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Sakata K, Komaki S, Takeshige N, Negoto T, Kikuchi J, Kajiwara S, Orito K, Nakamura H, Hirohata M, Morioka M. Visual Outcomes and Surgical Approach Selection Focusing on Active Optic Canal Decompression and Maximum Safe Resection for Suprasellar Meningiomas. Neurol Med Chir (Tokyo) 2023; 63:381-392. [PMID: 37423756 PMCID: PMC10556211 DOI: 10.2176/jns-nmc.2021-0142] [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: 05/05/2021] [Accepted: 04/17/2023] [Indexed: 07/11/2023] Open
Abstract
The goal of treating patients with suprasellar meningioma is improving or preserving visual function while achieving long-term tumor control. We retrospectively examined patient and tumor characteristics and surgical and visual outcomes in 30 patients with a suprasellar meningioma who underwent resection via an endoscopic endonasal (15 patients), sub-frontal (8 patients), or anterior interhemispheric (7 patients) approach. Approach selection was based on the presence of optic canal invasion, vascular encasement, and tumor extension. Optic canal decompression and exploration were performed as key surgical procedures. Simpson grade 1 to 3 resection was achieved in 80% of cases. Among the 26 patients with pre-existing visual dysfunction, vision at discharge improved in 18 patients (69.2%), remained unchanged in six (23.1%), and deteriorated in two (7.7%). Further gradual visual recovery and/or maintenance of useful vision were also observed during follow-up. We propose an algorithm for selecting the appropriate surgical approach to a suprasellar meningioma based on preoperative radiologic tumor characteristics. The algorithm focuses on effective optic canal decompression and maximum safe resection, possibly contributing to favorable visual outcomes.
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Affiliation(s)
- Kiyohiko Sakata
- Department of Neurosurgery, Kurume University School of Medicine
| | - Satoru Komaki
- Department of Neurosurgery, Kurume University School of Medicine
| | | | - Tetsuya Negoto
- Department of Neurosurgery, Kurume University School of Medicine
| | - Jin Kikuchi
- Department of Neurosurgery, Kurume University School of Medicine
| | - Sosho Kajiwara
- Department of Neurosurgery, Kurume University School of Medicine
| | - Kimihiko Orito
- Department of Neurosurgery, Kurume University School of Medicine
| | - Hideo Nakamura
- Department of Neurosurgery, Kurume University School of Medicine
| | - Masaru Hirohata
- Department of Neurosurgery, Kurume University School of Medicine
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine
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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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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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Anterior interhemispheric approach for anterior fossa dural arteriovenous fistulas. Neurosurg Rev 2021; 45:1791-1797. [PMID: 34618251 DOI: 10.1007/s10143-021-01658-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/31/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
Anterior fossa dural arteriovenous fistulas (AF-DAVF) usually display a cortical venous drainage and are therefore at risk for rupture. Microsurgery is traditionally considered in many centers as the first-line treatment since endovascular treatment (EVT) entails a lower cure rate and significant ophthalmic risks. The anterior interhemispheric approach (AIA), originally described by Mayfrank in 1996, seems to offer the effectiveness of microsurgery while limiting the risks related to subfrontal craniotomy. The objective of this study was to analyze the surgical outcomes of patients who underwent this surgical approach for the treatment of AF-DAVF. We hereby describe our 10 years' experience of patients treated for an AF-DAVF with this technique in our institution and retrospectively analyzed our results. In addition, we describe our operative technique and its specificities. Eleven patients with AF-DAVF were included in our study. The definitive cure of the fistula was confirmed in all cases with postoperative cerebral angiography. All patients had a good neurological outcome and no major complication occurred. Brain retractors were never used during surgery, the frontal sinus was never opened neither, and anosmia was never observed after surgery. Anterior interhemispheric approach seems to be safe and effective to treat AF-DAVF with lower risks than other surgical approaches. This technique could be more widely considered when facing such midline vascular lesion.
