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Sasaki T, Morisako H, Ikegami M, Wardhana DW, Fernandez-Miranda JC, Goto T. Endoscopic Supraorbital Eyebrow Approach for Medium-Sized Tuberculum Sellae Meningiomas: A Cadaveric Stepwise Dissection, Technical Nuances, and Surgical Outcomes. World Neurosurg 2023; 176:e40-e48. [PMID: 36940807 DOI: 10.1016/j.wneu.2023.03.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
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.
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Affiliation(s)
- Tsuyoshi Sasaki
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
| | - Hiroki Morisako
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, Stanford University, Palo Alto, California, USA
| | - Masaki Ikegami
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Donny Wisnu Wardhana
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | | | - Takeo Goto
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Roa Montes de Oca JC, Gonçalves Estella JM, Nieto-Librero AB, Galindo-Villardón P, Roa Ramírez CJ, Gonçalves Sánchez J, Berhouma M, Cornelius JF, Daniel RT, Zazpe I, Froelich S, Jouanneau E, Mazzatenta D, Messerer M, Meling T, Paraskevopoulos D, Roche PH, Schroeder HWS, Tatagiba M, Visocchi M, Voormolen E, Ekkehard K, Bruneau M. Olfactory Groove Meningiomas: Comprehensive assessment between the different microsurgical transcranial approaches and the Endoscopic Endonasal Approaches, systematic review and metanalysis on behalf of the EANS skull base section. BRAIN & SPINE 2022; 2:101661. [PMID: 36605386 PMCID: PMC9808463 DOI: 10.1016/j.bas.2022.101661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/23/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
•OGM surgery is much more complex than a simple debate of "from above or from below" (transcranial vs endoscopic).•Lateral Sub-frontal and Superior Interhemispheric seem the most effective, superior and versatile approaches for OGM.•Minimally Invasive Transcranial approaches showed no inferiority in OGM sized <4 cm.•Endoscopic Endonasal Approaches showed inferior results in surgical and in functional outcomes for OGM.
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Affiliation(s)
- Juan Carlos Roa Montes de Oca
- Department of Neurosurgery, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain,Department of Surgery - Neurosurgery, Universidad de Salamanca. Facultad de Medicina, Salamanca, Spain,Policlínica San Javier, Telemedicine Neurosurgery Consultant, Barquisimeto, Venezuela,Centro de Enseñanza e Investigación del Ultrasonido en Medicina (CEIUM), Barquisimeto, Venezuela
| | - Jesús María Gonçalves Estella
- Department of Neurosurgery, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain,Department of Surgery - Neurosurgery, Universidad de Salamanca. Facultad de Medicina, Salamanca, Spain,Corresponding author. University of Salamanca, Faculty of Medicine, Department of Surgery, Neurosurgery, Campus Miguel de Unamuno, C/ Alfonso X El Sabio s/n, 37007, Salamanca, Spain.
| | | | - Purificación Galindo-Villardón
- Department of Statistics, Universidad de Salamanca, Salamanca, Spain,Centro de Investigación Institucional (CII). Universidad Bernardo O’Higgins, Av. Viel 1497, Santiago, Chile
| | - Carlos Julio Roa Ramírez
- Department of Neuroradiology. Policlinica San Javier, Barquisimeto, Venezuela,Centro de Enseñanza e Investigación del Ultrasonido en Medicina (CEIUM), Barquisimeto, Venezuela,Centro Docente de Imágenes de Alta Tecnología (CEDIAT), Barquisimeto, Venezuela
| | | | - Moncef Berhouma
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | | | - Roy Thomas Daniel
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital Lausanne, Switzerland
| | - Idoya Zazpe
- Department of Neurosurgery, University Hospital of Navarre, Pamplona, Spain
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - Emmanuel Jouanneau
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Diego Mazzatenta
- Department of Neurosurgery, Neurological Sciences Institut IRCCS, Bologna, Italy
| | - Mahmoud Messerer
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital Lausanne, Switzerland
| | - Torstein Meling
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | - Dimitrios Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartolomew’s and the Royal London Hospital, Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - Pierre-Hugues Roche
- Department of Neurosurgery, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - Massimilliano Visocchi
- Department of Neurosurgery, Institute of Neurosurgery Catholic University of Rome, Italy
| | - Eduard Voormolen
- Department of Neurosurgery, University Medical Center Utrecht, Netherlands
| | - Kasper Ekkehard
- Department of Neurosurgery, Steward Medical Group, Brighton, USA
| | - Michaël Bruneau
- Department of Neurosurgery, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Qian K, Nie C, Zhu W, Zhao H, Zhang F, Wang H, Jiang X. Surgical management of tuberculum sellae meningioma: Transcranial approach or endoscopic endonasal approach? Front Surg 2022; 9:979940. [PMID: 36117830 PMCID: PMC9470762 DOI: 10.3389/fsurg.2022.979940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Tuberculum sellae meningioma (TSM), a common benign tumor in the sellae region, usually causes neurological deficits, such as vision impairment, by squeezing the peripheral neurovascular structures. Surgical management is recommended as the optimal strategy for TSM treatment and vision restoration. However, it remains challenging to resect TSM in the traditional transcranial approach (TCA). Recently, the endoscopic endonasal approach (EEA) has emerged as an effective option in skull base surgeries. Besides the effectivity, the advantages and limitations of EEA in TSM surgery remain controversial. Object We compared the surgical outcomes and complications between TCA and EEA surgeries to identify the principles in TSM surgical management. Methods Retrospective analysis was performed on the patients, who underwent TSM surgery in Wuhan Union Hospital between January 2017 and December 2021. The patients were assigned to TCA or EEA group according to the surgery they experienced. All patients were analyzed with the extent of tumor resection, vision outcome, postoperative complications, and follow-up results. Results A total of 112 patients were enrolled in this study, including 78 in TCA group and 34 in EEA group. The mean follow-up was 20.5 months (range 3–36 months). There were no statistically significant differences in patient demographic data, preoperative symptoms, and tumor characteristics between TCA and EEA groups. Both TCA and EEA surgeries are effective in TSM resection with relatively high gross total resection rates (85.9% in TCA vs. 91.2% in EEA, p > .05). Meanwhile, EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery (74.6% in TCA vs. 93.1% in EEA, p < .05). Whereas EEA surgery causes more occurrences of cerebrospinal fluid (CSF) leakage than TCA surgery (0% in TCA vs. 11.8% in EEA, p < .05). Conclusion Both TCA and EEA surgeries are effective in TSM resection. EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery, but induces higher risk of CSF leakage. As each approach has unique advantages and limitations, we must take all aspects into consideration, including approach feathers, tumor characteristics, and clinical requirements, to make the optimal choice in TSM surgical management.
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Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives. Cancers (Basel) 2022; 14:cancers14122878. [PMID: 35740543 PMCID: PMC9220797 DOI: 10.3390/cancers14122878] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/25/2022] [Accepted: 06/03/2022] [Indexed: 12/07/2022] Open
Abstract
Simple Summary Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. Over time, several corridors have been proposed, each one carrying its own pros and cons. During the last decades, the endoscopic endonasal route has been asserted among the classic routes for a growing number of midline and paramedian lesions. Therefore, the aim of our paper is to present a comprehensive review of the indications and techniques for the management of skull base meningiomas, emphasizing the ambivalent and complementary role of the low and high routes. Abstract Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection.
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Martinez-Perez R, Kortz MW, Florez-Perdomo W, Ung TH, Youssef AS. Endocrinological outcomes after transcranial resection of tuberculum sellae meningiomas: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1965-1975. [PMID: 35149901 DOI: 10.1007/s10143-022-01744-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/03/2022] [Accepted: 01/19/2022] [Indexed: 11/26/2022]
Abstract
Tuberculum sellae meningiomas (TSMs) arise from the anterior skull base. Endocrine status after TSM resection is an important determinant of quality of life. We sought to better characterize the risk of postoperative endocrinopathy for patients with TSM undergoing open transcranial approach (TCA) microsurgical resection. A systematic review was conducted following MOOSE and PRISMA guidelines. Results were screened against predefined criteria, which included studies evaluating endocrinopathy rates after open transcranial microsurgery for TSM. Outcome incidence was calculated using random-effect meta-analysis of proportions. Eight studies met the inclusion criteria, comprising 406 patients. The average age of the cohort was 52.2 years, and a majority (70%) of the patients were female. The pooled incidence of postoperative transient diabetes insipidus (DI) was 7.5% (95% CI 2.9-12%; p = 0.001; I2 = 75.9%) and permanent DI was 1.6% (95% CI 0.3-2.7%; p = 0.01; I2 = 0%). The pooled rate of postoperative hypopituitarism was 3.6% (95% CI 1.6-5.7%; p < 0.001; I2 = 22.2%), while the incidence of hyperprolactinemia was 1.3% (95% CI 0.1 = 2.6%; p = 0.036; I2 = 8.74%). The incidence of SIADH was 4% in one study but was not included in the meta-analysis. Endocrinopathy after TSM microsurgical resection is rare, but the available studies' poor quality of evidence and inconsistent methodology may reflect that it is underreported in the literature. Nevertheless, clinicians should consider the risk of hormonal impairment and counsel their patients accordingly when selecting a TCA for these lesions.
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Affiliation(s)
- Rafael Martinez-Perez
- Departments of Neurosurgery, Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, 1000 East Mountain Boulevard, Wilkes Barre, PA, 18711, USA.
| | - Michael W Kortz
- Department of Neurological Surgery, University of Colorado, Denver, CO, USA
| | - William Florez-Perdomo
- Department of Medicine, Concejo Latinoamericano de Neurointensivismo-CLaNi, Cartagena, Colombia
| | - Timothy H Ung
- Department of Otolaryngology, University of Colorado, Denver, CO, USA
| | - A Samy Youssef
- Department of Neurological Surgery, University of Colorado, Denver, CO, USA.
- Department of Otolaryngology, University of Colorado, Denver, CO, USA.
- Department of Neurosurgery, University of Colorado School of Medicine, 1635 Aurora Ct, 4th Floor, Denver, CO, 80045, USA.
