Evolution of minimally invasive approaches to the sella and parasellar region

3D Printing for Customized Bone Reconstruction in Spheno-Orbital Meningiomas: A Systematic Literature Review and Institutional Experience

Background: The treatment of spheno-orbital meningiomas (SOMs) requires extensive bone resections, creating significant defects in a complex geometrical space. Bone reconstruction represents a fundamental step that optimizes long-term aesthetic and functional outcomes. In recent years, 3D printing technology has also been exploited for complex skull base reconstructions, but reports remain scarce. Methods: We retrospectively analyzed four consecutive patients who underwent SOM resection and one-step 3D PEEK customized reconstruction from 2019 to 2023. A systematic review of 3D printing customized implants for SOM was then performed. Results: All patients underwent a frontotemporal craniotomy, removal of SOM, and reconstruction of the superolateral orbital wall and pterional region. The aesthetic outcome was extremely satisfactory in all cases. No orbital implant malposition or infectious complications were documented. Eleven papers were included in the literature review, describing 27 patients. Most (23) patients underwent a single-stage reconstruction; in three cases, the implant was positioned to correct postoperative delayed enophthalmos. Porous titanium was the most used material (16 patients), while PEEK was used in three cases. Prosthesis malposition was described in two (7.4%) patients. Conclusions: Single-step reconstruction with a personalized 3D PEEK prosthesis represents a valid reconstruction technique for the treatment of SOMs with good aesthetic outcomes.

Morphometric analysis of transsphenoidal surgery in Peruvian population

Background

Transsphenoidal surgery has become a key element in the approach to skull base pathologies. The objective of the study was to explore the morphometry of the sphenoidal region in the Peruvian population, with an emphasis on understanding its specific anatomical characteristics and providing quantitative data for the planning of transsphenoidal surgery.

Methods

A cross-sectional study included a random sample of 81 cases of healthy individuals who presented to the Radiology Department of a Private Hospital Center in Peru over 1 year. Skull computed tomography scans without contrast were performed, and a detailed morphometric analysis was conducted by an expert neurosurgeon, including measurements of four parameters to evaluate the anatomy of the craniofacial region.

Results

Most participants exhibited complete sellar pneumatization, followed by incomplete sellar pneumatization, while conchal pneumatization was rare. Significant differences were found between men and women in the distance from the nasal opening to the dorsum of the sella turcica. No significant gender differences were observed in other anatomical measurements or significant changes with age in anatomical measurements.

Conclusion

Morphometric analysis provides crucial data for the precise customization of surgical interventions in the Peruvian population, especially in transsphenoidal surgery. The results highlight the importance of considering individual anatomical differences and gender variability during surgical planning. Morphometry emerges as a valuable tool to enhance the quality and safety of transsphenoidal surgery by adapting surgical strategies to the specific anatomical dimensions of each patient.

Navigating the Surgical Landscape: A Comprehensive Analysis of Endoscopic vs. Microscopic Transsphenoidal Pituitary Surgery Outcomes

Pituitary surgery, a critical intervention for various pituitary disorders, has sparked ongoing debates regarding the preference between endoscopic and microscopic transsphenoidal approaches. This systematic review delves into the outcomes associated with these techniques, taking into account the recent advancements in neurosurgery. The minimally invasive nature of endoscopy, providing improved visualization and reduced morbidity, stands in contrast to the well-established track record of the conventional microscopic method. Examining outcomes for disorders such as Cushing's disease and acromegaly, the review synthesizes evidence from Denmark, Bulgaria, and China. Noteworthy advantages of endoscopy encompass higher resection rates, shorter surgery durations, and fewer complications, endorsing its effectiveness in pituitary surgery. While emphasizing the necessity for prospective trials, the review concludes that endoscopic approaches consistently showcase favorable outcomes, influencing the ongoing discourse on the optimal surgical strategies for pituitary disorders.

Comparison of the Endoscopic Endonasal Approach with the Endoscopic Supraorbital Keyhole Approach to the Tuberculum Sellae Region: A Quantitatively Cadaveric Study

BACKGROUND

 The endoscopic endonasal approach (EEA) and the endoscopic supraorbital keyhole approach (eSKA) provide minimally invasive access to tuberculum sellae (TS) tumors. Evaluation of the operating maneuverability is helpful for approach selection. Herein, we compared the two approaches and aimed to provide quantitative anatomic data for surgical decision-making in the management of TS lesions.

