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Agosti E, Alexander AY, Leonel LCPC, Gompel JJV, Link MJ, Choby G, Pinheiro-Neto CD, Peris-Celda M. Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Middle-Inferior Clivectomy, Odontoidectomy, and Far-Medial Approach. J Neurol Surg B Skull Base 2024; 85:526-539. [PMID: 39228882 PMCID: PMC11368465 DOI: 10.1055/a-2114-4660] [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: 02/26/2023] [Accepted: 06/19/2023] [Indexed: 09/05/2024] Open
Abstract
Introduction The clival, paraclival, and craniocervical junction regions are challenging surgical targets. To approach these areas, endoscopic endonasal transclival approaches (EETCAs) and their extensions (far-medial approach and odontoidectomy) have gained popularity as they obviate manipulating and working between neurovascular structures. Although several cadaveric studies have further refined these contemporary approaches, few provide a detailed step-by-step description. Thus, we aim to didactically describe the steps of the EETCAs and their extensions for trainees. Methods Six formalin-fixed cadaveric head specimens were dissected. All specimens were latex-injected using a six-vessel technique. Endoscopic endonasal middle and inferior clivectomies, far-medial approaches, and odontoidectomy were performed. Results Using angled endoscopes and surgical instruments, an endoscopic endonasal midclivectomy and partial inferior clivectomy were performed without nasopharyngeal tissue disruption. To complete the inferior clivectomy, far-medial approach, and partially remove the anterior arch of C1 and odontoid process, anteroinferior transposition of the Eustachian-nasopharynx complex was required by transecting pterygosphenoidal fissure tissue, but incision in the nasopharynx was not necessary. Full exposure of the craniocervical junction necessitated bilateral sharp incision and additional inferior mobilization of the posterior nasopharynx. Unobstructed access to neurovascular anatomy of the ventral posterior fossa and craniocervical junction was provided. Conclusion EETCAs are a powerful tool for the skull-base surgeon as they offer a direct corridor to the ventral posterior fossa and craniocervical junction unobstructed by eloquent neurovasculature. To facilitate easier understanding of the EETCAs and their extensions for trainees, we described the anatomy and surgical nuances in a didactic and step-by-step fashion.
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Affiliation(s)
- Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - A. Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Luciano C. P. C. Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Jamie J. Van Gompel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Garret Choby
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Carlos D. Pinheiro-Neto
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Shkarubo AN, Chernov IV, Veselkov AA, Andreev DN, Yakupova ZF, Kalinin PP. [Endoscopic transnasal resection of clival meningiomas]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:105-111. [PMID: 38549417 DOI: 10.17116/neiro202488021105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Surgical treatment of ventral and ventrolateral meningiomas of posterior cranial fossa is difficult in modern neurosurgery. This is due to peculiarities of approach to these areas and concentration of critical structures (cranial nerves and great vessels). Currently, endoscopic transnasal approach to these meningiomas allows partial, and in some cases, total resection. However, this technique is not widespread. OBJECTIVE To analyze the world literature data on postoperative outcomes in patients with clival and petroclival meningiomas after endoscopic transnasal resection. MATERIAL AND METHODS We analyzed 22 articles representing treatment of 61 patients with clival and petroclival meningiomas. RESULTS Total or near-total resection was achieved in 22.9% of cases, subtotal resection - 40.9%, partial resection - 26.2% (data were not provided in other cases). Even partial and subtotal resection leads to significant regression of symptoms. CONCLUSION Endoscopic transnasal surgery is a full-fledged alternative to transcranial approaches in surgical treatment of clival meningiomas. It is also an additional option for patients with petroclival meningiomas after ineffective transcranial approaches. Transnasal tumor shrinkage and devascularization lead to brainstem decompression, regression of hydrocephalus and baseline clinical symptoms.