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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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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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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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Dzhindzhikhadze RS, Dreval ON, Lazarev VA, Polyakov AV, Kambiev RL, Salyamova EI. Transpalpebral Approach for Microsurgical Removal of Tuberculum Sellae Meningiomas. Asian J Neurosurg 2020; 15:98-106. [PMID: 32181181 PMCID: PMC7057880 DOI: 10.4103/ajns.ajns_186_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 10/07/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The evolution of skull base approaches associated with individualization of surgical corridor and minimizing the collateral damage. Achieving the radical removal of tumor and preserving the neurological status of the patient is possible, both with the traditional approaches and keyhole approaches. Our work presents experience using the transpalpebral approach (TPA) for microsurgical removal of tuberculum sellae meningioma (TSM). MATERIALS AND METHODS A total of 15 patients with meningiomas underwent microsurgical removal of TSM through TPA. Ten patients were women and five were men. The standard preoperative diagnostic protocol includes magnetic resonance imaging with contrast enhancement, brain computed tomography for neuronavigation. We assess surgical complications, functional and cosmetic outcomes, and surgical parameters, including the time of surgery and intraoperative blood loss. RESULTS Visual impairment was finding in 100% patients, including slight decrease of vision (46,7%, seven patients), partial vision field loss (six patients, 40%), and serious visual impairment (two patients 13.3%). Visual improvement was noted in ten cases (66.7%), there was no improvement in four cases (26.7%), and one case (6.6%) had transient visual worsening for 4 days and slow improvement in 1 month. Headache disappeared in three patients (50%). There were no cases of cerebrospinal fluid leak. Transient frontal hypoesthesia was noted in all patients (100%) without permanent deficit. Transient palsy of the frontal muscle was noted in four patients for 4-6 months. Histological examination revealed WHO Grade I meningioma in 14 cases and in 1 case WHO Grade II meningioma. No deaths were identified in follow-up at 12 months. The average value of the Modified Rankin Scale was 1.4. The mean length of stay in hospital was 5. CONCLUSION TPA is technically difficult and requires some experience to work in deep structures in a small surgical corridor. This technique can be good alternative to traditional fronto-lateral, supraorbital keyhole craniotomies, and endoscopic endonasal approaches.
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Affiliation(s)
- Revaz Semenovich Dzhindzhikhadze
- Department of Neurosurgery, Russian Medical Academy for Continuing Postgraduate Education, Ministry of Health of Russia, Moscow, Russia
- Department of Vascular Neurosurgery, City Clinical Hospital Named After F.I. Inozemtseva, Moscow, Russia
| | - Oleg Nikolaevich Dreval
- Department of Neurosurgery, Russian Medical Academy for Continuing Postgraduate Education, Ministry of Health of Russia, Moscow, Russia
| | - Valeriy Aleksandrovich Lazarev
- Department of Neurosurgery, Russian Medical Academy for Continuing Postgraduate Education, Ministry of Health of Russia, Moscow, Russia
| | - Andrey Victorovich Polyakov
- Department of Neurosurgery, Russian Medical Academy for Continuing Postgraduate Education, Ministry of Health of Russia, Moscow, Russia
- Department of Vascular Neurosurgery, City Clinical Hospital Named After F.I. Inozemtseva, Moscow, Russia
| | - Renat Leonidovich Kambiev
- Department of Vascular Neurosurgery, City Clinical Hospital Named After F.I. Inozemtseva, Moscow, Russia
| | - Elvira Igorevna Salyamova
- Department of Neurosurgery, Russian Medical Academy for Continuing Postgraduate Education, Ministry of Health of Russia, Moscow, Russia
- Department of Vascular Neurosurgery, City Clinical Hospital Named After F.I. Inozemtseva, Moscow, Russia
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Lopez-Gonzalez MA, Jaeger A, Kaplan B, Eastin TM, Kore L, Gospodarev V, Patel PD, Sharafeddin F. Retractorless interhemispheric transtentorial approach for large lesions in the posterior incisural space. Surg Neurol Int 2019; 10:130. [PMID: 31528466 PMCID: PMC6744791 DOI: 10.25259/sni-117-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background: Surgical resection of lesions in the posterior incisural space presents a significant surgical challenge, which may result in postoperative visual complications and other neurological deficits. We, therefore, describe a retractorless interhemispheric transtentorial approach that avoids surrounding brain structures with positive outcomes and no complications or visual damage. Case Description: We present four cases of lesions in the posterior incisural space that was treated with a retractorless interhemispheric transtentorial approach. Two patients were previously seen at another institution for a falcotentorial meningioma. We resected the meningiomas with a parietal-occipital interhemispheric transtentorial approach with no neurological deficits. A third patient presented with a large superior vermian hemangioblastoma with a steep angle of the tentorium. The fourth patient had a large upper vermian metastatic lesion with progressive enlargement, which was refractory to radiation treatments and chemotherapy, and we achieved partial resection. Postoperative visual function was completely preserved in all patients. Conclusion: A carefully executed retractorless interhemispheric approach in select cases is an effective option to reduce morbidity and prevent visual complications when removing lesions in the posterior tentorial incisure.
