Neurosurgery Blog

Neurosurgery 70:110–124, 2012 DOI: 10.1227/NEU.0b013e31822e8ffc

The endoscopic, endonasal, extended transsphenoidal approach is a minimal-access technique for managing craniopharyngiomas. Outcome measures such as return to employment and body mass index (BMI) have not been reported and are necessary for comparison with open transcranial approaches. Most prior reports of the endoscopic, endonasal approach have reported unacceptably high cerebrospinal fluid (CSF) leak rates.

OBJECTIVE: To assess the outcome of endoscopic, endonasal surgery in a consecutive series of craniopharyngiomas with special attention to extent of resection, CSF leak, return to employment, and BMI.

METHODS: Twenty-six surgeries were performed on 24 patients at Weill Cornell Medical College-New York Presbyterian Hospital. Five patients had recurrent lesions. Gross-total resection (GTR) was attempted in 21 surgeries. Indications for intended subtotal resection were advanced age, medical comorbidities, preservation of pituitary function, and hypothalamic invasion.

RESULTS: Mean tumor diameter was 2.9 cm. GTR (18 surgeries) or near-total (.95%) resection (2 surgeries) was achieved in 95% when GTR was the goal. Seven patients received postoperative radiation therapy. Mean follow-up was 35 months with no recurrences in GTR cases and stable disease in all patients at last follow-up. Vision improved in 77%. Diabetes insipidus and panhypopituitarism developed in 42% and 38%, respectively. A more than 9% increase in BMI occurred in 39%; 69% returned to their preoperative profession/schooling. The postoperative CSF leak rate was 3.8%.

CONCLUSION: Minimal-access, endoscopic, endonasal surgery for craniopharyngioma can achieve high rates of GTR with low rates of CSF leak. Return to employment and obesity rates are comparable to microscope-assisted transcranial and transsphenoidal reports.

Neurosurgery 69:1046–1057, 2011 DOI: 10.1227/NEU.0b013e3182287bb9

Nonvestibular schwannomas of the skull base often represent a challenge owing to their anatomic location. With improved techniques in endoscopic endonasal skull base surgery, resection of various ventral skull base tumors, including schwannomas, has become possible.

OBJECTIVE: To assess the outcomes of using endoscopic endonasal approach (EEA) for nonvestibular schwannomas of the skull base.

METHODS: Seventeen patients operated on for skull base schwannomas by EEA at the University of Pittsburgh Medical Center from 2003 to 2009 were reviewed.

RESULTS: Three patients underwent combined approaches with retromastoid craniectomy (n = 2) and orbitopterional craniotomy (n = 1). Three patients underwent multistage EEA. The rest received a single EEA operation. Data on degree of resection were found for 15 patients. Gross total resection (n = 9) and near-total (.90%) resection (n = 3) were achieved in 12 patients (80%). There were no tumor recurrences or postoperative cerebrospinal fluid leaks. In 3 of 7 patients with preoperative sensory deficits of trigeminal nerve distribution, there were partial improvements. Patients with preoperative reduced vision (n = 1) and cranial nerve VI or III palsies (n = 3) also showed improvement. Five patients had new postoperative trigeminal nerve deficits: 2 had sensory deficits only, 1 had motor deficit only, and 2 had both motor and sensory deficits. Three of these patients had partial improvement, but 3 developed corneal neurotrophic keratopathy.

CONCLUSION: An EEA provides adequate access for nonvestibular schwannomas invading the skull base, allowing a high degree of resection with a low rate of complications.

Neurosurg Rev. DOI 10.1007/s10143-011-0329-2

Esthesioneuroblastoma is an uncommon malignant tumor originating in the upper nasal cavity. The surgical treatment for this tumor has traditionally been via an open craniofacial resection. Over the past decade, there has been tremendous development in endoscopic techniques.

In this report, we performed a retrospective analysis of patients with esthesioneuroblastomas treated with a purely endonasal endoscopic approach and resection at the Johns Hopkins Hospital between January 2005 and April 2010.

A total of eight patients with esthesioneuroblastoma, five men and three women, were identified. Six patients were treated for primary disease, and two were treated for tumor recurrence. The modified Kadish staging was A in one patient (12.5%), B in two patients (25%), C in four patients (50%), and D in one patient (12.5%). All patients had a complete resection with negative intraoperative margins. One patient had intraoperative hypertension; there were no perioperative complications. With a mean follow-up of over 27 months, all patients are without evidence of disease. In addition, we reviewed the literature and identified several overlapping case series of patients with esthesioneuroblastoma treated via a purely endoscopic technique.

Our series adds to the growing experience of expanded endonasal endoscopic surgery in the treatment of skull base tumors including esthesioneuroblastoma. Longer follow-up on a larger number of patients is required to further demonstrate the utility of endoscopic approaches in the management of this malignancy.

Neurosurgery 68[ONS Suppl 2]:ons310–ons316, 2011 DOI: 10.1227/NEU.0b013e3182117063

The anterior communicating artery (AcoA) aneurysm is one of the most challenging aneurysms. As endovascular techniques evolve, a remaining challenge is the reduction of complications related to the surgical approach. Although the endonasal approach is widely used for pituitary adenomas and is increasingly popular for suprasellar tumors, only 2 aneurysm cases have been reported.