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Affiliation(s)
| | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - D N Andreev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - Z F Yakupova
- Peoples' Friendship University of Russia, Moscow, Russia
| | - P P Kalinin
- Burdenko Neurosurgical Center, Moscow, Russia
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Gladi M, Di Rienzo A, Fasinella MR, Aiudi D, Balercia P, Dobran M, Iacoangeli M. Ruptured proximal pontine artery aneurysm and association with cerebellopontine angle cistern arterial venous malformation fed by the same artery: A surgical challenge. Surg Neurol Int 2023; 14:352. [PMID: 37941615 PMCID: PMC10629327 DOI: 10.25259/sni_246_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/29/2023] [Indexed: 11/10/2023] Open
Abstract
Background The coexistence of hyper-inflow aneurysms and cerebellopontine angle cistern (CPAc) arterial venous malformations (AVMs) have been rarely reported and most commonly associated with high risk of bleeding. Case Descriptions We present two cases of CPAc AVMs admitted for acute subarachnoid hemorrhage from rupture of a parent right pontine artery aneurysm. Admission history, neurology at presentation, pre/post-operative imaging, approach selection, and results are thoroughly reviewed and presented. The acute origin angle of the vessel from the basilar artery made both malformations unsuitable for endovascular treatment. The surgical strategy was differently tailored in the two patients, respectively, using a Le Fort I/transclival and a Kawase approach. The aneurysm was clipped in the first case, and the AVM was excised in the second one, as required by the anatomical context. Aneurysm exclusion and AVM size reduction were obtained in the first case, while complete AVM removal and later aneurysm disappearance were obtained in the second one. A high-flow cerebrospinal fluid leak in the first case was successfully treated by an endoscopic approach. Both patients experienced a satisfactory neurological outcome in the follow-up. Conclusion Pontine artery aneurysms, especially when associated with CPAc AVMs, represent a surgical challenge, due to their rarity and anatomical peculiarity, which typically requires complex operative approaches. Multimodal preoperative imaging, appropriate timing, and accurate target selection, together with versatile strategies, are the keys to a successful treatment.
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Affiliation(s)
- Maurizio Gladi
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Alessandro Di Rienzo
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Maria Rossella Fasinella
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Denis Aiudi
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Paolo Balercia
- Department of Maxillo-Facial Surgery, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Università Politecnica Delle Marche Facoltà di Medicina e Chirurgia, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Ancona, Italy
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Shkarubo AN, Chernov IV, Veselkov AA, Andreev DN, Sinelnikov ME, Karnaukhov VV, Yakupova ZF. [Endoscopic transnasal resection of clival meningiomas]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:27-34. [PMID: 37650274 DOI: 10.17116/neiro20238704127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Treatment of clival meningiomas is still one of the unresolved issues in modern neurosurgery. There are several treatment strategies. These ones include various combinations of follow-up, surgical CSF drainage, tumor resection and radiotherapy. OBJECTIVE To assess postoperative outcomes in patients with clival meningiomas. MATERIAL AND METHODS We analyzed 18 patients with large or giant clival meningiomas. RESULTS We assessed extent of resection using the scale by G. Frank and E. Pasquini (2002): total resection - 95-100%, subtotal - 80-95%, partial - 50-80%, extended biopsy - <50% of tumor. Total resection was achieved in 1 patient (5.5%), subtotal - 5 (27.8%), partial - 12 (66.7%). At the same time, brainstem decompression and regression of hydrocephalus were observed in all cases. Fourteen patients were followed-up. Median follow-up was 8.5 months. Seventeen patients underwent radiotherapy due to predominant partial and subtotal resection. Total focal dose ranged from 50 to 57 Gy in standard fractionation mode. None patient had residual tumor enlargement throughout the follow-up period. There were no lethal outcomes. CONCLUSION Endoscopic transnasal access to clival meningiomas in appropriate anatomical features of tumor and surrounding structures is a full-fledged alternative to transcranial treatment in these patients. This approach provides total resection and brainstem decompression. These facts increase life expectancy without deterioration of the quality of life.