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Xiao F, Shen J, Zhang L, Yang J, Weng Y, Fang Z, Zhang C, Ye H, Zhan R, Zheng X. Unilateral Subfrontal Approach for Giant Tuberculum Sellae Meningioma: Single Center Experience and Review of the Literature. Front Oncol 2021; 11:708235. [PMID: 34434897 PMCID: PMC8381050 DOI: 10.3389/fonc.2021.708235] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background Microsurgical Transcranial approach (mTCA) is the primary choice for the resection of giant Tuberculum Sellae Meningiomas (TSM). The objective of this study is to explore surgical details of unilateral subfrontal approach. Methods Ten patients with giant TSM treated by unilateral subfrontal approach were included from January 2018 to June 2021. Demographic characteristics, surgical data, post-procedure complications and outcomes of patients have been descriptive analyzed, combined with systematic literature review to explore the surgical details and the prognosis of unilateral subfrontal approach. Results Ten patients include six male and four females, age range from 35 to 77 years, duration of visual impairment from 1 to 12 months, were all performed unilateral subfrontal approach. Nine patients achieved radical resection (Simpson grades I-II) through post-operative imaging confirmation, and Simpson IV resection was performed in the remaining one due to cavernous sinus invasion. The postoperative visual acuity was improved or maintained in 8 patients. Visual acuity decreased in 2 cases, including 1 case of optic nerve atrophy and the other case of optic canal not opening. Five cases with frontal sinus opened were repaired during the operation and there was no postoperative cerebrospinal fluid leakage or intracranial infection. One patient suffered from postoperative anosmia, one patient developed left limb weakness, but their symptoms have improved in the follow-up. Conclusion Summarize the experience of our center and previous literature, unilateral forehead bottom craniotomy is a feasible surgical approach for giant tuberculum sellae meningioma. Intraoperative application of EC glue and pedicled fascia flap to repair the frontal sinus can prevent complications associated with frontal sinus opening. Optic canal unroofing has huge advantage in visual improvement.
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Affiliation(s)
- Feng Xiao
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Shen
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Luyuan Zhang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiqi Yang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuxiang Weng
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zebin Fang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Zhang
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongxing Ye
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Renya Zhan
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujue Zheng
- Department of Neurosurgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Ipsilateral vs controlateral approach in tuberculum sellae meningiomas surgery: a retrospective comparative study. Neurosurg Rev 2021; 44:3581-3591. [PMID: 33890190 DOI: 10.1007/s10143-021-01536-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/16/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
Most of tuberculum sellae meningiomas (TSM) show asymmetric growth. They are usually resected through ipsilateral approaches. The access of the inferior-medial side of the ipsilateral optic nerve might be challenging, which result in increased manipulation of the compromised optic nerve. The contralateral approach has been described to avoid these technical difficulties. Assessing the long-term visual and olfactory outcome, as well as recurrence rate in patients operated for TSM through ipsilateral or contralateral approaches. Single center retrospective cohort study about 94 patients operated on between March 2000 and April 2018. Seventy percent of the preoperative visual acuity loss totally resolved (44%) or showed varying degrees of improvement (26%) after surgery. Seventy-two percent of the preoperative visual field defects evolved favorably (44% recovery, 28% improvement). Eight patients showed aggravated visual disturbances (9%). A contralateral approach seemed to be predictive of visual field defects improvement after surgery (OR = 0.4), with borderline significant results (p = .08). There was a higher rate of postoperative olfactory nerve impairment after a contralateral approach (37% vs 17%, p = .03). Total removal of the tumor fragment entering the optic canal was accomplished in 96% in the contralateral vs 75% in the ipsilateral group (p = .04). The 2-, 5-, and 7-year tumor progression-free survival were 100% in the Simpson grade 2 group, and 85% (n = 17), 74% (n = 11), and 67% (n = 5) in the Simpson grade 4 group, respectively (p = .00). Resection of tuberculum sellae meningiomas through a contralateral approach seems to provide better visual outcome and tumor control at the cost of increased olfactory nerve disorders.
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Khan DZ, Muskens IS, Mekary RA, Zamanipoor Najafabadi AH, Helmy AE, Reisch R, Broekman MLD, Marcus HJ. The endoscope-assisted supraorbital "keyhole" approach for anterior skull base meningiomas: an updated meta-analysis. Acta Neurochir (Wien) 2021; 163:661-676. [PMID: 32889640 PMCID: PMC7474310 DOI: 10.1007/s00701-020-04544-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/16/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The gold-standard treatment for symptomatic anterior skull base meningiomas is surgical resection. The endoscope-assisted supraorbital "keyhole" approach (eSKA) is a promising technique for surgical resection of olfactory groove (OGM) and tuberculum sellae meningioma (TSM) but has yet to be compared with the microscopic transcranial (mTCA) and the expanded endoscopic endonasal approach (EEA) in the context of existing literature. METHODS An updated study-level meta-analysis on surgical outcomes and complications of OGM and TSM operated with the eSKA, mTCA, and EEA was conducted using random-effect models. RESULTS A total of 2285 articles were screened, yielding 96 studies (2191 TSM and 1510 OGM patients). In terms of effectiveness, gross total resection incidence was highest in mTCA (89.6% TSM, 91.1% OGM), followed by eSKA (85.2% TSM, 84.9% OGM) and EEA (83.9% TSM, 82.8% OGM). Additionally, the EEA group had the highest incidence of visual improvement (81.9% TSM, 54.6% OGM), followed by eSKA (65.9% TSM, 52.9% OGM) and mTCA (63.9% TSM, 45.7% OGM). However, in terms of safety, the EEA possessed the highest cerebrospinal fluid leak incidence (9.2% TSM, 14.5% OGM), compared with eSKA (2.1% TSM, 1.6% OGM) and mTCA (1.6% TSM, 6.5% OGM). Finally, mortality and intraoperative arterial injury were 1% or lower across all subgroups. CONCLUSIONS In the context of diverse study populations, the eSKA appeared not to be associated with increased adverse outcomes when compared with mTCA and EEA and offered comparable effectiveness. Case-selection is paramount in establishing a role for the eSKA in anterior skull base tumours.
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Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Ivo S Muskens
- Department of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, The Hague, The Netherlands
| | - Rania A Mekary
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Amir H Zamanipoor Najafabadi
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden, and The Hague, The Netherlands
| | - Adel E Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Robert Reisch
- ENDOMIN - Center for Endoscopic and Minimally Invasive Neurosurgery, Hirslanden Hospital, Zurich, Switzerland
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, The Hague, The Netherlands
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
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Bruneau M, Grenier-Chantrand F, Riva M. How I do it: anterior interhemispheric approach to tuberculum sellae meningiomas. Acta Neurochir (Wien) 2021; 163:643-648. [PMID: 33409742 DOI: 10.1007/s00701-020-04653-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tuberculum sellae meningiomas are deep-seated tumors difficult to access, located in close relation with important neurovascular structures. While the transsphenoidal approach is linked to specific complications, the different reported transcranial approaches are associated with advantages and drawbacks due to the respective angle of attack, with some areas adequately exposed and others partially hidden. METHOD We report the technical aspects of the anterior interhemispheric approach we practice. CONCLUSION This approach has the advantage of providing full control over all the vasculo-nervous structures involved and of allowing access to the medial aspect of both optic canals tangentially to the dorsum sellae.
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Affiliation(s)
- Michaël Bruneau
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Flavie Grenier-Chantrand
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Matteo Riva
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
- Cliniques Universitaires de Mont-Godinne, Université Catholique de Louvain, Yvoir, Belgium
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Midline Meningiomas of the Anterior Skull Base: Surgical Outcomes and a Decision-Making Algorithm for Classic Skull Base Approaches. Cancers (Basel) 2020; 12:cancers12113243. [PMID: 33153110 PMCID: PMC7692292 DOI: 10.3390/cancers12113243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 01/10/2023] Open
Abstract
Simple Summary Resectioning midline meningiomas of the anterior skull base such as olfactory groove, planum sphenoidale, or tuberculum sellae is challenging, and determining the appropriate approach is important. Based on our experience with midline meningiomas, we propose a decision algorithm for choosing suitable transcranial approaches. With dichotomizing classic skull bases approaches into median and lateral ones, we display that median approaches provide satisfactory results for olfactory groove meningiomas, whereas lateral approaches enable sufficient exposure of the visual apparatus for planum sphenoidale meningiomas or tuberculum sellae meningiomas. This manuscript aims to point out the sufficiency and feasibility of classic transcranial techniques. Abstract (1) Background: Midline meningiomas such as olfactory groove (OGMs), planum sphenoidale (PSMs), or tuberculum sellae meningiomas (TSMs) are challenging, and determining the appropriate approach is important. We propose a decision algorithm for choosing suitable transcranial approaches. (2) Methods: A retrospective chart review between 06/2007 and 01/2020. Clinical outcomes, radiographic findings, and postoperative complication rates were analyzed with respect to operative approaches. (3) Results: We included 88 patients in the analysis. Of these, 18.2% (16/88) underwent an interhemispheric approach, 72.7% (64/88) underwent a pterional/frontolateral/supraorbital approach, 2.3% (2/88) underwent a unilateral subfrontal approach, and 6.8% (6/88) underwent a bifrontal approach. All OGMs underwent median approaches, along with one PSM. All of the other PSMs and TSMs were resected via lateral approaches. The preoperative tumor volume was ∅20.2 ± 27.1 cm3. Median approaches had significantly higher tumor volume but also higher rates of Simpson I resection (75.0% vs. 34.4%). An improvement of visual deficits was observed in 34.1% (30/88). The adverse event rate was 17.0%. Median follow-up was 15.5 months (range 0–112 months). (4) Conclusions: Median approaches provides satisfying results for OGMs, lateral approaches enable sufficient exposure of the visual apparatus for PSMs and TSMs. In proposing a simple decision-making algorithm, the authors found that satisfactory outcomes can be achieved for midline meningiomas.
