Neurosurgery Blog

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Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Limitations of the endonasal endoscopic approach in treating olfactory groove meningiomas

Acta Neurochir (2017) 159:1875–1885

To review current management strategies for olfactory groove meningioma (OGM)s and the recent literature comparing endoscopic endonasal (EEA) with traditional transcranial (TCA) approaches.

Methods A PubMed search of the recent literature (2011– 2016) was performed to examine outcomes following EEA and TCA for OGM. The extent of resection, visual outcome, postoperative complications and recurrence rates were analyzed using percentages and proportions, the Fischer exact test and the Student’s t-test using Graphpad PRISM 7.0Aa (San Diego, CA) software.

Results There were 444 patients in the TCA group with a mean diameter of 4.61 (±1.17) cm and 101 patients in the EEA group with a mean diameter of 3.55 (± 0.58) cm (p = 0.0589). GTR was achieved in 90.9% (404/444) in the TCA group and 70.2% (71/101) in the EEA group (p < 0.0001). Of the patients with preoperative visual disturbances, 80.7% (21/26) of patients in the EEA cohort had an improvement in vision compared to 12.83%(29/226) in the TCA group (p < 0.0001). Olfaction was lost in 61% of TCA and in 100% of EEA patients. CSF leaks and meningitis occurred in 25.7% and 4.95% of EEA patients and 6.3% and 1.12% of TCA patients, respectively (p < 0.0001; p = 0.023).

Conclusions Our updated literature review demonstrates that despite more experience with endoscopic resection and skull base reconstruction, the literature still supports TCA over EEA with respect to the extent of resection and complications. EEA may be an option in selected cases where visual improvement is the main goal of surgery and postoperative anosmia is acceptable to the patient or in medium-sized tumors with existing preoperative anosmia. Nevertheless, based on our results, it seems more prudent at this time to use TCA for the majority of OGMs.

Microendoscopic laminotomy versus conventional laminoplasty for cervical spondylotic myelopathy: 5-year follow-up study

J Neurosurg Spine 27:403–409, 2017

The goal of this study was to characterize the long-term clinical and radiological results of articular segmental decompression surgery using endoscopy (cervical microendoscopic laminotomy [CMEL]) for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP).

METHODS Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n = 78) underwent CMEL or ELAP. All patients were followed postoperatively for more than 5 years. The preoperative and 5-year follow-up evaluations included neurological assessment (Japanese Orthopaedic Association [JOA] score), JOA recovery rates, axial neck pain (using a visual analog scale), the SF-36, and cervical sagittal alignment (C2–7 subaxial cervical angle).

RESULTS Sixty-one patients were included for analysis, 31 in the CMEL group and 30 in the ELAP group. The mean preoperative JOA score was 10.1 points in the CMEL group and 10.9 points in the ELAP group (p > 0.05). The JOA recovery rates were similar, 57.6% in the CMEL group and 55.4% in the ELAP group (p > 0.05). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (p < 0.01). At the 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.6° gain in lordosis (versus 1.2° loss of lordosis in the ELAP group [p < 0.05]) and lower incidence of postoperative kyphosis.

CONCLUSIONS CMEL is a novel, less invasive technique that allows for multilevel posterior cervical decompression for the treatment of CSM. This 5-year follow-up data demonstrates that after undergoing CMEL, patients have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional ELAP counterparts.

Surgical resection of skull-base chordomas: experience in case selection for surgical approach according to anatomical compartments and review of the literature

Acta Neurochir (2017) 159:1835–1845

Chordoma is a rare bony malignancy known to have a high rate of local recurrence after surgery. The best treatment paradigm is still being evaluated. We report our experience and review the literature. We emphasize on the difference between endoscopic and open craniotomy in regard to the anatomical compartment harboring the tumor, the limitations of the approaches and the rate of surgical resection.

Method: We retrospectively collected all patients with skullbase chordomas operated on between 2004 and 2014. Detailed radiological description of the compartments being occupied by the tumor and the degree of surgical resection is discussed.

