Endoscopic Endonasal Approach for Suprasellar Lesions in Children: Complications and Prevention

Effect of endoscopic endonasal skull base approaches on olfactory function and facial development in children

INTRODUCTION

Endoscopic approaches for skull base pathologies are increasingly being performed, and the subsequent complications, especially in the long term, have also been partially clarified. However, there is no information on the effects of endoscopic endonasal skull base surgeries (EESBS) in children on odor and facial development in parallel with long-term development. We conducted this study to investigate postoperative olfactory function and facial development in pediatric patients who underwent skull base surgery using the endoscopic endonasal method.

METHODS

We evaluated the smell test, sinonasal symptoms, and facial development of pediatric patients who underwent endoscopic endonasal skull base surgery after long-term follow-up. Odor was evaluated using the "Sniffin' Sticks" test kit, which assessed the T (odor threshold), D (odor discrimination), and I (odor identification) parameters. Sinonasal symptoms were evaluated using the SNOT-22 (sinus-nose outcome test) questionnaire. SNA (sella-nasion-A point), SNB (sella-nasion-B point), and ANB (A point-nasion-B point) angles were calculated from maxillofacial tomography and magnetic resonance imaging) to evaluate facial development. Data were compared with those of the healthy control group.

RESULTS

We included 30 patients comprising 19 (63.3%) boys and 11 (36.7%) girls, with no age difference between case and control groups. The mean follow-up period was 7 years. Odor test data, cephalometric measurements, and SNOT-22 analysis results showed no statistically significant differences between the two groups.

CONCLUSION

To our knowledge, this is a comprehensive study with the longest follow-up period in terms of evaluation of facial development after EESBS in children to analyze odor using the Sniffin' Sticks test kit and the quality of life using SNOT-22. Olfactory function, facial development, and quality of life remained unaffected after long-term follow-up after EESBS  in children. Although this surgical approach is minimally invasive, we recommend considering the possibility of complications, and the procedure should be performed by an experienced surgical team with adequate equipment.

Management of Internal Carotid Artery Injury During Transsphenoidal Surgery: A Case Series and Suggestion for Optimal Management

OBJECTIVE

Internal carotid artery (ICA) injury during transsphenoidal surgery is a rare but serious complication. We analyzed a series of ICA injuries that occurred during a transsphenoidal approach to suggest an optimal management strategy.

METHODS

Between January 2015 and May 2020, we enrolled 10 cases of ICA injury at our institution.

RESULTS

Among the 10 patients enrolled, 5 had pituitary adenoma, 2 had craniopharyngioma, and 1 each had skull base chondrosarcoma, tuberculum sellae meningioma, and nasopharyngeal cancer; 4 were revision surgery cases. The cavernous segment of the ICA was the most commonly injured area. The most common reason for ICA injury was a drill injury at the sellar floor opening. A direct repair was performed using a clip in only 1 patient. In the others, bleeding control of the injured ICA was achieved by packing multiple cotton pads. After angiography, 6 patients underwent immediate endovascular sacrifice of the injured ICA. In 3 patients who showed poor collateral flow from the anterior communicating and posterior communicating arteries, revascularization surgery was performed before endovascular trapping. After 6 postoperative months, 6 patients showed favorable functional outcomes, and 4 patients showed poor functional outcomes.

CONCLUSIONS

Prompt control of bleeding, endovascular management of injured ICA, and consideration of revascularization surgery based on collateral flow may prevent catastrophic neurological sequelae.

Complications of Endoscopic Skull Base Surgery for Sellar and Parasellar Tumors in Pediatric Population; Neurosurgical Perspectives

Background

Advances in surgical techniques based on in-depth anatomical knowledge of the skull base have broadened the indications for endoscopic skull base surgery (ESS) with the advantage of wide and direct surgical exposure while minimizing invasiveness. However, the low incidence of the indicated diseases and narrow surgical corridors in children have limited the popularization of ESS. In addition, surgical complications and preventive interventions are not yet well known. Therefore, we retrospectively investigated the complications and prevention methods of ESS in children with a comprehensive review.

Methods

We retrospectively analyzed the medical records of pediatric patients who underwent ESS for sellar and parasellar tumors at Seoul National University Children's Hospital from July 2010 to December 2020. Visual and endocrine status, extent of resection, complications, and recurrences were investigated depending on the pathology of the tumor. In addition, a comprehensive literature review regarding the complications of pediatric ESS was performed.