METHODS

 Fifteen dissections were performed on five silicone-injected cadaveric heads. The EEA and eSKA (both right and left) were performed on each head. Surgical freedom and working angles in the axial and sagittal planes were calculated using the stereotactic navigation system in the selected six targets: the midpoint of the leading edge of the sphenoid sinus (leSS), the midpoint of the edge of the dorsum sellae (eDS), the ipsilateral medial opticocarotid recess (imOCR), the contralateral medial opticocarotid recess (cmOCR), the ipsilateral lateral opticocarotid recess (ilOCR), and the contralateral lateral opticocarotid recess (clOCR).

RESULTS

 The surgical freedom at the ilOCR and the axial working angles at the leSS, ilOCR, and imOCR (imOCR with excessive manipulation of the optic apparatus) were greater in the eSKA. The EEA provided greater surgical freedom and/or working angles at most targets than eSKA (the surgical freedom at the imOCR, cmOCR, clOCR, and eDS; the axial working angles at the cmOCR and clOCR; and the sagittal working angles at the leSS, imOCR, cmOCR, clOCR, and eDS).

CONCLUSION

 The EEA provides greater surgical freedom and working angles for paramedian lesions, whereas the eSKA provides better surgical maneuverability for lesions with lateral extension.

The Pterional Keyhole Craniotomy Approach: A Historical Perspective

The pterional craniotomy is a workhorse of cranial surgery that provides access to the anterior and middle fossae. However, newer "keyhole" approaches, such as the micropterional or pterional keyhole craniotomy (PKC) can offer similar exposure for many pathologies while reducing surgical morbidity. The PKC is associated with shorter hospitalizations, reduced operative time, and superior cosmetic outcomes. Furthermore, it represents an ongoing trend toward smaller craniotomy size for elective cranial procedures. In this historical vignette, we trace the history of the PKC from its origins to its current role in the neurosurgeon's armamentarium.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Sellar and Parasellar Regions

Introduction  Surgery of the sellar and parasellar regions can be challenging due to the complexity of neurovascular relationships. The main goal of this study is to develop an educational resource to help trainees understand the pertinent anatomy and procedural steps of the endoscopic endonasal approaches (EEAs) to the sellar and parasellar regions. Methods  Ten formalin-fixed latex-injected specimens were dissected. Endoscopic endonasal transsphenoidal transsellar, transtuberculum-transplanum, and transcavernous approaches were performed by a neurosurgery trainee, under supervision from the senior authors and a PhD in anatomy with advanced neuroanatomy experience. Dissections were supplemented with representative case applications. Results  Endoscopic endonasal transsphenoidal approaches afford excellent direct access to sellar and parasellar regions. After a wide sphenoidotomy, a limited sellar osteotomy opens the space to sellar region and medial portion of the cavernous sinus. To reach the suprasellar space (infrachiasmatic and suprachiasmatic corridors), a transplanum-prechiasmatic sulcus-transtuberculum adjunct is needed. The transcavernous approach gains access to the contents of the cavernous sinus and both medial (posterior clinoid and interpeduncular cistern) and lateral structures of the retrosellar region. Conclusion  The anatomical understanding and technical skills required to confidently remove skull base lesions with EEAs are traditionally gained after years of specialized training. We comprehensively describe EEAs to sellar and parasellar regions for trainees to build knowledge and improve familiarity with these approaches and facilitate comprehension and learning in both the surgical anatomy laboratory and the operating room.

Endoscopic Supraorbital Eyebrow Approach for Medium-Sized Tuberculum Sellae Meningiomas: A Cadaveric Stepwise Dissection, Technical Nuances, and Surgical Outcomes

BACKGROUND

Tuberculum sellae meningiomas (TSMs) have traditionally been removed using a transcranial approach. In recent years, endoscopic surgery for TSMs has been reported with an expansion of indications.

OBJECTIVE

We have performed a fully endoscopic supraorbital keyhole approach for small to medium-sized TSMs and performed radical tumor removal similar to conventional transcranial procedure. We report the details of this surgical procedure including cadaveric stepwise dissection and initial surgical results for small to medium-sized TSMs.