Results: Eighteen patients were operated on in our facility for skull-base chordoma. Seventeen endoscopic surgeries were done in 15 patients, and 7 craniotomies were done in 5 patients. The mean age was 48.9 years (±19.8 years). When reviewing the anatomical compartments, we found that the most common were the upper clivus (95.6%) and lower clivus (58.3%), left cavernous sinus (66.7%) and petrous apex (∼60%). Most of the patients had intradural tumor involvement (70.8%). In all craniotomy cases, there was residual tumor in multiple compartments. In the endoscopic cases, the most difficult compartments for total resection were the lower clivus, and lateral extensions to the petrous apex or cavernous sinus.

Conclusions: Our experience shows that the endoscopic approach is a good option for midline tumors without significant lateral extension. In cases with very lateral or lower extensions, additional approaches should be added trying to achieve complete resection.

Image-guided endoscopic surgery for spontaneous supratentorial intracerebral hematoma

J Neurosurg 127:537–542, 2017

Endoscopic removal of intracerebral hematomas is becoming increasingly common, but there is no standard technique. The authors explored the use of a simple image-guided endoscopic method for removal of spontaneous supratentorial hematomas.

METHODS Virtual reality technology based on a hospital picture archiving and communications systems (PACS) was used in 3D hematoma visualization and surgical planning. Augmented reality based on an Android smartphone app, Sina neurosurgical assist, allowed a projection of the hematoma to be seen on the patient’s scalp to facilitate selection of the best trajectory to the center of the hematoma. A obturator and transparent sheath were used to establish a working channel, and an endoscope and a metal suction apparatus were used to remove the hematoma.

RESULTS A total of 25 patients were included in the study, including 18 with putamen hemorrhages and 7 with lobar cerebral hemorrhages. Virtual reality combined with augmented reality helped in achieving the desired position with the obturator and sheath. The median time from the initial surgical incision to completion of closure was 50 minutes (range 40–70 minutes). The actual endoscopic operating time was 30 (range 15–50) minutes. The median blood loss was 80 (range 40–150) ml. No patient experienced postoperative rebleeding. The average hematoma evacuation rate was 97%. The mean (± SD) preoperative Glasgow Coma Scale (GCS) score was 6.7 ± 3.2; 1 week after hematoma evacuation the mean GCS score had improved to 11.9 ± 3.1 (p < 0.01).

CONCLUSIONS Virtual reality using hospital PACS and augmented reality with a smartphone app helped precisely localize hematomas and plan the appropriate endoscopic approach. A transparent sheath helped establish a surgical channel, and an endoscope enabled observation of the hematoma’s location to achieve satisfactory hematoma removal.

Endoscopic approach via the interhemispheric fissure: the role of an endoscope in a surgical case of multiple falcine lesions

Acta Neurochir (2017) 159:1243–1246

For treating a patient with multiple falcine and parasagittal lesions, we believe that it is beneficial to resect the maximum possible number of lesions during one operation, even if some lesions are asymptomatic. This practice can potentially reduce the total number of operations during a patient’s lifetime.

Methods We provide an introduction of a concurrent endoscopic approach via the interhemispheric fissure.

Conclusions Applying this endoscopic approach concurrently with conventional microscopic surgery can enable the safe resection of as many lesions as possible during one operation.

Anterior trans-frontal endoscopic resection of third-ventricle colloid cyst

Acta Neurochir (2017) 159:1049–1052

The endoscopic technique has been recognised as a viable and safe alternative to microsurgery for the treatment of third-ventricle colloid cyst. However, the standard precoronal endoscopic approach does not always provide an adequate visualisation of the attachment of the cyst to the velum interpositum. Using a more anterior approach, it is easier to reach the roof of the cyst and its possible adherences with the tela choroidea.

Method The authors describe step by step the anterior transfrontal endoscopic approach for management of third ventricle colloid cyst.

Conclusions The described approach has shown to be safe, quick and effective for the treatment of third-ventricle colloid cyst.