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Affiliation(s)
| | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - D N Andreev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - M E Sinelnikov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Z F Yakupova
- Peoples' Friendship University of Russia, Moscow, Russia
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Gupta KK, Balai E, Darr A, Jolly K. Reconstruction and Cerebrospinal Fluid Leaks in Endoscopic Endonasal Approach for the Management of Clival Chordomas-A Systematic Review. Indian J Otolaryngol Head Neck Surg 2022; 74:4807-4815. [PMID: 36742692 PMCID: PMC9895481 DOI: 10.1007/s12070-022-03114-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
The success of the endoscopic endonasal approach (EEA) to surgically manage clival chordomas (CC) relies on robust repair methods to reduce complications, such as cerebrospinal fluid (CSF) leaks. Our study aims to evaluate the existing literature to assess reconstructive techniques utilised and post-operative CSF leak rates in this cohort. A systematic review and analysis was performed of all published data related to CC patients managed with an EEA. A total of 24 articles were included, representing 363 patients and 396 procedures. A variety of reconstruction methods were used with 95.9% of studies using an intracranial repair graft, 70.8% using a nasoseptal flap (NSF), 62.5% using glue/haemostat, 58.3% using nasal packs and 75.0% employing multi-layered reconstruction. Post-operative CSF leak rate was 10.1%. The leak rate was less in subgroups where a NSF was used (9.4%) although this was not statistically significant (p = 0.273). There were no differences in leak rates when glue/haemostat (p = 0.139) or nasal packs (p = 0.550) were used. Our review is the most up-to-date synthesis of the existing literature surrounding the EEA to CCs assessing reconstruction and post-operative CSF leaks. It demonstrates most authors employ a multi-layered reconstruction method. The lack of statistical significance observed for CSF leaks in subgroups is likely due to a variety of cofounding surgeon and patient factors. Higher quality prospective randomised multi-centric studies, with reporting of specific repair techniques will enable future systematic reviews to provide a more accurate consensus regarding optimal methods of reconstruction in this field.
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Affiliation(s)
- Keshav Kumar Gupta
- Department of Surgery, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Hallam Street, West Bromwich, B71 4HJ UK
| | - Edward Balai
- Department of Surgery, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Hallam Street, West Bromwich, B71 4HJ UK
| | - Adnan Darr
- Department of Otorhinolaryngology, New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, WV10 0QP UK
| | - Karan Jolly
- Department of Otorhinolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH UK
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Khan DZ, Ali AMS, Koh CH, Dorward NL, Grieve J, Layard Horsfall H, Muirhead W, Santarius T, Van Furth WR, Zamanipoor Najafabadi AH, Marcus HJ. Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review. Pituitary 2021; 24:698-713. [PMID: 33973152 PMCID: PMC8416859 DOI: 10.1007/s11102-021-01145-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Postoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques. METHODS Pubmed and Embase databases were searched for studies (2000-2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible. RESULTS 193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3-4.5%) for transsphenoidal, 9% (CI 7.2-11.3%) for expanded endonasal, and 5.3% (CI 3.4-7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity. CONCLUSIONS Modern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.
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Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Ahmad M S Ali
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Chan Hee Koh
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Neil L Dorward
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Joan Grieve
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Hugo Layard Horsfall
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - William Muirhead
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Thomas Santarius
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Wouter R Van Furth
- Department of Neurosurgery, University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - 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
| | - Hani J Marcus
- Division of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
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Adipofascial Radial Forearm Free Flap for Anterior Skull Base Reconstruction in Complicated Forebrain Oncological Surgery. J Craniofac Surg 2020; 30:1724-1729. [PMID: 31022131 DOI: 10.1097/scs.0000000000005559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Radical resections of ethmoidal tumors with intracranial extension present highly complex surgical and reconstructive problems. The purpose of report is to describe the authors' use of adipofascial radial forearm free flaps following unsuccessful anterior cranial fossa oncological surgery. METHODS Adipofascial radial forearm free flaps were used to treat 3 similar cases of cutaneous fistula following bone resorption with communication to anterior cranial fossa and nasal cavity. RESULTS No flap loss, no deaths, and no postoperative complications were observed. All patients underwent a nasal endoscopy, revealing adequate vitality and integration of the free flaps. One of the patients consented to additional surgery to improve outcome. CONCLUSIONS Meticulous preoperative selection and an experienced interdisciplinary team are required to achieve the best surgical outcomes in complex cases. Free adipofascial forearm flaps could be an excellent therapeutic option in the reconstruction of the anterior skull base, notably in cases involving major postoperative complications.
