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Sidabutar R, Hermanto Y, Sutiono AB, Naibaho G, Faried A. Surgical treatment of tuberculum sellae meningioma: A retrospective review of single institutional experience. Surg Neurol Int 2024; 15:440. [PMID: 39640330 PMCID: PMC11618804 DOI: 10.25259/sni_685_2024] [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: 08/14/2024] [Accepted: 10/27/2024] [Indexed: 12/07/2024] Open
Abstract
Background Tuberculum sellae meningiomas (TSMs) represent a distinct entity among intracranial meningiomas. Both transcranial approaches (TCAs) and endoscopic endonasal approaches (EEAs) have provided neurosurgeons with options for managing these difficult tumors. Still, controversies persist regarding the selection criteria for the most optimal approach. Methods The authors retrospectively reviewed 45 patients treated surgically for TSM between 2018 and 2023. The clinical reports of all subjects were assessed pre-and post-operatively, encompassing demographic information, clinical symptoms, imaging results, ophthalmological evaluations, operative details, and any complications. Results A total of 45 patients were included in this study, with 21 patients undergoing EEAs and 24 TCAs. TSMs treated with EEA are smaller than TCA (P = 0.0014), less prevalent in optic canal invasion (P = 0.0291) and in arterial encasement (P = 0.0050), and have no lateral extension (P < 0.0001). The majority of patients (36/45) had visual improvement or stabilization following the surgery, with the rate of achieving gross total resection (GTR) was higher in the EEA group (17/21) than in the TCA group (9/24) (P = 0.0032). The mortality tends to be higher in the TCA group and is related to arterial encasement, although statistically insignificant. Conclusion Both traditional TCAs and EEAs offer options for the surgical management of TSM, each with its advantages and limitations. Based on our experiences, several factors (lateral extension and arterial encasement) may guide the suitable approach, and multidisciplinary considerations, with the overarching goals of achieving maximal tumor resection and minimizing postoperative complications.
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Affiliation(s)
- Roland Sidabutar
- Department of Neurosurgery, Dr. Hasan Sadikin Hospital, Padjadjaran University, Bandung, West Java, Indonesia
| | - Yulius Hermanto
- Department of Neurosurgery, Dr. Hasan Sadikin Hospital, Padjadjaran University, Bandung, West Java, Indonesia
| | - Agung Budi Sutiono
- Department of Neurosurgery, Dr. Hasan Sadikin Hospital, Padjadjaran University, Bandung, West Java, Indonesia
| | - Guata Naibaho
- Department of Neurosurgery, Dr. Hasan Sadikin Hospital, Padjadjaran University, Bandung, West Java, Indonesia
| | - Ahmad Faried
- Department of Neurosurgery, Dr. Hasan Sadikin Hospital, Padjadjaran University, Bandung, West Java, Indonesia
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Quintana D, Ramesh R, Gurrola J, Goldschmidt E. Endonasal Endoscopic Resection of a Large Tuberculum Sellae Meningioma With Internal and External Carotid Artery Blood Supply: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01383. [PMID: 39495044 DOI: 10.1227/ons.0000000000001407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 08/12/2024] [Indexed: 11/05/2024] Open
Affiliation(s)
- Daniel Quintana
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rithvik Ramesh
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jose Gurrola
- Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ezequiel Goldschmidt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Maira G, LA Pira B, Serraino A, Tropeano MP, Cannizzaro D. Tuberculum sellae meningiomas: surgical outcomes in 65 patients, review of the literature and proposal for an anatomical and radiological classification. J Neurosurg Sci 2024; 68:631-641. [PMID: 37306618 DOI: 10.23736/s0390-5616.23.06061-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Tuberculum sellae meningiomas (TSM) are challenging tumors due to their proximity to vital neurovascular structures. We propose a new classification system based on anatomical and radiological parameters. All patients treated for TSM, between January 2003 and December 2016, have been retrospectively reviewed. A systematic research was performed in PubMed database to review all studies comparing the performance of transcranial (TCA) and transphenoidal (ETSA) approaches. Overall, 65 patients were included in the surgical series. Gross total removal (GTR) was achieved in 55 patients (85%) and near total resection in 10 (15%). 54 patients (83%) showed a stability or an improvement of visual functions and 11 (17%) worsened. Postoperative complications were observed in seven patients (11%): CSF leak in one patient (1.5%); diabetes insipidus in two (3%); hypopituitarism in two (3%) third cranial nerve paresis and subdural empyema in one (1.5%). For the literature review, data about 10,833 patients (TCA N.=9159; ETSA N.=1674) were recorded; GTR was achieved in 84.1% (range 68-92%) of TCA and in 79.1% (range 60-92%) of ETSA; visual improvement (VI) occurred in 59.3% of TCA (range 25-84%) and in 79.3% of ETSA (range 46-100%); visual deterioration (VD) was registered in 12.7% of TCA (0-24%) and in 4.1% of ETSA (range 0-17%); a CSF-leak was observed in 3.8% of TCA (range 0-8%) while in ETSA in 18.6% of patients (range 0-62%); vascular injuries was reported in 4% (range 0-15%) of TCA and in 1.5% (range 0-5%) of ETSA. In conclusion, TSMs represent a unique category of midline tumors. The proposed classification system provides an intuitive and reproducible method in the choice of the most suitable approach.
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Affiliation(s)
- Giulio Maira
- Department of Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Biagia LA Pira
- Department of Neurosurgery, Spaziani Hospital, Frosinone, Italy
| | | | - Maria P Tropeano
- Department of Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy -
| | - Delia Cannizzaro
- Department of Neurosurgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
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Tanaka Y, Abe D, Inaji M, Hara S, Sakai R, Maehara T. Intraoperative Telestration System in Endoscopic Transsphenoidal Surgery Contributes to Improved Surgical Safety and Efficient Surgical Education. World Neurosurg 2024; 190:e348-e354. [PMID: 39067687 DOI: 10.1016/j.wneu.2024.07.134] [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: 06/17/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of a "telestration" system in which the mentor annotates the view of the surgical field, for endoscopic transsphenoidal surgery (ETS). METHODS The use of telestration was evaluated for sellar floor-opening during ETS and for a task performed using ETS simulation training. During ETS, the mentor outlined the opening area of the sella turcica on the monitor and then the trainee surgeon opened the sella, either with the telestration displayed (telestration (+) group, n = 8) or without (telestration (-) group, n = 7). In the task using an ETS training model, 18 subjects were asked to touch the indicated targets with the forceps, once with the instructions given via telestration and once with verbal instructions only. RESULTS During ETS, the telestration (+) group had a significantly higher concordance rate between the planned bone window and actual bone window than the telestration (-) group (92.97 ± 4.16% vs. 77.57 ± 10.51%, P = 0.014). In the ETS model, the time required to finish the task was significantly less with telestration than with verbal instructions alone (P = 0.002). None of the subjects had errors when telestration was used, while subjects made an average of 0.33 ± 0.59 errors and had to re-listen to the instructions 0.27 ± 0.46 times when only verbal instructions were given. CONCLUSIONS The use of the telestration system during ETS facilitated the communication of the mentor's intentions to the trainee surgeon and contributed to safer, more accurate surgery. The system was also thought to be useful in reducing operative time.
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Affiliation(s)
- Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Daisu Abe
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Hara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryosuke Sakai
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
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Lasica N, Parikh KA, Arnautović KI. Cranio-Orbital Approach and Decompression of the Optic Nerves: A 2-Stage, 4-by-4-Step Approach to Improve Vision in Sellar and Parasellar Lesions. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01331. [PMID: 39292768 DOI: 10.1227/ons.0000000000001344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/09/2024] [Indexed: 09/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Despite advances in cranial base techniques, surgery of the sellar and parasellar regions remains challenging because of complex neurovascular relationships. Lesions within this region frequently present with progressive visual deterioration caused by distortion and compression of the optic chiasm and nerves. In addition to the direct mass effect from mechanical forces acting on the optic apparatus, these lesions alter blood supply and reduce vascular perfusion, prompting surgical treatment to remove the lesion, alleviate compression, and improve blood flow to the optic nerve. We sought to describe a 2-stage, 4-by-4-step approach, broken down and described as a "four-by-four" technique for optic apparatus decompression and a wide approach to different sellar and parasellar lesions. METHODS We describe the operative nuances and key anatomic points in the microsurgical removal of sellar and parasellar lesions. The technique is illustrated with examples of different cases with pre- and follow-up MRI imaging and a brief overview of visual outcomes. RESULTS The described technique has been demonstrated in various lesions in 5 patients. Patients presented with bilateral visual loss in 4 (80.0%) cases and with unilateral visual loss in 1 (20.0%) case. Improvement in visual function was noted in all cases, confirmed with visual acuity and visual field testing. DISCUSSION The transcranial approach ("from above") remains an important surgical option for patients with excellent exposure and visualization of the sellar and parasellar regions. It permits early access to the optic canal for careful microsurgical decompression and relaxation of the optic nerve to preserve and improve its microvascularization and ultimately vision. CONCLUSION The authors augmented the 2-stage, 4-by-4-step technique of decompression with elaborate illustrations of diverse sellar and parasellar lesions to demonstrate the versatility of this approach.
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Affiliation(s)
- Nebojsa Lasica
- Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | | | - Kenan I Arnautović
- Semmes-Murphey Clinic, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Schroeder LA, Starreveld YP. Outcomes of Endoscopic Endonasal Surgery for Tuberculum Sellae and Planum Sphenoidale Meningiomas: A Retrospective Study. Can J Neurol Sci 2024:1-6. [PMID: 39252175 DOI: 10.1017/cjn.2024.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND To evaluate clinical outcomes and volumetric changes following endoscopic endonasal approach (EEA) for tuberculum sellae (TS) and planum sphenoidale (PS) meningiomas. Key objectives included evaluating pre- and postoperative tumor volumes, visual assessments and EEA-related complications. METHODS A single-center retrospective study was conducted at Foothills Medical Centre, University of Calgary, Canada, from 2009 to 2022 including 24 patients meeting inclusion criteria for midline skull base tumors, confirmed as WHO Grade I or II meningiomas with optic canal extension. RESULTS EEA achieved gross total resection in 87.5% of cases, with a mean tumor volume reduction of 92.24%. Postoperatively, 91.67% exhibited visual improvement or stability. Cerebrospinal fluid leaks occurred in 12.5% of cases, necessitating revision surgery in one case. Persistent postoperative endocrine dysfunction affected 4.17%. Preoperative tumor volume did not demonstrate a correlation with complications. CONCLUSIONS This study delivers reproducible data for pre- and postoperative tumor volume following the EEA after TS or PS meningiomas. The EEA demonstrated favorable radiographic and clinical outcomes in TS and PS meningiomas, achieving gross total resection with minimal morbidity.
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Affiliation(s)
- Lynn Abigail Schroeder
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Yves Pieter Starreveld
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Mo J, Hasegawa H, Shin M, Shinya Y, Arisawa K, Umekawa M, Jiang X, Miyawaki S, Nishijima H, Kondo K, Saito N. Endoscopic Endonasal Approach Is Superior to Transcranial Approach for Small to Medium Tuberculum Sellae Meningiomas in Terms of Visual Outcome and Complications: A Retrospective Study in a Single Center. World Neurosurg 2024; 189:e814-e824. [PMID: 38981561 DOI: 10.1016/j.wneu.2024.07.010] [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: 04/17/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE This study compared the effectiveness of the endoscopic endonasal approach (EEA) with the conventional transcranial approach (TCA) for treating tuberculum sellae meningiomas (TSMs), aiming to identify the superior surgical method and the risk factors affecting outcomes. METHODS Patients treated for TSM from 1998 to 2023 at our institution were retrospectively analyzed, evaluating patient characteristics, tumor features, outcomes, and complications. A novel grading system for preoperative evaluation of TSMs was proposed. RESULTS Among 49 patients, 26 underwent EEA and 23 underwent TCA. The maximum diameters were comparable between the groups (mean 22 mm vs. 23 mm). Gross total resection rates were 62% for EEA and 70% for TCA, showing no significant difference. However, postsurgical visual improvement was significantly higher in the EEA group compared with the TCA group (77% vs. 44%; P = 0.020), with fewer complications in the EEA group (8% vs. 35%; P = 0.032). CONCLUSIONS EEA is a safe and effective treatment approach for small to medium TSMs, with outcomes comparable to TCA in terms of resection but superior in visual improvement and fewer complications. Selection of surgical approach should consider patient and tumor characteristics as well as surgeon experience.