Endoscopic versus microscopic microvascular decompression for trigeminal neuralgia

J Neurosurg 126:1676–1684, 2017

Endoscopic surgery has revolutionized surgery of the ventral skull base but has not yet been widely adopted for use in the cerebellopontine angle. Given the relatively normal anatomy of the cerebellopontine angle in patients with trigeminal neuralgia (TN), the authors hypothesized that a fully endoscopic microvascular decompression (E-MVD) might provide pain outcomes equivalent to those of microscopic MVD (M-MVD) but with fewer complications.

METHODS The authors conducted a single-institution, single-surgeon retrospective study with patients treated in the period of 2006–2013. Before surgery, all patients completed a questionnaire that included a validated multidimensional pain-outcome tool, the Penn Facial Pain Scale (PFPS, formerly known as Brief Pain Inventory–Facial), an 11-point scale that measures pain intensity, interference with general activities of daily living (ADLs), and facial-specific ADLs. Using a standardized script, independent research assistants conducted follow-up telephone interviews.

RESULTS In total, 167 patients were available for follow-ups (66.5% female; 93 patients underwent M-MVD and 74 underwent E-MVD). Preoperative characteristics (i.e., TN classification, PFPS components, and medication use) were similar for the 2 surgical groups except for 2 variables. Patients in the M-MVD group had slightly higher incidence of V3 pain, and the 2 groups differed in the date of surgery and hence in the length of follow-up (2.4 years for the M-MVD group and 1.3 years for the E-MVD group, p < 0.05). There was a trend toward not finding neurovascular conflict at the time of surgery more frequently in the M-MVD than in the E-MVD group (11% vs 7%, p = 0.052). Internal neurolysis was more often performed in the E-MVD group (26% vs 7%, p = 0.001). The 2 groups did not significantly differ in the length of the MVD procedure (approximately 2 hours). Self-reported headaches at 1 month postoperatively were present in 21% of the patients in the M-MVD group versus 7% in the E-MVD group (p = 0.01). Pain outcomes at the most recent followup were equivalent, with patients reporting a 5- to 6-point (70%–80%) improvement in pain intensity, a 5-point (85%) improvement in pain interference with ADLs, and a 6-point (85%) improvement in interference with facial-specific ADLs. Actuarial freedom from pain recurrence was equivalent in the 2 groups, with 80% pain control at 3 years.

CONCLUSIONS Both the fully endoscopic MVD and the conventional M-MVD appear to provide patients with equivalent pain outcomes. Complication rates were also similar between the groups, with the exception of the rate of headaches, which was significantly lower in the E-MVD group 1 month postoperatively.

Fluorescein-Guided Neuroendoscopy for Intraventricular Lesions

Operative Neurosurgery 13:173–181, 2017

The benefits of neuroendoscopy in the pathological diagnosis of intraand paraventricular tumors have already been shown in many neurosurgical studies. However, most authors agree that neuroendoscopic biopsies are not infrequently inconclusive due to small or inadequate samples, prompting the need for new diagnostic strategies.

OBJECTIVE: To describe a technique not previously reported in the literature, combining neuroendoscopy with angiofluorescein guidance for the pathological diagnosis of intraand paraventricular tumors.

METHODS: The 4-mm steerable fiberscope used was equipped with dual observation modes for white light and fluorescein. Access was by the classical precoronal burr hole. After inspecting the ventricular system in white light, a 10-mg/kg dose of fluorescein sodium (FS) was administered intravenously to the patient. The endoscope was then switched to the blue light fluorescent mode to better localize the pathological tissue. The protocol had been submitted to the local ethics committee.

RESULTS: From September 2011 to March 2015, 9 consecutive patients (aged 1-56 yr) harboring intra- and paraventricular lesions prospectively underwent angiofluoresceinguided endoscopy. In all cases, a pathological diagnosis was obtained without complications. In 5 patients, an endoscopic third ventriculostomy, and, in 1 patient, a septostomy was performed during the same procedure. Fluorescein guidance definitely modified our site of biopsy in 4 cases.

CONCLUSION: In our experience, FS has proven to be a strong enhancer of all ventricular lesions presentingwith a disrupted blood–brain barrier, including inflammatory processes. Fluorescein-guided neuroendoscopy appears to be a safe, economic method to improve diagnostic potential in ventricular lesions.