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Aftahy AK, Barz M, Wagner A, Liesche-Starnecker F, Negwer C, Meyer B, Gempt J. The interhemispheric fissure-surgical outcome of interhemispheric approaches. Neurosurg Rev 2020; 44:2099-2110. [PMID: 32852637 PMCID: PMC8338818 DOI: 10.1007/s10143-020-01372-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/14/2020] [Accepted: 08/17/2020] [Indexed: 01/10/2023]
Abstract
Exposure of the anterior skull base is challenging due to strategic structures. The interhemispheric approach (IHA) has turned out to be a feasible technique. We report our experience with IHAs in patients with extraaxial lesions (EAL). We performed a retrospective chart review at a tertiary neurosurgical center between April 2009 and March 2020. We included patients with resection of EAL through IHAs concentrating on surgical technique, complete resection rate, postoperative outcome, and complications. Seventy-four patients resected by an IHA were included: 49 (66.2%) frontal (FIA), nine (12.1%) parietooccipital (PIA), and 16 (21.6%) frontobasal IHAs (FBIAs). Median age at time of surgery was 59 years (range 16–88 years), 47 (63.5%) female and 27 (36.5%) male. Complete resection rate was 83.8% (FIA 89.8%, PIA 55.6%, FBIA 81.3%). Rate of new minor deficits was 17.6%, rate of major deficits 5.4%, total rate 23.0%. 51 (68.9%) WHO°I meningiomas, ten (13.5%) WHO°II meningiomas, two (2.7%) WHO°III meningiomas, nine (12.2%) metastases, one (1.4%) sarcoma, and one (1.4%) local adenocarcinoma were resected. Total complication rate was 27.0%. Rate of major complications requiring intervention was 9.6%. Mean follow-up was 34.2 (± 33.2) months. In patients with lesions of the interhemispheric fissure, overall morbidity and complications are comparatively high. Extensions of IHAs with potential even higher morbidity are not necessary though; we support the use of standardized IHAs. Our findings suggest regular usage of relatively feasible IHAs for a satisfying outcome. Invasive, complicated, or contralateral trajectories were not needed.
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Affiliation(s)
- A Kaywan Aftahy
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Friederike Liesche-Starnecker
- Department of Neuropathology Klinikum rechts der Isar Institute of Pathology School of Medicine, Technical University Munich, Munich, Germany
| | - Chiara Negwer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Youngerman BE, Banu MA, Gerges MM, Odigie E, Tabaee A, Kacker A, Anand VK, Schwartz TH. Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data. J Neurosurg 2020; 135:113-125. [PMID: 32707549 PMCID: PMC8111689 DOI: 10.3171/2020.4.jns20475] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has gained increasing popularity for the resection of suprasellar meningiomas (SSMs). Appropriate case selection is critical in optimizing patient outcome. Long-term outcome data are lacking. The authors systematically identified preoperative factors associated with extent of resection (EOR) and determined the relationship between EOR and long-term recurrence after EEA for SSMs. METHODS In this retrospective cohort study, the authors identified preoperative clinical and imaging characteristics associated with EOR and built on the recently published University of California, San Francisco resectability score to propose a score more specific to the EEA. They then examined the relationship between gross-total resection (GTR; 100%), near-total resection (NTR; 95%-99%), and subtotal resection (STR; < 95%) and recurrence or progression with Kaplan-Meier survival analysis. RESULTS A total of 51 patients were identified. Radiographic GTR was achieved in 40 of 47 (85%) patients in whom it was the surgical goal. Significant independent risk factors for incomplete resection were prior surgery (OR 25.94, 95% CI < 2.00 to 336.49, p = 0.013); tumor lateral to the optic nerve (OR 13.41, 95% CI 1.82-98.99, p = 0.011); and complete internal carotid artery (ICA) encasement (OR 15.12, 95% CI 1.17-194.08, p = 0.037). Tumor size and optic canal invasion were not significant risk factors after adjustment for other variables. A resectability score based on the multivariable model successfully predicted the likelihood of GTR; a score of 0 had a positive predictive value of 97% for GTR, whereas a score of 2 had a negative predictive value of 87.5% for incomplete resection. After a mean follow-up of 40.6 ± 32.4 months (mean ± SD), recurrence was 2.7% after GTR (1 patient with atypical histology), 44.4% after NTR, and 80% after STR (p < 0.0001). Vision was stable or improved in 93.5% and improved in 67.4% of patients with a preoperative deficit. There were 5 (9.8%) postoperative CSF leaks, of which 4 were managed with lumbar drains and 1 required a reoperation. CONCLUSIONS The EEA is a safe and effective approach to SSMs, with favorable visual outcomes in well-selected cases. The combination of postoperative MRI-based EOR with direct endoscopic inspection can be used in lieu of Simpson grade to predict recurrence. GTR dramatically reduces recurrence and can be achieved regardless of tumor size, proximity or encasement of the anterior cerebral artery, or medial optic canal invasion. Risk factors for incomplete resection include prior surgery, tumor lateral to the optic nerve, and complete ICA encasement.
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Affiliation(s)
- Brett E. Youngerman
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
- Department of Neurosurgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Matei A. Banu
- Department of Neurosurgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Mina M. Gerges
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eseosa Odigie
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Abtin Tabaee
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Ashutosh Kacker
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Vijay K. Anand
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Theodore H. Schwartz
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
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Surgical management of Tuberculum sellae Meningiomas: Myths, facts, and controversies. Acta Neurochir (Wien) 2020; 162:631-640. [PMID: 31834502 DOI: 10.1007/s00701-019-04114-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/21/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The optimal management of tuberculum sellae (TS) meningiomas, especially the surgical strategy, continues to be debated along with several controversies that persist. METHODS A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumors on a European perspective. To achieve this, the task force also reviewed in detail the literature in this field and had formal discussions within the group. RESULTS The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological and endocrinological assessments, optimal surgical strategies, and follow-up management. CONCLUSION This article represents the consensually derived opinion of the task force with respect to the surgical treatment of tuberculum sellae meningiomas. Areas of uncertainty where further clinical research is required were identified.
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Solari D, Cavallo LM, Cappabianca P. Commentary: Endoscopic Endonasal Removal of Primary/Recurrent Meningiomas in the Medial Optic Canal: Surgical Technique and Long-Term Visual Outcome. Oper Neurosurg (Hagerstown) 2019; 17:E192-E194. [PMID: 31058992 DOI: 10.1093/ons/opz080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/19/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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15
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Ottenhausen M, Rumalla K, Alalade AF, Nair P, La Corte E, Younus I, Forbes JA, Ben Nsir A, Banu MA, Tsiouris AJ, Schwartz TH. Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas. Neurosurg Focus 2019; 44:E7. [PMID: 29606040 DOI: 10.3171/2018.1.focus17734] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anterior skull base meningiomas are benign lesions that cause neurological symptoms through mass effect on adjacent neurovascular structures. While traditional transcranial approaches have proven to be effective at removing these tumors, minimally invasive approaches that involve using an endoscope offer the possibility of reducing brain and nerve retraction, minimizing incision size, and speeding patient recovery; however, appropriate case selection and results in large series are lacking. METHODS The authors developed an algorithm for selecting a supraorbital keyhole minicraniotomy (SKM) for olfactory groove meningiomas or an expanded endoscopic endonasal approach (EEA) for tuberculum sella (TS) or planum sphenoidale (PS) meningiomas based on the presence or absence of olfaction and the anatomical extent of the tumor. Where neither approach is appropriate, a standard transcranial approach is utilized. The authors describe rates of gross-total resection (GTR), olfactory outcomes, and visual outcomes, as well as complications, for 7 subgroups of patients. Exceptions to the algorithm are also discussed. RESULTS The series of 57 patients harbored 57 anterior skull base meningiomas; the mean tumor volume was 14.7 ± 15.4 cm3 (range 2.2-66.1 cm3), and the mean follow-up duration was 42.2 ± 37.1 months (range 2-144 months). Of 19 patients with olfactory groove meningiomas, 10 had preserved olfaction and underwent SKM, and preservation of olfaction in was seen in 60%. Of 9 patients who presented without olfaction, 8 had cribriform plate invasion and underwent combined SKM and EEA (n = 3), bifrontal craniotomy (n = 3), or EEA (n = 2), and one patient without both olfaction and cribriform plate invasion underwent SKM. GTR was achieved in 94.7%. Of 38 TS/PS meningiomas, 36 of the lesions were treated according to the algorithm. Of these 36 meningiomas, 30 were treated by EEA and 6 by craniotomy. GTR was achieved in 97.2%, with no visual deterioration and one CSF leak that resolved by placement of a lumbar drain. Two patients with tumors that, based on the algorithm, were not amenable to an EEA underwent EEA nonetheless: one had GTR and the other had a residual tumor that was followed and removed via craniotomy 9 years later. CONCLUSIONS Utilizing a simple algorithm aimed at preserving olfaction and vision and based on maximizing use of minimally invasive approaches and selective use of transcranial approaches, the authors found that excellent outcomes can be achieved for anterior skull base meningiomas.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Matei A Banu
- 2Department of Neurosurgery, Columbia-Presbyterian Medical Center, New York, New York
| | | | - Theodore H Schwartz
- Departments of1Neurological Surgery.,3Otorhinolaryngology.,5Neuroscience, Weill Cornell Medical College; and
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16
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Small Extended Bifrontal Approach for Midline Anterior Skull Base Meningiomas: Our Experience with 54 Consecutive Patients. World Neurosurg 2019; 125:e35-e43. [PMID: 30639482 DOI: 10.1016/j.wneu.2018.12.172] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe the technique of a small extended bifrontal approach and review the clinical outcome of patients with midline anterior skull base (MASB) meningiomas treated using this technique. METHODS The small extended bifrontal craniotomy extends inferiorly to the nasofrontal suture without entering the orbit, superiorly 3 cm above the supraorbital rim, and laterally 3 cm to the midline on both sides. A review of a prospectively acquired database was performed of 54 consecutive patients with MASB meningiomas who underwent this craniotomy. RESULTS Twenty-nine patients with olfactory groove meningiomas, 2 with planum sphenoidale meningiomas (PSMs), and 23 with tuberculum sellae meningiomas (TSMs) were treated using this technique. Gross total resection was achieved in all patients. Of 29 patients with olfactory groove meningiomas, 12 (41.4%) had normal olfaction at presentation and 8 had preservation of olfaction postoperatively. Of 25 patients with TSMs/PSMs, 23 (92.0%) had preoperative visual impairment, with 13 showing improved vision (56.5%), 8 unchanging (34.8%), and 2 deteriorating (8.7%) after surgery. The most common complications were anosmia and hyposmia, which occurred in 5 patients (20.0%) and 3 patients (12.0%) with TSMs/PSMs, respectively. No mortality was reported. There was no recurrence in all patients after a mean follow-up of 39.5 months (range, 16-64 months). CONCLUSIONS The small extended bifrontal approach is a safe and effective technique for resection of MASB meningiomas, which provides adequate surgical exposure with less approach-related morbidity. It is an excellent alternative for surgeons who favor the bifrontal approach and its extended variations.