Results

A total of 98 patients were enrolled. The median age of the patients was 12 years, and 52 patients were male. Preoperative visual disturbance was found in 53 patients, anterior pituitary function deficit in 69, and diabetes insipidus in 32. Gross total resection was attempted in 67 patients and achieved in 62 (93%). Biopsy and cyst fenestration were the goals of surgery in 26 patients, and all were achieved as planned. Regarding outcomes, visual disturbance worsened in two patients (2%), endocrine status was aggravated in 34 (35%) patients, and new-onset diabetes insipidus occurred in 27 (41%) patients. The overall surgical complication rate (other than aggravation of visual or endocrine status) was 17%. Postoperative meningitis (12%) was the most common complication, followed by cerebrospinal fluid leakage (2%), vasospasm, hemorrhage and infarction. By pathological diagnosis, craniopharyngioma had the highest complication rate of 29%. All but one patient with postoperative hemorrhage showed no permanent deficits.

Conclusion

ESS in children is feasible and relatively safe. More attention and different postoperative management protocols are required in children to avoid complications, especially in craniopharyngiomas. However, the complications can be mostly managed conservatively without permanent neurologic deficits.

Crisis Management Simulation: Review of Current Experience

Crisis management simulation is important in training the next generation of surgeons. In this review, we highlight our experiences with the cavernous carotid injury model. We then delve into other crisis simulation models available for the neurosurgical specialty. The discussion focuses upon how these trainings can continue to evolve. Much work is yet to be done in this exciting arena and we present several avenues for future discovery. Simulation continues to be an important training tool for the surgical learner.

Influence of Pediatric Endoscopic Endonasal Skull Base Resections on Midface and Skull Base Development

OBJECTIVE

The purpose of this study is to use imaging data to determine if endoscopic endonasal surgery (EES) for skull base tumor resection interrupts skull base growth and development, resulting in an atrophic midface skeletal structure, compared to matched normal controls.

METHODS

Data were collected by a retrospective chart review done on children aged 16 years and below who underwent endoscopic tumor resection and had pre- and postoperative magnetic resonance imaging with relevant midface anatomy. 121 normal controls were matched to 20 EES patients by age and gender. Three measurements related to midface anatomy were taken from 1 sagittal T1 slice and 1 axial T2 slice of each scan. Statistical analysis was used to compare growth measures between cases and controls.

RESULTS

Twenty patients who underwent EES between November 2015 and April 2018 met our inclusion criteria. The mean age of the patients, 11 males and 9 females, was 10 years, and 8 patients (38%) were aged 7 years or younger. Six patients who had a high-flow CSF leak obtained a nasoseptal flap. A student T test and multivariate regression analysis found that EES did not affect midface and skull base growth. Among the variables assessed, age appears to be the only driver of growth.

CONCLUSION

There were no identified differences in craniofacial growth in pediatric patients undergoing EES for skull base tumor resection as compared to the control group. EES does not appear to significantly interfere with midface/skull base development and is a good surgical option for pediatric patients.

Suprasellar pituitary adenomas: a 10-year experience in a single tertiary medical center and a literature review

BACKGROUND

Suprasellar pituitary adenomas (SPAs) are a special type of pituitary adenoma. Although dozens of SPA cases have been reported, the exact definition and the characteristics of SPA have not been exhaustively discussed before.

METHODS

In a retrospective electronic medical records review, 13 patients with SPA were identified in our hospital between January 2010 and December 2019. A literature review was performed by searching the online database PubMed, and 39 cases conformed to the criteria based on the previous literature. Data regarding clinical symptoms, imaging manifestations, surgical information and follow-ups were analyzed.

RESULTS

The mean age at diagnosis of 52 patients with SPA was 36.73 years, and most of the patients were female (61.5%). The most common hormone-secreting subtypes of SPA were nonfunctioning (36.5%) and ACTH-secreting (34.6%) SPA. Macroadenomas (68.9%) were more common than microadenomas (31.1%). The origins of the SPAs included the intrasellar pituitary gland (type I), the subdiaphragmatic (type IIa) and supradiaphragmatic (type IIb) part of the pituitary stalk, and the suprasellar peri-infundibular region (type III). The most common anatomic subtype of SPA was type III, and type IIb was also common. The most common presentations of SPA were visual symptoms, especially for type III SPA. In addition, 64.7% and 73.1% of type IIb and III SPAs, respectively, were suspected to be of suprasellar origin based on presurgical imaging examination. Patients with tumors of suspected suprasellar origin were more likely to receive transcranial surgery (TCS) initially than those with tumors of suspected intrasellar origin (70.6% vs. 22.2%, p = 0.0013). The intact rate for the pituitary stalk after surgery for type II SPA was lower than that for type I and III SPA (52.6% vs. 92.6%, p = 0.0036). More patients with type II SPA experienced postoperative central diabetes insipidus (CDI) than those with type I and III SPA (57.9% vs. 11.1%, p = 0.0011). There was no significant difference in the incidence of postoperative CDI between transsphenoidal surgery (TSS) and TCS (p = 0.1304). Nine patients in our hospital received extended endoscopic TSS; only one experienced tumor recurrence, and no severe complications occurred after surgery.