Craniotomy for perisellar meningiomas: comparison of simple (appropriate for endoscopic approach) versus complex anatomy and surgical outcomes

J Neurosurg 126:1191–1200, 2017

Microsurgical resection of perisellar meningiomas has remained the gold standard for treatment, with extended endoscopic endonasal surgery emerging as a viable alternative. Historical microsurgical series do not distinguish based on tumor anatomy, but are being used as a comparison against endonasal surgery. In this study, the authors retrospectively reviewed and compared the anatomy of perisellar meningiomas seen at their institution. The tumors were separated into 2 groups based on whether they would be appropriate for endoscopic resection, and the authors compared the surgical outcomes.

METHODS Between 2001 and 2013, 53 patients (73.6% women) with perisellar meningiomas underwent open microsurgical resection at Vancouver General Hospital performed by the senior author (R.A.). These tumors were separated into 2 groups based on their anatomy, and the authors analyzed the resection rates, surgical results, patient quality of life, and complications.

RESULTS Among the 53 patients who presented with perisellar meningiomas, the authors were able to identify 18 lesions with “simple” anatomy suitable for endoscopic resection and 35 lesions with “complex” anatomy suitable for craniotomy resection. The mean age of patients in the study cohort was 57.4 years (range 33–91 years), and most patients presented with visual loss (68.0%) and visual field restriction (64.2%). There were no major differences in patient demographic data between the 2 groups. Patients with simple anatomy had smaller lesions (2.1 vs 3.5 cm; p = 0.004), no optic canal invasion (89% vs 26%; p < 0.0001), minimal vascular encasement (cortical cuff 83% vs 9%; p < 0.0001), and a rounded tumor shape (100% vs 31.8%; p = 0.0001) when compared with those with complex anatomy. The majority of lesions originated from the tuberculum sellae and planum sphenoidale. A greater degree of resection was achieved in the favorable anatomy group (99% vs 87.1%; p < 0.0001). Vision was improved or normalized in 96.6% of patients. Patients in the cohort with complex anatomy had more transient complications; there were no incidents of surgical-site infection, meningitis, or death in this series. One patient who underwent removal of a recurrent lesion experienced a CSF leak that required endoscopic repair. The overall persisting complications rate was higher in the group with complex anatomy (11.1% vs 37.1%; p = 0.0498); overall, 28.3% of patients experienced disabling complications. Patient-perceived quality of life improved in the simple anatomy group following surgery (DSF-36 +16.6 vs -8.4; p = 0.0045).

CONCLUSIONS Extended endoscopic surgery is emerging as a viable alternative to microsurgical resection of perisellar meningiomas. The authors identified 2 patient groups based on tumor anatomy, with distinctly separate surgical outcomes. In the future, patients considered for endoscopic resection should be compared against the surgical group with simple anatomy that includes smaller tumors, no vascular encasement, and limited optic canal invasion.

 

 

The mononostril endonasal transethmoidal-paraseptal approach

Acta Neurochir (2017) 159:453–457

The use of endoscopes in transnasal surgery offers increased visualization. To minimize rhinological morbidity without restriction in manipulation, we introduced the mononostril transethmoidal-paraseptal approach.

Methods The aim of the transethmoidal-paraseptal approach is to create sufficient space within the nasal cavity, without removal of nasal turbinates and septum. Therefore, as a first step, a partial ethmoidectomy is performed. The middle and superior turbinates are then lateralized into the ethmoidal space, allowing a wide sphenoidotomy with exposure of the central skull base.

Conclusions This minimally invasive transethmoidal-paraseptal approach is a feasible alternative to traumatic transnasal concepts with middle turbinate and extended septal resection.

Outcomes in craniotomy vs endoscopic craniopharyngioma resection

Neurosurg Focus 41 (6):E6, 2016

Craniopharyngiomas have historically been resected via transcranial microsurgery (TCM). In the last 2 decades, the extended endoscopic endonasal (transtuberculum) approach to these tumors has become more widely accepted, yet there remains controversy over which approach leads to better outcomes. The purpose of this study is to determine whether differences in outcomes were identified between TCM and extended endoscopic endonasal approaches (EEEAs) in adult patients undergoing primary resection of suprasellar craniopharyngiomas at a single institution.