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17
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Bernat AL, Priola SM, Elsawy A, Farrash F, Pasarikovski CR, Almeida JP, Lenck S, De Almeida J, Vescan A, Monteiro E, Zadeh GM, Gentili F. Recurrence of Anterior Skull Base Meningiomas After Endoscopic Endonasal Resection: 10 Years' Experience in a Series of 52 Endoscopic and Transcranial Cases. World Neurosurg 2018; 120:e107-e113. [PMID: 30077030 DOI: 10.1016/j.wneu.2018.07.210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Although the indication of endoscopic approaches for anterior skull base meningiomas (ASBM) has been progressively refined, there remains a paucity of data on recurrence rates after resection. To analyze and compare recurrence rates of ASBM resected through endoscopic endonasal (EEE) versus transcranial (TCA) approaches. MATERIAL AND METHODS We performed a retrospective analysis of patients submitted to the EEE or TCA approach for ASBM resection from May 2006 to January 2016 in our center. Clinical, radiological, and pathology data were retrieved for analysis. Tumor size, location, surgical technique, extent of resection, and tumor grade were assessed. The 2 groups were compared to identify predictors and differences regarding tumor recurrence. RESULTS Fifty-two patients (17 olfactory groove meningioma [OGM] and 35 tuberculum sellae meningioma [TSM]) were included; 26 (6 OGM and 20 TSM) underwent EEE and 26 (13 OGM and 13 TSM) TCA, with a mean follow-up of 41 months. Gross total resection was achieved in 38 (73%) patients (18 [69%] in EEE and 20 [77%] in TCA). Eight (15%) patients presented with recurrence: 5 (19%) in the EEE group and 3 (11.5%) in the TCA group without a statistical difference (P = 0.69). Among the recurrences, gross total resection had been achieved in 1 case of each group. In the EEE group, 1 patient underwent TCA for a recurrent tumor and another patient was referred for radiosurgery. CONCLUSIONS This study has shown an overall similar recurrence rate of ASBM regardless of the technique used. However, the analysis of larger series with longer follow-up is necessary to clearly define the indications and to fully validate the efficacy of EEE.
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Affiliation(s)
- Anne-Laure Bernat
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, University Paris-Diderot, Lariboisière Hospital, Paris, France.
| | - Stefano Maria Priola
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Ahmad Elsawy
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Faisal Farrash
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Christopher R Pasarikovski
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Joao Paulo Almeida
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada
| | - Stéphanie Lenck
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Interventional Neuroradiology, University Pierre et Marie Curie, La Pitié-Salpêtrière Hospital, Paris, France
| | - John De Almeida
- Department of Otolaryngology, UHN, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Allan Vescan
- Department of Otolaryngology, UHN, Toronto, Ontario, Canada; Department of Otolaryngology, Mount Sinai Hospital, UHN, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric Monteiro
- Department of Otolaryngology, UHN, Toronto, Ontario, Canada; Department of Otolaryngology, Mount Sinai Hospital, UHN, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Mohammed Zadeh
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fred Gentili
- Department of Neurosurgery (Neuro-oncology Division), Toronto Western Hospital, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Magill ST, Morshed RA, Lucas CHG, Aghi MK, Theodosopoulos PV, Berger MS, de Divitiis O, Solari D, Cappabianca P, Cavallo LM, McDermott MW. Tuberculum sellae meningiomas: grading scale to assess surgical outcomes using the transcranial versus transsphenoidal approach. Neurosurg Focus 2018; 44:E9. [DOI: 10.3171/2018.1.focus17753] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVETuberculum sellae meningiomas (TSMs) are surgically challenging tumors that can severely impair vision. Debate exists regarding whether the transcranial (TC) or endoscopic transsphenoidal (TS) approach is best for resecting these tumors, and there are few large series comparing these approaches.METHODSA retrospective chart review was performed at 2 academic centers comparing TC and TS approaches with respect to vision, extent of resection, recurrence, and complications. The authors report surgical outcomes and propose a simple preoperative tumor grading scale that scores tumor size (1–2), optic canal invasion (0–2), and arterial encasement (0–2). The authors performed univariate, multivariate, and recursive partitioning analysis (RPA) to evaluate outcomes.RESULTSThe TSMs were resected in 139 patients. The median follow-up was 29 months. Ninety-five (68%) cases were resected via a TC and 44 (32%) via a TS approach. Tumors treated via a TC approach had a higher tumor (p = 0.0007), artery (p < 0.0001), and total score (p = 0.0012) on the grading scale. Preoperative visual deficits were present in 87% of patients. Vision improved in 47%, stayed the same in 35%, declined in 10%, and was not recorded in 8%. The extent of resection was 65% gross-total resection, 23% near-total resection (95%–99% resection), and 12% subtotal resection (< 95%). A lower tumor score was significantly associated with better or stable vision postoperatively (p = 0.0052). The RPA confirmed low tumor score as the key predictor of postoperative visual improvement or stability. Multivariate analysis and RPA demonstrate that lower canal score (p < 0.0001) and TC approach (p = 0.0019) are associated with gross-total resection. Complications occurred in 20 (14%) patients, including CSF leak (5%) and infection (4%). There was no difference in overall complication rates between TC and TS approaches; however, the TS approach had more CSF leaks (OR 5.96, 95% CI 1.10–32.04). The observed recurrence rate was 10%, and there was no difference between the TC and TS approaches.CONCLUSIONSTuberculum sellae meningiomas can be resected using either a TC or TS approach, with low morbidity and good visual outcomes in appropriately selected patients. The simple proposed grading scale provides a standard preoperative method to evaluate TSMs and can serve as a starting point for selection of the surgical approach. Higher scores were associated with worsened visual outcomes and subtotal resection, regardless of approach. The authors plan a multicenter review of this grading scale to further evaluate its utility.
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Affiliation(s)
- Stephen T. Magill
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Ramin A. Morshed
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Calixto-Hope G. Lucas
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Manish K. Aghi
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | | | - Mitchel S. Berger
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Oreste de Divitiis
- 2Divsion of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Domenico Solari
- 2Divsion of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- 2Divsion of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Luigi M. Cavallo
- 2Divsion of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Michael W. McDermott
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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Giordano M, Gerganov VM, Gallieni M, Samii A, Samii M. Evaluation of Olfactory Outcome After Frontolateral Approach for Treatment of Suprasellar Tumors. World Neurosurg 2018; 114:e1002-e1006. [PMID: 29597015 DOI: 10.1016/j.wneu.2018.03.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We present the findings of our prospective study assessing olfactory function outcome in patients undergoing a frontolateral approach for the resection of suprasellar lesions. METHODS Eighteen consecutive patients (7 females, 11 males) surgically treated at our institute for suprasellar tumors were included in this prospective study. Olfactory function was evaluated at the admission and 14 days after the surgery using the standard 12-item "Sniffin' Sticks" screening (SSS) test. The olfactory outcome was correlated to the following variables: tumor type, size, consistency, and extent of vertical and lateral growth. RESULTS Preoperative and postoperative SSS test mean values were, respectively, 9.11 and 8.72 (not significant: P = 0.274). In only 1 case (5%), with larger suprasellar extension, the difference between preoperative and postoperative SSS was ≥3 (reduction of 5 points). At the subjective evaluation, no patient stated a deficit in smelling. CONCLUSION The frontolateral craniotomy is a minimally invasive route to treat suprasellar tumors and has a low approach-related morbidity. It allows tumor resection with low risk for the olfactory function. A risk factor for postoperative olfactory deficit could be significant brain retraction.
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Affiliation(s)
- Mario Giordano
- International Neuroscience Institute, Department of Neurosurgery, Hannover, Germany.
| | - Venelin M Gerganov
- International Neuroscience Institute, Department of Neurosurgery, Hannover, Germany
| | - Massimo Gallieni
- International Neuroscience Institute, Department of Neurosurgery, Hannover, Germany
| | - Amir Samii
- International Neuroscience Institute, Department of Neurosurgery, Hannover, Germany; Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - Madjid Samii
- International Neuroscience Institute, Department of Neurosurgery, Hannover, Germany
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20
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Muskens IS, Briceno V, Ouwehand TL, Castlen JP, Gormley WB, Aglio LS, Zamanipoor Najafabadi AH, van Furth WR, Smith TR, Mekary RA, Broekman MLD. The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis. Acta Neurochir (Wien) 2018; 160:59-75. [PMID: 29127655 PMCID: PMC5735207 DOI: 10.1007/s00701-017-3390-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/31/2017] [Indexed: 12/02/2022]
Abstract
Object In the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes. Methods A systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values. Results Of 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results. Conclusion In this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs. Electronic supplementary material The online version of this article (10.1007/s00701-017-3390-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ivo S Muskens
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands.
- Department of Neurosurgery, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508GA, Utrecht, The Netherlands.
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Vanessa Briceno
- School of Pharmacy, Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
| | - Tom L Ouwehand
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Neurosurgery, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508GA, Utrecht, The Netherlands
| | - Joseph P Castlen
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - William B Gormley
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Linda S Aglio
- Department of Anesthesiology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Timothy R Smith
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- School of Pharmacy, Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
| | - Marike L D Broekman
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Neurosurgery, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508GA, Utrecht, The Netherlands
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
The resection of anterior skull base meningiomas has traditionally been performed via pterional or unilateral/bilateral subfrontal craniotomies. The supraorbital keyhole approach and the endoscopic endonasal approach, techniques in which the endoscope is used to aid visualization, were developed to provide alternative, less-invasive approaches to aid the resection of these tumors. The individual characteristics of each tumor, such as location and size, are the main determinants guiding the choice of approach. In this article, the advantages and disadvantages of each approach are discussed, along with complications specific to each technique. Furthermore, a detailed procedural description of each surgical approach is described.