OBJECTIVE: To the best of our knowledge, we are reporting the first case of successful endoscopic endonasal clipping of an unruptured ACoA aneurysm.

METHODS: An ACoA aneurysm was discovered in a 55-year-old man before he was to undergo an endoscopic biopsy of an orbital lesion. Because of the operative corridor formed during this first operation and ideal conformation of the aneurysm for this line of sight, we formulated an endoscopic route for this ACoA aneurysm.

RESULTS: An endoscopic endonasal transplanum-transtuberculum approach was performed. Proximal and distal control was obtained, and the AcoA aneurysm was successfully clipped. The postoperative course was uneventful with a rapid recovery.

CONCLUSION: On the road of innovation in the treatment of intracranial aneurysms, the endoscopic approach provided another option whose value must be weighed in terms not only of feasibility but in the patient’s best interest. We caution extreme prudence if considering this procedure as an alternative to well-established techniques. Yet its upward route offers limited retraction for deep-seated lesions. Rapid progress of endoscopic techniques may prove promising for well-selected cases of ACoA aneurysms.

http://youtu.be/lGOXYTtvS7o

Neurosurg Focus 29 (4):E5, 2010. DOI: 10.3171/2010.7.FOCUS10153

Using strict biochemical remission criteria, the authors assessed surgical outcomes after endoscopic transsphenoidal resection of growth hormone (GH)–secreting pituitary adenomas and identified preoperative factors that significantly influence the rate of remission.

Methods. A retrospective review of a prospectively maintained database was performed. The authors reviewed cases in which an endoscopic resection of GH-secreting pituitary adenomas was performed. The cohort consisted of 26 patients who had been followed for 3–60 months (mean 24.5 months). The thresholds of an age-appropriate, normalized insulin-like growth factor–I concentration, a nadir GH level after oral glucose load of less than 1.0 μg/l, and a random GH value of less than 2.5 μg/l were required to establish biochemical cure postoperatively.

Results. Overall, in 57.7% of patients undergoing a purely endoscopic transsphenoidal pituitary adenectomy for acromegaly, an endocrinological cure was achieved. The mean clinical follow-up duration was 24.5 months. In patients with microadenomas (4 cases) the cure rate was 75%, whereas in patients harboring macroadenomas (22 cases) the cure rate was 54.5%. Cavernous sinus invasion (Knosp Grades 3 and 4) was associated with a significantly lower remission rate (p = 0.0068). Hardy Grade 3 and 4 tumors were also less likely to achieve biochemical cure (p = 0.013). The overall complication rate was 11.5% including 2 incidents of transient diabetes insipidus and 1 postoperative CSF leak, which were treated nonoperatively.

Conclusions. A purely endoscopic transsphenoidal approach to GH-secreting pituitary adenomas leads to similar outcome for noninvasive macroadenomas compared with traditional microsurgical techniques. Furthermore, this approach may often provide maximal visualization of the tumor, the pituitary gland, and the surrounding neurovascular structures.

Neurosurgery 67[ONS Suppl 1]:ons00-ons00, 2010. DOI: 10.1227/01.NEU.0000354351.00684.B9

To describe a transnasal endoscopic route to the jugular foramen and the endoscopic anatomy of the infratemporal fossa.

CLINICAL PRESENTATION: Endoscopic transnasal dissection of the infratemporal fossa was performed in 3 injected fresh heads (1 head only in arteries and 2 heads in arteries and veins). Two other double-injected specimens were dissected externally (2 of them side laterally and 1 anteriorly) to compare the different views and better understand the 3-dimensionality of the region. Detailed endoscopic anatomy of the infratemporal fossa was clearly observed. The realization of a septal and posterior maxillary window allows surgeons to gain space to the jugular foramen. The ability to manage the vessels, especially the veins, and identify the muscles is mandatory. The fundamental role of the vidian canal in targeting the anterior genu of the internal carotid artery is confirmed. The role of the maxillary and mandibular branches of the trigeminal nerve and the eustachian tube in this kind of approach is critical.

CONCLUSION: A fully transnasal endoscopic route to the jugular foramen is feasible. The most important landmark for this kind of approach is the eustachian tube.

Acta Neurochir (2010) 152:931–939. DOI 10.1007/s00701-010-0646-1

Meningiomas of the anterior skull base show specific characteristics, which render them difficult to handle. These tumors include olfactory groove, supra- and parasellar, anterior sphenoid ridge, cavernous sinus, and spheno-orbital meningiomas. Tumor localization and size, encasement of important structures as well as the extent of dural attachment may influence the decision for an adequate approach.

Discussion Various approaches to the anterior cranial fossa exist, each with corresponding advantages and disadvantages. Recently, endoscopic approaches have increasingly been used. In this review, the different approaches to meningiomas of the anterior cranial fossa in respect of anatomical issues, indications, and associated risks are discussed.