Methods A retrospective review of all patients who underwent resection of their histopathologically confirmed craniopharyngiomas at the authors’ institution between 2005 and 2015 was performed. Pediatric patients, revision cases, and patients with tumors greater than 2 standard deviations above the mean volume were excluded. The patients were divided into 2 groups: those undergoing primary TCM and those undergoing a primary EEEA. Preoperative patient demographics, presenting symptoms, and preoperative tumor volumes were determined. Extent of resection, tumor histological subtype, postoperative complications, and additional outcome data were obtained. Statistical significance between variables was determined utilizing Student t-tests, chi-square tests, and Fisher exact tests when applicable.

Results After exclusions, 21 patients satisfied the aforementioned inclusion criteria, 12 underwent TCM for resection while 9 benefitted from the EEEA. There were no significant differences in patient demographics, presenting symptoms, tumor subtype, or preoperative tumor volumes, no tumors had significant lateral or prechiasmatic extension. The extent of resection was similar between these 2 groups, as was the necessity for additional surgery or adjuvant therapy. CSF leakage was encountered only in the EEEA group (2 patients). Importantly, the rate of postoperative visual improvement was significantly higher in the EEEA group than in the TCM group (88.9% vs 25.0%, p = 0.0075). Postoperative visual deterioration only occurred in the TCM group (3 patients). Recurrence was uncommon, with similar rates between the groups. Other complication rates, overall complication risk, and additional outcome measures were similar between these groups as well.

Conclusions Based on this study, most outcome variables appear to be similar between TCM and EEEA routes for similarly sized tumors in adults. The multidisciplinary EEEA to craniopharyngioma resection represents a safe and compelling alternative to TCM. The authors’ data demonstrate that postoperative visual improvement is statistically more likely in the EEEA despite the increased risk of CSF leakage. These results add to the growing evidence that the EEEA may be considered the approach of choice for resection of select confined primary craniopharyngiomas without significant lateral extension in centers with experienced surgeons. Further prospective, multiinstitutional collaboration is needed to power studies capable of fully evaluating indications and appropriate approaches for craniopharyngiomas.

Microscopic versus endoscopic approaches for craniopharyngiomas

microscopic-versus-endoscopic-approaches-for-craniopharyngiomas

Neurosurg Focus 41 (6):E5, 2016

Resection remains the mainstay of treatment for craniopharyngiomas with the goal of radical resection, if safely possible, to minimize the rate of recurrence. Endoscopic endonasal and microscopic transcranial surgical approaches have both become standard methods for the treatment for craniopharyngiomas. However, the approach selection paradigm for craniopharyngiomas is still a point of discussion. Choosing the optimal surgical approach can play a significant role in maximizing the extent of resection and surgical outcome while minimizing the risks of potential complications.

Craniopharyngiomas can present with a variety of different sizes, locations, and tumor consistencies, and each individual tumor has distinct features that favor one specific approach over another.

The authors review standard cranial base techniques applied to craniopharyngioma surgery, using both the endoscopic endonasal approach and traditional open microsurgical approaches, and analyze factors involved in approach selection. They discuss their philosophy of approach selection based on the location and extent of the tumor on preoperative imaging as well as the advantages and limitations of each surgical corridor, and they describe the operative nuances of each technique, using a personalized, tailored approach to the individual patient with illustrative cases and videos.

Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients

ETV

Neurosurg Focus 41 (3):E3, 2016

The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994–2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts.

Results A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1–230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p < 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p < 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor.

Conclusions ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.

Neuroendoscopic intracranial stenting in adults

Neuroendoscopic

J Neurosurg 125:576–584, 2016

Since its revival in the early 1990s, neuroendoscopy has become an integral component of modern neurosurgery. Endoscopic stent placement for treatment of CSF pathway obstruction is a rarely used and underestimated procedure. The authors present the first series of neuroendoscopic intracranial stenting for CSF pathway obstruction in adults with associated results and complications spanning a long-term follow-up of 20 years.

