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Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea

Daniel C. Kreatsoulas, Varun S. Shah, Bradley A. Otto, Ricardo L. Carrau, Daniel M. Prevedello, and Douglas A. Hardesty

OBJECTIVE

Spontaneous CSF leaks are rare, their diagnosis is often delayed, and they can precipitate meningitis. Craniotomy is the historical “gold standard” repair for these leaks. An endonasal endoscopic approach (EEA) offers potentially less invasiveness and lower surgical morbidity than a traditional craniotomy but must yield the same surgical success. A paucity of data exists studying EEA as the primary management for spontaneous CSF leaks.

METHODS

The authors retrospectively reviewed patients undergoing spontaneous CSF rhinorrhea repair at their institution from July 2010 to August 2018. Standardized management includes EEA as first-line treatment, and lumbar puncture (LP) performed 24–48 hours postoperatively. If opening pressure on LP is elevated, CSF diversion or acetazolamide therapy is used as needed. Perioperative lumbar drains are not used.

RESULTS

Of 46 patients identified, the most common CSF rhinorrhea etiology was encephalocele (28/46, 60.9%), and the most common location was cribriform/ethmoid (26/46, 56.5%). Forty-three patients underwent EEA alone, and 3 underwent a simultaneous EEA/craniotomy. The most common repair strategy was nasoseptal or other pedicled flaps (18/46, 39.1%). Postoperatively, 15 patients (32.6%) received CSF diversion due to elevated ICP, with BMI > 40 kg/m2 being a significant risk factor (odds ratio 4.35, p = 0.033) for postrepair shunt placement. Twelve patients received acetazolamide therapy for treatment of mildly elevated pressures. The average opening pressure of the shunted group was 36 cm H2O and the average for the acetazolamide-only group was 26 cm H2O. Two patients underwent CSF leak repair revision, one because of progressive fungal sinusitis and the other because of recurrent CSF leak. The mean follow-up duration was 15 months.

CONCLUSIONS

The paradigm of EEA repair of spontaneous CSF rhinorrhea with postoperative LP to identify undiagnosed idiopathic intracranial hypertension appears to be safe and effective. In the authors’ cohort, morbid obesity was statistically associated with the need for postoperative CSF diversion. This has implications for future surgical treatment as obesity levels continue to rise worldwide.

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Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010–2018

Douglas A. Hardesty, Alaa Montaser, Daniel Kreatsoulas, Varun S. Shah, Kyle K. VanKoevering, Bradley A. Otto, Ricardo L. Carrau, and Daniel M. Prevedello

OBJECTIVE

The endoscopic endonasal approach (EEA) has evolved into a mainstay of skull base surgery over the last two decades, but publications examining the intraoperative and perioperative complications of this technique remain scarce. A prior landmark series of 800 patients reported complications during the first era of EEA (1998–2007), parallel to the development of many now-routine techniques and technologies. The authors examined a single-institution series of more than 1000 consecutive EEA neurosurgical procedures performed since 2010, to elucidate the safety and risk factors associated with surgical and postoperative complications in this modern era.

METHODS

After obtaining institutional review board approval, the authors retrospectively reviewed intraoperative and postoperative complications and their outcomes in patients who underwent EEA between July 2010 and June 2018 at a single institution.

RESULTS

The authors identified 1002 EEA operations that met the inclusion criteria. Pituitary adenoma was the most common pathology (n = 392 [39%]), followed by meningioma (n = 109 [11%]). No patients died intraoperatively. Two (0.2%) patients had an intraoperative carotid artery injury: 1 had no neurological sequelae, and 1 had permanent hemiplegia. Sixty-one (6.1%) cases of postoperative cerebrospinal fluid leak occurred, of which 45 occurred during the original surgical hospitalization. Transient postoperative sodium dysregulation was noted after 87 (8.7%) operations. Six (0.6%) patients were treated for meningitis, and 1 (0.1%) patient died of a fungal skull base infection. Three (0.3%) patients died of medical complications, thereby yielding a perioperative 90-day mortality rate of 0.4% (4 deaths). High-grade (Clavien-Dindo grade III–V) complications were identified after 103 (10%) EEA procedures, and multivariate analysis was performed to determine the associations between factors and these more serious complications. Extradural EEA was significantly associated with decreased rates of these high-grade complications (OR [95% CI] 0.323 [0.153–0.698], p = 0.0039), whereas meningioma pathology (OR [95% CI] 2.39 [1.30–4.40], p = 0.0053), expanded-approach intradural surgery (OR [95% CI] 2.54 [1.46–4.42], p = 0.0009), and chordoma pathology (OR [95% CI] 9.31 [3.87–22.4], p < 0.0001) were independently associated with significantly increased rates of high-grade complications.

