Tag: anterior skull base

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Reconstruction of the anterior skull base after major trauma or extensive tumour resection

Reconstruction of the anterior skull base after major trauma or extensive tumour resectionActa Neurochir (2015) 157:139–144

The authors describe their experience with the reconstruction of complex anterior skull base defects after trauma or tumour resection using a “sandwich” technique with pericranial flap, titanium mesh and TachoSil.

Methods Description of surgical anatomy, surgical technique, indications, limitations, complications, specific perioperative considerations and specific information to give to the patient about surgery and potential risks. A summary of ten key points is given.

Conclusions After a bifrontal craniotomy and a subfrontal approach, it is possible to achieve a reliable reconstruction of the anterior skull base in a watertight manner by fixing a pericranial flap or a fascia lata graft to the orbital roofs and planum sphenoidale with an individually tailored titanium mesh and closing the frontobasal dura lesion with TachoSil.

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The 1-piece transbasal approach

The 1-piece transbasal approach

J Neurosurg 121:1446–1452, 2014

The transbasal approach (TBA) is an anterior skull base approach, which provides access to the anterior skull base, sellar-suprasellar region, and clivus. The TBA typically involves a bifrontal craniotomy with orbital bar and/or nasal bone osteotomies performed in 2 separate steps. The authors explored the feasibility of routinely performing this approach in 1 piece with a quantitative cadaveric anatomical study, and present an operative case example of their approach.

Methods. Seven latex-injected cadaveric heads underwent a 1-piece TBA, followed by additional bone removal typical for a traditional 2-piece approach. Six surgical angles relative to the pituitary stalk, as well as the surface area of the orbital roof osteotomy, were measured before and after additional bone removal. The vertical angle from the frontonasal suture to the foramen cecum was measured in all specimens. In addition to an anatomical study, the authors have used this technique in the operating room, and present an illustrative case of resection of an anterior skull base meningioma.

Results. Morphometric results were as follows: the vertical angle from the frontonasal suture to the foramen cecum ranged from 17.4° to 29.7° (mean 23.8° ± 4.8°) superiorly. Of the 6 surgical angle measures, only the middle horizontal angle was increased in the 2-piece versus the 1-piece approach (mean 43.4° ± 4.6° vs 43.0° ± 4.3°, respectively; p = 0.049), with a mean increase of 0.4°. The surface area of the orbital osteotomy was increased in the 2-piece versus the 1-piece approach (mean 2467 mm2 ± 360 mm2 vs 2045 mm2 ± 352 mm2, respectively; p < 0.001). The patient in the illustrative clinical case had a good outcome, both clinically and cosmetically.

Conclusions. The 1-piece TBA provides an alternative to the traditional 2-piece approach. It allows easier reconstruction, potentially decreased operative time, and improved cosmesis. While more of the orbital roof can be removed with the 2-piece approach, this additional bone removal offers only a small increase in 1 of 6 surgical angles that were measured.

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The anterior interhemispheric approach – a safe and effective approach to anterior skull base lesions

Interhemispheric app

Acta Neurochir (2014) 156:689–696

Many approaches to the anterior skull base have been reported. Frequently used are the pterional, the unilateral or bilateral frontobasal, the supraorbital and the frontolateral approach. Recently, endoscopic transnasal approaches have become more popular. The benefits of each approach has to be weighted against its complications and limitations. The aim of this study was to investigate if the anterior interhemispheric approach (AIA) could be a safe and effective alternative approach to tumorous and non-tumorous lesions of the anterior skull base.

Methods We screened the operative records of all patients with an anterior skull base lesion undergoing transcranial surgery.We have used the AIA in 61 patients. These were exclusively patients with either olfactory groove meningioma (OGM) (n =43), ethmoidal dural arteriovenous fistula (dAVF) ( n =6) or frontobasal fractures of the anterior midline with cerebrospinal fluid (CSF) leakage ( n =12). Patient records were evaluated concerning accessibility of the lesion, realization of surgical aims (complete tumor removal, dAVF obliteration, closure of the dural tear), and approach related complications.

Results The use of the AIA exclusively in OGMs, ethmoidal dAVFs and midline frontobasal fractures indicated that we considered lateralized frontobasal lesions not suitable to be treated successfully. If restricted to these three pathologies, the AIA is highly effective and safe. The surgical aim (complete tumor removal, complete dAVF occlusion, no rhinorrhea) was achieved in all patients. The complication rate was 11.5 % (wound infection (n =2; 3.2 %), contusion of the genu of the corpus callosum, subdural hygroma, epileptic seizure, anosmia and asymptomatic bleed into the tumor cavity (n =1 each). Only the contusion of the corpus callosum was directly related to the approach (1.6 %). Olfaction, if present before surgery, was preserved in all patients, except one (1.6 %).

Conclusions The AIA is an effective and a safe approach to tumorous, vascular and traumatic pathologies of the midline anterior skull base. This approach should be part of the armamentarium of skull base surgeons.

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