METHODS

We used an endoscopic supraorbital eyebrow approach for 6 patients with TSMs between September 2020 and September 2022. Mean tumor diameter was 16.0 mm (range, 10-20 mm). The surgical approach included an eyebrow skin incision ipsilateral to the lesion, a small frontal craniotomy, subfrontal exposure of the lesion, removal of the tuberculum sellae, unroofing of the optic canal, and resection of the tumor. The extent of resection, preoperative and postoperative visual function, complications, and operative time were evaluated.

RESULTS

Optic canal involvement was observed in all patients. Two patients (33%) showed visual dysfunction before surgery. Simpson grade 1 tumor resection was achieved in all cases. Visual function was improved in 2 cases, and remained unchanged in 4 cases. Postoperative pituitary function was preserved in all cases, with no decreases in olfaction.

CONCLUSIONS

The endoscopic supraorbital eyebrow approach for TSMs allowed resection of the lesion, including tumor extending to the optic canal, with a good surgical view. This technique is minimally invasive for patients and may represent a good surgical option for medium-sized TSMs.

History, Current Techniques, and Future Prospects of Surgery to the Sellar and Parasellar Region

The sellar and parasellar region can be affected by diverse pathologies. The deep-seated location and surrounding critical neurovascular structures make treatment challenging; there is no singular, optimal approach for management. The history and development of transcranial and transsphenoidal approaches by pioneers in skull base surgery were largely aimed at treating pituitary adenomas, which are the most common lesions of the sella. This review explores the history of sellar surgery, the most commonly used approaches today, and future considerations for surgery of the sellar/parasellar region.

Proposal of a Novel Anatomic Guide to the Sphenoid Sinus

BACKGROUND

Landmarks for transsphenoidal surgery have been described to facilitate resection for pituitary lesions. However, carrying out sphenoidotomy for access to the sellar floor could still be challenging, especially for young surgeons during the steep learning curve.

OBJECTIVE

We describe the LUTH (Lagos University Teaching Hospital) line as a simple anatomic guide to avoid missing the trajectory to the sella during anterior sphenoidotomy in microscopic transsphenoidal pituitary surgery.

METHODS

We identified this line as an impression on the floor of the sphenoid sinus across the point at which the floor of the anterior cranial fossa and the bony projection from the clivus meet. We carried out a literature review of articles describing landmarks for anterior sphenoidotomy using data obtained from PubMed and Ovid MEDLINE databases according to PRISMA guidelines.

RESULTS

A total of 80 patients were operated using the LUTH line as a guide for anterior sphenoidotomy during microscopic transsphenoidal pituitary. We did not find any previous description of this anatomic landmark over the anterior sphenoid sinus in the literature. The LUTH line was clearly identified in all 80 cases. The line was used as a bony landmark to the sphenoid sinus in all cases and was found to be consistently accurate.

CONCLUSIONS

The LUTH line is a consistent and easy-to-identify landmark that could be useful in preventing potential complications of access to the pituitary sella through the sphenoid sinus. We believe it to be useful in the absence of intraoperative guidance, especially for young surgeons who are just starting off their career in pituitary surgery.

Keyhole supraorbital eyebrow approach for fully endoscopic resection of tuberculum sellae meningioma

Background

The fully endoscopic supraorbital trans-eyebrow keyhole approach is a technique utilized for the transcranial resection of tuberculum sellae meningioma (TSM). Surgery is the first choice for TSM treatment. This study aimed to summarize and analyze the safety, feasibility, limitations, and technical requirements of the fully endoscopic supraorbital trans-eyebrow keyhole approach for TSM resection.

Methods

Data of 19 TSM fully endoscopic supraorbital trans-eyebrow keyhole approach resections cases (six and 13 on the left and right eyebrows, respectively) were retrospectively analyzed at the Neurosurgery Department of the First Affiliated Hospital of Bengbu Medical College (Bengbu, China) from August 2015 to March 2022.