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Affiliation(s)
- Jun Mo
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan; Department of Neurosurgery, The Fourth Affiliated Hospital of School of Medicine and International School of Medicine, International Institutes of Medicine, Zhejiang University, Zhejiang, China
| | | | - Masahiro Shin
- Department of Neurosurgery, Teikyo University, Tokyo, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan
| | - Kei Arisawa
- Department of Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan
| | - Xiaohang Jiang
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan
| | - Hironobu Nishijima
- Department of Otorhinolaryngology, The University of Tokyo, Tokyo, Japan
| | - Kenji Kondo
- Department of Otorhinolaryngology, The University of Tokyo, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan
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Ius T, Raffa G, Aiudi D, Panciani PP, Della Pepa GM, Pessina F, Solari D, Somma T, Angileri FF, Nichelatti M, Cappabianca P, Esposito V, Fornari M, Iacopino DG, Olivi A, Sala F, Cavallo LM, La Camera A. From data to practice: brain meningioma treatment in elderly patients - a survey of the Italian Society of Neurosurgery (SINch®) and systematic review and meta-analysis. Neurosurg Rev 2024; 47:373. [PMID: 39083092 PMCID: PMC11291526 DOI: 10.1007/s10143-024-02524-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/02/2024] [Accepted: 06/17/2024] [Indexed: 08/03/2024]
Abstract
The management of meningioma in elderly patients (MEP) presents a complex and evolving challenge. Data available offer conflicting information on treatment options and complications. This survey aimed to examine the current approach to MEP, comparing the national profile to data in the current literature. A survey addressing the treatments options and management of meningioma in elderly was designed on behalf of SINch® (Società Italiana di Neurochirurgia) and sent via email to all Chiefs of Neurosurgical Departments. The survey remained open for responses from May 5th, 2022, until November 21st, 2022. A search of the literature published between January 2000 and March 2023, in accordance to PRISMA guidelines, was included. A total of 51 Neurosurgical centers participated in the survey. The caseload profile of each center influences the choice of treatment selection (Stereotactic Radiosurgery versus open surgery) (p = 0.01) and the consolidated practice of discussing cases within a multidisciplinary group (p = 0.02). The pooled meta-analysis demonstrated a significant increased risk in the elderly group for permanent deficits (p < 0.00001), postoperative infections (p = 0.0004) and hemorrhage (p = 0.0001), perioperative mortality (p < 0.00001), and medical complications (p < 0.00001) as compared to the young population. This study presents the initial comprehensive analysis of the existing trends in the surgical management of MEP in Italy. The significant variation in practices primarily stems from the absence of standardized guidelines. While most centers have adopted an integrated approach, there is a need to promote a multidisciplinary care model. Prospective studies are needed to gather robust evidence in this clinical setting.
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Affiliation(s)
- Tamara Ius
- Neurosurgery Unit, Head-Neck and Neurosciences Department, Santa Maria Della Misericordia University Hospital, Udine, Italy
| | - Giovanni Raffa
- Neurosurgery Unit, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Denis Aiudi
- Neurosurgical Department, Università Politecnica Delle Marche, Marche General University Hospital, Ancona, Italy
| | - Pier Paolo Panciani
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Di Brescia, Brescia, Italy.
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Teresa Somma
- Division of Neurosurgery, Department of Neurological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Filippo Flavio Angileri
- Neurosurgery Unit, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Michele Nichelatti
- Department of Clinical Research & Innovation, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | | | - Maurizio Fornari
- Neurosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Domenico Gerardo Iacopino
- Department of Biomedicine Neurosciences and Advanced Diagnostics, Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, School of Medicine, University of Palermo, Palermo, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Francesco Sala
- Department of Neurosciences, Biomedicine and Movement Sciences, Neurosurgery Unit, University of Verona, Verona, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Alessandro La Camera
- Division of Neurosurgery, Department of Neuroscience, Grande Ospedale Metropolitano Niguarda, Milano, Italy
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Ungureanu G, Florian A, Florian SI. The impact of arachnoid structures on skull-base meningioma surgical management: a radiological analysis and narrative review. J Med Life 2024; 17:682-689. [PMID: 39440328 PMCID: PMC11493166 DOI: 10.25122/jml-2024-0349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 07/04/2024] [Indexed: 10/25/2024] Open
Abstract
The presence of intact arachnoid membranes between skull base meningiomas and critical neurovascular structures is crucial for predicting surgical outcomes, understanding tumor development and growth, and planning the feasibility of tumor resection or the need for adjuvant treatments. While neurosurgeons often utilize the subarachnoid cisterns to enhance access to these tumors and facilitate their removal, a comprehensive review aimed at health professionals involved in the diagnosis and treatment of this complex pathology, including radiologists, neurologists, oncologists, ophthalmologists, and neurosurgeons is still lacking. This study aims to summarize the interaction between skull base meningiomas, subarachnoid cisterns, and arachnoid membranes, emphasizing their significance in both the diagnosis and treatment of this pathology. By conducting a thorough radiological assessment of skull base meningiomas, correlating these findings with intraoperative observations, and reviewing relevant literature, we summarize the critical relationship between skull base meningiomas and the surrounding subarachnoid spaces. We concisely describe how arachnoid structures influence tumor growth and interaction with neurovascular elements. We advocate for the inclusion of tumor-arachnoid relationships in the medical literature concerning the treatment of these tumors. A better understanding and description of the interaction between tumors and neurovascular structures will aid in planning and attempting safer treatments, minimizing surgical risks, predicting potential tumor progression, and the need for adjuvant treatments.
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Affiliation(s)
- Gheorghe Ungureanu
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Neurosurgery Department, Cluj County Emergency Hospital, Cluj-Napoca, Romania
| | - Alexandru Florian
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Neurosurgery Department, Cluj County Emergency Hospital, Cluj-Napoca, Romania
| | - Stefan Ioan Florian
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Neurosurgery Department, Cluj County Emergency Hospital, Cluj-Napoca, Romania
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10
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Marian-Magaña R, Sangrador-Deitos MV, Rodríguez-Hernández L, Lara-Olivas JA, López-Valencia G, Villalobos-Díaz R, Aragón-Arreola JF, Padilla-Leal KE, García-Zazueta JH, Camacho-Castro A, Gómez-Amador JL. Visual outcomes in tuberculum sellae meningiomas comparing transcranial and endoscopic endonasal approaches. World Neurosurg X 2024; 23:100319. [PMID: 38511160 PMCID: PMC10950694 DOI: 10.1016/j.wnsx.2024.100319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
Background Tuberculum sellae meningiomas (TSM) account for 3-10% of intracranial meningiomas. Visual loss is the presenting symptom in up to 80% of cases. Surgical management poses a great challenge due to tumor proximity to neurovascular structures such as the optic nerve and the internal carotid artery (ICA); hence, there is controversy regarding the optimal approach. The aim of this study is to determine differences in visual outcomes between transcranial (TCA) and endoscopic endonasal (EEA) approaches. Methods A retrospective study including 29 patients with TSM surgically treated by TCA or EEA between 2011 and 2023 in a single referral center was conducted. Pre-and post-operative neuro-ophthalmologic evaluations, focusing on visual acuity and campimetry, were evaluated. Results Sixteen (55.16%) patients were intervened through a TCA and the remaining 13 (44.84%) via an EEA. The lesions in each group were similar in terms of pre- operative volume (15.12 vs 12.9 cm3, p = 0.497) and neurovascular invasion (optic canal invasion 48.26 vs 41.37%, p = 0.664; ICA 44.81 vs 31.03%, p = 0.797). There were no significant differences in visual outcomes between both approaches; TCA presented an improvement of 5.18 points in visual fields (p = 0.140), whereas EEA had an improvement of 17.39 points in visual acuity (p = 0.114). Conclusion EEA seems to offer greater improvement in visual acuity than TCA. However, the ideal approach should be individualized; taking into account the tumor's volume and invasiveness, as well as the patient's visual complaints.
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Affiliation(s)
- Ricardo Marian-Magaña
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Marcos V Sangrador-Deitos
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Luis Rodríguez-Hernández
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Jorge A Lara-Olivas
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Germán López-Valencia
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Rodolfo Villalobos-Díaz
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Jorge F Aragón-Arreola
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Karen E Padilla-Leal
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
| | - Jesús Humberto García-Zazueta
- Department of Neurosurgery, Culiacan General Hospital Dr Bernard J Gastelum, Av. Juan Aldama s/n Esquina Calle Estado de Nayarit Col. Gral. Antonio Rosales, Culiacán, Mexico
| | - Alfredo Camacho-Castro
- Department of Neurosurgery, Culiacan General Hospital Dr Bernard J Gastelum, Av. Juan Aldama s/n Esquina Calle Estado de Nayarit Col. Gral. Antonio Rosales, Culiacán, Mexico
| | - Juan L Gómez-Amador
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", Av. Insurgentes Sur 3877, Tlalpan, 14269, Mexico City, Mexico
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Morales-Roccuzzo D, Sabahi M, Obrzut M, Najera E, Monterroso-Cohen D, Bsat S, Adada B, Borghei-Razavi H. A primer to vascular anatomy of the brain: an overview on anterior compartment. Surg Radiol Anat 2024; 46:829-842. [PMID: 38630270 PMCID: PMC11161539 DOI: 10.1007/s00276-024-03359-0] [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: 02/05/2024] [Accepted: 03/30/2024] [Indexed: 06/09/2024]
Abstract
PURPOSE Knowledge of neurovascular anatomy is vital for neurosurgeons, neurologists, neuro-radiologists and anatomy students, amongst others, to fully comprehend the brain's anatomy with utmost depth. This paper aims to enhance the foundational knowledge of novice physicians in this area. METHOD A comprehensive literature review was carried out by searching the PubMed and Google Scholar databases using primary keywords related to brain vasculature, without date restrictions. The identified literature was meticulously examined and scrutinized. In the process of screening pertinent papers, further articles and book chapters were obtained through analysis and additional assessing of the reference lists. Additionally, four formalin-fixed, color latex-injected cadaveric specimens preserved in 70% ethanol solution were dissected under surgical microscope (Leica Microsystems Inc, 1700 Leider Ln, Buffalo Grove, IL 60089 USA). Using microneurosurgical as well as standard instruments, and a high-speed surgical drill (Stryker Instruments 1941 Stryker Way Portage, MI 49002 USA). Ulterior anatomical dissection was documented in microscopic images. RESULTS Encephalic circulation functions as a complex network of intertwined vessels. The Internal Carotid Arteries (ICAs) and the Vertebral Arteries (VAs), form the anterior and posterior arterial circulations, respectively. This work provides a detailed exploration of the neurovascular anatomy of the anterior circulation and its key structures, such as the Anterior Cerebral Artery (ACA) and the Middle Cerebral Artery (MCA). Embryology is also briefly covered, offering insights into the early development of the vascular structures of the central nervous system. Cerebral venous system was detailed, highlighting the major veins and tributaries involved in the drainage of blood from the intracranial compartment, with a focus on the role of the Internal Jugular Veins (IJVs) as the primary, although not exclusive, deoxygenated blood outflow pathway. CONCLUSION This work serves as initial guide, providing essential knowledge on neurovascular anatomy, hoping to reduce the initial impact when tackling the subject, albeit the intricate vasculature of the brain will necessitate further efforts to be conquered, that being crucial for neurosurgical and neurology related practice and clinical decision-making.