CONCLUSIONS

The authors have reported a large 1002-operation cohort of EEA procedures and associated complications. Modern EEA surgery for skull base pathologies has an acceptable safety profile with low morbidity and mortality rates. Nevertheless, significant intraoperative and postoperative complications were correlated with complex intradural procedures and meningioma and chordoma pathologies.

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Quantitative analysis of the surgical exposure and surgical freedom between transcranial and transorbital endoscopic anterior petrosectomies to the posterior fossa

Raywat Noiphithak, Juan C. Yanez-Siller, Juan Manuel Revuelta Barbero, Bradley A. Otto, Ricardo L. Carrau, and Daniel M. Prevedello

OBJECT

This study proposes a variation of the transorbital endoscopic approach (TOEA) that uses the lateral orbit as the primary surgical corridor, in a minimally invasive fashion, for the posterior fossa (PF) access. The versatility of this technique was quantitatively analyzed in comparison with the anterior transpetrosal approach (ATPA), which is commonly used for managing lesions in the PF.

METHODS

Anatomical dissections were carried out in 5 latex-injected human cadaveric heads (10 sides). During dissection, the PF was first accessed by TOEAs through the anterior petrosectomy, both with and without lateral orbital rim osteotomies (herein referred as the lateral transorbital approach [LTOA] and the lateral orbital wall approach [LOWA], respectively). ATPAs were performed following the orbital approaches. The stereotactic measurements of the area of exposure, surgical freedom, and angles of attack to 5 anatomical targets were obtained for statistical comparison by the neuronavigator.

RESULTS

The LTOA provided the smallest area of exposure (1.51 ± 0.5 cm2, p = 0.07), while areas of exposure were similar between LOWA and ATPA (1.99 ± 0.7 cm2 and 2.01 ± 1.0 cm2, respectively; p = 0.99). ATPA had the largest surgical freedom, whereas that of LTOA was the most restricted. Similarly, for all targets, the vertical and horizontal angles of attack achieved with ATPA were significantly broader than those achieved with LTOA. However, in LOWA, the removal of the lateral orbital rim allowed a broader range of movement in the horizontal plane, thus granting a similar horizontal angle for 3 of the 5 targets in comparison with ATPA.

CONCLUSIONS

The TOEAs using the lateral orbital corridor for PF access are feasible techniques that may provide a comparable surgical exposure to the ATPA. Furthermore, the removal of the orbital rim showed an additional benefit in an enhancement of the surgical maneuverability in the PF.

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The role of indocyanine green fluorescence in endoscopic endonasal skull base surgery and its imaging correlations

Mostafa Shahein, Daniel M. Prevedello, Thomas L. Beaumont, Khalid Ismail, Radwan Nouby, Marilly Palettas, Luciano M. Prevedello, Bradley A. Otto, and Ricardo L. Carrau

OBJECTIVE

The use of endoscope-integrated indocyanine green (E-ICG) has recently been introduced in skull base surgery. The quantitative correlation between E-ICG and T1-weighted gadolinium-enhanced (T1WGd) images for skull base tumors has not been previously assessed, to the authors’ knowledge. In this study, the authors investigated the indications for use and the limitations of E-ICG and sought to correlate the endoscopic fluorescence pattern with MRI contrast enhancement.

METHODS

Following IRB approval, 20 patients undergoing endoscopic endonasal skull base surgery between June 2017 and August 2018 were enrolled in the study. Tumor fluorescence was measured using a blue color value and blood fluorescence as a control. Signal intensities (SIs) of tumor T1WGd images were measured and the internal carotid artery (ICA) SI was used as a control. For pituitary adenoma, the pituitary gland fluorescence was also measured. The relationships between ICG fluorescence and MRI enhancement measurements were analyzed.

RESULTS

Data showed that in pituitary adenoma there was a strong correlation between the ratios of gland/blood fluorescence to gland/ICA SI (n = 8; r = 0.92; p = 0.001) and tumor/blood fluorescence to tumor/ICA SI (n = 9; r = 0.82; p = 0.006). In other pathologies there was a strong correlation between the ratios of tumor/blood fluorescence and tumor/ICA SI (n = 9; r = 0.74; p = 0.022). The ICG fluorescence allowed perfusion assessment of the pituitary gland as well as of the nasoseptal flaps. Visualization of the surrounding vasculature was also feasible.

CONCLUSIONS

Defining the indications and understanding the limitations are critical for the effective use of E-ICG. Tumor fluorescence seems to correlate with preoperative MRI contrast enhancement.