Results

All 19 patients were diagnosed with meningioma (World Health Organization grade I), and according to the scope of tumor resection (EOR), 18 patients (94.7%) had gross total resection (GTR), and one patient (5.3%) had near-total resection (NTR). Preoperative chief complaints were symptomatic visual dysfunction (n = 12), headache and dizziness (n = 6), and accidental discovery (n = 1). Postoperative visual function improved in 83.3% of cases (10/12), and headache and dizziness were relieved in 83.3% of cases (5/6 patients). Postoperative intracranial infection occurred in one case and was cured by external drainage of the lumbar cistern and anti-infective treatment. Two cases of frontal lobe injury were discharged after conservative treatment. There was no postoperative olfactory dysfunction, eyelid ptosis, cerebrospinal fluid leakage, or death. There were no reports of disease recurrence or death during the 3-month follow-up at an outpatient clinic or by telephone.

Conclusion

Fully endoscopic TSM resection through the keyhole approach is safe and feasible. It can be used to explore angles that cannot be seen under a microscope and show the true value of endoscopy technology. The endoscopic equipment and technical skills of the surgeon and surgical team are important in this technique.

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.

Sellar, suprasellar, and parasellar masses: Imaging features and neurosurgical approaches

The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.

Prior smoking and nasoseptal flap usage adversely impact quality of life and healing after endoscopic pituitary surgery

OBJECTIVE

Endoscopic pituitary surgery (EPS) via the endonasal transsphenoidal approach is well established as an effective treatment modality for sellar masses. The objective of this study was to determine the relationship between key patient and operative variables and rhinological outcomes as determined by the 22-item Sino-Nasal Outcome Test (SNOT-22) and endoscopic scores following EPS.

METHODS

Prospectively collected SNOT-22 scores and objective endoscopic data were analyzed from a cohort of 109 patients who underwent EPS and had at least 90 days of postoperative follow-up. Trends in postoperative SNOT-22 scores were analyzed using linear mixed-effects models. Time to return to baseline endoscopic score was analyzed using Cox regression.

RESULTS

After adjusting for age and sex, the authors found that prior smokers had higher total and rhinological subdomain SNOT-22 scores (p < 0.01, 95% CI 5.82-16.39; p = 0.01, 95% CI 1.38-5.09, respectively) following EPS. Nasoseptal flap use also showed higher total and rhinological subdomain SNOT-22 scores (p = 0.01, 95% CI 1.62-12.60; p = 0.02, 95% CI 0.42-4.30, respectively). Prior sinonasal surgery and concurrent septoplasty did not affect the change in SNOT-22 total scores over time (p = 0.08, 95% CI -0.40 to 0.02; p = 0.33, 95% CI -0.09 to 0.29).

CONCLUSIONS

The findings suggest that the evolution of healing and patient-reported quality of life (QOL) measures are multifaceted with contributions from two key variables. Nasoseptal flap usage and prior smoking status may adversely impact postoperative QOL. No variables were found to be associated with objective postoperative endoscopic findings.

Combined Simultaneous Multiportal Approach via Minimally Invasive Transciliary and Endoscopic Endonasal Approaches for Tumors Invading Both the Skull Base and the Sinonasal Area

BACKGROUND

A combined transcranial and transfacial approach has long been the gold standard for surgical management of large tumors with sinonasal and skull base involvement. The extended endoscopic endonasal approach for such pathologies has its advantages, but it has flaws as well, such as anatomic limitations and more ponderous skull base reconstruction and thus higher risk of postoperative complications. Our primary technique for surgical treatment of these pathologies has been a combination of transfacial and minimally invasive transciliary supraorbital keyhole approaches. With the aim to further minimize invasiveness, potential complications, and unsatisfactory aesthetic outcomes during surgical treatment of large tumors invading both the sinonasal area and the skull base, we abandoned the transfacial approach and simultaneously combined the transciliary supraorbital keyhole approach with the endoscopic endonasal approach.

METHODS

The well-known microscope-assisted minimally invasive approach via a transciliary supraorbital keyhole craniotomy was combined with the endoscopic endonasal approach.

RESULTS

Six patients with different histologic types of tumors affecting the sinonasal area and the skull base were operated on. The mean operative time was 3 hours, there were no unexpected intraoperative or postoperative complications, and total tumor removal was achieved in each patient. None of the patients experienced complications associated with the surgery during follow-up.

CONCLUSIONS

Our combined simultaneous multiportal approach enables total tumor eradication with reduced operative time and is associated with minimal intraoperative and postoperative complications, low mortality rate, and excellent cosmetic results.