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Lee S, Hong SH, Cho YH, Kim JH, Kim CJ. Anatomical Origin of Tuberculum Sellae Meningioma: Off-Midline Location and Its Clinical Implications. World Neurosurg 2016; 89:552-61. [PMID: 26875651 DOI: 10.1016/j.wneu.2016.02.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Tuberculum sellae meningiomas (TSM) arise from the dura mater of tuberculum sellae, limbus sphenoidale, and chiasmatic sulcus and cause asymmetric visual disturbances. In this study, we analyzed the laterality of the origin of TSM and discussed its clinical implications on immediate and long-term visual outcomes. METHODS Between 1994 and 2013, TSM was diagnosed in 100 patients after microsurgical resection. The medical records, radiologic features, and operative findings were retrospectively reviewed and analyzed in these patients. RESULTS Visual disturbances were evident in 95 patients (95%) after neuro-ophthalmologic testing. Among them, 89 patients (89%) showed marked asymmetric visual field defect, and 6 patients (6%) had relatively symmetric visual field defect. On intraoperative inspection, the origin of TSM was at the one lateral end portion of the tuberculum sellae in 85 patients (85%). In 15 patients (15%), the TSM originated from the midline region, including the central portion of the tuberculum sellae (n = 13) and diaphragm sellae (n = 2). Optic canal involvement was observed in 73 patients (73%). Preexisting visual field defects were improved in 70 patients (70%), were stationary in 25 patients (25%), and aggravated in 5 patients (5%) during postoperative follow-up (mean 58 months, 24∼122 months). The preoperative symptom duration, the laterality of the origin of TSM, and optic disc atrophy were associated with long-term poor visual outcomes. CONCLUSIONS Most TSMs that originated from the dura of one lateral end portion of the tuberculum sellae correlated with asymmetric visual symptoms and poor visual outcomes. This microsurgical feature should be considered in the planning of optimal surgical strategy to achieve favorable outcomes.
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Affiliation(s)
- Seungjoo Lee
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Seok Ho Hong
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Young Hyun Cho
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Jeong Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Chang Jin Kim
- Department of Neurological Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea.
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23
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Hannequin P, Paviot A, Chaussy O, Gilard V, Cébula H, Marie JP, Proust F. Olfaction preservation after removal of large tuberculum sellae meningiomas via a superior interhemispheric approach. A quantitative and qualitative study. Neurochirurgie 2015; 61:318-23. [DOI: 10.1016/j.neuchi.2015.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 05/28/2015] [Accepted: 06/07/2015] [Indexed: 10/23/2022]
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Matano F, Murai Y, Mizunari T, Tateyama K, Kobayashi S, Adachi K, Kamiyama H, Morita A, Teramoto A. Olfactory preservation during anterior interhemispheric approach for anterior skull base lesions: technical note. Neurosurg Rev 2015; 39:63-8; discussion 69. [PMID: 26178238 DOI: 10.1007/s10143-015-0647-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 04/12/2015] [Accepted: 04/25/2015] [Indexed: 11/29/2022]
Abstract
Anosmia is not a rare complication of surgeries that employ the anterior interhemispheric approach. Here, we present a fibrin-gelatin fixation method that provides reinforcement and moisture to help preserve the olfactory nerve when using the anterior interhemispheric approach and describe the results and outcomes of this technique. We analyze the outcomes with this technique in 45 patients who undergo surgery for aneurysms, brain tumors, or other pathologies via the anterior interhemispheric approach. Anosmia occurred in 4 patients (8.8%); it was transient in 2 (4.4%) and permanent in the remaining 2 (4.4%). Brain tumors clearly attached to the olfactory nerve were resected in the patients with permanent anosmia. We found a significant difference in the presence of anosmia between patients with or without lesions that were attaching the olfactory nerve (p = 0.011). Our results suggested that fibrin-gelatin fixation method can reduce the reported risk of anosmia. However, the possibility of olfactory nerve damage is relatively high when operating on brain tumors attaching olfactory nerve.
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Affiliation(s)
- Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Takayuki Mizunari
- Department of Neurological Surgery, Chiba Hokusou Hospital, Chiba, Japan
| | - Kojiro Tateyama
- Department of Neurological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Shiro Kobayashi
- Department of Neurological Surgery, Chiba Hokusou Hospital, Chiba, Japan
| | - Koji Adachi
- Department of Neurological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hiroyasu Kamiyama
- Department of Neurological Surgery, Teishinkai Hospital, Sapporo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Akira Teramoto
- Department of Neurological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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Akçakaya MO, Aras Y, İzgi N, Gayretli Ö, Sabancı PA, Aydoseli A, Gürses İA, Sencer A, Öztürk A, Hepgül K. Fully endoscopic supraorbital keyhole approach to the anterior cranial base: A cadaveric study. J Neurosci Rural Pract 2015; 6:361-8. [PMID: 26167020 PMCID: PMC4481791 DOI: 10.4103/0976-3147.154568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction: The supraorbital keyhole approach for anterior cranial base lesions has been increasingly used in clinical practice. Anatomical studies focusing on the endoscopic anatomy via this approach are few, although the microscopic anatomy has been well studied. The aim of this study is to describe the anatomical features and surgical exposure provided by the endoscopic supraorbital keyhole approach using quantitative measurements. Materials and Methods: Nine formalin-fixed human cadavers from the inventory of the Anatomy department were used. A total of 18 supraorbital keyhole cranitomies were conducted. The distances between the target anatomical structures and the dura mater at the craniotomy site, and the distances between deep anatomical structures were measured with purpose-designed hooks. Results: The distance between the dura mater and optic canal was measured as 69.5 ± 6.7 mm (62–83 mm); optic chiasm as 76.2 ± 5.4 mm (67–86 mm); anterior communicating artery as 82.6 ± 6.1 mm (71–93 mm); internal carotid artery (ICA) bifurcation as 74.7 ± 6.0 mm (66–84 mm) and the basilar tip as 94.9 ± 7.0 mm (87–111 mm). The mean diameter of the optic canal was 7.4 ± 1.3 mm (6–11 mm), whereas the mean diameter of diaphragma sellae was measured as 8.4 ± 1.1 mm (7–10 mm). Conclusions: The results of this study showed that the anterior and medial aspects of the anterior cranial fossa can be visualized properly. Dissection of the ipsilateral arteries of Circle of Willis can be performed easily using an endoscopic supraorbital keyhole approach.
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Affiliation(s)
- Mehmet Osman Akçakaya
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Yavuz Aras
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Nail İzgi
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Özcan Gayretli
- Department of Anatomy, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Pulat Akın Sabancı
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydın Aydoseli
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - İlke Ali Gürses
- Department of Anatomy, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Altay Sencer
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Adnan Öztürk
- Department of Anatomy, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Kemal Hepgül
- Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
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Khan OH, Anand VK, Schwartz TH. Endoscopic endonasal resection of skull base meningiomas: the significance of a "cortical cuff" and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection. Neurosurg Focus 2015; 37:E7. [PMID: 25465040 DOI: 10.3171/2014.7.focus14321] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This paper describes a consecutive series of skull base meningiomas resected using an endoscopic endonasal approach through various corridors at a single institution over 7 years. The impact of case selection and experience, the presence of a cortical cuff between the tumor and surrounding vessels, and brain edema on morbidity and rates of gross-total resection (GTR) were examined. METHODS A retrospective review of a series of 46 skull base meningiomas from a prospective database was conducted. The series of cases were divided by location: olfactory groove (n = 15), tuberculum and planum (n = 20), sellar/cavernous (n = 9) and petroclival (n = 2). Gross-total resection was never intended in the sellar/cavernous tumors, which generally invaded the cavernous sinus. Clinical charts, volumetric imaging, and pathology were reviewed to assess the extent of resection and complications. Cases were divided based on a time point in which surgical technique and case selection improved into Group 1 (surgery prior to June 2008; n = 21) and Group 2 (surgery after June 2008; n = 25) and into those with and without a cortical cuff and with and without brain edema. RESULTS Improved case selection had the greatest impact on extent of resection. For the entire cohort, rates of GTR went from 38% to 76% (p = 0.02), and for cases in which GTR was the intent, the rates went from 63% to 84% (not significant), which was mostly driven by the planum and tuberculum meningiomas, which went from 75% to 91.7 % (nonsignificant difference). The presence of a cortical cuff and brain edema had no impact on outcomes. There were 3 CSF leaks (6.5%) but all were in Group 1. Hence, CSF leak improved from 14.2% to 0% with surgical experience. Lessons learned for optimal case selection are discussed. CONCLUSIONS Surgical outcome for endonasal endoscopic resection of skull base meningiomas depends mostly on careful case selection and surgical experience. Imaging criteria such as the presence of a cortical cuff or brain edema are less important.
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Affiliation(s)
- Osaama H Khan
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Ontario, Canada
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27
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Ditzel Filho LFS, Prevedello DM, Jamshidi AO, Dolci RL, Kerr EE, Campbell R, Otto BA, Carrau RL, Kassam A. Endoscopic Endonasal Approach for Removal of Tuberculum Sellae Meningiomas. Neurosurg Clin N Am 2015; 26:349-61. [PMID: 26141355 DOI: 10.1016/j.nec.2015.03.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tuberculum sellae meningiomas are challenging lesions; their critical location and often insidious growth rate enables significant distortion of the superjacent optic apparatus before the patient notices any visual impairment. This article describes the technical nuances, selection criteria and complication avoidance strategies for the endonasal resection of tuberculum sellae meningiomas. A stepwise description of the surgical technique is presented; indications, adjuvant technologies, pitfalls and the relevant anatomy are also reviewed. Tuberculum sellae meningiomas may be safely and effectively resected through the endonasal route; invasion of the optic canals does not represent a limitation.