CONCLUSIONS

SPAs could be defined as pituitary adenomas completely or partially located in the suprasellar region. There were both similarities and differences among the different anatomic subtypes of SPA. For patients who were suspected of having SPAs, visual field tests, pituitary hormone evaluation and MRI were necessary. Because imaging examination is not a reliable method, surgery is the only way to confirm the tumor origin. Extended endoscopic TSS might be a safe and efficient approach to remove these tumors, but more studies are needed to verify this conclusion. For type II SPA, the pituitary stalk should be carefully protected during surgery, and postoperative CDI should be monitored.

Differentiation of suprasellar meningiomas from non-functioning pituitary macroadenomas by 18F-FDG and 13N-Ammonia PET/CT

Background

Differentiation of suprasellar meningiomas (SSMs) from non-functioning pituitary macroadenomas (NFPMAs) is useful for clinical management. We investigated the utility of ¹³N-ammonia combined with ¹⁸F-FDG positron emission tomography (PET)/computed tomography (CT) in distinguishing SSMs from NFPMAs retrospectively.

Methods

Fourteen NFPMA patients and eleven SSM patients with histopathologic diagnosis were included in this study. Every patient underwent both ¹⁸F-FDG and ¹³N-ammonia PET/CT scans. The tumor to gray matter (T/G) ratios were calculated for the evaluation of tumor uptake.

Results

The uptake of ¹⁸F-FDG was higher in NFPMAs than SSMs, whereas the uptake of ¹³N-ammonia was obviously lower in NFPMAs than SSMs. The differences of ¹⁸F-FDG and ¹³N-ammonia uptake between the two groups were significant respectively (0.92[0.46] vs 0.59[0.29], P < 0.05, ¹⁸F-FDG; 1.58 ± 0.56 vs 2.80 ± 1.45, P < 0.05, ¹³N-ammonia). Tumor classification demonstrated a high overall accuracy of 96.0% for differential diagnosis. When the two traces were combined, only 1 SSM was misclassified into the NFPMA group.

Conclusion

SSMs and NFPMAs have different metabolic characteristics on ¹⁸F-FDG and ¹³N-ammonia PET images. The combination of these two tracers can effectively distinguish SSMs from NFPMAs.

Endoscopic endonasal skull base surgery for pediatric brain tumors

PURPOSE

The utility of endoscopic endonasal skull base surgery (EES) in various pathologic entities in adults has been published in the literature. However, the role of EES in children has not been clearly elucidated. We evaluated the feasibility of EES in children with brain tumors.

METHODS

We retrospectively reviewed clinical features, surgical outcomes, and complications in children who underwent EES for intracranial and skull base tumors at a single institution from July 2010 to October 2018.

RESULTS

A total of 82 patients underwent EESs for 77 intracranial and 5 skull base bony tumors. The mean age at diagnosis was 11.4 years (range 4-18 years), and the mean follow-up period was 46.8 months. The most common tumors were craniopharyngioma in the intracranial tumor and chordoma in the skull base. Gross total resection was the goal of surgery in 55 patients and achieved in 90.9%. The vision was improved in 76.1% of patients with visual impairments. Preoperatively, various endocrinological deficiencies were revealed in 73.7% of 76 patients with hypothalamus-pituitary lesions, and the hyposomatotropism was most common. Endocrinological status was improved only in 10. Aseptic or bacterial meningitis (7.3%) was the most common surgical complication, and the cerebrospinal fluid leakage rate was 2.4%.

CONCLUSIONS

EES provides favorable neurological outcomes with acceptable risk for children with brain tumors. The high incidence of endocrinological deficits in cases with hypothalamus-pituitary lesions emphasizes the importance of judicious pre- and postoperative evaluation.

CSF leak after endoscopic skull base surgery in children: A single institution experience

INTRODUCTION

The endoscopic expanded endonasal approach (EEA) has been shown to be a safe and effective surgical technique in the resection of pediatric skull base lesions. Cerebrospinal fluid (CSF) leaks are among the most common complications of this approach. Here we review skull base resections using EEA in pediatric patients at our single institution, to identify potential risk factors for this surgical complication.

METHODS

A retrospective chart review was conducted on pediatric patients at our single institution for patients 19 years-old and under, who underwent an EEA for resection of a skull base tumor.