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Affiliation(s)
| | - Andrew Jaeger
- Department of Basic Science, School of Medicine, Loma Linda University, Loma Linda
| | - Brett Kaplan
- Department of General Surgery, Tripler Army Medical Center, Honolulu, Hawaii, United States
| | | | - Lydia Kore
- Department of Basic Science, School of Medicine, Loma Linda University, Loma Linda
| | - Vadim Gospodarev
- Department of Basic Sciences, Loma Linda University Medical Center, Loma Linda
| | - Puja D Patel
- Department of Neurosciences, University of Southern California, Los Angeles, California, United States
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Gordon WE, Michael Ii LM, VanLandingham MA. Exposure of Dural Venous Sinuses: A Review of Techniques and Description of a Single-piece Troughed Craniotomy. Cureus 2018; 10:e2184. [PMID: 29657909 PMCID: PMC5896975 DOI: 10.7759/cureus.2184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Intracranial lesions along the falx and tentorium often require exposure of a dural venous sinus. Craniotomies that cross a sinus should maximize exposure while minimizing the risk of sinus injury and provide a cosmetically appealing result with simple reconstruction techniques. We describe the published techniques for exposing dural venous sinuses, and introduce a new technique for a single-piece craniotomy exposing the superior sagittal sinus or transverse sinus using drilled troughs. A review of the literature was performed to identify articles detailing operative techniques for craniotomies over dural venous sinuses. Our troughed craniotomy for dural sinus exposure is described in detail as well as our experience using this technique in 82 consecutive cases from 2007-2015. Five distinct techniques for exposure of the dural venous sinus were identified in the literature. In our series of patients undergoing a trough craniotomy, there were no sinus injuries despite a range of various locations and pathology along the sagittal and transverse sinuses. Our technique was found to be safe and simple to reconstruct compared to other techniques found in the literature. A variety of different techniques for exposing the dural venous sinuses are available. A single-piece craniotomy using a trough technique is a safe means to achieve venous sinus exposure with minimal reconstruction required. Surgeons should consider this method when removing lesions adjacent to the falx or tentorium.
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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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Liu HC, Wu Z, Wang L, Xiao XR, Li D, Jia W, Zhang LW, Zhang JT. Frontolateral Approach Applied to Sellar Region Lesions: A Retrospective Study in 79 Patients. Chin Med J (Engl) 2016; 129:1558-64. [PMID: 27364792 PMCID: PMC4931262 DOI: 10.4103/0366-6999.184457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Various surgical approaches for the removal of sellar region lesions have previously been described. This study aimed to evaluate the reliability and safety of the frontolateral approach (FLA) to remove sellar region lesions. Methods: We presented a retrospective study of 79 patients with sellar region lesions who were admitted and operated by the FLA approach from August 2011 to August 2015 in Department of Neurosurgery of Beijing Tian Tan Hospital. We classified FLA into three types, compared the FLA types to the areas of lesion invasion, and analyzed operation bleeding volume, gross total resection (GTR) rate, visual outcome, and mortality. Results: Seventy-nine patients were followed up from 2.9 to 50.3 months with a mean follow-up of 20.5 months. There were 42 cases of meningiomas, 25 cases of craniopharyngiomas, and 12 cases of pituitary adenomas. The mean follow-up Karnofsky Performance Scale was 90.4. GTR was achieved in 75 patients (94.9%). Two patients (2.5%) had tumor recurrence. No patients died perioperatively or during short-term follow-up. Three patients (3.8%) with craniopharyngioma died 10, 12, and 23 months, respectively, after surgery. The operative bleeding volume of this study was no more than that of the other approaches in the sellar region (P = 0.783). In this study, 35 patients (44.3%) had visual improvement after surgery, 38 patients (48.1%) remained unchanged, and three patients’ visual outcome (3.8%) worsened. Conclusions: FLA was an effective approach in the treatment of sellar region lesions with good preservation of visual function. FLA classification enabled tailored craniotomies for each patient according to the anatomic site of tumor invasion. This study found that FLA had similar outcomes to other surgical approaches of sellar region lesions.