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Affiliation(s)
- Leo F S Ditzel Filho
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Ali O Jamshidi
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Ricardo L Dolci
- Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Edward E Kerr
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Raewyn Campbell
- Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Bradley A Otto
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Ricardo L Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
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28
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Zygourakis CC, Sughrue ME, Benet A, Parsa AT, Berger MS, McDermott MW. Management of Planum/Olfactory Meningiomas: Predicting Symptoms and Postoperative Complications. World Neurosurg 2014; 82:1216-23. [DOI: 10.1016/j.wneu.2014.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/24/2014] [Accepted: 08/06/2014] [Indexed: 11/28/2022]
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Liu Y, Chotai S, Ming C, Jin S, Pan J, Qi S. Characteristics of midline suprasellar meningiomas based on their origin and growth pattern. Clin Neurol Neurosurg 2014; 125:173-81. [PMID: 25171391 DOI: 10.1016/j.clineuro.2014.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/01/2014] [Accepted: 08/02/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the present study was to elucidate clinical and prognostic characteristics of the midline suprasellar meningiomas based on their origin and growth pattern. METHODS A retrospective review of the medical records was conducted for patients undergoing surgical resection of the midline suprasellar meningioma. The meningiomas were divided into group A - planum sphenoidale meningioma (PSM), group B - tuberculum sellae meningioma (TSM) and group C - diaphragma sellae meningioma (DSM), based on their growth pattern in relation to the optic pathway and pituitary stalk, group C was then divided into groups C1 and C2. RESULTS The mean age of 32 men and 74 women was 48.5±13.1 years (range, 20-78 years). The rate of visual impairment was highest in patients in group C2 and lowest in group A patients (P<0.001). The h-p axis impairment and MRI evidence of the pituitary stalk involvement was more frequent in patients with group C1 meningioma (P<0.001). The gross total resection (GTR) was achieved in 84/106 (79%) patients. The mean follow-up period was 70.4 months (median 86 months, range 64.5-76.3 months). The fronto-temporal approach was the only significant predictor of the postoperative visual acuity impairment (P=0.001, OR: 8.2, CI: 2.45-27.42) and visual field impairment (P=0.016, OR: 0.071, CI: 0.008-0.607). The meningiomas in groups B (P=0.024, OR: 0.198, CI: 0.049-0.812) and C1 (P=0.012, OR: 0.082, CI: 0.012-0.580) were significant predictors of the postoperative visual field deficits. The group C1 (P=0.036, OR: 0.244, CI: 0.065-0.912) and surgical approach employed (P=0.032, OR: 0.013, CI: 0.000-0.684) was significant predictors of the postoperative h-p function impairment. The mean recurrence free survival (RFS) time and rate were 102.9±3.2 months and 86%. The group C1 meningiomas had the lowest RFS rate and time (33.3% and 55.6±8.3 months). The subtotal resection and the group C1 meningioma (P=0.001, OR: 15.6, CI: 2.9-82.8) were the significant predictors of recurrence (P=0.008, OR: 0.08, CI: 0.014-0.529). CONCLUSION The group A meningioma had the high rate of complete resection and favorable RFS. Groups B and C2 involve optic pathway and optic canal predominately. The group C1 DSM was an independent predictor of subtotal resection, postoperative visual field and h-p axis impairment. The subtotal resection was an independent predictor of the recurrence.
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Affiliation(s)
- Yi Liu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Silky Chotai
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chen Ming
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shi Jin
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Pan
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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30
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Santarius T, Jian BJ, Englot D, McDermott MW. Delayed neurological deficit following resection of tuberculum sellae meningioma: report of two cases, one with permanent and one with reversible visual impairment. Acta Neurochir (Wien) 2014; 156:1099-102. [PMID: 24639145 DOI: 10.1007/s00701-014-2046-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
The most common presentation of patients with tuberculum sellae meningiomas is visual loss, and surgical resection is the main mode of treatment. Preservation of vision is not only the main objective of the surgery; loss of vision is also its main risk. Visual deterioration following surgery is usually apparent immediately post-operatively. Here we present two cases of patients who underwent resection of tuberculum sellae meningioma and whose vision following surgery was initially unchanged until the postoperative day two when dramatic visual deterioration occurred. In the first case this resulted in blindness, whereas in the second case vision recovered back to the preoperative state. The possible mechanisms of visual deterioration and modes of treatment are discussed.
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Khan OH, Krischek B, Holliman D, Klironomos G, Kucharczyk W, Vescan A, Gentili F, Zadeh G. Pure endoscopic expanded endonasal approach for olfactory groove and tuberculum sellae meningiomas. J Clin Neurosci 2013; 21:927-33. [PMID: 24433951 DOI: 10.1016/j.jocn.2013.10.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/18/2013] [Indexed: 11/30/2022]
Abstract
The expanded endoscopic endonasal (EEE) approach for the removal of olfactory groove (OGM) and tuberculum sellae (TSM) meningiomas is currently becoming an acceptable surgical approach in neurosurgical practice, although it is still controversial with respect to its outcomes, indications and limitations. Here we provide a review of the available literature reporting results with use of the EEE approach for these lesions together with our experience with the use of the endoscope as the sole means of visualization in a series of patients with no prior surgical biopsy or resection. Surgical cases between May 2006 and January 2013 were retrospectively reviewed. Twenty-three patients (OGM n=6; TSM n=17) were identified. In our series gross total resection (GTR) was achieved in 4/6 OGM (66.7%) and 11/17 (64.7%) TSM patients. Vision improved in the OGM group (2/2) and 8/11 improved in the TSM group with no change in visual status in the remaining three patients. Post-operative cerebrospinal fluid (CSF) leak occurred in 2/6 (33%) OGM and 2/17 (11.8%) TSM patients. The literature review revealed a total of 19 OGM and 174 TSM cases which were reviewed. GTR rate was 73% for OGM and 56.3% for TSM. Post-operative CSF leak was 30% for OGM and 14% for TSM. With careful patient selection and a clear understanding of its limitations, the EEE technique is both feasible and safe. However, longer follow-ups are necessary to better define the appropriate indications and ideal patient population that will benefit from the use of these newer techniques.
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Affiliation(s)
- Osaama H Khan
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Ontario M5T 2S8, Canada.
| | - Boris Krischek
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Ontario M5T 2S8, Canada
| | - Damian Holliman
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Ontario M5T 2S8, Canada
| | - George Klironomos
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Ontario M5T 2S8, Canada
| | - Walter Kucharczyk
- Department of Diagnostic Imaging, University Health Network, Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - Allan Vescan
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - Fred Gentili
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Ontario M5T 2S8, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Ontario M5T 2S8, Canada
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Gadgil N, Thomas JG, Takashima M, Yoshor D. Endoscopic resection of tuberculum sellae meningiomas. J Neurol Surg B Skull Base 2013; 74:201-10. [PMID: 24436913 DOI: 10.1055/s-0033-1342922] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022] Open
Abstract
Objective To evaluate the results of endoscopic transnasal resection of tuberculum sellae meningiomas (TSMs) as compared with transcranial approaches. Design We retrospectively analyzed five patients who underwent endoscopic endonasal resection of TSM and performed a comprehensive review of articles published between 2000 and 2012 describing the operative treatment of TSMs. Results Gross total resection (GTR) was achieved in four patients (80%). Transient diabetes insipidus occurred in three patients (60%). Preoperative visual field deficit resolved in all patients. Cerebrospinal fluid (CSF) leak occurred in one patient. Analysis of published studies included 1,026 transcranial and 144 transnasal cases. GTR was achieved in 85% of transcranial and 72% of transnasal cases. Visual field deficit improved in 65% of transcranial and 82% of transnasal cases. Rate of diabetes insipidus and CSF leak was higher in the transnasal series. Rate of GTR and visual improvement was higher in endoscopic endonasal as compared with microsurgical transnasal series. Conclusion The literature supports transsphenoidal surgery for the resection of TSMs with significant optic nerve compromise and limited lateral extension. This approach may have an equivalent if not superior outcome over transcranial surgery in visual outcome. CSF leaks are still a challenge but may improve with the use of vascularized nasoseptal flaps.
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Affiliation(s)
- Nisha Gadgil
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jonathan G Thomas
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Masayoshi Takashima
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel Yoshor
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
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Margalit N, Shahar T, Barkay G, Gonen L, Nossek E, Rozovski U, Kesler A. Tuberculum sellae meningiomas: surgical technique, visual outcome, and prognostic factors in 51 cases. J Neurol Surg B Skull Base 2013; 74:247-58. [PMID: 24436920 DOI: 10.1055/s-0033-1342920] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 01/28/2013] [Indexed: 10/27/2022] Open
Abstract
Complete tumor resection with preservation or improvement of visual function is the goal of tuberculum sellae meningioma (TSM) treatment. The authors retrospectively reviewed 51 patients treated surgically for TSM between 2003 and 2010, with special attention to surgical technique, visual outcomes, and prognostic factors for treatment outcome. All patients were operated via the lateral subfrontal approach. The cohort mean age and Karnofsky performance status (KPS) on admission was 57.1 ± 13.6 and 84.3 ± 11.7, respectively. The most common presenting sign was visual impairment. The mean tumor size was 29.4 ± 10.7 mm. In 45 of the patients (88.2%), gross total resection was achieved. Improvement and/or preservation of visual acuity and visual field were achieved in 95.9% and 85.3%, respectively. Visual functions on admission were found to be the strongest predictors for postoperative improvement in visual outcome, followed by better KPS on admission, smaller tumor size, and young age. Postoperative neurological complications included cerebrospinal fluid (CSF) leak, meningitis, and postoperative seizures. TSM can be safely operated on through the lateral subfrontal approach. A high percentage of complete tumor resection and excellent visual outcomes are achieved using this technique. Surgical treatment in the early stage of the disease may result in a better visual outcome.