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Affiliation(s)
- Diego Morales-Roccuzzo
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
| | - Mohammadmahdi Sabahi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Michal Obrzut
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Edinson Najera
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - David Monterroso-Cohen
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Shadi Bsat
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
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12
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Agosti E, Alexander AY, Antonietti S, Zeppieri M, Piazza A, Panciani PP, Fontanella MM, Pinheiro-Neto C, Ius T, Peris-Celda M. Comparative Efficacy of Transsphenoidal and Transcranial Approaches for Treating Tuberculum Sellae Meningiomas: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:2356. [PMID: 38673630 PMCID: PMC11051146 DOI: 10.3390/jcm13082356] [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: 03/04/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Tuberculum sellae meningiomas (TSMs) constitute 5-10% of intracranial meningiomas, often causing visual impairment. Traditional microsurgical transcranial approaches (MTAs) have been effective, but the emergence of innovative surgical trajectories, such as endoscopic endonasal approaches (EEAs), has sparked debate. While EEAs offer advantages like reduced brain retraction, they are linked to higher cerebrospinal fluid leak (CSF leak) risk. This meta-analysis aims to comprehensively compare the efficacy and safety of EEAs and MTAs for the resection of TSMs, offering insights into their respective outcomes and complications. Methods: A comprehensive literature review of the databases PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted for articles published on TSMs treated with either EEA or MTA until 2024. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analysis was performed to estimate pooled event rates and assess heterogeneity. Fixed- and random-effects were used to assess 95% confidential intervals (CIs) of presenting symptoms, outcomes, and complications. Results: A total of 291 papers were initially identified, of which 18 studies spanning from 2000 to 2024 met the inclusion criteria. The exclusion of 180 articles was due to reasons such as irrelevance, non-reporting of selected results, systematic literature review or meta-analysis, and a lack of details on method/results. The 18 studies comprised a total sample of 1093 patients: 444 patients who underwent EEAs and 649 patients who underwent MTAs for TSMs. Gross total resection (GTR) rates ranged from 80.9% for EEAs to 79.8% for MTAs. The rate of visual improvement was 86.6% in the EEA group and 65.4% in the MTA group. The recurrence rate in the EEA group was 6.9%, while it was 5.1% in MTA group. The postoperative complications analyzed were CSF leak, infections, dysosmia, intracranial hemorrhage (ICH), and endocrine disorders. The rate of CSF leak was 9.8% in the EEA group and 2.1% in MTA group. The rate of infections in the EEA group was 5.7%, while it was 3.7% in the MTA group. The rate of dysosmia ranged from 10.3% for MTAs to 12.9% for EEAs. The rate of ICH in the EEA group was 0.9%, while that in the MTA group was 3.8%. The rate of endocrine disorders in the EEA group was 10.8%, while that in the MTA group was 10.2%. No significant difference was detected in the rate of GTR between the EEA and MTA groups (OR 1.15, 95% CI 0.7-0.95; p = 0.53), while a significant benefit in visual outcomes was shown in EEAs (OR 3.54, 95% CI 2.2-5.72; p < 0.01). There was no significant variation in the recurrence rate between EEA and MTA groups (OR 0.92, 95% CI 0.19-4.46; p = 0.89). While a considerably increased chance of CSF leak from EEAs was shown (OR 4.47, 95% CI 2.52-7.92; p < 0.01), no significant difference between EEA and MTA groups was detected in the rate of infections (OR 1.92, 95% CI 0.73-5.06; p = 0.15), the rate of dysosmia (OR 1.25, 95% CI 0.31-4.99; p = 0.71), the rate of ICH (OR 0.61, 95% CI 0.20-1.87; p = 0.33), and the rate of endocrine disorders (OR 1.16, 95% CI 0.69-1.95; p = 0.53). Conclusions: This meta-analysis suggests that both EEAs and MTAs are viable options for TSM resection, with distinct advantages and drawbacks. The EEAs demonstrate superior visual outcomes in selected cases while GTR and recurrence rates support the overall effectiveness of MTAs and EEAs. Endoscopic endonasal approaches had a higher chance of CSF leaks, but there are no appreciable variations in other complications. These results provide additional insights regarding patient outcomes in the intricate clinical setting of TSMs.
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Affiliation(s)
- Edoardo Agosti
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy; (E.A.)
| | | | - Sara Antonietti
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy; (E.A.)
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Amedeo Piazza
- Department of Neurosurgery, “Sapienza” University, 00185 Rome, Italy
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy; (E.A.)
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy; (E.A.)
| | | | - Tamara Ius
- Neurosurgery Unit, Head-Neck and NeuroScience Department, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Maria Peris-Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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13
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Chen L, Gao M, Zhang H, Chen W, Sun K, Xu R. Effect of Optic Canal Opening on Postoperative Visual Acuity in Patients with Tuberculum Sellae Meningiomas. J Neurol Surg A Cent Eur Neurosurg 2024; 85:1-6. [PMID: 35144298 DOI: 10.1055/a-1768-3553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Tuberculum sellae meningiomas (TSMs) account for 5 to 10% of all intracranial meningiomas. They typically invade the optic canal and displace the optic nerve upward and laterally. The transcranial approach has been the standard surgical approach, while the transsphenoidal approach has been proposed for its minimally invasive nature; however, some reservations concerning this approach remain. METHODS From January 2000 to December 2018, a total of 97 patients who were diagnosed with TSM with invasion of the optic canal were enrolled and underwent microsurgery for tumor removal with optic canal opening. A retrospective analysis was performed on the effect of optic canal opening on postoperative visual acuity improvement. The median follow-up was 17.4 months (range: 3-86 months). RESULTS Among the 97 patients with TSM involving the optic canal, optic canal invasion was seen on preoperative imaging in 73 patients and during intraoperative exploration in all patients. In total, 87/97 patients (89.7%) underwent optic canal opening to remove tumors involving the optic canal, and the rate of total macroscopic resection of tumors invading the optic canal was 100%. Among the 10 patients who did not undergo optic canal opening, the rate of total resection of tumors involving the optic canal was 80% (8/10, p < 0.001). There were no deaths or serious complications. The postoperative visual acuity improvement rate was 64.4%, 23.7% maintained the preoperative level, and the visual acuity deteriorated 11.9%. CONCLUSION Intraoperative optic canal opening is the key to total resection of TSMs involving the optic canal and improving postoperative visual acuity.
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Affiliation(s)
- Lihua Chen
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Mou Gao
- Department of Neurosurgery, the PLA General Hospital, Beijing, People's Republic of China
| | - Hongtian Zhang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Wenjin Chen
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Kai Sun
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Ruxiang Xu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
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14
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Cavallo LM, d'Avella E, Tortora F, Bove I, Cappabianca P, Solari D. Endonasal Route for Tuberculum and Planum Meningiomas. Adv Tech Stand Neurosurg 2024; 53:65-78. [PMID: 39287803 DOI: 10.1007/978-3-031-67077-0_5] [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] [Indexed: 09/19/2024]
Abstract
Tuberculum and planum meningiomas are challenging tumors per their critical location and neurovascular relationships. The standard treatment is usually represented by complete tumor removal, being the transcranial approaches the well-established routes. During the last decades, novel surgical routes have been experimented with emphasis on the concept of minimal invasive approaches. The peculiar perspective from below the endoscopic endonasal approach provides a short and direct access avoiding brain and neurovascular structures manipulation, featuring excellent outcomes and a reduced morbidity. Ideal indications are small or medium size midline meningiomas, with wide tuberculum sellae angle and deep sella at the sphenoid sinus, possibly with no optic nerve and/or vessels encasement. Adequate removal of paranasal structures and extended bony opening over the dural attachment provide a wide surgical corridor ensuring safe intradural exposure at the suprasellar area. The main advantage is related to early decompression of the optic apparatus and reduced manipulation of subchiasmatic perforating vessels, with improved visual outcomes. Direct exposure of the inferomedial aspect of the optic canals allows for maximal decompression in cases of tumor extending within. Transcranial approaches tend to be selected for larger tumors with lateral extension beyond optic nerves and supraclinoid carotid arteries, in inaccessible areas from an endonasal corridor.
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Affiliation(s)
- Luigi Maria Cavallo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy.
| | - Elena d'Avella
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Fabio Tortora
- Department of Advanced Biomedical Science, University of Napoli "Federico II", Naples, Italy
| | - Ilaria Bove
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Domenico Solari
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
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15
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Azab WA, Najibullah M, Shabbir Z, Alali F, Yousef W. Fully Endoscopic Supraorbital Approach for Anterior Cranial Base Meningiomas. Adv Tech Stand Neurosurg 2024; 52:139-158. [PMID: 39017792 DOI: 10.1007/978-3-031-61925-0_11] [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] [Indexed: 07/18/2024]
Abstract
BACKGROUND Anterior cranial base meningiomas include those meningiomas originating from the tuberculum sellae, the planum sphenoidale, or the olfactory groove, with surgical excision being the main treatment modality for these tumors. Conventional microscopic and endoscope-assisted versions of the supraorbital keyhole approach via an eyebrow incision emerged into minimally invasive options that are frequently utilized nowadays for treating these tumors. At the early attempts of endoscope-assisted cranial surgery, it was noted that rigid endoscopes enabled overcoming the problem of suboptimal visualization when small exposures are used. The technical specifications and design of the currently available rigid endoscopes are associated with a group of unique features that define the endoscopic view and lay the basis for its superiority over the microscopic view during brain surgery. Notwithstanding, the fully endoscopic or endoscope-controlled version of the supraorbital keyhole approach is not routinely practiced by neurosurgeons, with few series published so far. In this chapter we elaborate on the surgical technique and nuances of the fully endoscopic supraorbital approach for anterior cranial base meningiomas. METHODS From a prospective database of endoscopic procedures maintained by the senior author, clinical data, imaging studies, operative charts, and videos of cases undergoing fully endoscopic excision of anterior cranial base meningiomas via supraorbital approach were retrieved and analyzed. The pertinent literature was also reviewed. RESULTS The surgical technique of the fully endoscopic supraorbital approach for anterior cranial base meningiomas was formulated. CONCLUSION The fully endoscopic supraorbital approach for anterior cranial base meningiomas has many advantages over the conventional procedures. In our hands, the technique has proven to be feasible, efficient, and minimally invasive with excellent results.
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Affiliation(s)
| | - Mustafa Najibullah
- Neurosurgery Department, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait City, Kuwait
| | - Zafdam Shabbir
- Neurosurgery Department, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait City, Kuwait
| | - Fatemah Alali
- Neurosurgery Department, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait City, Kuwait
| | - Waleed Yousef
- Neurosurgery Department, Ibn Sina Hospital, Al-Sabah Medical Area, Kuwait City, Kuwait
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16
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Magill ST, Schwartz TH, Couldwell WT, Gardner PA, Heilman CB, Sen C, Akagami R, Cappabianca P, Prevedello DM, McDermott MW. International Tuberculum Sellae Meningioma Study: Surgical Outcomes and Management Trends. Neurosurgery 2023; 93:1259-1270. [PMID: 37389475 DOI: 10.1227/neu.0000000000002569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/25/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Tuberculum sellae meningiomas (TSMs) can be resected through transcranial (TCA) or expanded endonasal approach (EEA). The objective of this study was to report TSM management trends and outcomes in a large multicenter cohort. METHODS This is a 40-site retrospective study using standard statistical methods. RESULTS In 947 cases, TCA was used 66.4% and EEA 33.6%. The median maximum diameter was 2.5 cm for TCA and 2.1 cm for EEA ( P < .0001). The median follow-up was 26 months. Gross total resection (GTR) was achieved in 70.2% and did not differ between EEA and TCA ( P = .5395). Vision was the same or better in 87.5%. Vision improved in 73.0% of EEA patients with preoperative visual deficits compared with 57.1% of TCA patients ( P < .0001). On multivariate analysis, a TCA (odds ratio [OR] 1.78, P = .0258) was associated with vision worsening, while GTR was protective (OR 0.37, P < .0001). GTR decreased with increased diameter (OR: 0.80 per cm, P = .0036) and preoperative visual deficits (OR 0.56, P = .0075). Mortality was 0.5%. Complications occurred in 23.9%. New unilateral or bilateral blindness occurred in 3.3% and 0.4%, respectively. The cerebrospinal fluid leak rate was 17.3% for EEA and 2.2% for TCA (OR 9.1, P < .0001). The recurrence rate was 10.9% (n = 103). Longer follow-up (OR 1.01 per month, P < .0001), World Health Organization II/III (OR 2.20, P = .0262), and GTR (OR: 0.33, P < .0001) were associated with recurrence. The recurrence rate after GTR was lower after EEA compared with TCA (OR 0.33, P = .0027). CONCLUSION EEA for appropriately selected TSM may lead to better visual outcomes and decreased recurrence rates after GTR, but cerebrospinal fluid leak rates are high, and longer follow-up is needed. Tumors were smaller in the EEA group, and follow-up was shorter, reflecting selection, and observation bias. Nevertheless, EEA may be superior to TCA for appropriately selected TSM.