The Supraorbital Eyebrow Craniotomy for Intra- and Extra-Axial Brain Tumors: A Single-Center Series and Technique Modification

BACKGROUND

The supraorbital (SO) eyebrow craniotomy provides minimally invasive access to the anterior and middle fossae and parasellar region.

OBJECTIVE

To present a series of patients treated with the SO approach to assess outcomes, the impact of endoscopy, and describe a modified pericranial flap aimed at reducing postoperative frontalis paresis and hypesthesia.

METHODS

A retrospective analysis was undertaken of our prospective database of patients who underwent SO craniotomy for tumor/cyst removal. Patients were evaluated based on pathology, utility of endoscopy, extent of resection, complications, and functional/esthetic recovery.

RESULTS

From 2007 to 2018, 129 operations were performed in 117 patients (54% women; mean age 60 ± 16.5 yr). The most common lesions were meningiomas (43%), gliomas (15%), and metastases (15%). Prior surgery and/or radiation had been performed in 37% and 26% of patients, respectively. Endoscopy was used in 76 (61%) operations and allowed more complete tumor removal in 38 (50%). For first-time operations, gross-total removal was achieved in 78%. Major complications included stroke (3%), cranial nerve deficit (3%), acute hematoma (1%), and cerebrospinal fluid leak (1%). The modified pericranial flap technique used in 18 recent patients resulted in a shorter duration of transient frontalis paresis and forehead hypesthesia with complete functional recovery in all 18.

CONCLUSION

The SO craniotomy is an effective keyhole approach for intra- and extra-axial tumors. Endoscopic assistance may allow additional tumor removal in almost 30% of the cases. The modified pericranial flap appears to accelerate functional recovery, although additional patients and follow-up are required to better assess this technique.

Work-related musculoskeletal disorders among endoscopic transsphenoidal surgeons: a systematic review of prevalence and ergonomic interventions

Endoscopic transsphenoidal surgery is a surgical technique introduced in the last 20 years for the treatment of skull base pathologies and, in particular, pituitary tumours. Although the prevalence of work-related musculoskeletal disorders is usually significantly higher in endoscopists and minimally invasive surgeons compared to other surgical and medical specialties, reviews on the prevalence of disorders among neurosurgeons dedicated to endoscopic transsphenoidal surgery are not available. This article performs a systematic review to identify the work-related musculoskeletal disorders among transsphenoidal neurosurgeons, their prevalence and the ergonomic interventions proposed to reduce risk factors and prevent disorders. The results show that the ergonomics of transsphenoidal neurosurgeons is an under-investigated topic. Indeed, specific prevalence data are not available. In addition, only a few papers suggest interventions and guidelines, but without objective assessment of the outcomes to confirm the ergonomic benefit. Based on these gaps in the literature, a future research agenda is proposed.

The effects of combined exposure of solvents and noise on auditory function - A systematic review and meta-analysis

BACKGROUND

 Chemical substances can negatively affect the auditory system. Chemical substances alone or combined with high-level noise have recently become a major concern as a cause of occupational hearing loss.

OBJECTIVE

 To assess the combined effect of solvents and noise versus solvents only, or noise only, on the auditory function of workers.

METHOD

 Published articles which included noise and/or solvent exposure or combined effects of solvents and noise, studies conducted on human beings only and the use of audiological tests on participants.

RESULTS

 Thirteen papers were eligible for inclusion. The participants' ages ranged from 18 to 68 years. Results revealed that 24.5% presented with hearing loss as a result of noise exposure only; 18% presented with hearing loss owing to solvent exposure only; and a total of 43.3% presented with hearing loss owing to combined noise and solvent exposure. Furthermore, the prevalence of hearing loss in the noise and solvent group was significantly (p < 0.001) higher than the other groups in 10 out of the 13 studies analysed, with a pooled odds ratio (OR) of 2.754. Of the 178 participants (total of all participants exposed to solvents), a total of 32 participants presented with auditory pathology as a result of exposure to solvents only. There was a significantly higher pooled odds of hearing loss in noise and solvent-exposed group compared to solvent-only group (pooled OR = 2.15, 95% CI: 1.24-3.72, p = 0.006).