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Transclival approaches for intradural pathologies: historical overview and present scenario. Neurosurg Rev 2020; 44:279-287. [PMID: 32060761 DOI: 10.1007/s10143-020-01263-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/29/2019] [Accepted: 02/06/2020] [Indexed: 12/17/2022]
Abstract
Recently, endoscopic transsphenoidal transclival approaches have been developed and their role is widely accepted for extradural pathologies. Their application to intradural pathologies is still debated, but is undoubtedly increasing. In the past five decades, different authors have reported various extracranial, anterior transclival approaches for intradural pathologies. The aim of this review is to provide a historical overview of transclival approaches applied to intradural pathologies. PubMed was searched in October 2018 using the terms transcliv*, cliv* intradural, transsphenoidal transcliv*, transoral transcliv*, transcervical transcliv*, transsphenoidal brainstem, and transoral brainstem. Exclusion criteria included not reporting reconstruction technique, anatomical studies, reviews without new data, and transcranial approaches. Ninety-one studies were included in the systematic review. Since 1966, transcervical, transoral, transsphenoidal microsurgical, and, recently, endoscopic routes have been used as a corridor for transclival approaches to treat intradural pathologies. Each approach presents a curve that follows Scott's parabola, with evident phases of enthusiasm that quickly faded, possibly due to high post-operative CSF leak rates and other complications. It is evident that the introduction of the endoscope has led to a significant increase in reports of transclival approaches for intradural pathologies. Various reconstruction techniques and materials have been used, although rates of CSF leak remain relatively high. Transclival approaches for intradural pathologies have a long history. We are now in a new era of interest, but achieving effective dural and skull base reconstruction must still be definitively addressed, possibly with the use of newly available technologies.
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Endoscopic Endonasal Approaches for Treatment of Craniovertebral Junction Tumours. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:209-224. [PMID: 30610324 DOI: 10.1007/978-3-319-62515-7_30] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tumours involving the craniovertebral junction (CVJ) are challenging because of their local invasiveness and high recurrence rates, as well as their proximity to critical neurovascular structures and the difficulty of reconstructing the resulting skull base defect at this site. Several surgical techniques are currently available to access these lesions, including the far lateral, extreme lateral, direct lateral, transcervical, transoral and transnasal approaches. In this paper, application of the endoscopic endonasal approach (EEA) in the treatment of CVJ tumours is analysed. The indications, contraindications, preoperative workup, step-by-step surgical technique, skull base reconstruction options and postoperative management are described. The advantages and limitations of the EEA are also discussed. Finally, a systematic review of the literature is provided to elucidate the levels of evidence supporting the use of the EEA in this field. Employment of this approach to the CVJ has contributed to high success rates in achieving gross total resection of tumours and improvement in neurological symptoms. Intraoperative and postoperative complication rates are acceptable, with cerebrospinal fluid leakage being the major concern (with a 17-25% incidence). Moreover, in comparison with traditional approaches to the CVJ, the EEA provides lower rates of postoperative dysphagia and respiratory complications. Use of the EEA for treatment of CVJ tumours appears to be a rational alternative to the conventional transoral, transcranial and transcervical approaches in selected cases. Multidisciplinary teamwork including different specialists-such as medical and radiation oncologists, radiologists, otorhinolaryngologists and neurosurgeons-is strongly recommended for the purpose of offering the best treatment strategy for the patient.
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Endoscopic Endonasal Odontoidectomy with Anterior C1 Arch Preservation in Rheumatoid Arthritis: Long-Term Follow-Up and Further Technical Improvement by Anterior Endoscopic C1-C2 Screw Fixation and Fusion. World Neurosurg 2017; 107:820-829. [DOI: 10.1016/j.wneu.2017.08.063] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 08/06/2017] [Accepted: 08/10/2017] [Indexed: 12/19/2022]
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Iacoangeli M, Colasanti R, Esposito D, Di Rienzo A, di Somma L, Dobran M, Gladi M, Scerrati M. Supraorbital subfrontal trans-laminar endoscope-assisted approach for tumors of the posterior third ventricle. Acta Neurochir (Wien) 2017; 159:645-654. [PMID: 28236180 DOI: 10.1007/s00701-017-3117-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Different surgical approaches have been developed for dealing with third ventricle lesions, all aimed at obtaining a safe removal minimizing brain manipulation. The supraorbital subfrontal trans-lamina terminalis route, commonly employed only for the anterior third ventricle, could represent, in selected cases with endoscopic assistance, an alternative approach to posterior third ventricular lesions. METHODS Seven patients underwent a supraorbital subfrontal trans-laminar endoscope-assisted approach to posterior third ventricle tumors (two craniopharyngiomas, one papillary tumor of the pineal region, one pineocytoma, two neurocytomas, one glioblastoma). Moreover, a conventional third ventriculostomy was performed via the same trans-laminar approach in four cases. RESULTS Complete tumor removal was accomplished in four cases, subtotal removal in two cases, and a simple biopsy in one case. Adjuvant radiotherapy and/or chemotherapy was administered, if required, on the basis of the histologic diagnosis. No major complications occurred after surgery except for an intratumoral hemorrhage in a patient undergoing a biopsy for a glioblastoma, which simply delayed the beginning of adjuvant radiochemotherapy. No ventriculoperitoneal shunt placement was needed in these patients at the most recent clinical and radiologic session (average 39.57 months, range 13-85 months). Two illustrative cases are presented. CONCLUSIONS The supraorbital subfrontal trans-laminar endoscope-assisted approach may provide, in selected cases, an efficient and safe route for dealing with posterior third ventricular tumors.