Neurosurgery 66:883-892, 2010 DOI: 10.1227/01.NEU.0000368395.82329.C4

The anterior skull base, in front of the sphenoid sinus, can be approached using a variety of techniques including extended subfrontal, transfacial, and craniofacial approaches. These methods include risks of brain retraction, contusion, cerebrospinal fluid leak, meningitis, and cosmetic deformity. An alternate and more direct approach is the endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach.

METHODS: An endoscopic, endonasal approach was used to treat a variety of conditions of the anterior skull base arising in front of the sphenoid sinus and between the orbits in a series of 44 patients. A prospective database was used to detail the corridor of approach, closure technique, use of intraoperative lumbar drainage, operative time, and postoperative complications. Extent of resection was determined by a radiologist using volumetric analysis.

RESULTS: Pathology included meningo/encephaloceles (19), benign tumors (14), malignant tumors (9), and infectious lesions (2). Lumbar drains were placed intraoperatively in 20 patients. The CSF leak rate was 6.8% for the whole series and 9% for intradural cases. Leaks were effectively managed with lumbar drainage. Early reoperation for cerebrospinal fluid (CSF) leak occurred in 1 patient (2.2%). There were no intracranial infections. Greater than 98% resection was achieved in 12 of 14 benign and 5 of 9 malignant tumors.

CONCLUSION: The endoscopic, endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach is versatile and suitable for managing a variety of pathological entities. This minimal access surgery is a feasible alternative to transcranial, transfacial, or combined craniofacial approaches to the anterior skull base and anterior cranial fossa in front of the sphenoid sinus. The risk of CSF leak and infection are reasonably low and decrease with experience. Longer follow-up and larger series of patients will be required to validate the long-term efficacy of this minimally invasive approach.

Neurosurg Focus 28 (4):E9, 2010. (DOI: 10.3171/2010.1.FOCUS09319)

Although the transsphenoidal approach for subdiaphragmatic craniopharyngiomas has been performed for many years, there are few reports describing the role of the endoscopic transsphenoidal technique for suprasellar craniopharyngiomas. The purpose of this study was to report the outcomes of the endoscopic transsphenoidal approach for adults with craniopharyngiomas in whom the goal was gross-total resection.

Methods. Twelve patients were identified who were older than 18 years at the time of their pure endoscopic transsphenoidal surgery. Their medical records and imaging studies were retrospectively reviewed.

Results. Gross-total resection was achieved in 42% of cases when assessed by intraoperative impression alone and in 75% when assessed by the first postoperative MR imaging study. However, 83% of patients achieved at least a 95% resection when assessed by both intraoperative impression and the first postoperative MR imaging study. Permanent diabetes insipidus occurred postoperatively in 44% of patients. Six (67%) of 9 patients who had a functioning hypothalamic-pituitary axis preoperatively developed panhypopituitarism after surgery. Visual improvement or normalization occurred in 78% of patients with preoperative visual deficits. Although no patient experienced a postoperative CSF leak, 1 patient was treated for meningitis.

Conclusions. The authors have achieved a high rate of radical resection and symptomatic improvement with the endoscopic transsphenoidal technique for both subdiaphragmatic (sellar/suprasellar) and supradiaphragmatic (suprasellar) craniopharyngiomas. However, this is also associated with a high incidence of new endocrinopathy. Endoscopic assessment of tumor resection may be more sensitive for residual tumor than the first postoperative MR imaging study.

Neurosurgery 66:1-10, 2010. DOI: 10.1227/01.NEU.0000368395.82329.C4

The anterior skull base, in front of the sphenoid sinus, can be approached using a variety of techniques including extended subfrontal, transfacial, and craniofacial approaches. These methods include risks of brain retraction, contusion, cerebrospinal fluid leak, meningitis, and cosmetic deformity. An alternate and more direct approach is the endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach.

METHODS: A purely endoscopic, endonasal approach was used to treat a variety of conditions of the anterior skull base arising in front of the sphenoid sinus and between the orbits in a series of 44 patients. A prospective database was used to detail the corridor of approach, closure technique, use of intraoperative lumbar drainage, operative time, and postoperative complications. Extent of resection was determined by a radiologist using volumetric analysis.

RESULTS: Pathology included meningo/encephaloceles (19), benign tumors (14), malignant tumors (9), and infectious lesions (2). Lumbar drains were placed intraoperatively in 20 patients. The CSF leak rate was 6.8% for the whole series and 9% for intradural cases. Leaks were effectively managed with lumbar drainage. Early reoperation for cerebrospinal fluid (CSF) leak occurred in 1 patient (2.2%). There were no intracranial infections. Greater than 98% resection was achieved in 12 of 14 benign and 5 of 9 malignant tumors.

CONCLUSION: The purely endoscopic, endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach is versatile and suitable for managing a variety of pathological entities. This minimal access surgery is a feasible alternative to transcranial, transfacial, or combined craniofacial approaches to the anterior skull base and anterior cranial fossa in front of the sphenoid sinus. The risk of CSF leak and infection are reasonably low and decrease with experience. Longer follow-up and larger series of patients will be required to validate the long-term efficacy of this minimally invasive approach.