Methods The authors retrospectively reviewed a prospectively maintained clinical database for endoscopic stent placement performed in adults between 1993 and 2013.

Results Of 526 endoscopic intraventricular procedures, stents were placed for treatment of CSF disorders in 25 cases (4.8%). The technique was used in the management of arachnoid cysts (ACs; n = 8), tumor-related CSF disorders (n = 13), and hydrocephalus due to stenosis of the foramen of Monro (n = 2) or aqueduct (n = 2). The mean follow-up was 87.1 months. No deaths or infections occurred that were related to endoscopic placement of intracranial stents. Late stent dislocation or migration was observed in 3 patients (12%).

Conclusions Endoscopic intracranial stent placement in adults is rarely required but is a safe and helpful technique in select cases. It is indicated when reliable and long-lasting restoration of CSF pathway obstructions cannot be achieved with standard endoscopic techniques. In the treatment of tumor-related hydrocephalus, it is a good option to avoid reclosure of the restored CSF pathway by tumor growth. Currently, routine stent placement after endoscopic fenestration of ACs is not recommended. Stent placement for treatment of CSF disorders due to tumor is a good option for avoiding CSF shunting. To avoid stent migration and dislocation, and to allow for easy removal if needed, the device should be fixed to a bur hole reservoir.

Endoscopic endonasal anatomy of the ophthalmic artery in the optic canal

Endoscopic endonasal anatomy of the ophthalmic artery in the optic canal

Acta Neurochir (2016) 158:1343–1350

The endoscopic endonasal opening of the optic canal has been recently proposed for tumors with medial invasion of this canal, such as tuberculum sellae meningiomas. Injury of the ophthalmic artery represents a dramatic risk during this maneuver. Therefore, the aim of this study was to analyze the endoscopic endonasal anatomy of the precanalicular and canalicular portion of this vessel, discussing its clinical implication.

Methods The course of the ophthalmic artery was analyzed through five endoscopic endonasal dissections, and 40 nonpathological consecutive MRAs were reviewed.

Results The ophthalmic artery arises from the intradural portion of the supraclinoid internal carotid artery, in 93%of cases about 1.9 mm (range: 1–3) posterior to the falciform ligament. At the entrance into the optic canal, the ophthalmic artery is located infero-medially to the optic nerve in 13 % of cases. In 50 % of these cases the artery moves infero-laterally along its course, remaining in a medial position in the others. In cases with an non medial entrance of the ophthalmic artery, it runs infero-lateral to the optic nerve for its entire canalicular portion, with just one exception.

Conclusion The endoscopic endonasal approach gives a direct, extensive and panoramic view of the course of the precanalicular and canalicular portion of the ophthalmic artery. Dedicated high-field neuroimaging studies are of paramount importance in preoperative planning to evaluate the anatomy of the ophthalmic artery, reducing the risk of jeopardizing the vessel, particularly for those uncommon cases with an infero-medial course of the artery.

Endo ICG videoangiography: localizing the carotid artery in skull-base endonasal approaches

Endo ICG videoangiography- localizing the carotid artery in skull-base endonasal approaches

Acta Neurochir (2016) 158:1351–1353

In this work, the applicability of ICG-VA to skull base endoscopic surgery and its capacity to locate the internal carotid artery are shown.

Methods: An adapted optical module to perform ICG-VA was used to perform endoscopic procedures. There were two intraoperative phases of interest that were used to evaluate the ICA: upon exposure of the skull base and during the intradural exploration.

This new tool for obtaining ICA images in real time (as opposed to with navigation), and it is demonstrated that this tool provides a superior ability to detect the margins of the ICA compared with the Doppler technique. On the other hand, the present technique also provides enhancement of the artery through the bone of the skull base without the need for drilling.

Conclusions: ICG-VA is a safe and effective technique for locating the ICA in skull-base expanded endonasal surgery. Furthermore, this technique can provide real-time guidance for the surgeon and increase safety for the patient.