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Iacoangeli M, Di Rienzo A, Colasanti R, Re M, Nasi D, Nocchi N, Alvaro L, di Somma L, Dobran M, Specchia N, Scerrati M. Endoscopic Transnasal Odontoidectomy With Anterior C1 Arch Preservation and Anterior Vertebral Column Reconstruction in Patients With Irreducible Bulbomedullary Compression by Complex Craniovertebral Junction Abnormalities: Operative Nuance. Oper Neurosurg (Hagerstown) 2016; 12:222-230. [DOI: 10.1227/neu.0000000000001330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 03/14/2016] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND
During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working angle, tracheostomy, and incision of the oral mucosa, causing exposure to a higher risk of infection by oral flora.
OBJECTIVE
To describe our experience with the minimally invasive pure endoscopic transnasal odontoidectomy in patients with bulbomedullary compression affected by complex anterior craniovertebral junction abnormalities.
METHODS
Five patients underwent a pure endoscopic neuronavigation-assisted transnasal odontoidectomy with anterior C1 arch preservation. Moreover, the anterior cervical spine column was reconstructed by filling the gap between the C1 arch and the residual C2 body with autologous/artificial bone. Neither tracheostomy nor enteral tube feeding were needed in any case.
RESULTS
A postoperative neurological improvement was observed in all patients. Postoperative imaging confirmed a satisfactory spinal cord decompression with cervical anterior column arthrodesis, and without evidence of instability at follow-up, so far.
CONCLUSION
The endoscopic transnasal approach seems to represent an efficient and safe alternative to the transoral route for the resection of odontoid process causing irreducible bulbomedullary compression. It provides a straightforward and minimally invasive natural surgical corridor to the anterior craniocervical junction, allowing a better working angle with preservation of spine biomechanics, while minimizing potential comorbidities.
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Affiliation(s)
- Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Alessandro Di Rienzo
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Roberto Colasanti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Re
- Department of ENT Surgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Niccolò Nocchi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Lorenzo Alvaro
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia di Somma
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Nicola Specchia
- Department of Orthopedic Surgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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Liebelt BD, Boghani Z, Haider AS, Takashima M. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci 2016; 28:152-6. [DOI: 10.1016/j.jocn.2015.10.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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Mason E, Rompaey JV, Solares CA, Figueroa R, Prevedello D. Subtemporal Retrolabyrinthine (Posterior Petrosal) versus Endoscopic Endonasal Approach to the Petroclival Region: An Anatomical and Computed Tomography Study. J Neurol Surg B Skull Base 2016; 77:231-7. [PMID: 27175318 DOI: 10.1055/s-0035-1566123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 09/03/2015] [Indexed: 10/22/2022] Open
Abstract
Background The petroclival region seats many neoplasms. Traditional surgical corridors to the region can result in unacceptable patient morbidity. The combined subtemporal retrolabyrinthine transpetrosal (posterior petrosal) approach provides adequate exposure with hearing preservation; however, the facial nerve and labyrinth are put at risk. Approaching the petroclival region with an endoscopic endonasal approach (EEA) could minimize morbidity. Objective To provide an anatomical and computed tomography (CT) comparison between the posterior petrosal approach and EEA to the petroclival region. Methods The petroclival region was approached transclivally with EEA. Different aspects of dissection were compared with the posterior petrosal approach. The two approaches were also studied using CT analysis. Results A successful corridor medial to the internal auditory canal (IAC) was achieved with EEA. Wide exposure was achieved with no external skin incisions, although significant sinonasal resection was required. The posterior petrosal was comparable in terms of exposure medially; however, the dissection involved more bone removal, greater skill, and a constricting effect upon deeper dissection. Importantly, access lateral to the IAC was obtained, whereas EEA could not reach this area. Conclusion An EEA to the petroclival region is feasible. This approach can be considered in lesions medial to the IAC.
