bone of the mastoid air cells and posterior surface of the petrous bone are carefully removed behind the semicircular canals. When removal of cancellous bone is extended superomedially through the infralabyrinthine space, the surgeon can expose the IAC and petrous portion of the internal carotid artery to reach the petrous apex (infralabyrinthine route). When removal of cancellous bone is extended inferomedially along the sigmoid sinus, the surgeon can safely reach the jugular foramen (transjugular route). Drilling of the inferior surface of petrous bone is extended further inferoposteriorly behind the jugular bulb to approach the hypoglossal canal and parapharyngeal space through the lateral aspect of the occipital condyle (infrajugular route).

RESULTS

Of the 7 tumors, gross-total resection was achieved in 4 (57.1%), subtotal resection (> 95% removal) in 2 (28.6%), and partial resection (90% removal) in 1 (14.2%). Postoperatively, 2 of 3 patients with exudative otitis media showed improvement of hearing deterioration, as did 2 patients with tinnitus. Hypoglossal nerve palsy and swallowing difficulty were improved after surgery in 2 patients and 1 patient, respectively. In 1 patient with severe cranial nerve deficits before surgery, symptoms did not show any improvement.

CONCLUSIONS

The authors present their preliminary experience with EPPAP for skull base tumors in the petrous part of the temporal bone and the lateral part of the occipital condyle involving the cranial nerves and internal carotid arteries. The microscope showed a higher-quality image and illumination in the low-power field. However, the endoscope could offer wider visualization of the surgical field and contribute to minimizing the size of the surgical pathways, necessity of brain retraction, and eventually the invasiveness of surgery. Thus, the EPPAP may be safe and effective for skull base tumors in the petrous region, achieving balance between the radicality and invasiveness of the skull base surgery.

Clinial Features, Individualized Treatment and Long-Term Surgical Outcomes of Skull Base Meningiomas With Extracranial Extensions

Object: Skull base meningiomas with extracranial extensions are rarely described. This study describes the clinical features, surgical management and clinical outcomes of these rare tumors and investigates risk factors associated with progression-free survival (PFS). Methods: The clinical data of 34 consecutive patients who underwent surgery for skull base meningiomas with extracranial extensions from 2007 to 2018 were retrospectively collected and analyzed. Results: The mean patient age was 47.9 ± 13.9 years; 50.0% were male. The most common symptoms on admission were ophthalmic. All patients underwent a multidisciplinary consultation before surgery, and received individualized surgical management. The gross total resection (GTR) rate was 55.9% (19/34). Twelve patients received post-operative adjuvant radiotherapy (RT). Twelve patients experienced tumor recurrence during the follow-up period. The median PFS duration was 54 months. The mean overall survival (OS) duration was 111 months. By univariate analysis, a higher histological grade (WHO grade II and III), Ki-67 LI ≥ 5 and the extent of resection (EOR) were significantly associated with tumor recurrence. Multivariate analysis revealed Ki-67 LI ≥ 5, the EOR and adjuvant RT as prognostic factor of PFS. Conclusions: These relatively rare meningiomas are difficult to resect and have a poor prognosis; they are more common in males and have a higher histological grade than intracranial meningiomas. Multidisciplinary collaboration and individualized surgical strategies are crucial for surgically managing these complex tumors. Total removal of the tumor remains challenging. Subtotal resection (STR) or partial resection (PR) followed by RT is a reasonable strategy when radical resection is infeasible. Adjuvant RT should be recommended especially for tumors with histopathological risk factors (Ki-67 LI ≥ 5 or high histological grade).

A New Bony Anatomical Landmark for Lateral Skull Base Surgery

BACKGROUND AND OBJECTIVE

The aim of the study was to propose a new bony landmark, point O, which is the junction point of the temporosphenoid suture and the infratemporal ridge; this landmark may improve the identification and preservation of neurovascular structures when approaches are used to access the middle cranial fossa in lateral skull base tumor surgeries.

METHODS

Fifteen cadaveric heads were measured for anatomical analysis. Related surgical landmarks were studied using the Destroscope virtual reality system and during the dissection procedures, and the results were analyzed and compared.

RESULTS

From the perspective of the middle skull base, the radial lines from point O to the interior point of the superior orbital fissure, foramen rotundum, foramen ovale, and foramen spinosum are approximately equal in length, with an average length of 23.22 mm, and the above 5 points form a sector with an angle of 66.07° and an area of 310.71 mm.