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Affiliation(s)
- Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago , Illinois , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Cornell University, New York , New York , USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Carl B Heilman
- Department of Neurological Surgery, Tufts University, Boston , Massachusetts , USA
| | - Chandranath Sen
- Department of Neurological Surgery, New York University, New York , New York , USA
| | - Ryojo Akagami
- Department of Neurological Surgery, University of British Columbia, Vancouver , British Columbia , Canada
| | - Paolo Cappabianca
- Department of Neurological Surgery, Universita degli Studi di Napoli Federico II, Naples , Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus , Ohio , USA
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health South Florida, Miami , Florida , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
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17
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Magill ST, Schwartz TH, Couldwell WT, Gardner PA, Heilman CB, Sen C, Akagami R, Cappabianca P, Prevedello DM, McDermott MW. International Tuberculum Sellae Meningioma Study: Preoperative Grading Scale to Predict Outcomes and Propensity-Matched Outcomes by Endonasal Versus Transcranial Approach. Neurosurgery 2023; 93:1271-1284. [PMID: 37418417 DOI: 10.1227/neu.0000000000002581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/26/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Tuberculum sellae meningiomas are resected via an expanded endonasal (EEA) or transcranial approach (TCA). Which approach provides superior outcomes is debated. The Magill-McDermott (M-M) grading scale evaluating tumor size, optic canal invasion, and arterial involvement remains to be validated for outcome prediction. The objective of this study was to validate the M-M scale for predicting visual outcome, extent of resection (EOR), and recurrence, and to use propensity matching by M-M scale to determine whether visual outcome, EOR, or recurrence differ between EEA and TCA. METHODS Forty-site retrospective study of 947 patients undergoing tuberculum sellae meningiomas resection. Standard statistical methods and propensity matching were used. RESULTS The M-M scale predicted visual worsening (odds ratio [OR]/point: 1.22, 95% CI: 1.02-1.46, P = .0271) and gross total resection (GTR) (OR/point: 0.71, 95% CI: 0.62-0.81, P < .0001), but not recurrence ( P = .4695). The scale was simplified and validated in an independent cohort for predicting visual worsening (OR/point: 2.34, 95% CI: 1.33-4.14, P = .0032) and GTR (OR/point: 0.73, 95% CI: 0.57-0.93, P = .0127), but not recurrence ( P = .2572). In propensity-matched samples, there was no difference in visual worsening ( P = .8757) or recurrence ( P = .5678) between TCA and EEA, but GTR was more likely with TCA (OR: 1.49, 95% CI: 1.02-2.18, P = .0409). Matched patients with preoperative visual deficits who had an EEA were more likely to have visual improvement than those undergoing TCA (72.9% vs 58.4%, P = .0010) with equal rates of visual worsening (EEA 8.0% vs TCA 8.6%, P = .8018). CONCLUSION The refined M-M scale predicts visual worsening and EOR preoperatively. Preoperative visual deficits are more likely to improve after EEA; however, individual tumor features must be considered during nuanced approach selection by experienced neurosurgeons.
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Affiliation(s)
- Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago , Illinois , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Cornell University, New York , New York , USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Carl B Heilman
- Department of Neurological Surgery, Tufts University, Boston , Massachusetts , USA
| | - Chandranath Sen
- Department of Neurological Surgery, New York University, New York , New York , USA
| | - Ryojo Akagami
- Department of Neurological Surgery, University of British Columbia, Vancouver , British Columbia , Canada
| | - Paolo Cappabianca
- Department of Neurological Surgery, Universita degli Studi di Napoli Federico II, Naples , Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus , Ohio , USA
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health South Florida, Miami , Florida , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
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18
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Ali A, Morris JM, Decker SJ, Huang YH, Wake N, Rybicki FJ, Ballard DH. Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: neurosurgical and otolaryngologic conditions. 3D Print Med 2023; 9:33. [PMID: 38008795 PMCID: PMC10680204 DOI: 10.1186/s41205-023-00192-w] [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: 09/11/2023] [Accepted: 10/03/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND Medical three dimensional (3D) printing is performed for neurosurgical and otolaryngologic conditions, but without evidence-based guidance on clinical appropriateness. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness recommendations for neurologic 3D printing conditions. METHODS A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with neurologic and otolaryngologic conditions. Each study was vetted by the authors and strength of evidence was assessed according to published guidelines. RESULTS Evidence-based recommendations for when 3D printing is appropriate are provided for diseases of the calvaria and skull base, brain tumors and cerebrovascular disease. Recommendations are provided in accordance with strength of evidence of publications corresponding to each neurologic condition combined with expert opinion from members of the 3D printing SIG. CONCLUSIONS This consensus guidance document, created by the members of the 3D printing SIG, provides a reference for clinical standards of 3D printing for neurologic conditions.
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Affiliation(s)
- Arafat Ali
- Department of Radiology, Henry Ford Health, Detroit, MI, USA
| | | | - Summer J Decker
- Division of Imaging Research and Applied Anatomy, Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Yu-Hui Huang
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Nicole Wake
- Department of Research and Scientific Affairs, GE HealthCare, New York, NY, USA
- Center for Advanced Imaging Innovation and Research, Department of Radiology, NYU Langone Health, New York, NY, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, USA.
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19
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Cavallo LM, Solari D, d'Avella E, Colangelo M, Cappabianca P. Endoscopic Endonasal Approach for Tuberculum Sellae Meningioma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e273. [PMID: 37846141 DOI: 10.1227/ons.0000000000000746] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/14/2023] [Indexed: 10/18/2023] Open
Abstract
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE Ideal indications for tuberculum sellae meningiomas (TSM) removal through endoscopic endonasal approach (EEA) are midline tumors (<3.5 cm), possibly with no optic canal invasion and no vessels encasement. The EEA is favored by a wide tuberculm sellae (TS) angle and a deep sella at the sphenoid sinus (SS). 1 Adequate removal of paranasal structures provides a wider surgical corridor ensuring exposure at the suprasellar area and safe instruments manuevrability. 2. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT The endoscopic transtuberculum transplanum approach allows for wide suprasellar intradural exposure. 3 Removal of the supraoptic recess (SOR) provides further lateral extension over the planum sphenoidale (PS) and proper management of dural involvement at the optic canal. 4. ESSENTIAL STEPS OF THE PROCEDURE The patients have consented to the procedure. Bone removal starts at the upper sella and TS and is extended anteriorly over the PS and laterally, upon needs, at the SORs. On dural opening, tumor devascularization, dedressing, debulking, and dissection are run. Skull base reconstruction is performed using the 3F technique. 5. PITFALLS/AVOIDANCE OF COMPLICATIONS In those cases with vessel encasement, possibility of achieving total resection has to be balanced with risk of vascular injury. 6 Optic canal dural invasion precludes tumor total removal; however, bony decompression is maximal using the EEA. Concerning postoperative cerebrospinal fluid fistula, nowadays the rates have dropped to <2%. VARIANTS AND INDICATIONS FOR THEIR USE A wider skull base osteodural opening allows for the removal of selected meningiomas extending to the PS and cribriform plate.
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Affiliation(s)
- Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, University of Napoli "Federico II," Naples, Italy
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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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21
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Hannan CJ, Kewlani B, Browne S, Javadpour M. Multi-layered repair of high-flow CSF fistulae following endoscopic skull base surgery without nasal packing or lumbar drains: technical refinements to optimise outcome. Acta Neurochir (Wien) 2023; 165:2299-2307. [PMID: 37074392 PMCID: PMC10409672 DOI: 10.1007/s00701-023-05581-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
AIMS Post-operative CSF leak remains a significant problem following endoscopic skull base surgery, particularly when there is a high-flow intra-operative CSF leak. Most skull base repair techniques are accompanied by the insertion of a lumbar drain and/or the use of nasal packing which have significant shortcomings. Our aim was to review the results of a large series of endoscopic skull base cases where a high-flow intra-operative CSF leak rate was encountered and repaired to assess if modifications in technique could reduce the post-operative CSF leak rate. METHODS A retrospective review of a prospectively maintained database of skull base cases performed by a single surgeon over a 10-year period was performed. Data regarding patient demographics, underlying pathology, skull base repair techniques and post-operative complications were analysed. RESULTS One hundred forty-two cases with high-flow intra-operative CSF leak were included in the study. The most common pathologies were craniopharyngiomas (55/142, 39%), pituitary adenomas (34/142, 24%) and meningiomas (24/142, 17%). The CSF leak rate was 7/36 (19%) when a non-standardised skull base repair technique was used. However, with the adoption of a standardised, multi-layer repair technique, the post-operative CSF leak rate decreased significantly (4/106, 4% vs. 7/36, 19%, p = 0.006). This improvement in the rate of post-operative CSF leak was achieved without nasal packing or lumbar drains. CONCLUSION With iterative modifications to a multi-layered closure technique for high-flow intra-operative CSF leaks, it is possible to obtain a very low rate of post-operative CSF leak, without lumbar drains or nasal packing.
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Affiliation(s)
| | - Bharti Kewlani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Steven Browne
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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22
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Rawanduzy CA, Couldwell WT. History, Current Techniques, and Future Prospects of Surgery to the Sellar and Parasellar Region. Cancers (Basel) 2023; 15:cancers15112896. [PMID: 37296858 DOI: 10.3390/cancers15112896] [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: 03/24/2023] [Revised: 04/27/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
The sellar and parasellar region can be affected by diverse pathologies. The deep-seated location and surrounding critical neurovascular structures make treatment challenging; there is no singular, optimal approach for management. The history and development of transcranial and transsphenoidal approaches by pioneers in skull base surgery were largely aimed at treating pituitary adenomas, which are the most common lesions of the sella. This review explores the history of sellar surgery, the most commonly used approaches today, and future considerations for surgery of the sellar/parasellar region.
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Affiliation(s)
- Cameron A Rawanduzy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA
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Feng Z, Li C, Cao L, Liu C, Qiao N, Wu W, Ma G, Gui S. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal approach resection of tuberculum sellae meningiomas: a single-institution study. Front Neurol 2023; 14:1139968. [PMID: 37260603 PMCID: PMC10228730 DOI: 10.3389/fneur.2023.1139968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/20/2023] [Indexed: 06/02/2023] Open
Abstract
Background Traditionally, supratentorial craniotomy has been used to sever tuberculum sellae meningiomas (TSMs), but there has been a remarkably increasing tendency of extended endoscopic endonasal approach (EEEA) used to treat TSMs in the recent decade. Several documents have described the advantages and disadvantages of both approaches, but there is no consensus on whether one is superior to the other. Objective This study aimed to compare surgical outcomes between craniotomy and EEEA for TSMS treated at our institution. Methods From January 2015 to December 2021, a total of 84 cases of TSMs were included in this study. Cases were separated into two groups: the craniotomy group and the EEEA group. Their anamneses and surgical records were reviewed. Demographic data, presenting symptoms, tumor volume, extent of resection, visual outcomes, and follow-up data were tabulated. The Kaplan-Meier curves were constructed for the PFS for both cohorts. Results Complete data were available for 84 surgeries; 39 cases were treated via craniotomy, and 45 were treated via EEEA. Patient demographic data, pre-operative symptoms, and tumor characteristics were similar between the two cohorts. The extent of resection was similar between the two groups (GTR: 91.11% EEEA vs. 87.18% craniotomy; STR 8.89 vs. 12.82%, p = 0.91). There was no difference in visual outcomes between both groups (92.1 vs. 84.84%, p = 0.46). An increased rate of cranial nerve injury was noted in the craniotomy group (0 vs. 10.25%, p = 0.04). Post-operative CSF leak rate occurred in one patient in the EEEA group. The PFS curves (p = 0.52) and recurrence/progression rates (13.33 vs. 20.51%, p = 0.39) were similar between the two groups. Conclusion Both EEEA and craniotomy can successfully sever TSMs. The recurrence/progression rate and PFS appear to be similar between the two groups. Although there are no differences in EOR and visual outcomes between the two groups, there was a clear trend in the EEEA group to obtain a better outcome. CSF leakage was common in the EEEA cohort, whereas the rate of cranial nerve injury was found to be higher in the craniotomy cohort. We believe that our data support the conclusion that EEEA surgery is the preferred approach for the removal of TSMs.