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Affiliation(s)
- Eric Mason
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, United States; Center for Cranial Base Surgery, Georgia Regents University, Augusta, Georgia, United States
| | - Jason Van Rompaey
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, United States
| | - C Arturo Solares
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, United States; Center for Cranial Base Surgery, Georgia Regents University, Augusta, Georgia, United States
| | - Ramon Figueroa
- Department of Radiology, Georgia Regents University, Augusta, Georgia, United States
| | - Daniel Prevedello
- Department of Neurosurgery, Ohio State University, Columbus, Ohio, United States
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15
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Re M, Iacoangeli M, Di Somma L, Alvaro L, Nasi D, Magliulo G, Gioacchini FM, Fradeani D, Scerrati M. Endoscopic endonasal approach to the craniocervical junction: the importance of anterior C1 arch preservation or its reconstruction. ACTA OTORHINOLARYNGOLOGICA ITALICA 2016; 36:107-18. [PMID: 27196075 PMCID: PMC4907157 DOI: 10.14639/0392-100x-647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 10/19/2015] [Indexed: 12/02/2022]
Abstract
We report our experience with the endoscopic endonasal approaches (EEA) for different craniocervical junction (CCJ) disorders to analyse outcomes and demonstrate the importance and feasibility of anterior C1 arch preservation or its reconstruction. Between January 2009 and December 2013, 10 patients underwent an endoscopic endonasal approach for different CCJ pathologies at our Institution. In 8 patients we were able to preserve the anterior C1 arch, while in 2 post-traumatic cases we reconstructed it. The CCJ disorders included 4 cases of irreducible anterior bulbo-medullary compression secondary to rheumatoid arthritis or CCJ anomalies, 4 cases of inveterate fractures of C1 and/or C2 and 2 tumours. Pre- and postoperative neuroradiological evaluation was always obtained by magnetic resonance imaging (MRI), computed tomographic (CT) scanning and dynamic cranio-vertebral junction x-ray. Pre- and postoperative neurologic disability assessment was obtained by Ranawat classification for patients with rheumatoid arthritis and by Nurick classification for the others. At a mean follow-up of 31 months (range: 14-73 months), an improvement of at least one Ranawat or Nurick classification level was observed in 6 patients, while in another 4 patients neurological conditions were stable. Radiological follow-up revealed an adequate bulbo-medullary decompression in all patients and a regular bone fusion in cases of C1 and/or C2 fractures. In all patients spinal stability was preserved and none required subsequent posterior fixation. The endoscopic endonasal surgery provided adequate exposure and a low morbidity minimally invasive approach to the antero-medial located lesions of the CCJ, resulting in a safe, effective and well-tolerated procedure. This approach allowed preservation of the anterior C1 arch and the avoidance of a posterior fixation in all patients of this series, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.
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Affiliation(s)
- M Re
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Iacoangeli
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - L Di Somma
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - L Alvaro
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Nasi
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - G Magliulo
- Organi di Senso Department, University ''la Sapienza'', Rome, Italy
| | - F M Gioacchini
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Fradeani
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Scerrati
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
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16
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di Somma L, Iacoangeli M, Nasi D, Balercia P, Lupi E, Girotto R, Polonara G, Scerrati M. Combined supra-transorbital keyhole approach for treatment of delayed intraorbital encephalocele: A minimally invasive approach for an unusual complication of decompressive craniectomy. Surg Neurol Int 2016; 7:S12-6. [PMID: 26862452 PMCID: PMC4722521 DOI: 10.4103/2152-7806.173561] [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] [Received: 09/04/2015] [Accepted: 10/20/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Intraorbital encephalocele is a rare entity characterized by the herniation of cerebral tissue inside the orbital cavity through a defect of the orbital roof. In patients who have experienced head trauma, intraorbital encephalocele is usually secondary to orbital roof fracture. CASE DESCRIPTION We describe here a case of a patient who presented an intraorbital encephalocele 2 years after severe traumatic brain injury, treated by decompressive craniectomy and subsequent autologous cranioplasty, without any evidence of orbital roof fracture. The encephalocele removal and the subsequent orbital roof reconstruction were performed by using a modification of the supraorbital keyhole approach, in which we combine an orbital osteotomy with a supraorbital minicraniotomy to facilitate view and access to both the anterior cranial fossa and orbital compartment and to preserve the already osseointegrated autologous cranioplasty. CONCLUSIONS The peculiarities of this case are the orbital encephalocele without an orbital roof traumatic fracture, and the combined minimally invasive approach used to fix both the encephalocele and the orbital roof defect. Delayed intraorbital encephalocele is probably a complication related to an unintentional opening of the orbit during decompressive craniectomy through which the brain herniated following the restoration of physiological intracranial pressure gradients after the bone flap repositioning. The reconstruction of the orbital roof was performed by using a combined supra-transorbital minimally invasive approach aiming at achieving adequate surgical exposure while preserving the autologous cranioplasty, already osteointegrated. To the best of our knowledge, this approach has not been previously used to address intraorbital encephalocele.