CONCLUSIONS

Identification of point O as a landmark for lateral skull base surgery when other landmarks are not recognizable optimizes patient safety and surgeon confidence during complicated operations. The interior points of the superior orbital fissure, foramen rotundum, foramen ovale, and foramen spinosum are distributed on the arc of a circle whose center is point O. The sector formed by the above 5 points is not only a crucial area for the communication of lesions between the middle skull base and the infratemporal fossa but also a safe avenue through which to remove skull base lesions.

CT-MRI Image Fusion-Based Computer-Assisted Navigation Management of Communicative Tumors Involved the Infratemporal-Middle Cranial Fossa

Objective  Computed tomography (CT) and magnetic resonance imaging (MRI) are crucial for preoperative assessment of the three-dimensional (3D) spatial position relationships of tumor, vital vessels, brain tissue, and craniomaxillofacial bones precisely. The value of CT-MRI-based image fusion was explored for the preoperative assessment, virtual planning, and navigation surgery application during the treatment of communicative tumors involved the infratemporal fossa (ITF) and middle cranial fossa. Methods  Eight patients with infratemporal-middle cranial fossa communicative tumors (ICFCTs) were enrolled in this retrospective study. Plain CT, contrast CT, and MRI image data were imported into a workstation for image fusion, which were used for 3D image reconstruction, virtual surgical planning, and intraoperative navigation sequentially. Therapeutic effect was evaluated through the clinical data analysis of ICFCT patients after CT-MRI image fusion-based navigation-guided biopsy or surgery. Results  High-quality CT-MRI image fusion and 3D reconstruction were obtained in all eight cases. Image fusion combined with 3D image reconstruction enhanced the preoperative assessment of ICFCT, and improved the surgical performance via virtual planning. Definite pathological diagnosis was obtained in all four navigation-guided core needle biopsies. Complete removal of the tumor was achieved with one exception among the seven navigation-guided operations. Postoperative cerebrospinal fluid leakage occurred in one patient with recurrent meningioma. Conclusion  CT-MRI image fusion combined with computer-assisted navigation management, optimized the accuracy, safety, and surgical results for core needle biopsy and surgery of ICFCTs.

Neuroendoscopic Resection of Trigeminal Schwannoma in the Pterygopalatine/Infratemporal Fossa via the Transnasal Perpendicular Plate Palatine Bone or Transnasal Maxillary Sinus Approach

BACKGROUND

Both the pterygopalatine fossa (PPF) and the infratemporal fossa (ITF) lie outside the midline of the skull base. Lesions in the PPF or ITF include trigeminal schwannoma (trigeminal schwannoma, TS), which originates from the second or third branch of the trigeminal nerve (maxillary nerve or mandibular nerve). Due to their typically deep anatomic location, lesions in the PPF or ITF can be difficult to treat using traditional surgical approaches. In recent years, because of their advantages, which include the fact that they allow the problem to be observed close up, neuroendoscopic techniques are increasingly being applied in skull base surgery, especially in treatment of lesions around the midline of the base of the skull. This study aims to 1) evaluate the neuroendoscopic treatment of lesions in PPF or ITF via the transnasal palate bone perpendicular plate or transnasal maxillary sinus approach and 2) analyze the clinical significance of this approach.

METHODS

We retrospectively analyzed 3 cases of PPF TSs and 1 case of ITF TS treated between January 2015 and May 2017. All of the cases underwent neuroendoscopic resection of TSs located in the PPF via the nasal perpendicular plate palatine bone (or nasal maxillary sinus) approach.

RESULTS

Two cases of PPF TSs were characterized by a thin palate bone perpendicular plate due to oppressed absorption of the tumor. Therefore the endoscopic transnasal palate bone perpendicular plate approach was employed. Additionally, 1 case of PPF TSs and 1 case of ITF TS were resected via the transnasal maxillary sinus approach. All 4 patients received total resection under endoscopy and recovered well after their respective operations without cerebrospinal fluid leakage, although 1 patient experienced postoperative dry eye symptoms and 1 other patient showed no improvement in facial numbness before and after the operation.

CONCLUSIONS

Neuroendoscopic surgery performed via the transnasal perpendicular plate palatine bone or transnasal maxillary sinus approach has its own unique advantages in removing TSs in PPF and in ITF: Notably, the tumor can be exposed and dealt with under direct vision, which prevents damage to important structures, such as the internal carotid and maxillary nerves, while at the same time helping to achieve total removal of TSs. Furthermore, by adopting this approach versus traditional skull base surgery, postoperative trauma can be reduced significantly, which should be advocated for in this time of minimal invasive surgery.