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Affiliation(s)
- Zhenguang Feng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Tianjin First Central Hospital, Tianjin, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunhui Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Qiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wentao Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guofo Ma
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Bove I, Cheok S, Ruzevick JJ, Zada G. Endoscopic Endonasal and Keyhole Surgery for Skull Base Meningiomas. Neurosurg Clin N Am 2023; 34:393-402. [DOI: 10.1016/j.nec.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Kim YJ, Moon KS, Jang WY, Jung TY, Kim IY, Jung S. Contralateral subfrontal approach for tuberculum sellae meningioma: techniques and clinical outcomes. J Neurosurg 2023; 138:598-609. [PMID: 35901684 DOI: 10.3171/2022.5.jns212899] [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: 12/20/2021] [Accepted: 05/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tuberculum sellae meningiomas (TSMs) present a burdensome surgical challenge because of their adjacency to vital neurovascular structures. The contralateral subfrontal approach provides an outstanding corridor for removing a TSM with an excellent visual outcome and limited complications. The authors present their long-term surgical experience in treating TSMs via the contralateral subfrontal approach and discuss patient selection, surgical techniques, and clinical outcomes. METHODS Between 2005 and 2021, the authors used the contralateral subfrontal approach in 74 consecutive patients presenting with TSMs. The surgical decision-making process and surgical techniques are described, and the clinical outcomes were retrospectively analyzed. RESULTS The mean patient age was 54.4 years, with a female predominance (n = 61, 82%). Preoperatively, 61 patients (82%) had vision symptoms and 73 (99%) had optic canal invasion by tumor. Gross-total resection was achieved in almost all patients (n = 70, 95%). The visual function improvement and stabilization rate was 91% (67/74). Eight patients (11%) showed a worsening of visual function on the less-compromised (approach-side) optic nerve. There was no occurrence of cerebrospinal fluid leakage. Four patients (5%) experienced recurrences after the initial operation (mean follow-up duration 63 months). There were no deaths in this study. CONCLUSIONS The contralateral subfrontal approach provides a high chance of complete tumor removal and visual improvement with limited complications and recurrences, especially when the tumor is in a unilateral or midline location causing unilateral visual symptoms or bilateral asymmetrical visual symptoms, regardless of tumor size or encasement of major vessels. With the appropriate patient selection, surgical technique, and familiarity with surrounding neurovascular structures, this approach is reliable for TSM surgery.
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Affiliation(s)
- Yeong Jin Kim
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Science, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Jeollanam-do, South Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Science, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Jeollanam-do, South Korea
| | - Woo-Youl Jang
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Science, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Jeollanam-do, South Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Science, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Jeollanam-do, South Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Science, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Jeollanam-do, South Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Science, Chonnam National University Hwasun Hospital & Medical School, Hwasun, Jeollanam-do, South Korea
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Westphal M, Saladino A, Tatagiba M. Skull Base Meningiomas. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1416:47-68. [PMID: 37432619 DOI: 10.1007/978-3-031-29750-2_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Skull base meningiomas are among the most challenging meningiomas to treat clinically due to their deep location, involvement or encasement of adjacent essential neurovascular structures (such as key arteries, cranial nerves, veins, and venous sinuses), and their often-large size prior to diagnosis. Although multimodal treatment strategies continue to evolve with advances in stereotactic and fractionated radiotherapy, surgical resection remains the mainstay of treatment for these tumors. Resection of these tumors however is challenging from a technical standpoint, and requires expertise in several skull-base surgical approaches that rely on adequate bony removal, minimization of brain retraction, and respect for nearby neurovascular structures. These skull base meningiomas originate from a variety of different structures including, but are not limited to: the clinoid processes, tuberculum sellae, dorsum sellae, sphenoid wing, petrous/petroclival area, falcotentorial region, cerebellopontine angle, and foramen magnum. In this chapter, we will cover the common anatomical areas in the skull base from which these tumors arise, and the specific or optimal surgical approaches and other treatment modalities for meningiomas in these such locations.
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Affiliation(s)
- Manfred Westphal
- Department of Neurological Surgery, UK Eppendorf, Hamburg, Germany.
| | - Andrea Saladino
- Department of Neurological Surgery, IRCCS Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
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27
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Silvestri M, Signorelli F, Rapisarda A, D'Onofrio GF, Visocchi M. Tuberculum Sellae Meningioma: Report of Two Cases and Literature Review of Limits of the Transcranial and Endonasal Endoscopic Approaches. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:75-79. [PMID: 38153452 DOI: 10.1007/978-3-031-36084-8_13] [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: 12/29/2023]
Abstract
BACKGROUND Tuberculum sellae (TS) meningioma is one of the most frequent meningiomas of the anterior skull base. Herein we perform a review of the literature concerning the preferred surgical approaches to TS meningiomas; in addition, we describe two explicative cases, operated on by our group using different approaches, with the aim to critically revise surgical indications and contraindications. METHODS In October 2021, two female patients with tuberculum sellae meningioma were treated at the Policlinico Gemelli of Rome. The patients presented with visual deterioration. Surgery was performed using the fronto-temporal approach and transsphenoidal approach. The visual function before and after surgery was evaluated as the main outcome parameter of the surgical treatment of these tumors. CONCLUSIONS Tuberculum sellae meningioma can be safely resected using the transcranial approach and the transsphenoidal endoscopic approach with preservation and even improvement of visual function after surgery. The relationship of the tumor with the optic nerves, optic canal, and anterior cerebral artery complex are important issues that have to be considered when dealing with tuberculum sellae meningioma. Both transcranial and endonasal approaches, in experienced hands, can allow complete resection of the lesion.
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Affiliation(s)
- Martina Silvestri
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Alessandro Rapisarda
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Ginevra Federica D'Onofrio
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
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Parikh KP, Motiwala M, Beer-Furlan A, Michael LM, Rangarajan SV, Choby GW, Kshettry VR, Saleh S, Mukherjee D, Kirsch C, McKean E, Sorenson JM. Skull Base Registries: A Roadmap. J Neurol Surg B Skull Base 2022; 83:561-578. [PMID: 36393883 PMCID: PMC9653294 DOI: 10.1055/a-1934-9191] [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: 08/13/2022] [Accepted: 08/29/2022] [Indexed: 01/17/2023] Open
Abstract
Hospitals, payors, and patients increasingly expect us to report our outcomes in more detail and to justify our treatment decisions and costs. Although there are many stakeholders in surgical outcomes, physicians must take the lead role in defining how outcomes are assessed. Skull base lesions interact with surrounding anatomy to produce a complex spectrum of presentations and surgical challenges, requiring a wide variety of surgical approaches. Moreover, many skull base lesions are relatively rare. These factors and others often preclude the use of prospective randomized clinical trials, thus necessitating alternate methods of scientific inquiry. In this paper, we propose a roadmap for implementing a skull base registry, along with expected benefits and challenges.
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Affiliation(s)
- Kara P. Parikh
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Mustafa Motiwala
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Andre Beer-Furlan
- Department of Neurosurgery, Moffitt Cancer Center, Tampa, Florida, United States
| | - L. Madison Michael
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Sanjeet V. Rangarajan
- Department of Otolaryngology-Head and Neck Surgery, The University of Tennessee Health Science Center College of Medicine Memphis, Memphis, Tennessee, United States
| | - Garret W. Choby
- Department of Otorhinolaryngology, Mayo Clinic Rochester, Rochester, Minnesota, United States
| | - Varun R. Kshettry
- Brain Tumor and Neuro-Oncology Center Cleveland Clinic, Cleveland, Ohio, United States
| | - Sara Saleh
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, United States
| | - Claudia Kirsch
- Yale University School of Medicine Department of Radiology and Biomedical Imaging, New Haven, Connecticut, United States
- Department of Clinical Dentistry, University of Sheffield, Sheffield, South Yorkshire, England
- Mount Sinai Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Erin McKean
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
- Department of Otolaryngology–Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Jeffrey M. Sorenson
- Department of Neurosurgery, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, United States
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29
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Roa Montes de Oca JC, Gonçalves Estella JM, Nieto-Librero AB, Galindo-Villardón P, Roa Ramírez CJ, Gonçalves Sánchez J, Berhouma M, Cornelius JF, Daniel RT, Zazpe I, Froelich S, Jouanneau E, Mazzatenta D, Messerer M, Meling T, Paraskevopoulos D, Roche PH, Schroeder HWS, Tatagiba M, Visocchi M, Voormolen E, Ekkehard K, Bruneau M. Olfactory Groove Meningiomas: Comprehensive assessment between the different microsurgical transcranial approaches and the Endoscopic Endonasal Approaches, systematic review and metanalysis on behalf of the EANS skull base section. BRAIN & SPINE 2022; 2:101661. [PMID: 36605386 PMCID: PMC9808463 DOI: 10.1016/j.bas.2022.101661] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/23/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
•OGM surgery is much more complex than a simple debate of "from above or from below" (transcranial vs endoscopic).•Lateral Sub-frontal and Superior Interhemispheric seem the most effective, superior and versatile approaches for OGM.•Minimally Invasive Transcranial approaches showed no inferiority in OGM sized <4 cm.•Endoscopic Endonasal Approaches showed inferior results in surgical and in functional outcomes for OGM.
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Affiliation(s)
- Juan Carlos Roa Montes de Oca
- Department of Neurosurgery, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Department of Surgery - Neurosurgery, Universidad de Salamanca. Facultad de Medicina, Salamanca, Spain
- Policlínica San Javier, Telemedicine Neurosurgery Consultant, Barquisimeto, Venezuela
- Centro de Enseñanza e Investigación del Ultrasonido en Medicina (CEIUM), Barquisimeto, Venezuela
| | - Jesús María Gonçalves Estella
- Department of Neurosurgery, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
- Department of Surgery - Neurosurgery, Universidad de Salamanca. Facultad de Medicina, Salamanca, Spain
| | | | - Purificación Galindo-Villardón
- Department of Statistics, Universidad de Salamanca, Salamanca, Spain
- Centro de Investigación Institucional (CII). Universidad Bernardo O’Higgins, Av. Viel 1497, Santiago, Chile
| | - Carlos Julio Roa Ramírez
- Department of Neuroradiology. Policlinica San Javier, Barquisimeto, Venezuela
- Centro de Enseñanza e Investigación del Ultrasonido en Medicina (CEIUM), Barquisimeto, Venezuela
- Centro Docente de Imágenes de Alta Tecnología (CEDIAT), Barquisimeto, Venezuela
| | | | - Moncef Berhouma
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France
| | | | - Roy Thomas Daniel
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital Lausanne, Switzerland
| | - Idoya Zazpe
- Department of Neurosurgery, University Hospital of Navarre, Pamplona, Spain
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - Emmanuel Jouanneau
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Diego Mazzatenta
- Department of Neurosurgery, Neurological Sciences Institut IRCCS, Bologna, Italy
| | - Mahmoud Messerer
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital Lausanne, Switzerland
| | - Torstein Meling
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | - Dimitrios Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartolomew’s and the Royal London Hospital, Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - Pierre-Hugues Roche
- Department of Neurosurgery, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - Massimilliano Visocchi
- Department of Neurosurgery, Institute of Neurosurgery Catholic University of Rome, Italy
| | - Eduard Voormolen
- Department of Neurosurgery, University Medical Center Utrecht, Netherlands
| | - Kasper Ekkehard
- Department of Neurosurgery, Steward Medical Group, Brighton, USA
| | - Michaël Bruneau
- Department of Neurosurgery, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Castle-Kirszbaum M, Kam J, Dixon B, Goldschlager T, King J, Wang YY. Surgical outcomes and longitudinal quality of life after endoscopic endonasal surgery for anterior skull base meningioma. J Neurosurg 2022; 137:953-960. [PMID: 35171831 DOI: 10.3171/2021.11.jns212090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to establish the effect of endoscopic endonasal surgery on longitudinal quality of life (QOL) in patients with anterior skull base meningioma. METHODS A prospectively collected cohort of consecutively operated anterior skull base meningiomas was analyzed. All cases were performed using the endoscopic endonasal approach (EEA). Sinonasal-specific and overall QOL were measured using the 22-Item Sinonasal Outcome Test and the Anterior Skull Base Questionnaire longitudinally (at 3 weeks, 6 weeks, and 3, 6, and 12 months) across the first postoperative year. The relationship between surgical and QOL outcomes to clinical and radiological characteristics was analyzed using multivariate regression. RESULTS Fifty cases were available, with a mean age of 61.5 years and female predominance (74.0%). Visual dysfunction and headache were the most common presenting symptoms, and tumors commonly took origin from the planum (46.0%), tuberculum (44.0%), and olfactory groove (24.0%). Median tumor volume was 4.6 cm3. Visual improvement was noted in 73.1% of cases with preoperative field deficits, while nonimprovement was associated with greater tumor height (p = 0.04). Gross-total resection was not possible in patients with 360° vessel encasement and high-grade cavernous sinus extension with ophthalmoplegia. Postoperative diabetes insipidus was observed only in cases with suprasellar extension. Sinonasal-specific QOL worsened transiently after surgery but returned to baseline levels after 3 weeks. Olfaction and taste scores returned to preoperative baseline scores within the year. Overall QOL at presentation was worse in those with larger tumors (p = 0.04) and visual failure (p = 0.04) and better in those presenting with headache (p = 0.04). Transient worsening of QOL was seen in the first 3 weeks, which returned to baseline by 6 weeks, and then improved to above preoperative levels at 6 months and beyond. Worse QOL at baseline (p = 0.01) and visual improvement (p = 0.01) predicted QOL improvement after surgery. CONCLUSIONS Longitudinal QOL in anterior skull base meningioma has been examined for the first time. Endoscopic endonasal surgery improves overall QOL after a transient 3-week worsening due to the sinonasal morbidity of the approach. Visual function is intimately tied to QOL, with worse vision associated with worse preoperative QOL, and QOL improving in parallel with visual restoration after surgery. The EEA is associated with better visual outcomes and should be the preferred approach in accessible tumors.