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Affiliation(s)
- Lucia di Somma
- Department of Neurosurgery, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Balercia
- Department of Oral and Head-Neck Surgery, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Ettore Lupi
- Department of Oral and Head-Neck Surgery, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Riccardo Girotto
- Department of Oral and Head-Neck Surgery, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Gabriele Polonara
- Department of Radiology, Section of Neuroradiology, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Polytechnic University of Marche, Ancona, Italy
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17
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Iacoangeli M, Nocchi N, Nasi D, DI Rienzo A, Dobran M, Gladi M, Colasanti R, Alvaro L, Polonara G, Scerrati M. Minimally Invasive Supraorbital Key-hole Approach for the Treatment of Anterior Cranial Fossa Meningiomas. Neurol Med Chir (Tokyo) 2016; 56:180-5. [PMID: 26804334 PMCID: PMC4831943 DOI: 10.2176/nmc.oa.2015-0242] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The most important target of minimally invasive surgery is to obtain the best therapeutic effect with the least iatrogenic injury. In this background, a pivotal role in contemporary neurosurgery is played by the supraorbital key-hole approach proposed by Perneczky for anterior cranial base surgery. In this article, it is presented as a possible valid alternative to the traditional craniotomies in anterior cranial fossa meningiomas removal. From January 2008 to January 2012 at our department 56 patients underwent anterior cranial base meningiomas removal. Thirty-three patients were submitted to traditional approaches while 23 to supraorbital key-hole technique. A clinical and neuroradiological pre- and postoperative evaluation were performed, with attention to eventual complications, length of surgical procedure, and hospitalization. Compared to traditional approaches the supraorbital key-hole approach was associated neither to a greater range of postoperative complications nor to a longer surgical procedure and hospitalization while permitting the same lesion control. With this technique, minimization of brain exposition and manipulation with reduction of unwanted iatrogenic injuries, neurovascular structures preservation, and a better aesthetic result are possible. The supraorbital key-hole approach according to Perneckzy could represent a valid alternative to traditional approaches in anterior cranial base meningiomas surgery.
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Affiliation(s)
- Maurizio Iacoangeli
- Department of Neurosurgery, Università Politecnica delle Marche, Umberto I General Hospital
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Vogin G, Calugaru V, Bolle S, George B, Oldrini G, Habrand JL, Mammar H, Dendale R, Salleron J, Noël G, Feuvret L. Investigation of ectopic recurrent skull base and cervical chordomas: The Institut Curie's proton therapy center experience. Head Neck 2015; 38 Suppl 1:E1238-46. [DOI: 10.1002/hed.24199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 06/11/2015] [Accepted: 07/07/2015] [Indexed: 11/06/2022] Open
Affiliation(s)
- Guillaume Vogin
- Department of Radiation Oncology; Institut de Cancérologie de Lorraine; Nancy France
| | - Valentin Calugaru
- Department of Radiation Oncology; Institut Curie; Paris France
- Protontherapy Center; Institut Curie; Orsay France
| | - Stéphanie Bolle
- Department of Radiation Oncology; Institut Gustave Roussy; Villejuif France
- Protontherapy Center; Institut Curie; Orsay France
| | - Bernard George
- Department of Neurosurgery; Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris; Paris France
| | - Guillaume Oldrini
- Department of Radiology; Institut de Cancérologie de Lorraine; Nancy France
| | - Jean-Louis Habrand
- Department of Radiation Oncology; Centre François Baclesse; Caen France
- Protontherapy Center; Institut Curie; Orsay France
| | - Hamid Mammar
- Department of Radiation Oncology; Institut Curie; Paris France
- Protontherapy Center; Institut Curie; Orsay France
| | - Rémi Dendale
- Department of Radiation Oncology; Institut Curie; Paris France