CONCLUSION

 The findings revealed significantly higher odds of acquiring hearing loss when workers were exposed to a combination of solvents and noise as opposed to solvents only, motivating for its inclusion into hearing conservation programmes.

From above or from below? That is the question. Comparison of the supraorbital approach with the endonasal approach. A cadaveric study

BACKGROUND

Nowadays the endoscopic endonasal approach is increasingly being used to remove craniopharyngiomas, tuberculum sellae meningiomas and other presellar and parasellar lesions and its value in anterior skull base surgery is undisputed. Herein, we assess the relative advantages, disadvantages and feasibility of the keyhole eyebrow approach and the endonasal endoscopic approach in four cadaveric heads for the removal of presellar and parasellar lesions.

METHODS

We used four cadaveric heads for 12 surgical dissections. The specimens were embalmed with two different techniques. Two bilateral supraorbital endoscopic assisted approaches and one transnasal expanded endonasal approach were performed for each head. We evaluated the feasibility, maneuverability and safety of each approach. We measured the operating room obtained with each approach and the distance from the main structures we reached.

RESULTS

The technical feasibility of the endoscopic endonasal transphenoidal approach and the supraorbital eyebrow approach was reproduced in all four cadaveric heads. The transnasal approach gave us a good operating field medial to the two optic nerves and the two carotid arteries anteriorly until the frontal sinus and, posteriorly, the basilar artery, the emergence of the superior cerebellar arteries and posterior cerebral arteries. After performing the supraorbital approach, we viewed a wider field of the anterior skull base and we were able to reach the ipsilateral carotid artery, the optico-carotid recess, the pituitary stalk, the lamina terminalis until the contra lateral optic nerve and carotid artery, keeping a wider angle of maneuverability.

CONCLUSIONS

Although the endoscopic transnasal approach has developed in leaps and bounds in the last decade, other transcranial approaches maintain their value. The supraorbital endoscopic approach is a minimally invasive approach and seems to be optimal for those lesions wider than 2 cm in the lateral extension and for all the paramedian lesions.

The supraorbital eyebrow approach for removal of craniopharyngioma in children: a case series

OBJECTIVE

Craniopharyngiomas can be a surgical challenge for the pediatric neurosurgeon. Ideally, total removal must be achieved. However, the need to reduce surgical morbidity and preserve quality of life has led to a number of neurosurgical approaches in order to attain this goal. The aim of this article is to present an alternative surgical approach to these lesions and to provide the rationale for this technique.

MATERIAL AND METHODS

Medical charts and operative records of eight pediatric patients harboring craniopharyngiomas who underwent surgical treatment using a supraorbital eyebrow approach (SOA) were reviewed from 2014 to 2016. Only patients younger than 18 years with a minimum follow-up of 12 months were included in this study. Using pre-operative magnetic resonance (MRI) scans, tumors were classified according to their degree of hypothalamic involvement. The surgical technique is also described in detail.

RESULTS

The study group included six males and two females with a mean age of 10 years (range, 2-16 years). The SOA was used successfully in elective surgery of eight craniopharyngiomas. The hypothalamus was displaced by the tumor in three patients and severely involved in five patients. Subtotal resection was undertaken in six patients, whereas gross-total resection was achieved in two. Endoscopic assistance was used after standard microscopic visualization in two out of eight cases. Cosmetic outcomes were excellent, and the complication rate related to the surgical procedure was quite low, apart from diabetes insipidus (which occurred in three out of the eight patients). In one patient, a large subdural collection needed surgery for evacuation. Mean follow-up was 23.2 months (range, 12-36 months). Additionally, no CSF leak or wound infection was identified.

CONCLUSIONS

The supraorbital eyebrow approach is an alternative route to operate on craniopharyngiomas in properly selected cases 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.

[A supraorbital trans-eyebrow approach in surgery of chiasmatic-sellar and anterior cranial fossa tumors]

OBJECTIVE

to analyze 31 resections of chiasmatic-sellar region (CSR) and anterior cranial fossa (ACF) tumors using the supraorbital trans-eyebrow approach (STA).