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Affiliation(s)
- Nevo Margalit
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Shahar
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Gal Barkay
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Gonen
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Erez Nossek
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Uri Rozovski
- Department of Hematology and Bone Marrow Transplantation, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Anat Kesler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel ; Department of Ophthalmology, Neuro Ophthalmology Unit, Tel Aviv Medical Center, Tel Aviv, Israel
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Seol HJ, Park HY, Nam DH, Kong DS, Lee JI, Kim JH, Park K. Clinical outcomes of tuberculum sellae meningiomas focusing on reversibility of postoperative visual function. Acta Neurochir (Wien) 2013. [PMID: 23203796 DOI: 10.1007/s00701-012-1551-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Tuberculum sellae meningiomas present a special challenge because of their proximity to major arteries, visual pathways, and the hypothalamus. The aim of this study was to determine the prognostic determinants of clinical and visual outcomes of these tumors, focusing on the functional reversibility of an unserviceable eye after surgery. METHODS We retrospectively reviewed 86 patients on the basis of clinical and radiological factors that appeared to affect outcome. The visual acuity and visual fields were analyzed according to the visual impairment score (VIS). Unserviceable visual acuity included no perception of light (NPL), hand movement (HM), and counting fingers (CF). Ophthalmological functioning was tested in the preoperative period, the postoperative short-term period (≤2 weeks after surgery), and the postoperative long-term period (>6 months after surgery). Our own clinical outcome criteria including tumor control, visual improvement, and complications were used for evaluation. RESULTS Seventy-four of 86 patients (86 %) underwent total removal of the tumor. In three of these cases (3.4 %), recurrence developed. Thirty patients were classified into the "Excellent" group, 21 into the "Good" group, 20 into the "Fair" group, and 15 into the "Poor" group. In multivariate analysis, adhesion to optic nerve was an independent and significant predictor of clinical outcome. Favorable visual outcomes in both short- and long-term postoperative periods were achieved in 80.8 % of cases. Preoperative and short-term visual outcomes were closely related to long-term visual outcome. Six of eight patients with preoperative CF status showed reversibility to a serviceable status after surgery. However, there was no conversion to serviceable status from NPL or HM. CONCLUSIONS For patients with unilateral unserviceable visual function, maintenance of serviceable visual function on the opposite side might be more important. Of the patients with unserviceable visual function, careful surgery might be able to improve the visual function in CF eyes.
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Treatment outcomes after surgical resection of midline anterior skull base meningiomas at a single center. J Clin Neurosci 2012; 19:1654-8. [DOI: 10.1016/j.jocn.2011.11.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/14/2011] [Accepted: 11/16/2011] [Indexed: 11/23/2022]
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Carlson AP, Stippler M, Myers O. Predictive factors for vision recovery after optic nerve decompression for chronic compressive neuropathy: systematic review and meta-analysis. J Neurol Surg B Skull Base 2012; 74:20-38. [PMID: 24436885 DOI: 10.1055/s-0032-1329624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 06/08/2012] [Indexed: 10/27/2022] Open
Abstract
Objectives Surgical optic nerve decompression for chronic compressive neuropathy results in variable success of vision improvement. We sought to determine the effects of various factors using meta-analysis of available literature. Design Systematic review of MEDLINE databases for the period 1990 to 2010. Setting Academic research center. Participants Studies reporting patients with vision loss from chronic compressive neuropathy undergoing surgery. Main outcome measures Vision outcome reported by each study. Odds ratios (ORs) and 95% confidence intervals (CIs) for predictor variables were calculated. Overall odds ratios were then calculated for each factor, adjusting for inter study heterogeneity. Results Seventy-six studies were identified. Factors with a significant odds of improvement were: less severe vision loss (OR 2.31[95% CI = 1.76 to 3.04]), no disc atrophy (OR 2.60 [95% CI = 1.17 to 5.81]), smaller size (OR 1.82 [95% CI = 1.22 to 2.73]), primary tumor resection (not recurrent) (OR 3.08 [95% CI = 1.84 to 5.14]), no cavernous sinus extension (OR 1.88 [95% CI = 1.03 to 3.43]), soft consistency (OR 4.91 [95% CI = 2.27 to 10.63]), presence of arachnoid plane (OR 5.60 [95% CI = 2.08 to 15.07]), and more extensive resection (OR 0.61 [95% CI = 0.4 to 0.93]). Conclusions Ophthalmologic factors and factors directly related to the lesion are most important in determining vision outcome. The decision to perform optic nerve decompression for vision loss should be made based on careful examination of the patient and realistic discussion regarding the probability of improvement.
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Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, United States
| | - Martina Stippler
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, United States
| | - Orrin Myers
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, United States
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Bohman LE, Stein SC, Newman JG, Palmer JN, Adappa ND, Khan A, Sitterley TT, Chang D, Lee JYK. Endoscopic versus open resection of tuberculum sellae meningiomas: a decision analysis. ORL J Otorhinolaryngol Relat Spec 2012; 74:255-63. [PMID: 23107968 DOI: 10.1159/000343794] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 08/31/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Tuberculum sellae meningiomas (TSMs) are challenging tumors for surgical resection. Endoscopic endonasal (EE) approaches to these lesions have not been directly compared to open craniotomy in a controlled trial. METHODS We searched Medline and Embase online databases for English-language articles containing key words related to TSMs. Data were pooled, including 5 of our own patients reported here for the first time. Metaregression was used and a decision-analytical model was constructed to compare outcomes between open microsurgery and EE approaches. RESULTS The overall quality of life (QOL) was not significantly different between the approaches (p = 0.410); however, there were large differences in individual complication rates. The Monte Carlo simulation yielded an overall average QOL in craniotomy patients of 0.915 and in endoscopic patients of 0.952. Endoscopy had a higher CSF leak rate (26.8 vs. 3.5%, p < 0.001) but a lower rate of injury to the optic apparatus (1.4 vs. 9.2%, p < 0.001) compared with craniotomy. The 3-year recurrence rates were not statistically different (p = 0.529). CONCLUSION EE resection of TSMs appears to be a comparable alternative to traditional open microsurgical resection with respect to overall QOL based on available publications. A meaningful comparison of recurrence rates will require a longer follow-up.
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Affiliation(s)
- Leif-Erik Bohman
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA
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Curey S, Derrey S, Hannequin P, Hannequin D, Fréger P, Muraine M, Castel H, Proust F. Validation of the superior interhemispheric approach for tuberculum sellae meningioma: clinical article. J Neurosurg 2012; 117:1013-21. [PMID: 23061383 DOI: 10.3171/2012.9.jns12167] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The objective of this study was to evaluate the ophthalmological outcome, nonvisual morbidity, and surgical complications after tuberculum sellae meningioma (TSM) removal using a superior interhemispheric approach. METHODS In the last decade, 20 consecutive patients with TSM underwent operations using the superior interhemispheric approach. Visual acuity, visual field, and ocular fundus examination were assessed both preoperatively and 6-months postoperatively. Nonvisual morbidity was determined at an early postoperative period and at 6 months based on assessment of the Karnofsky Performance Scale score, leakage of CSF, endocrinological status, and olfactory function, which was assessed using a visual analog scale (VAS). The potential brain injury related to the approach was assessed by MRI at 6 months. Magnetic resonance imaging was then performed yearly to detect a recurrence. The mean follow up was 56.3 ± 34 months. RESULTS The primary presenting symptom for diagnosis of TSM in 20 patients (female:male ratio of 6.6:1, mean age 59.1 ± 11.1 years) was visual disturbance in 12 patients (60%), headache in 4 (20%), cognitive alteration in 1 (5%), epilepsy in 2 (10%), and accidental in 1 (5%). In a total of 40 eyes, 17 eyes in 11 patients presented with preoperative deterioration of visual acuity. Postoperatively, the visual acuity improved in 13 eyes in 8 patients (72.8%), remained unchanged in 3 eyes in 2 patients (18.2%) and deteriorated in 1 patient (9%). The nonvisual morbidity included olfactory deterioration in 7 patients (35%), and panhypopituitarism in 1 patient (5%). No patients experienced a CSF leak. The impact of olfactory deterioration on the quality of life, as estimated by a VAS score (range 0-10), was a mean of 5.7 ± 2.2 (95% CI 4.1-7.3). On the follow-up MRI, no additional lesions or recurrences were observed on the medial aspect of the frontal lobe along the surgical corridor. CONCLUSIONS The superior interhemispheric approach appears to be effective in resolving the problem of visual deterioration due to a TSM, without inducing surgical injury on the brain surface along the surgical corridor. Olfactory deterioration remained the challenging predominant nonvisual morbidity using this approach.
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Affiliation(s)
- Sophie Curey
- Department of Neurosurgery, Rouen University Hospital, Rouen, France
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Romani R, Laakso A, Kangasniemi M, Niemelä M, Hernesniemi J. Lateral supraorbital approach applied to tuberculum sellae meningiomas: experience with 52 consecutive patients. Neurosurgery 2012; 70:1504-18; discussion 1518-9. [PMID: 22240812 DOI: 10.1227/neu.0b013e31824a36e8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Various surgical approaches for the removal of tuberculum sellae meningiomas (TSMs) have previously been described. OBJECTIVE To assess the reliability and safety of the lateral supraorbital (LSO) approach to remove TSMs. METHODS We identified all TSM patients operated on at the Department of Neurosurgery at Helsinki University Central Hospital, Finland, by the senior author (J.H.) using the LSO approach between September 1997 and August 2010. We retrospectively analyzed the clinical data, radiological findings, surgical treatment, histology, and outcome of patients and discuss the operative technique. RESULTS Apparent complete tumor removal was achieved in 45 patients (87%). Of 42 patients, preexisting visual deficit improved in 22, remained the same in 13, and worsened in 7, and de novo visual deficit occurred in 1 patient. At 3 months post-discharge, 47 patients (90%) had a good recovery, 4 (8%) were moderately disabled, and 1 (2%) died 40 days after surgery of unexplained cardiac arrest. Seven patients (13%) had minimal residual tumors, 2 of which required reoperation. During the median follow-up of 59 months (range, 1-133 months), tumor recurred in 1 of the patients who had undergone a second operation. CONCLUSION TSMs of all sizes can be removed via the LSO approach with minimal morbidity and mortality. Low-power or no coagulation is recommended near the optic nerves and the optic chiasm to preserve their vascular support from the internal carotid artery perforators. Our results are comparable to those obtained using more extensive and time-consuming approaches. We recommend the LSO approach to remove TSMs.