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors

Endoscopic endonasal surgery for craniopharyngiomas

J Neurosurg 124:627–638, 2016

Craniopharyngiomas and similar midline suprasellar tumors have traditionally been resected via transcranial approaches. More recently, expanded endoscopic endonasal transsphenoidal approaches have gained interest. Surgeons have advocated for both approaches, and at present there is no consensus whether one approach is superior to the other. The authors therefore compared surgical outcomes between craniotomy and endoscopic endonasal transsphenoidal surgery (EETS) for suprasellar tumors treated at their institution.

Methods: A retrospective review of patients undergoing resection of suprasellar lesions at Cedars-Sinai Medical Center between 2000 and 2013 was performed. Patients harboring suspected craniopharyngioma were selected for extensive review. Other pathologies or predominantly intrasellar masses were excluded. Cases were separated into 2 groups, based on the surgical approach taken. One group underwent EETS and the other cohort underwent craniotomy. Patient demographic data, presenting symptoms, and previous therapies were tabulated. Preoperative and postoperative tumor volume was calculated for each case based on MRI. Student t-test and the chi-square test were used to evaluate differences in patient demographics, tumor characteristics, and outcomes between the 2 cohorts. To assess for selection bias, 3 neurosurgeons who did not perform the surgeries reviewed the preoperative imaging studies and clinical data for each patient in blinded fashion and indicated his/her preferred approach. These data were subject to concordance analysis using Cohen’s kappa test to determine if factors other than surgeon preference influenced the choice of surgical approach.

Results: Complete data were available for 53 surgeries; 19 cases were treated via EETS, and 34 were treated via craniotomy. Patient demographic data, preoperative symptoms, and tumor characteristics were similar between the 2 cohorts, except that fewer operations for recurrent tumor were observed in the craniotomy cohort compared with EETS (17.6% vs 42.1%, p = 0.05). The extent of resection was similar between the 2 groups (85.6% EETS vs 90.7% craniotomy, p = 0.77). An increased rate of cranial nerve injury was noted in the craniotomy group (0% EETS vs 23.5% craniotomy, p = 0.04). Postoperative CSF leak rate was higher in the EETS group (26.3% EETS vs 0% craniotomy, p = 0.004). The progression-free survival curves (log-rank p = 0.99) and recurrence rates (21.1% EETS vs 23.5% craniotomy, p = 1.00) were similar between the 2 groups. Concordance analysis of cases reviewed by 3 neurosurgeons indicated that individual surgeon preference was the only factor that determined surgical approach (kappa coefficient -0.039, p = 0.762)

Conclusions: Surgical outcomes were similar for tumors resected via craniotomy or EETS, except that more CSF leaks occurred in the EETS cohort, whereas more neurological injuries occurred in the craniotomy cohort. Surgical approach appears to mostly reflect surgeon preference rather than specific tumor characteristics. These data support the view that EETS is a viable alternative to craniotomy, providing a similar extent of resection with less neurological injury.

Endoscopic versus microscopic surgery using a port retractor

Comparison of endoscope- versus microscope-assisted resection of deep-seated intracranial lesions using a minimally invasive port retractor system

J Neurosurg 124:799–810, 2016

Tubular brain retractors may improve access to deep-seated brain lesions while potentially reducing the risks of collateral neurological injury associated with standard microsurgical approaches. Here, microscope-assisted resection of lesions using tubular retractors is assessed to determine if it is superior to endoscope-assisted surgery due to the technological advancements associated with modern tubular ports and surgical microscopes.

Methods Following institutional approval of the tubular port, data obtained from the initial 20 patients to undergo transportal resection of deep-seated brain lesions were analyzed in this study. The pathological entities of the resected tissues included metastatic tumors (8 patients), glioma (7), meningioma (1), neurocytoma (1), radiation necrosis (1), primitive neuroectodermal tumor (1), and hemangioblastoma (1). Surgery incorporated endoscopic (5 patients) or microscopic (15) assistance. The locations included the basal ganglia (11 patients), cerebellum (4), frontal lobe (2), temporal lobe (2), and parietal lobe (1). Cases were reviewed for neurological outcomes, extent of resection (EOR), and complications. Technical data for the port, surgical microscope, and endoscope were analyzed.