MATERIAL AND METHODS

We analyzed medical histories of 31 patients who underwent tumor resection using STA in the period between October 2013 and April 2017. We analyzed the age and gender of patients, size and location of the tumor, presence of a neurological deficit, vision and olfactory functions before and after surgery, surgery duration, amount of intraoperative blood loss, rate of frontal sinus trephination and nasal liquorrhea, hemorrhagic and ischemic complications after surgery, Simpson grade of tumor resection, patient's condition before and after surgery (Glasgow Outcome Scale and Karnofsky Scale), and degree of patient satisfaction with the cosmetic result of surgery. A total of 26 meningiomas (20 sphenoid plate, tubercle, and diaphragm tumors, 3 lesser sphenoid wing meningiomas, 2 orbital roof tumors, and 1 anterior clinoid process meningioma), 3 frontal lobe gliomas, and 2 pituitary adenomas were resected.

RESULTS

In all 31 operations, the approach was adequate and enabled tumor resection without lethal outcomes. The mean surgery duration was 174.6±64.4 min. The mean blood loss was 190±96.6 mL (50-380 mL). After surgery, none of the patients developed motor deficits and new epileptic seizures. Neurological deficit aggravation in the form of impaired vision and mental disorders occurred in 8 (25.8%) patients. Vision impaired in 4 (12.9%) patients, improved in 6 (19.3%) patients, and remained unchanged in 21 (67.7%) patients. An endocrinological deficit in the form of partial hypopituitarism developed in 3 (9.6%) patients; in 4 (12.9%) patients, there were mental disorders that regressed by the end of the first month of therapy. There were no intracerebral and subarachnoid hemorrhages. In 2 (6.4%) patients, small epidural hematomas were diagnosed, which did not require surgical treatment. There were only good outcomes (a GOS score of 4 or 5). After surgery, the median Karnofsky index in the STA group was 90±7. In all 31 (100%) patients, the postoperative wound healed by primary intention, without infectious complications and wound liquorrhea. One (4%) patient developed eyebrow palsy; 3 (12%) patients had hypoesthesia in the supraorbital region. The mean VAS score of patient satisfaction with the cosmetic result was 9.36 (median 10±1). The mean follow-up period was 16.2±13.5 months (2-38 months).

CONCLUSION

The STA is adequate for removal of CSR and ACF tumors under proper selection of patients. It provides an adequate view of anatomical structures and enables successful tumor resection through a less traumatic access.

Impact of optic canal decompression on visual outcome in subtotal resected skull base meningiomas

BACKGROUND

Visual impairment (VI) due to neoplastic infiltration of the optic canal (OC) is frequently seen in skull base meningiomas representing a significant restriction in patients` quality of life. However, the delicate anatomy of this region often prevents gross total tumor resection. The aim of the present study was to evaluate the impact of intradural OC decompression and postoperative oncological procedure on preservation of visual acuity in subtotal resected skull base meningiomas.

METHODS

A retrospective analysis of 31 consecutive patients (19 females, 12 males; mean age 53 [range 18-78]), treated in our institution between 01/2011- 09/2014 was performed. Patients` charts were analyzed with special respect to operative procedure, postoperative treatment and procedural impact on late visual function.

RESULTS

Most patients (74.2%) had VI prior to surgery. A pterional craniotomy (97%) facilitated subtotal tumor removal in 71% of the patients with no intraoperative and a low rate (6.4%) of postoperative complications. Adjunctive radiotherapy was performed in 19.3% of the patients. Preoperative visual acuity was preserved or improved in 92% of the patients. Substantial tumor regrowth occurred in only 11.2% of the patients.

CONCLUSIONS

Intradural decompression of the OC stabilizes visual function in subtotally resected skull base meningiomas. Moreover, adjuvant radiotherapy seems to further benefit visual outcome which has to be evaluated in further prospective studies.

Endoscopic vs. Microscopic Resection of Sellar Lesions-A Matched Analysis of Clinical and Socioeconomic Outcomes

BACKGROUND

Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages.

OBJECTIVE

To determine if the proposed benefits of endoscopic resection are realized on a population level.

METHODS

We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions. Coarsened matching was applied to estimate the effects of surgical approach on complication rates, length of stay (LOS), costs, and likelihood of postoperative radiation.