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Affiliation(s)
- Rossana Romani
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
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Mortini P, Barzaghi LR, Serra C, Orlandi V, Bianchi S, Losa M. Visual outcome after fronto-temporo-orbito-zygomatic approach combined with early extradural and intradural optic nerve decompression in tuberculum and diaphragma sellae meningiomas. Clin Neurol Neurosurg 2012; 114:597-606. [DOI: 10.1016/j.clineuro.2011.12.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 12/06/2011] [Accepted: 12/13/2011] [Indexed: 10/14/2022]
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The contralateral subfrontal approach can simplify surgery and provide favorable visual outcome in tuberculum sellae meningiomas. Neurosurg Rev 2012; 35:601-7; discussion 607-8. [DOI: 10.1007/s10143-012-0397-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 03/13/2012] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
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Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches. Br J Neurosurg 2012; 26:637-48. [PMID: 22324437 DOI: 10.3109/02688697.2012.654837] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Little data exists comparing endoscopic endonasal approaches to pathology of the anterior skull base with more traditional transcranial and transsphenoidal microscopic approaches. In order to more fully characterize the role of endoscopy in the management of pathology of the anterior cranial base, we conducted a systematic review of case series and case reports documenting surgical and clinical outcomes. We found that for craniopharyngiomas, clival chordomas, esthesioneuroblastomas and giant pituitary adenomas, the endonasal endoscopic approach can result in equivalent or higher rates of gross total resection than open approaches. For meningiomas, however, open transcranial approaches are still able to achieve higher rates of total resection. CSF leak rates are higher for patients undergoing endoscopic surgery for meningiomas and craniopharyngiomas, but not for chordomas, esthesioneuroblastomas or giant pituitary adenomas. In certain patients, the endonasal endoscopic approach may be a safe and effective alternative for the treatment of a wide variety of skull base pathology, particularly those with small midline tumours.
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Affiliation(s)
- Ricardo J Komotar
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
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Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 2011; 77:713-24. [PMID: 22120296 DOI: 10.1016/j.wneu.2011.08.025] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 05/26/2011] [Accepted: 08/16/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To assess the advantages and limitations of the endoscopic endonasal approach to anterior skull base meningiomas, a minimally invasive approach that avoids extensive bone drilling, brain retraction, and manipulation of nerves and critical vessels, versus open transcranial surgery. METHODS A MEDLINE (2000-2010) search was performed to identify series for either olfactory groove meningiomas or tuberculum sellae (TS) or planum sphenoidale meningiomas. Statistical analyses of categorical variables such as extent of resection, morbidity, and visual outcome were performed using χ(2) and Fisher exact tests. RESULTS The literature review included 60 studies, involving 1426 patients. Open surgery achieved a higher rate of gross total resection (GTR) for both olfactory groove (P < 0.001) and TS and planum (P < 0.001) meningiomas. Postoperative cerebrospinal fluid (CSF) leak occurred more frequently in the endoscopic cohort (P < 0.001). Other postoperative complications occurred more frequently in the open cohort, although this difference was not statistically significant. There were no significant differences in postoperative visual outcome between the groups. CONCLUSIONS Based on the current literature, open transcranial approaches for olfactory groove and TS and planum sphenoidale meningiomas still result in higher rates of total resection with lower postoperative CSF leak rates. The endoscopic endonasal approach may be safe and effective for certain skull base meningiomas; careful patient selection and multilayer closure techniques are essential.
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Affiliation(s)
- Ricardo J Komotar
- Department of Neurological Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Bowers CA, Altay T, Couldwell WT. Surgical decision-making strategies in tuberculum sellae meningioma resection. Neurosurg Focus 2011; 30:E1. [PMID: 21529165 DOI: 10.3171/2011.2.focus1115] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although the transcranial route (TCR) has been the traditional approach for removing tuberculum sellae meningiomas (TSMs), the use of the microscopic and/or more recently the endoscopic transsphenoidal approach (ETSA) has gained acceptance for selected cases. In this study, the authors present their experience with the ETSA and the TCR and examine the criteria most important for deciding the optimal approach in a particular case. METHODS The authors retrospectively reviewed recent cases of TSMs treated surgically by the senior author via either the TCR or the ETSA or both. Demographic information, clinical presentation, and clinical and radiological outcomes of the patients were evaluated. RESULTS Twenty-seven patients underwent removal of a TSM during a recent period. Gross-total or near-total resection was achieved in 20 (91%) of 22 patients who underwent resection via the TCR and in 3 (60%) of 5 patients who underwent the ETSA. Among the patients in whom gross- or near-total resection was achieved, recurrence was observed in only 1 patient, whose tumor was removed via the ETSA. CONCLUSIONS In the majority of patients, the TCR provided complete resection of the tumor without compromising the safety of the procedure. In select cases of tumors with a reasonable size and location (midline and/or extending into the sphenoid sinus) as well as no involvement of inaccessible neurovascular and bony elements via this approach, the ETSA could also be a viable option.
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Affiliation(s)
- Christian A Bowers
- Department of Neurosurgery, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA
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Telera S, Carapella CM, Caroli F, Crispo F, Cristalli G, Raus L, Sperduti I, Pompili A. Supraorbital keyhole approach for removal of midline anterior cranial fossa meningiomas: a series of 20 consecutive cases. Neurosurg Rev 2011; 35:67-83; discussion 83. [DOI: 10.1007/s10143-011-0340-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 11/30/2010] [Accepted: 04/03/2011] [Indexed: 11/28/2022]
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Superior interhemispheric approach for midline meningioma from the anterior cranial base. Neurochirurgie 2011; 57:105-13. [DOI: 10.1016/j.neuchi.2011.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 07/02/2011] [Indexed: 11/17/2022]
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Terasaka S, Asaoka K, Kobayashi H, Yamaguchi S. Anterior interhemispheric approach for tuberculum sellae meningioma. Neurosurgery 2011; 68:84-8; discussion 88-9. [PMID: 21206321 DOI: 10.1227/neu.0b013e31820781e1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The tuberculum sellae meningioma (TSM) arises from the tuberculum sellae, chiasmatic sulcus, and limbus sphenoidale. OBJECTIVE To retrospectively analyze patients with TSM who underwent surgery via an anterior interhemispheric approach, with special attention to visual outcomes. METHODS Nine consecutive patients between April 2004 and December 2009 were examined. Visual impairment score (VIS) was used to analyze the visual status of the patients. A VIS is the sum of the scores in specific tables for visual acuity and visual field defects. Visual status was sequentially evaluated in the preoperative period and within 2 weeks of the operation. Any change in the VIS was considered an improvement or deterioration of visual function. All tumors were removed via an anterior interhemispheric approach. Following the wide dissection of the interhemispheric fissure, the tumor was first detached from its origin and debulked with the ultrasonic aspirator starting at the midline. The debulking continued until the arachnoid plane separating the nerve and tumor was visualized. RESULTS Gross total resection (Simpson I + II) was achieved in all 9 patients. The average VIS was 56.1 in the preoperative period and 26.3 in the postoperative period. Among 9 patients, 8 patients had an improvement of the VIS after surgery. VIS was unchanged in 1 patient, and no patients experienced visual deterioration. Other nonvisual complications, such as rhinoliquorrhea, venous infarction, and permanent anosmia, occurred in 3 patients. CONCLUSION Despite the small number of patients, a high resection rate and favorable visual outcome support the suitability of this approach for resection of TSM.
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Affiliation(s)
- Shunsuke Terasaka
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
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Van Gompel JJ, Frank G, Pasquini E, Zoli M, Hoover J, Lanzino G. Expanded endonasal endoscopic resection of anterior fossa meningiomas: report of 13 cases and meta-analysis of the literature. Neurosurg Focus 2011; 30:E15. [DOI: 10.3171/2011.1.focus118] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Transnasal endoscopic (TNE) approaches have been proposed for the resection of anterior cranial base meningiomas. The purpose of this article was to evaluate the results of endoscopic resection of anterior cranial fossa meningiomas by reviewing available published data in addition to the authors' experience with 13 cases.
Methods
The literature was searched via OVID to identify all available disaggregate data pertaining to anterior fossa meningiomas treated primarily by TNE. In addition, the authors reviewed the records of a personal series of 13 patients who underwent TNE removal of parasellar meningiomas through a pure TNE approach.
Results
Meta-analysis from studies included a total of 69 patients with adequate disaggregated data to summarize. Mean age (± SD) at surgery was 53.3 ± 13.0 years (range 27–80 years); 78% of the patients were women. Tumor size was skewed toward smaller lesions, with a mean volume of 24.4 ± 2.9 cm3. Intraoperative impressions were of gross-total resection in 76% of cases. The most common complication reported was CSF leakage, occurring in 32% of the cases (22 of 69). The rate of CSF leakage was not affected by size (p = 0.52), location of tumor (p = 0.9), or age (p = 0.56). There was 1 death overall. The mean duration of follow-up was 21 ± 18 months.
Conclusions
Transnasal endoscopic resection of anterior cranial base meningiomas is feasible in selected cases. Reported resection rates are adequate, although the follow-up in the reported series is too short (mean 21 months) to make definitive conclusions regarding the long-term effectiveness. Cerebrospinal fluid leakage is a common complication, although it appears not to be associated with additional morbidity except for the need for reoperation. Long-term results are necessary before considering TNE resection as a valid alternative, in selected cases, to the more established transcranial techniques.
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Affiliation(s)
| | - Giorgio Frank
- 2Center of Surgery for Pituitary Tumors and Endoscopic Skull Base Surgery, Bellaria Hospital, Bologna, Italy
| | - Ernesto Pasquini
- 2Center of Surgery for Pituitary Tumors and Endoscopic Skull Base Surgery, Bellaria Hospital, Bologna, Italy
| | - Matteo Zoli
- 2Center of Surgery for Pituitary Tumors and Endoscopic Skull Base Surgery, Bellaria Hospital, Bologna, Italy
| | - Jason Hoover
- 1Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Giuseppe Lanzino
- 1Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota; and
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