Results EOR was considered total in 14 (70%), near total (> 95%) in 4 (20%), and subtotal (< 90%) in 2 (10%) of 20 patients. Incomplete resection was associated with the basal ganglia location (p < 0.05) and use of the endoscope (p < 0.002). Four of 5 (80%) endoscope-assisted cases were near-total (2) or subtotal (2) resection. Histopathological diagnosis, presenting neurological symptoms, and demographics were not associated with EOR. Complication rates were low and similar between groups.

Conclusions Initial experience with tubular retractors favors use of the microscope rather than the endoscope due to a wider and 3D field of view. Improved microscope optics and tubular retractor design allows for binocular vision with improved lighting for the resection of deep-seated brain lesions.

Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma

Intraoperative high-field MRI for transsphenoidal reoperations of nonfunctioning pituitary adenoma

J Neurosurg 124:596–604, 2016

The comparative efficacy of microscopic and fully endoscopic transsphenoidal surgery for pituitary adenomas has not been well studied despite the adoption of fully endoscopic surgery by many pituitary centers. The influence of surgeon experience has also not been examined in this setting. The authors therefore compared the extent of tumor resection (EOR) and the endocrine outcomes of 1 very experienced surgeon performing a microscopic transsphenoidal surgery technique with those of a less experienced surgeon using a fully endoscopic transsphenoidal surgery technique for resection of nonfunctioning pituitary adenomas in a concurrent series of patients.

Methods Post hoc analysis was conducted of a cohort of adult patients prospectively enrolled in a pituitary adenoma quality-of-life study between October 2011 and June 2014. Patients were followed up for 6 months after surgery. Patients were treated either by a less experienced surgeon (100 independent cases) who practices fully endoscopic surgery exclusively or by a very experienced surgeon (1800 independent cases) who practices microscopic surgery exclusively. Patient demographic characteristics, tumor characteristics, hypopituitarism, complications, and length of hospital stay were analyzed. Tumor volumes and EOR were determined by formal volumetric analysis involving manual segmentation of MR images performed before surgery and within 6 months after surgery. Logistic regression analysis was used to determine predictors of EOR.

Results Fifty-five patients underwent fully endoscopic transsphenoidal surgery, and 80 patients underwent fully microscopic transsphenoidal surgery. The baseline characteristics of the 2 treatment groups were well matched. EOR was similar between the endoscopic and microscopic groups, respectively, as estimated by gross-total resection rate (78.2% vs 81.3%, p = 0.67), percentage of tumor resected (99.2% vs 98.7%, p = 0.42), and volume of residual tumor (0.12 cm3 vs 0.20 cm3, p = 0.41). Multivariate modeling suggested that preoperative tumor volume was the most important predictor of EOR (p = 0.001). No difference was found in the development of anterior gland dysfunction (p > 0.14), but there was a higher incidence of permanent posterior gland dysfunction in the microscopic group (p = 0.04). Combined rates of major complications and unplanned readmissions were lower in the endoscopic group (p = 0.02), but individual complications were not significantly different.

Conclusions A less experienced surgeon using a fully endoscopic technique was able to achieve outcomes similar to those of a very experienced surgeon using a microscopic technique in a cohort of patients with nonfunctioning tumors smaller than 60 cm3. The study raises the provocative notion that certain advantages afforded by the fully endoscopic technique may impact the learning curve in pituitary surgery for nonfunctioning adenomas.

Full endoscopic endonasal transsellar-transclival approach: the modularity concept

Full endoscopic endonasal transsellar-transclival approach- the modularity concept

Acta Neurochir (2016) 158:437–439

Endoscopic endonasal approaches (EEAs) constitute a reasonable option for the treatment of lesions that involve the sellar and clival regions.

Methods We describe, step by step, the full EEA expanded to the middle and lower clivus for the treatment of perisellar lesions. Delimiting different modules around the sellar region is useful in establishing the best endoscopic approach for each tumor.

A craniopharyngioma (CP) with clival extension will be used as an illustrative example of the modularity concept of these approaches.

Conclusions Transsellar-transclival EEA allows complete resection of lesions located in the sellar and infrasellar region with a low rate of complications.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain

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