RESULTS

We found that LOS, readmission, and revision rates did not differ significantly between approaches. The overall complication rate was higher for endoscopy (47% compared to 39%, OR 1.37, 95% CI 1.22-1.53). Endoscopic approach was associated with greater risk of neurological complications (OR 1.32, 95% CI 1.11-1.55), diabetes insipidus (OR 1.65, 95% CI 1.37-2.00), and cerebrospinal fluid rhinorrhea (OR 1.83, 95% CI 1.07-3.13) compared to the microscopic approach. Although the total index payment was higher for patients receiving endoscopic resection ($32,959 compared to $29,977 for microscopic resection), there was no difference in long-term payments. Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery (OR 0.67, 95% CI 0.49-0.90) and intensity-modulated radiation therapy (OR 0.78, 95% CI 0.65-0.93).

CONCLUSION

Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation. Although there are evident advantages to transsphenoidal endoscopy, our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.

Morphometric Analysis of the Middle Clinoid Process Using Maxillofacial Computed Tomography Scans

BACKGROUND

The interest in detailed anatomy of the sella and parasellar regions has resurged recently due to the wide clinical applications of the expanded endoscopic approaches to the skull base. The middle clinoid process (MCP) is a bony structure that can affect wide endoscopic exposure of the sella and parasellar region.

OBJECTIVE

To study and analyze the anatomic variations of the MCP in the general population using computed tomography scans.

METHODS

A total of 150 maxillofacial computed tomography scans were reviewed to characterize the MCP. Only adult patients without intracranial or nasal pathology were included. Measurements were made in the axial and sagittal planes to determine the maximum diameter, length, angulation, and location of the MCP.

RESULTS

The prevalence of the MCP was 30.7% in male and 42.7% in female patients. Of the MCPs, 41.8% were ring forming, whereas 76.4% were pneumatized. Quantitatively, the average axial base diameter was 4.6 ± 1.4 mm, the average sagittal base diameter was 5.0 ± 1.8 mm, the average length was 4.7 ± 1.7 mm, the average midline distance was 5.9 ± 2.3 mm, the average distance from the sellar-clival junction was 10.6 ± 3.3 mm, the average sagittal angle was 91.0 ± 21.1°, and the average axial angle was 45.2 ± 15.5°. A significant increase was found in the prevalence of MCPs in white patients compared with black patients, and a significantly greater midline distance and axial angle were found in male compared with female patients.

CONCLUSION

A clear understanding of the sellar and parasellar anatomy is crucial for successful and safe expanded endoscopic approaches. This study provides a quantitative anatomic characterization of the MCP in the U.S. population with demographic data analysis.

Endoscopic Versus Microscopic Transsphenoidal Approach for Pituitary Adenomas: Comparison of Outcomes During the Transition of Methods of a Single Surgeon

OBJECTIVE

The transition from microscopic to fully endoscopic transsphenoidal surgery requires a surgeon to assess how the change in technique will affect the extent of tumor resection (EOR), outcomes, and complications. We compared a single surgeon's experience transitioning from one technique to the other and examined the operative outcomes and EOR between microscopic versus endoscopic transsphenoidal surgery.

METHODS

Retrospective data analysis of adult patients who were treated surgically for a pituitary adenoma between August 2005 and May 2015 by a single neurosurgeon, who was originally trained and practiced in the microscopic transsphenoidal approach. Patient demographics, perioperative conditions, tumor characteristics, operative times, volumetric EOR, postoperative outcome, and the endoscopic learning curve were evaluated.

RESULTS

One hundred and nine patients underwent microscopic transsphenoidal surgery and 275 patients underwent a fully endoscopic approach. The patient characteristics were similar in the 2 groups. Operative room time was significantly shorter in the endoscopic group than in the microscopic group (180.2 vs. 215.6 minutes; P < 0.001). The endoscopic and microscopic groups had similar volumetric EOR (85.1% vs. 82.8%; P = 0.371) as well as residual tumor volume (1.06 cm³ vs. 1.15 cm³; P = 0.765). The mean length of hospital stay was 2.4 days in the endoscopic group and 3.2 days in the microscopic group (P = 0.03).

CONCLUSIONS

During the transition from the microscopic to the endoscopic approach, similar surgical outcomes and EOR were achieved in the 2 cohorts. In our experience, the endoscopic approach offers the advantage of shorter operative times and lengths of hospital stays after the surgeon has developed more experience with the technique.

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.