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Affiliation(s)
| | - Jeremy Kam
- 1Department of Neurosurgery, Monash Health
| | | | - Tony Goldschlager
- 1Department of Neurosurgery, Monash Health
- 3Department of Surgery, Monash University; and
| | - James King
- 4Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
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Zheng X, Shao D, Li Y, Cai L, Xie S, Sun Z, Jiang Z. Keyhole supraorbital eyebrow approach for fully endoscopic resection of tuberculum sellae meningioma. Front Surg 2022; 9:971063. [PMID: 36157417 PMCID: PMC9491022 DOI: 10.3389/fsurg.2022.971063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022] Open
Abstract
Background The fully endoscopic supraorbital trans-eyebrow keyhole approach is a technique utilized for the transcranial resection of tuberculum sellae meningioma (TSM). Surgery is the first choice for TSM treatment. This study aimed to summarize and analyze the safety, feasibility, limitations, and technical requirements of the fully endoscopic supraorbital trans-eyebrow keyhole approach for TSM resection. Methods Data of 19 TSM fully endoscopic supraorbital trans-eyebrow keyhole approach resections cases (six and 13 on the left and right eyebrows, respectively) were retrospectively analyzed at the Neurosurgery Department of the First Affiliated Hospital of Bengbu Medical College (Bengbu, China) from August 2015 to March 2022. Results All 19 patients were diagnosed with meningioma (World Health Organization grade I), and according to the scope of tumor resection (EOR), 18 patients (94.7%) had gross total resection (GTR), and one patient (5.3%) had near-total resection (NTR). Preoperative chief complaints were symptomatic visual dysfunction (n = 12), headache and dizziness (n = 6), and accidental discovery (n = 1). Postoperative visual function improved in 83.3% of cases (10/12), and headache and dizziness were relieved in 83.3% of cases (5/6 patients). Postoperative intracranial infection occurred in one case and was cured by external drainage of the lumbar cistern and anti-infective treatment. Two cases of frontal lobe injury were discharged after conservative treatment. There was no postoperative olfactory dysfunction, eyelid ptosis, cerebrospinal fluid leakage, or death. There were no reports of disease recurrence or death during the 3-month follow-up at an outpatient clinic or by telephone. Conclusion Fully endoscopic TSM resection through the keyhole approach is safe and feasible. It can be used to explore angles that cannot be seen under a microscope and show the true value of endoscopy technology. The endoscopic equipment and technical skills of the surgeon and surgical team are important in this technique.
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Affiliation(s)
- Xialin Zheng
- School of Continuing Education, Anhui Medical University, Hefei, China
- Department of Neurosurgery, The First Affliated Hospital of Bengbu Medical College, Bengbu, China
| | - Dongqi Shao
- Department of Neurosurgery, The First Affliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yu Li
- Department of Neurosurgery, The First Affliated Hospital of Bengbu Medical College, Bengbu, China
| | - Longjie Cai
- Department of Neurosurgery, The First Affliated Hospital of Bengbu Medical College, Bengbu, China
| | - Shan Xie
- Department of Neurosurgery, The First Affliated Hospital of Bengbu Medical College, Bengbu, China
| | - Zhixiang Sun
- Department of Neurosurgery, The First Affliated Hospital of Bengbu Medical College, Bengbu, China
| | - Zhiquan Jiang
- School of Continuing Education, Anhui Medical University, Hefei, China
- Department of Neurosurgery, The First Affliated Hospital of Bengbu Medical College, Bengbu, China
- Correspondence: Zhiquan Jiang
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Li Y, Zhang C, Su J, Qin C, Wang X, Li Y, Liu Q. Individualized surgical treatment of giant tuberculum sellae meningioma: Unilateral subfrontal approach vs. endoscopic transsphenoidal approach. Front Surg 2022; 9:990646. [PMID: 36743895 PMCID: PMC9890549 DOI: 10.3389/fsurg.2022.990646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 08/03/2022] [Indexed: 01/19/2023] Open
Abstract
Objective Giant tuberculum sellae meningiomas (TSMs) are deeply located in the suprasellar region and extensively compressed or encased in the surrounding neurovascular structures, making gross total resection (GTR) without postoperative visual impairment challenging. The authors presented individualized unilateral subfrontal approach and endoscopic transsphenoidal approach (ETSA) in a series of patients and elaborated on their advantages and indications in resecting giant TSMs. Methods A total of 38 patients with giant TSMs operated by a single surgeon between March 2012 and November 2021 were retrospectively reviewed. Patients underwent unilateral subfrontal approach and ETSA according to preoperative imaging characteristics. Tumor characteristics, surgical details, preoperative symptoms, and neurological outcomes of TSMs patients were collected and analyzed. Results In 31 patients operated with the unilateral subfrontal approach, total resection (Simpson grade I or II) was achieved in 27 patients (87.0%), while 6 patients (85.7%) achieved GTR in 7 patients using ETSA. The postoperative visual improvement was maintained in 22 (81.5%) and 5 patients (83.3%). Recurrence or progression was only observed in 2 (7.4%) patients operated with the unilateral subfrontal approach. There was no mortality in our series. Conclusions Preoperative imaging and visual function are important for surgical approach selection. Maximum tumor resection and optic nerve protection can be achieved concurrently by taking advantage of these surgical approaches. The cerebral artery protection strategies and individualized surgical techniques provide great utility in improving a patient's quality of life.
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Affiliation(s)
- Yang Li
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Chao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Jun Su
- Department of Neurosurgery, Hunan Children’s Hospital, Changsha, China
| | - Chaoying Qin
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Xiangyu Wang
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Yue Li
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Qing Liu
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China,Correspondence: Qing Liu
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Henderson F, Youngerman BE, Niogi SN, Alexander T, Tabaee A, Kacker A, Anand VK, Schwartz TH. Endonasal transsphenoidal surgery for planum sphenoidale versus tuberculum sellae meningiomas. J Neurosurg 2022; 138:1338-1346. [PMID: 36461840 DOI: 10.3171/2022.8.jns22632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The aim of this study was to determine if the distinction between planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas is clinically meaningful and impacts the results of the endoscopic endonasal approach (EEA).
METHODS
A consecutive series of patients who were 18 years of age or older and underwent EEA for newly diagnosed grade I PS meningiomas (PSMs) and TS meningiomas (TSMs) between October 2007 and May 2021 were included. The PS and TS were distinguished by drawing a line passing through the center of the TS and perpendicular to the PS on postcontrast T1-weighted MRI. Probabilistic heatmaps were created to display the actual distribution of tumor volumes. Tumor volume, extent of resection (EOR), visual outcome, and complications were assessed.
RESULTS
The 47 tumors were distributed in a smooth continuum. Using an arbitrary definition, 24 (51%) were PSMs and 23 (49%) were TSMs. The mean volume of PSMs was 5.6 cm3 compared with 4.5 cm3 for TSMs. Canal invasion was present in 87.5% of PSMs and 52% of TSMs. GTR was achieved in 38 (84%) of 45 cases in which it was the goal, slightly less frequently for PSMs (78%) compared with TSMs (91%), although the difference was not significant. Th mean EOR was 99% ± 2% for PSMs and 98% ± 11% for TSMs. Neither the suprasellar notch angle nor the percentage of tumor above the PS impacted the rate of GTR. After a median follow-up of 28.5 months (range 0.1–131 months), there were 2 (5%) recurrences after GTR (n = 38) both of which occurred in patients with PSMs. Forty-two (89%) patients presented with preoperative impaired vision. Postoperative vision was stable or improved in 96% of patients with PSMs and 91% of patients with TSMs. CSF leakage occurred in 4 (16.6%) patients with a PSM, which resolved with only lumbar drainage, and in 1 (4.3%) patient with a TSM, which required reoperation.
CONCLUSIONS
PSM and TSMs arise in a smooth distribution, making the distinction arbitrary. Those classified as PSMs were larger and more likely to invade the optic canals. Surgical outcome for both locations was similar, slightly favoring TSMs. The arbitrary distinction between PSMs and TSMs is less useful at predicting outcome than the lateral extent of the tumor, regardless of the site of origin.
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Affiliation(s)
| | - Brett E. Youngerman
- Department of Neurosurgery, Columbia University Medicine, NewYork-Presbyterian Hospital, New York, New York; and
| | | | - Tyler Alexander
- Thomas Jefferson University, School of Medicine, Philadelphia, Pennsylvania
| | - Abtin Tabaee
- Otolaryngology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | - Ashutosh Kacker
- Otolaryngology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | - Vijay K. Anand
- Otolaryngology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
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Qian K, Nie C, Zhu W, Zhao H, Zhang F, Wang H, Jiang X. Surgical management of tuberculum sellae meningioma: Transcranial approach or endoscopic endonasal approach? Front Surg 2022; 9:979940. [PMID: 36117830 PMCID: PMC9470762 DOI: 10.3389/fsurg.2022.979940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Tuberculum sellae meningioma (TSM), a common benign tumor in the sellae region, usually causes neurological deficits, such as vision impairment, by squeezing the peripheral neurovascular structures. Surgical management is recommended as the optimal strategy for TSM treatment and vision restoration. However, it remains challenging to resect TSM in the traditional transcranial approach (TCA). Recently, the endoscopic endonasal approach (EEA) has emerged as an effective option in skull base surgeries. Besides the effectivity, the advantages and limitations of EEA in TSM surgery remain controversial. Object We compared the surgical outcomes and complications between TCA and EEA surgeries to identify the principles in TSM surgical management. Methods Retrospective analysis was performed on the patients, who underwent TSM surgery in Wuhan Union Hospital between January 2017 and December 2021. The patients were assigned to TCA or EEA group according to the surgery they experienced. All patients were analyzed with the extent of tumor resection, vision outcome, postoperative complications, and follow-up results. Results A total of 112 patients were enrolled in this study, including 78 in TCA group and 34 in EEA group. The mean follow-up was 20.5 months (range 3–36 months). There were no statistically significant differences in patient demographic data, preoperative symptoms, and tumor characteristics between TCA and EEA groups. Both TCA and EEA surgeries are effective in TSM resection with relatively high gross total resection rates (85.9% in TCA vs. 91.2% in EEA, p > .05). Meanwhile, EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery (74.6% in TCA vs. 93.1% in EEA, p < .05). Whereas EEA surgery causes more occurrences of cerebrospinal fluid (CSF) leakage than TCA surgery (0% in TCA vs. 11.8% in EEA, p < .05). Conclusion Both TCA and EEA surgeries are effective in TSM resection. EEA surgery has a better outcome in vision restoration or stabilization than TCA surgery, but induces higher risk of CSF leakage. As each approach has unique advantages and limitations, we must take all aspects into consideration, including approach feathers, tumor characteristics, and clinical requirements, to make the optimal choice in TSM surgical management.