- Protontherapy Center; Institut Curie; Orsay France
| | - Julia Salleron
- Department of Biostatistics; Institut de Cancérologie de Lorraine; Nancy France
| | - Georges Noël
- Department of Radiation Oncology; Centre Paul Strauss; Strasbourg France
| | - Loïc Feuvret
- Protontherapy Center; Institut Curie; Orsay France
- Department of Radiation Oncology; Hôpital La Pitié Salpétrière, Assistance Publique - Hôpitaux de Paris; Paris France
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Cranial Base Repair Using Suturing Technique Combined with a Mucosal Flap for Cerebrospinal Fluid Leakage During Endoscopic Endonasal Surgery. World Neurosurg 2015; 84:1887-93. [PMID: 26341445 DOI: 10.1016/j.wneu.2015.08.025] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate a cranial base repair method using the dural suturing technique in combination with a mucosal flap in the endoscopic endonasal approach. METHODS We analyzed 190 patients (mean age, 52.3 years; age range, 3-86 years) who underwent 194 endoscopic endonasal approaches. The degree of intraoperative cerebrospinal fluid (CSF) leakage was graded based on previously published criteria: grade 0, absent; grade 1, small; grade 2, moderate; and grade 3, large. Cranial base repair using the dural suturing technique was performed according to the grade of CSF leakage: grades 1 and 2, autologous fat graft anchored by dural suturing covered with a sphenoid sinus mucosal flap, and grade 3, multilayered, inlay sutured and onlay nonsutured fascial grafts covered with a nasoseptal flap. RESULTS Intraoperative CSF leakage was observed in 125 of 194 cases (64.4%). The degree of CSF leakage was grade 0 in 69 cases, grade 1 in 51 cases, grade 2 in 30 cases, and grade 3 in 44 cases. A postoperative CSF leak was encountered in 2 of 125 repaired cases (1.6%). Both cases with CSF leak involved grade 3 CSF leak (4.5%), and both were successfully treated with lumbar drainage. CONCLUSION Our graded cranial base repair method using the dural suturing technique is simple and reliable.
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Beer-Furlan A, Vellutini EAS, Balsalobre L, Stamm AC. Endoscopic Endonasal Approach to Ventral Posterior Fossa Meningiomas: From Case Selection to Surgical Management. Neurosurg Clin N Am 2015; 26:413-26. [PMID: 26141360 DOI: 10.1016/j.nec.2015.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Clival, petroclival, and foramen magnum meningiomas are challenging lesions to manage independently of the selected surgical approach. The expanded endoscopic endonasal approach (EEA) provided a safe alternative on the armamentarium of skull base approaches. There is a paucity of literature regarding endoscopic management of meningiomas because of certain limiting factors, including rarity of the pathologic condition, technical challenges, expertise of the surgical team, and available resources. The surgical technique, possible complications, and postoperative care are described in detail. This article highlights the important aspects in choosing this surgical approach and managing ventral posterior fossa meningiomas through the EEA.
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Affiliation(s)
- André Beer-Furlan
- Neurosurgical Department, São Paulo Skull Base Center, Rua Adma Jafet, 74 - cj. 121, São Paulo 01308, Brazil; DFV Neuro Neurosurgical Group, Rua Adma Jafet, 74 - cj.121, São Paulo 01308, Brazil
| | - Eduardo A S Vellutini
- Neurosurgical Department, São Paulo Skull Base Center, Rua Adma Jafet, 74 - cj. 121, São Paulo 01308, Brazil; DFV Neuro Neurosurgical Group, Rua Adma Jafet, 74 - cj.121, São Paulo 01308, Brazil.
| | - Leonardo Balsalobre
- Neurosurgical Department, São Paulo Skull Base Center, Rua Adma Jafet, 74 - cj. 121, São Paulo 01308, Brazil; ENT Department, São Paulo ENT Center, Professor Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525 - cj. 13, São Paulo 04511, Brazil
| | - Aldo C Stamm
- Neurosurgical Department, São Paulo Skull Base Center, Rua Adma Jafet, 74 - cj. 121, São Paulo 01308, Brazil; ENT Department, São Paulo ENT Center, Professor Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525 - cj. 13, São Paulo 04511, Brazil
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