RESULTS

Thirty-nine pediatric patients (ages 1-19 years) with 8 different tumor pathologies underwent an EEA for resection of their skull base tumors. 21 patients experienced an intraoperative CSF leak, of which 10 (48%) were "high-flow" leaks and 11 (52%) were "low-flow" leaks. Nasoseptal flaps were only used to repair the intraoperative "high flow" leaks (n = 10), and "low flow" and "no leaks" were repaired with allograft and fat. No patients experienced a post-operative CSF leak.

CONCLUSION

In our pediatric series, the skull base repair algorithm of using an NSF only in cases of "high flow" intraoperative leaks was effective, and no post-operative CSF leaks occurred. Not using an NSF in cases of "low-flow" or "no leak" cases allows for decreased anatomical disruption in the growing patient.

Approaching the Sella through the Nonpneumatized Sphenoid in Pediatric Patients

Objective  The purpose of this study is to specifically assess pediatric patients with nonpneumatized sphenoid sinuses who have undergone transsphenoidal resections of skull base tumors and assess the complications and outcomes. Methods  Data was collected by a retrospective chart review done on children ages 7 and under who underwent endoscopic tumor resection and had a partially or completely nonpneumatized sphenoid sinus on preoperative computed tomography imaging. Surgical data collected included surgical corridor, gross total versus subtotal resection, repair method, use of septal flap, intraoperative and postoperative cerebrospinal fluid leak, and estimated blood loss. Results  Six patients were identified that fit our inclusion criteria who underwent surgery between November 2015 and April 2018 (3 males, 3 females; average age = 4.28 years). Tumor pathologies include three craniopharyngiomas, Rathke cleft cyst, meningocele, and neuroblastoma. All cases involved varying percentages of sphenoid sinus pneumatization. All cases except one craniopharyngioma and the neuroblastoma required removal of cancellous bone to access pathology. Degree of sphenoid pneumatization tended to be greater with age and resulted in less intraoperative bleeding. The two youngest patients with completely nonpneumatized sphenoid sinuses lost 61.73 and 17.52% of their total blood volume intraoperatively. Procedures were able to be adequately performed and pathology completely addressed with minimal postoperative complications and no postoperative CSF leaks. Conclusions  Intraoperative challenges including hemorrhage are likely in nonpneumatized patients, and thus surgeons should be prepared with adequate vascular access and blood products. Hemorrhage and total blood volume loss are increased in the younger patients with no sphenoid pneumatization. Despite the additional challenges, a nonpneumatized sphenoid sinus is not a contraindication for an endoscopic resection in the pediatric population.

The extended, transnasal, transsphenoidal approach for anterior skull base meningioma: considerations in patient selection

PURPOSE

In this study, we set out to define our institutional criteria for patient eligibility for transsphenoidal resection of parasellar meningiomas, and to report our experience with extended transnasal approaches for these lesions. We aimed to discuss the important considerations of patient selection and risk stratification to optimize outcomes for patients with these difficult lesions, and also include considerations that should be reviewed during surgical approach selection.

METHODS

Medical records from Brigham and Women's Hospital were retrospectively reviewed for all patients who underwent transsphenoidal surgery for pituitary disease with the senior author from April 2008 to March 2017 (938 procedures). Patients undergoing surgery for anterior skull base meningioma were identified and patient data were collected.

RESULTS

Seven patients (four women, three men) underwent transsphenoidal resection (five endoscopic, one microscopic, and one hybrid endoscopic/microscopic) of pathologically-confirmed anterior skull base meningiomas during the study period. Five patients presented with visual field deficits, three presented with headache, two presented with hypopituitarism, and one woman presented with infertility. The median maximum tumor diameter was 1.7 cm (range 1.4-4.2 cm). Six patients underwent subtotal resection, and one underwent gross total resection. The median MIB-1 index was 2.3 (range 1.0-7.6). Complications included two readmissions (one on POD11 for small bowel obstruction, one on POD48 for epistaxis), and the development of new onset thyroid deficiency and transient diabetes insipidus in one patient. Two patients had reoperations by craniotomy for tumor recurrence after 5 and 6 years, respectively.

CONCLUSIONS

Although more commonly treated transcranially, anterior skull base meningiomas are sometimes amenable to resection transphenoidally. Patient selection is critical, and multiple factors, including tumor size, consistency, and location, patient and surgeon preference, and presenting symptoms each affect the optimum surgical approach. We have developed criteria for patient selection so that transsphenoidal surgery can be used to resect or debulk anterior skull base meningiomas safely and with favorable outcomes.