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Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives. Cancers (Basel) 2022; 14:cancers14122878. [PMID: 35740543 PMCID: PMC9220797 DOI: 10.3390/cancers14122878] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/25/2022] [Accepted: 06/03/2022] [Indexed: 12/07/2022] Open
Abstract
Simple Summary Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. Over time, several corridors have been proposed, each one carrying its own pros and cons. During the last decades, the endoscopic endonasal route has been asserted among the classic routes for a growing number of midline and paramedian lesions. Therefore, the aim of our paper is to present a comprehensive review of the indications and techniques for the management of skull base meningiomas, emphasizing the ambivalent and complementary role of the low and high routes. Abstract Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection.
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Kachhara R, Nigam P, Nair S. Tuberculum Sella Meningioma: Surgical Management and Results with Emphasis on Visual Outcome. J Neurosci Rural Pract 2022; 13:431-440. [PMID: 35945998 PMCID: PMC9357473 DOI: 10.1055/s-0042-1745817] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background
Tuberculum sella meningioma form a distinct surgical entity with significant morbidity for the patient due to early and profound visual involvement. Surgical treatment of tuberculum sella meningioma is challenging in view of the proximity of vital neuro-vasculature. These lesions may be approached via a high-route (trans-cranial) or a low-route (trans-sphenoidal).
Materials and Methods
The authors present a consecutive series of 36 patients, operated by the first author from 1996 onward, with an analysis of clinical presentation (emphasizing visual deterioration), imaging features, operative approaches, and outcome with postoperative visual status.
Results
There were 36 patients (72 eyes) in the series, 75% females and 25% males. The mean age of patients was 48.05 ± 10.02 years. In all, 88.89% had visual diminution, 50% had headache, 5.56% had behavioral changes, and 2.78% had seizures. The mean tumor size was 4.01 ± 1.01 cm. The frontotemporal approach was employed in 66.67% of patients, and all patients underwent a right-sided approach. There was no significant difference between improvement in the vision between the right eye and left eye, despite the fact that right-sided approach was employed in nearly cases.
Conclusion
While tuberculum sella meningioma have profound morbidity in terms of visual deterioration, timely surgical intervention may help patients gain serviceable vision postoperatively. We advocate the trans-cranial approach and find no difference in visual outcomes on employing right-sided approach, regardless of the side with worse vision.
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Affiliation(s)
- Rajneesh Kachhara
- Department of Neurosurgery, Institute of Neurosciences, Medanta Multi-Speciality Hospital, Indore, Madhya Pradesh, India
| | - Pulak Nigam
- Department of Neurosurgery, Institute of Neurosciences, Medanta Multi-Speciality Hospital, Indore, Madhya Pradesh, India
| | - Suresh Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India
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Lubomirsky B, Jenner ZB, Jude MB, Shahlaie K, Assadsangabi R, Ivanovic V. Sellar, suprasellar, and parasellar masses: Imaging features and neurosurgical approaches. Neuroradiol J 2022; 35:269-283. [PMID: 34856828 PMCID: PMC9244752 DOI: 10.1177/19714009211055195] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.
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Affiliation(s)
- Bryan Lubomirsky
- Department of Radiology, Section of
Neuroradiology, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Zachary B Jenner
- Department of Radiology, Diagnostic
and Interventional Radiology Residency, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Morgan B Jude
- School of Medicine, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of
Neuroradiology, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of
Neuroradiology, University of California Davis
Medical Center, Sacramento, CA, USA
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Ved R, Mo M, Hayhurst C. Olfactory Outcomes after Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas via a Transcranial Approach. Skull Base Surg 2022; 83:296-304. [DOI: 10.1055/s-0040-1722671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery.
Study Design A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center.
Participants & Main Outcome Measures All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations).
Results Twenty-two patients were included in the study analysis, (range = 27–76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up.
Conclusion Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately.
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Affiliation(s)
- Ronak Ved
- Department of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
- School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Matthew Mo
- Department of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
- School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
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Comparison and evolution of transcranial versus endoscopic endonasal approaches for suprasellar Meningiomas: A systematic review. J Clin Neurosci 2022; 99:302-310. [DOI: 10.1016/j.jocn.2022.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 12/15/2022]
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Extent of Resection Research in Skull Base Neurosurgery: Previous Studies and Future Directions. World Neurosurg 2022; 161:396-404. [PMID: 35505559 DOI: 10.1016/j.wneu.2021.10.184] [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: 07/08/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 10/18/2022]
Abstract
Surgery is the first-line therapy for most benign and malignant skull base tumors. Extent of resection (EOR) is a metric commonly used for preoperative surgical planning and to predict risk of postoperative tumor recurrence. Therefore, understanding the evidence on EOR in skull base neurosurgery is essential to providing optimal care for each patient. Several studies from the skull base neurosurgery literature have presented investigations of various topics related to EOR, including 1) preoperative EOR scoring systems, 2) intraoperative EOR scoring systems, 3) EOR and tumor recurrence, and 4) EOR and functional outcomes. We propose that future investigations should focus on the following elements to improve EOR research in skull base neurosurgery: 1) multi-institutional collaboratives with treatment propensity matching; 2) expert consensus and mixed-methods study design; and 3) predictive analytics/machine learning. We believe that these methods offer several advantages that have been described in the literature and that they address limitations of previous studies. The aim of this review was to inform future study design and improve the overall quality of subsequent investigations on EOR in skull base neurosurgery.
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Zhao K, Nimchinsky E, Agarwalla PK. Differential Diagnosis and Radiographic Imaging of Pituitary Lesions. Otolaryngol Clin North Am 2022; 55:247-264. [DOI: 10.1016/j.otc.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Cler SJ, Dunn GP, Zipfel GJ, Dacey RG, Chicoine M. A Low Subfrontal Dural Opening for Operative Management of Anterior Skull Base Lesions. J Neurol Surg B Skull Base 2022; 84:201-209. [PMID: 37180868 PMCID: PMC10171938 DOI: 10.1055/a-1774-6281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022] Open
Abstract
Introduction
A low subfrontal dural opening technique that limits brain manipulation was assessed in patients that underwent frontotemporal approaches for anterior fossa lesions.
Methods
A retrospective review was performed for cases using a low subfrontal dural opening including characterization of demographics, lesion size and location, neurological and ophthalmological assessments, clinical course, and imaging findings.
Results
A low subfrontal dural opening was performed in 23 patients (17F, 6M), median age of 53 years (range 23-81) with median follow-up duration of 21.9 months (range 6.2-67.1). Lesions included 22 meningiomas (9 anterior clinoid, 12 tuberculum sellae, and 1 sphenoid wing), 1 unruptured internal carotid artery aneurysm clipped during a meningioma resection, and 1 optic nerve cavernous malformation. Maximal possible resection was achieved in all cases including gross total resection in 16/22 (72.7%), near total in 1/22 (4.5%), and subtotal in 5/22 (22.7%) in which tumor involvement of critical structures limited complete resection. Eighteen patients presented with vision loss; 11 (61%) improved postoperatively, 3 (17%) were stable, and 4 (22%) worsened. The mean ICU stay and time to discharge was 1.3 days (range 0-3) and 3.8 days (range 2-8).
Conclusions
A low subfrontal dural opening for approaches to the anterior fossa can be performed with minimal brain exposure, early visualization of the optico-carotid cistern for cerebrospinal fluid release, minimizing need for fixed brain retraction and Sylvian fissure dissection. This technique can potentially reduce surgical risk and provide excellent exposure for anterior skull base lesions with favorable extent of resection, visual recovery, and complication rates.
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Affiliation(s)
- Samuel J Cler
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Gavin P Dunn
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Gregory J Zipfel
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Ralph G Dacey
- Neurosurgery, Washington University School of Medicine in Saint Louis, St Louis, United States
| | - Michael Chicoine
- Neurosurgery, Washington University in Saint Louis, Saint Louis, United States
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Martinez-Perez R, Kortz MW, Florez-Perdomo W, Ung TH, Youssef AS. Endocrinological outcomes after transcranial resection of tuberculum sellae meningiomas: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1965-1975. [PMID: 35149901 DOI: 10.1007/s10143-022-01744-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/03/2022] [Accepted: 01/19/2022] [Indexed: 11/26/2022]
Abstract
Tuberculum sellae meningiomas (TSMs) arise from the anterior skull base. Endocrine status after TSM resection is an important determinant of quality of life. We sought to better characterize the risk of postoperative endocrinopathy for patients with TSM undergoing open transcranial approach (TCA) microsurgical resection. A systematic review was conducted following MOOSE and PRISMA guidelines. Results were screened against predefined criteria, which included studies evaluating endocrinopathy rates after open transcranial microsurgery for TSM. Outcome incidence was calculated using random-effect meta-analysis of proportions. Eight studies met the inclusion criteria, comprising 406 patients. The average age of the cohort was 52.2 years, and a majority (70%) of the patients were female. The pooled incidence of postoperative transient diabetes insipidus (DI) was 7.5% (95% CI 2.9-12%; p = 0.001; I2 = 75.9%) and permanent DI was 1.6% (95% CI 0.3-2.7%; p = 0.01; I2 = 0%). The pooled rate of postoperative hypopituitarism was 3.6% (95% CI 1.6-5.7%; p < 0.001; I2 = 22.2%), while the incidence of hyperprolactinemia was 1.3% (95% CI 0.1 = 2.6%; p = 0.036; I2 = 8.74%). The incidence of SIADH was 4% in one study but was not included in the meta-analysis. Endocrinopathy after TSM microsurgical resection is rare, but the available studies' poor quality of evidence and inconsistent methodology may reflect that it is underreported in the literature. Nevertheless, clinicians should consider the risk of hormonal impairment and counsel their patients accordingly when selecting a TCA for these lesions.
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Affiliation(s)
- Rafael Martinez-Perez
- Departments of Neurosurgery, Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, 1000 East Mountain Boulevard, Wilkes Barre, PA, 18711, USA.
| | - Michael W Kortz
- Department of Neurological Surgery, University of Colorado, Denver, CO, USA
| | - William Florez-Perdomo
- Department of Medicine, Concejo Latinoamericano de Neurointensivismo-CLaNi, Cartagena, Colombia
| | - Timothy H Ung
- Department of Otolaryngology, University of Colorado, Denver, CO, USA
| | - A Samy Youssef
- Department of Neurological Surgery, University of Colorado, Denver, CO, USA.
- Department of Otolaryngology, University of Colorado, Denver, CO, USA.
- Department of Neurosurgery, University of Colorado School of Medicine, 1635 Aurora Ct, 4th Floor, Denver, CO, 80045, USA.
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Piscopo A, Seaman SC, Beer MA, Torner JC, Greenlee JD. A meta-analysis of proportions of single arm observational series for anterior skull base meningiomas comparing supraorbital craniotomy to the endoscopic endonasal approach. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Surgical management of anterior clinoidal meningiomas: consensus statement on behalf of the EANS skull base section. Acta Neurochir (Wien) 2021; 163:3387-3400. [PMID: 34398339 PMCID: PMC8599327 DOI: 10.1007/s00701-021-04964-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/04/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The optimal management of clinoidal meningiomas (CMs) continues to be debated. METHODS We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of these tumors. The data from the literature along with contemporary practice patterns were discussed within the task force to generate consensual recommendations. RESULTS AND CONCLUSION This article represents the consensus opinion of the task force regarding pre-operative evaluations, patient's counselling, surgical classification, and optimal surgical strategy. Although this analysis yielded only Class B evidence and expert opinions, it should guide practitioners in the management of patients with clinoidal meningiomas and might form the basis for future clinical trials.
