Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results

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OBJECTIVE

Tumors involving Meckel’s cave remain extremely challenging because of the surrounding complex neurovascular structures and deep-seated location. The authors investigated a new minimal-access technique using the endoscopic transorbital approach (eTOA) through the superior eyelid crease to Meckel’s cave and middle cranial fossa lesions and reviewed the most useful surgical procedures and pitfalls of this approach.

METHODS

Between September 2016 and January 2018, the authors performed eTOA in 9 patients with tumors involving Meckel’s cave and the middle cranial fossa. The lesions included trigeminal schwannoma in 4 patients, meningioma in 2 patients, metastatic brain tumor in 1 patient, chondrosarcoma in 1 patient, and dermoid cyst in 1 patient. In 7 of the 9 patients, eTOA alone was performed, while the other 2 patients underwent a combined eTOA and endoscopic endonasal approach or retrosigmoid craniotomy. Data including details of surgical techniques and clinical outcomes were recorded.

RESULTS

Gross-total resection was performed in 7 of the 9 patients (77.8%). Four patients underwent extended eTOA (with lateral orbital rim osteotomy). Drilling of the trapezoid sphenoid floor, a middle fossa “peeling” technique, and full visualization of Meckel’s cave were applied to approach the lesions. Tumors were exposed and removed extradurally in 3 patients and intradurally in 6 patients. There was no postoperative CSF leak.

CONCLUSIONS

The eTOA affords a direct route to access Meckel’s cave and middle cranial fossa lesions. With experience, this novel approach can be successfully applied to selected skull base lesions. To achieve successful removal of the tumor, emphasis should be placed on the importance of adequately removing the greater sphenoid wing and vertical crest. However, because of limited working space eTOA may not be an ideal approach for posterior fossa lesions.

ABBREVIATIONS eTOA = endoscopic transorbital approach; GTR = gross-total resection; ICA = internal carotid artery; IOF = inferior orbital fissure; MOB = meningo-orbital band; PTR = partial tumor resection; SOF = superior orbital fissure; STR = subtotal resection.

Article Information

Correspondence Doo-Sik Kong: Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. neurokong@gmail.com; kds026@skku.edu.

INCLUDE WHEN CITING Published online November 30, 2018; DOI: 10.3171/2018.6.JNS181099.

C.J. and C.K.H. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Artistic illustration of each step in the endoscopic transorbital surgery. Superior eyelid incision (A). Periosteal incision on the superolateral orbital rim after subocularis dissection (B). Periosteal and periorbital elevation (C). Exposure of the SOF (D). Bone drilling on the greater sphenoid wing (GSW) while the orbit is covered with a silastic sheet (E). Exposure of the MOB between the orbit and the temporal dura (TD) (F). Exposure of tumor (Tm) between the TD and orbit after interdural dissection (G). Comparative illustration of the MOB as viewed in the transcranial approach (H). FD = frontal dura. Copyright Doo-Sik Kong. Used with permission.

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    Illustrative case 2. A 66-year-old woman with trigeminal schwannoma involving the lateral orbit and Meckel’s cave presented with progressive proptosis of 18 mm (A). After endoscopic transorbital surgery, the patient had third nerve palsy and complete ptosis. However, the third nerve palsy was resolved 6 months after surgery (B). Preoperative MR imaging indicated that the tumor involved the cavernous sinus and extended into the orbit, resulting in severe proptosis (C). Postoperative MR imaging shows the area after GTR (D). Surgical details are as follows: after a skin incision along the superior eyelid crease, the periosteum was exposed over the lateral orbital rim, and lateral orbital osteotomy was performed. The periorbita was then elevated posteriorly up to the outer margin of the superior orbital fissure (arrow, E). Drilling with a high-speed diamond burr was performed with covering of the periorbita with a silastic sheet (F). After full exposure of the temporal dura, the MOB (arrow) was cut and interdural dissection exposed the tumor capsule (G). Tumor capsules were separately dissected from the surrounding tissues (H). The tumor was first debulked (I) and then totally removed. The opening of the posterior fossa was sealed with TachoSil (J).

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    Illustrative case 4. A 64-year-old woman with a trigeminal schwannoma involving the middle cranial fossa (A). During the endoscopic transorbital superior eyelid approach, subperiosteal elevation was performed along the lateral orbital wall (B). Bony drilling was started from the lateral to the medial side of the greater sphenoid wing (C). The MOB was exposed and cut (D). Profuse bleeding from the cavernous sinus was encountered, but was easily controlled with a Floseal. The tumor was exposed between the outer cavernous membrane and the dural propria (E). After removal of the tumor within Meckel’s cave, some portion of the tumor extending into the posterior fossa was found (F). Gross-total resection was done (G). Allograft dermis was placed for the dural defect (H) and polymerized absorbable Medpor was used for reconstruction.

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    Illustrative case 6. A 60-year-old woman presented with sudden dizziness from the rupture of a dermoid cyst. MR imaging showed a high signal intensity lesion within Meckel’s cave. An endoscopic transorbital superior eyelid crease approach was performed. Subocularis dissection was carefully performed so as not to injure the levator aponeurosis (A). Gentle subperiosteal elevation along the lateral orbital wall exposed the superior orbital fissure (B). After identification of the MOB, dissection of the MOB exposed the interdural plane (C). The dermoid capsule within Meckel’s cave was exposed (D). After dermoid contents were removed, Meckel’s cave and the posterior fossa space were identified (E). The dermoid capsule was removed (F). Allograft fascia lata was placed for reconstruction of the dural defect (G). Finally, polymerized absorbable Medpor was placed to prevent postoperative enophthalmos (H).

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    Preoperative and postoperative MR images obtained in this series for cases 1–5. A: Case 1, chondrosarcoma involving Meckel’s cave, the middle cranial fossa, and the infratemporal fossa shown on the preoperative MR images (A1 and A2) and postoperative MR images (A3 and A4) after GTR. B: Case 2, trigeminal schwannoma involving the orbit and Meckel’s cave on preoperative MR images (B1 and B2) and postoperative MR images (B3 and B4) after GTR. C: Case 3, metastatic brain tumor on the preoperative MR images (C1 and C2) and postoperative MR images (C3 and C4) after GTR. D: Case 4, trigeminal schwannoma involving the middle cranial fossa on the preoperative MR images (D1 and D2) and postoperative MR images (D3 and D4) after GTR. E: Case 5, trigeminal schwannoma on the preoperative MR images (E1 and E2) and postoperative MR images after an intended PTR using eTOA (E3), followed by the retrosigmoid approach for the remaining posterior fossa tumor (E4).

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    Preoperative and postoperative MR images obtained in this series for cases 6–9. A: Case 6, dermoid cyst rupture on the preoperative MR images (A1 and A2) and postoperative MR images (A3 and A4) after GTR. B: Case 7, trigeminal schwannoma preoperative MR images (B1 and B2) and postoperative MR images (B3 and B4) after GTR. C: Case 8, middle cranial fossa meningioma on the preoperative MR images (C1 and C2) and postoperative MR images (C3 and C4). D: Case 9, middle cranial fossa meningioma on the preoperative MR images (D1 and D2) and postoperative MR images (D3 and D4).

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