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Affiliation(s)
- Hao-Cheng Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050; Department of Neurosurgery, Beijing Tong Ren Hospital, Capital Medical University, Beijing 100730, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Liang Wang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Xin-Ru Xiao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Da Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing 100050, China
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14
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Frontobasal Midline Meningiomas: Is It Right To Shed Doubt on the Transcranial Approaches? Updates and Review of the Literature. World Neurosurg 2015; 88:374-382. [PMID: 26555506 DOI: 10.1016/j.wneu.2015.11.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/01/2015] [Accepted: 11/02/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Traditionally, the surgical removal of tuberculum sellae meningioma (TSM) and olfactory groove meningioma (OGM) requires transcranial approaches and microsurgical techniques, but in the last decade endoscopic expanded endonasal approaches have been introduced: transcribriform for OGMs and transtuberculum-transplanum for TSM. A comparative analysis of the literature concerning the two types of surgical treatment of OGMs and TSM is, however, difficult. METHODS We conducted a literature search using the PubMed database to compare data for endoscopic and microsurgical techniques in the literature. We also conducted a retrospective analysis of selected cases from our series presenting favorable characteristics for an endoscopic approach, based on the criteria of operability of these lesions as generally accepted in the literature, and we compared the results obtained in these patients with those in the endoscopic literature. RESULTS We believe that making the sample more homogeneous, the difference between microsurgical technique and endoscopic technique is no longer so striking. A greater radical removal rate, a reduced incidence of cerebrospinal fluid fistula and, especially, the possibility of removing lesions of any size are advantages of transcranial surgery; a higher percentage of improvement in visual outcome and a lower risk of a worsening of a pre-existing deficit or onset of a new deficit are advantages of the endoscopic technique. CONCLUSION At present, the microsurgical technique is still the gold standard for the removal of the anterior cranial fossa meningiomas of all sizes, and the endoscopic technique remains a second option in certain cases.
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15
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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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16
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Initial experiences with endoscopic rhino-neurosurgery in Amsterdam. Eur Arch Otorhinolaryngol 2013; 271:1525-32. [PMID: 24065187 DOI: 10.1007/s00405-013-2662-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 08/14/2013] [Indexed: 10/26/2022]
Abstract
Endoscopic surgery of the skull base has been on the rise for several years. Endoscopic access for surgery can be achieved from the frontal sinus anteriorly along the skull base to the odontoid process posterior inferiorly. An endoscope is inserted through one nasal corridor and allows visualization of the working field and up to three surgical instruments can be used to address the lesion. This is called the "two nostrils-four hands technique". This is a retrospective study of 67 cases. Setting of the study is an Amsterdam University hospital. Cases were identified in the department of otorhinolaryngology and department of neurosurgery database. All patients operated between 1 January, 2008 and 1 February, 2012 with pituitary tumours that extend beyond the sella, sinonasal tumours and all non-pituitary skull-base tumours were included. Mean tumour diameter was 3.8 cm. We performed a near-to-gross total resection in 92% of cases where we intended to perform a total resection. The most frequent complication was CSF leakage. This study demonstrates that this technique is safe and reliable. What is needed is a dedicated team, which includes a dedicated anesthesiologist, endocrinologist, ophthalmologist, and radiation oncologist.
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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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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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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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