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Khalafallah AM, Rakovec M, Burapachaisri K, Fung S, Kozachik SL, Valappil B, Abou-Al-Shaar H, Wang EW, Snyderman CH, Zenonos GA, Gardner PA, Baskaya MK, Dornbos D, Choby G, Kuan EC, Roxbury C, Overdevest JB, Gudis DA, Lee VS, Levy JM, Thamboo A, Schlosser RJ, Huang J, Bettegowda C, London NR, Rowan NR, Wu AW, Mukherjee D. The Suprasellar Meningioma Patient-Reported Outcome Survey: a disease-specific patient-reported outcome measure for resection of suprasellar meningioma. J Neurosurg 2021:1-9. [PMID: 34874673 DOI: 10.3171/2021.6.jns21517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas. METHODS Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument. RESULTS Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO. CONCLUSIONS The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach. ABBREVIATIONS EEA = endoscopic endonasal approach; GTR = gross-total resection; PRO = patient-reported outcome; PROMIS29 = Patient-Reported Outcomes Measurement Information System-29; QOL = quality of life; SMPRO = Suprasellar Meningioma Patient-Reported Outcome Survey; TCA = transcranial approach.
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Affiliation(s)
| | - Maureen Rakovec
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | | | - Shirley Fung
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Sharon L. Kozachik
- Medical University of South Carolina College of Nursing, Charleston, South Carolina
| | - Benita Valappil
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric W. Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Carl H. Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine
| | - Georgios A. Zenonos
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paul A. Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mustafa K. Baskaya
- Department of Neurosurgery, University of Wisconsin–Madison School of Medicine and Public Health, Madison, Wisconsin
| | - David Dornbos
- Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Garrett Choby
- Department of Otorhinolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Edward C. Kuan
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology–Head and Neck Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Jonathan B. Overdevest
- Department of Otolaryngology–Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York
| | - David A. Gudis
- Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, Illinois
| | - Victoria S. Lee
- Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, Illinois
| | - Joshua M. Levy
- Department of Otolaryngology–Head and Neck Surgery, Division of Rhinology and Anterior Skull Base, Emory University Hospital, Atlanta, Georgia
| | - Andrew Thamboo
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Rodney J, Schlosser
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Nyall R. London
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicholas R. Rowan
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Albert W. Wu
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine
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Mallari RJ, Thakur JD, Rhee JH, Eisenberg A, Krauss H, Griffiths C, Sivakumar W, Barkhoudarian G, Kelly DF. Endoscopic Endonasal and Supraorbital Removal of Tuberculum Sellae Meningiomas: Anatomic Guides and Operative Nuances for Keyhole Approach Selection. Oper Neurosurg (Hagerstown) 2021; 21:E71-E81. [PMID: 34114024 DOI: 10.1093/ons/opab138] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With growing worldwide endoscopy experience, endonasal and supraorbital removal of tuberculum sellae meningiomas (TSM) has increased. OBJECTIVE To describe anatomic factors for guiding approach selection and outcomes. METHODS Retrospective analysis of patients undergoing endonasal or supraorbital TSM resection: approach criteria, clinical outcomes, acute magnetic resonance imaging (MRI) fluid-attenuated inversion-recovery (FLAIR)/T2 changes. RESULTS From 2008 to 2020, 33 patients (mean age 55 ± 11 yr) were identified: 20 (61%) had endonasal and 13 (39%) supraorbital removal. Comparing endonasal and supraorbital approaches, mean tumor volume (3.7 ± 3.5 cm3 vs 7.7 ± 8.5 cm3, P = .07); percent tumor above planum (42% vs 65%, P = .02), and lateral tumor beyond supraclinoid internal carotid arteries (1.4 ± 2.0 mm vs 4.0 ± 3.2 mm, P = .006) were greater for supraorbital route. Sellar depth was greater for endonasal route tumors (12.2 ± 2.6 mm vs 9.3 ± 2.4 mm, P = .003). Endoscopy, used in 10/13(77%) supraorbital cases, was helpful in additional tumor removal in 4/10(40%). Gross total removal and mean volumetric tumor resection were 16/20(80%) and 97.5% by endonasal, and 5/13(39%) and 96% by supraorbital route. Vision improved in 12/17 (71%) endonasal, 6/8 (75%) supraorbital operations, and worsened in 1 (3%) supraorbital case. Endonasal approach with optic canal decompression increased over study period: 15/20 (75%) endonasal patients vs 1/13(8%) supraorbital (P < .001). Postoperative FLAIR/T2 MRI changes occurred in 2/12 supraorbital and 0/20 endonasal cases. CONCLUSION In our experience, both endonasal and supraorbital routes are safe and effective for TSM removal. Greater tumor extension below planum and medial optic canal invasion favor endonasal route, while larger size and lateral extension favor supraorbital route. Given high frequency of TSM growth into optic canals and better access for medial optic canal tumor removal, endonasal route may be preferred for most TSMs.
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Affiliation(s)
| | - Jai Deep Thakur
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA.,University of South Alabama, Mobile, Alabama, USA
| | - John H Rhee
- Pacific Neuroscience Institute, Santa Monica, California, USA
| | | | - Howard Krauss
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, Santa Monica, California, USA.,Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA
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Setty P, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Residual and Recurrent Disease Following Endoscopic Endonasal Approach as a Reflection of Anatomic Limitation for the Resection of Midline Anterior Skull Base Meningiomas. Oper Neurosurg (Hagerstown) 2021; 21:207-216. [PMID: 34245152 DOI: 10.1093/ons/opab244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/02/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Endoscopic endonasal approaches (EEAs) to anterior skull base meningiomas have grown in popularity, though anatomic limitations remain unclear. OBJECTIVE To show the anatomic limits of EEA for meningiomas. METHODS Retrospective chart review for all patients that underwent EEA for anterior skull base meningiomas from 2005 to 2014. RESULTS A total of 100 patients averaged follow-up of 46.9 mo (24-100 mo). A total of 35 patients (35%) had olfactory groove, 33 planum sphenoidale (33%), and 32 tuberculum sella (32%) meningiomas. The average diameter was 2.9 cm (0.5-8.1 cm). Vascular encasement was seen in 11 patients (11%) and calcification in 20 (20%). Simpson Grade 1 (SG1) resection was achieved in 64 patients (64%). Only calcification impacted degree of resection (40% SG1, P = .012). The most common residual was on the anterior clinoid dura (11 patients [11%]). Six (6%) had residual superior/lateral to the optic nerve. Residual tumor was adherent to the optic apparatus or arteries in 5 patients (5%) each, and 3 patients (3%) had residual lateral to the mid-orbit. Rates of residual decreased over time. A total of 11 patients (11%) had tumor recurrence (mean of 40 mo): 4 (4%) on the anterior clinoid, 2 (2%) each on the lateral orbital roof, adherent to optic apparatus and superolateral to the optic nerve, and 1 (1%) was at the anterior falx. CONCLUSION Anterior skull base meningiomas can effectively be approached via EEA in most patients; tumors extending to the anterior clinoid, anterior falx, or superolateral to the optic nerve or orbital roof, especially if calcified, may be difficult to reach via EEA.
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Affiliation(s)
- Pradeep Setty
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Youngerman BE, Banu MA, Gerges MM, Odigie E, Tabaee A, Kacker A, Anand VK, Schwartz TH. Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data. J Neurosurg 2021; 135:113-125. [PMID: 32707549 PMCID: PMC8111689 DOI: 10.3171/2020.4.jns20475] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has gained increasing popularity for the resection of suprasellar meningiomas (SSMs). Appropriate case selection is critical in optimizing patient outcome. Long-term outcome data are lacking. The authors systematically identified preoperative factors associated with extent of resection (EOR) and determined the relationship between EOR and long-term recurrence after EEA for SSMs. METHODS In this retrospective cohort study, the authors identified preoperative clinical and imaging characteristics associated with EOR and built on the recently published University of California, San Francisco resectability score to propose a score more specific to the EEA. They then examined the relationship between gross-total resection (GTR; 100%), near-total resection (NTR; 95%-99%), and subtotal resection (STR; < 95%) and recurrence or progression with Kaplan-Meier survival analysis. RESULTS A total of 51 patients were identified. Radiographic GTR was achieved in 40 of 47 (85%) patients in whom it was the surgical goal. Significant independent risk factors for incomplete resection were prior surgery (OR 25.94, 95% CI < 2.00 to 336.49, p = 0.013); tumor lateral to the optic nerve (OR 13.41, 95% CI 1.82-98.99, p = 0.011); and complete internal carotid artery (ICA) encasement (OR 15.12, 95% CI 1.17-194.08, p = 0.037). Tumor size and optic canal invasion were not significant risk factors after adjustment for other variables. A resectability score based on the multivariable model successfully predicted the likelihood of GTR; a score of 0 had a positive predictive value of 97% for GTR, whereas a score of 2 had a negative predictive value of 87.5% for incomplete resection. After a mean follow-up of 40.6 ± 32.4 months (mean ± SD), recurrence was 2.7% after GTR (1 patient with atypical histology), 44.4% after NTR, and 80% after STR (p < 0.0001). Vision was stable or improved in 93.5% and improved in 67.4% of patients with a preoperative deficit. There were 5 (9.8%) postoperative CSF leaks, of which 4 were managed with lumbar drains and 1 required a reoperation. CONCLUSIONS The EEA is a safe and effective approach to SSMs, with favorable visual outcomes in well-selected cases. The combination of postoperative MRI-based EOR with direct endoscopic inspection can be used in lieu of Simpson grade to predict recurrence. GTR dramatically reduces recurrence and can be achieved regardless of tumor size, proximity or encasement of the anterior cerebral artery, or medial optic canal invasion. Risk factors for incomplete resection include prior surgery, tumor lateral to the optic nerve, and complete ICA encasement.
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Affiliation(s)
- Brett E. Youngerman
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
- Department of Neurosurgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Matei A. Banu
- Department of Neurosurgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Mina M. Gerges
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eseosa Odigie
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Abtin Tabaee
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Ashutosh Kacker
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Vijay K. Anand
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
| | - Theodore H. Schwartz
- Departments of Neurosurgery Weill Cornell Medicine, NewYork-Presbyterian Hospital
- Otolaryngology Weill Cornell Medicine, NewYork-Presbyterian Hospital
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50
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Alessandro P, Giovanni C, Benedetta RC, Luca R, Claudia F, Francesco GT, Enrico G, Roberta A, Cecilia C, Torstein MR, Maria FM, Francesco D. The "STARS-CT-MADE" Study: Advanced Rehearsal and Intraoperative Navigation for Skull Base Tumors. World Neurosurg 2021; 154:e19-e28. [PMID: 34157459 DOI: 10.1016/j.wneu.2021.06.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/11/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Skull base meningiomas represent a challenge for neurosurgeons, and the procedures are typically performed by experienced neurosurgeons, thus limiting resident training. A new simulation and rehearsal device can be used as an aid for senior surgeons during these operations and serve as a training tool for junior surgeons. METHODS Forty patients harboring an anterior/middle fossa meningioma were recruited. Surgical Theater, a rehearsal/simulation platform, was used for preoperative planning and intraoperative 3D navigation on 20 patients (CT-MADE group), while the remaining (control group) underwent a traditional navigation. Qualitative comparisons between the 2 groups were made with regard to surgical procedure and patient outcome. Satisfaction questionnaires were completed by expert neurosurgeons and residents to assess the overall usefulness of the platform. Furthermore, the surface of the simulated craniotomy performed during the planning was compared with the one actually performed during surgery in order to evaluate the reliability of the planning. RESULTS No differences between the 2 groups were found (surgery duration: P = 0.4; visual impairment: P = 0.56). Both residents and senior neurosurgeons enjoyed using the platform for intraoperative navigation and planning; simulated craniotomies were significantly smaller as compared with the real ones (P = 0.009), probably because it was not intuitive to depict the exact margins of the operculum with the platform. CONCLUSION Surgical Theater helped residents to improve their anatomic and procedural comprehension and was deemed as a useful aid to safely perform some demanding neurosurgical procedures, by both senior and junior surgeons.
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Affiliation(s)
- Perin Alessandro
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Life Sciences, University of Trieste, Trieste, Italy.
| | - Carone Giovanni
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Rui Chiara Benedetta
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Raspagliesi Luca
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Fanizzi Claudia
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Galbiati Tommaso Francesco
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gambatesa Enrico
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ayadi Roberta
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Casali Cecilia
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Meling R Torstein
- Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurosurgery, Geneva University Hospital, Geneva, Switzerland; EANS Training Committee, Sint Martens Latem, Belgium
| | - Fontanella Marco Maria
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - DiMeco Francesco
- Department of Neurosurgery, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; Besta NeuroSim Center, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy; EANS Training Committee, Sint Martens Latem, Belgium; Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, Maryland, USA
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