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Amin Kassam, Carl H. Snyderman, Ricardo L. Carrau, Paul Gardner and Arlan Mintz

The increasing popularity of minimally invasive neurosurgery has led to the development of transnasal expanded approaches for the treatment of skull base lesions. One of the greatest challenges in safely accomplishing resection of tumors, particularly intradural lesions, is effective hemostasis. Over the past 7 years the authors have progressively developed an organized approach to address this challenge. This has required the development of new instrumentation as well as variations on standard techniques. In this report they present the technique that has evolved at their institution for endoneurosurgical hemostasis.

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Amin Kassam, Carl H. Snyderman, Arlan Mintz, Paul Gardner and Ricardo L. Carrau

Object

Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. More recently, the standard endonasal approach has been expanded to provide access to other, parasellar lesions. With the addition of the endoscope, this expansion carries significant potential for the resection of skull base lesions.

Methods

The anatomical landmarks and surgical techniques used in expanded (extended) endoscopic approaches to the rostral, anterior skull base are reviewed and presented, accompanied by case illustrations of each segment (or module) of approach. The rostral half of the anterior skull base is divided into modules of approach: sellar/parasellar, transplanum/transtuberculum, and transcribriform. Case illustrations of successful resections of lesions with each module are presented and discussed.

Conclusions

Endoscopic, expanded endonasal approaches to rostral anterior skull base lesions are feasible and hold great potential for decreased morbidity. The effectiveness and appropriate use of these techniques must be evaluated by close examination of outcomes as case series expand.

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Amin Kassam, Carl H. Snyderman, Arlan Mintz, Paul Gardner and Ricardo L. Carrau

Object

Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. Recently, however, the standard endonasal approach has been expanded to provide access to other parasellar lesions. With the addition of the endoscope, this expansion has significant potential for the resection of skull base lesions.

Methods

The anatomical landmarks and surgical techniques used in expanded (extended) endoscopic approaches to the clivus and cervicomedullary junction are reviewed and presented, accompanied by case illustrations of each segment (or module) of approach.

The caudal portion of the midline anterior skull base and the cervicomedullary junction is divided into modules of approach: the middle third of the clivus, its lower third, and the cervicomedullary junction. Case illustrations of successful resections of lesions via each module of the approach are presented and discussed.

Conclusions

Endoscopic expanded endonasal approaches to caudally located midline anterior skull base and cervicomedullary lesions are feasible and hold great potential for decreased morbidity. The effectiveness and appropriate use of these techniques must be evaluated by close examination of outcomes as case series expand.

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Daniel M. Prevedello, Amin B. Kassam, Ricardo L. Carrau, Carl H. Snyderman, Ajith Thomas, Paul Gardner, Arlan Mintz, Lisa Vecchione and Joseph Losee

the epignathus teratoma described in this report, is an excellent alternative to conventional transfacial/transcranial approaches for the treatment of neonatal skull base lesions. This new approach has the advantage of allowing better visualization for adequate resection of skull base lesions in the neonate while preserving craniofacial growth harmony with extremely low morbidity. Optimistically, this approach may prove to be a method that can diminish the incidence of recurrence of skull base teratomas. Yet because these are very rare lesions, a long period of time

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Marc R. Mayberg

Kassam and colleagues 8 retrospectively analyzed their experience using endonasal endoscopic approaches to treat 800 patients with a variety of ventrally situated skull base lesions at a single institution over a 9-year interval. The latter 200 patients were analyzed from a prospectively derived database. Patients were categorized according to age and the complexity of the surgical approach. Outcomes in this analysis were restricted to complications that occurred in the perioperative period, including mortality, nonfatal vascular and systemic events, and

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Amin B. Kassam, Daniel M. Prevedello, Ricardo L. Carrau, Carl H. Snyderman, Ajith Thomas, Paul Gardner, Adam Zanation, Bulent Duz, S. Tonya Stefko, Karin Byers and Michael B. Horowitz

compression due to the use of a graft used for reconstruction after a transbasal approach for anterior skull base lesions. Origitano et al. 48 reported a 7.4% incidence of delayed deficits caused by postoperative hematoma or by problems with the reconstructive flap after skull base surgery for malignancies. An EEA for craniopharyngiomas has been associated with delayed complications in the literature. Frank et al. 21 encountered a 20% rate of subdural hematomas, and de Divitiis et al. 10 had the same complication in 10% of their cases. De Divitiis et al. 11 encountered

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José M. Pascual, Ruth Prieto, Rodrigo Carrasco, Inés Castro-Dufourny and Laura Barrios

, Yu Y , Gu Y : 3D-FIESTA MR images are useful in the evaluation of the endoscopic expanded endonasal approach for midline skull-base lesions . Acta Neurochir (Wien) 153 : 12 – 18 , 2011 39 Yaşargil MG , Curcic M , Kis M , Siegenthaler G , Teddy PJ , Roth P : Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients . J Neurosurg 73 : 3 – 11 , 1990

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Andrew S. Little, Daniel F. Kelly, John Milligan, Chester Griffiths, Daniel M. Prevedello, Ricardo L. Carrau, Gail Rosseau, Garni Barkhoudarian, Heidi Jahnke, Charlene Chaloner, Kathryn L. Jelinek, Kristina Chapple and William L. White

speculum. 9 , 19–21 In microscopic surgery, the surgeon expands the nasal corridor with a speculum, which stretches the nasal vestibule and fractures the turbinates. In contrast, in the endoscopic technique, the surgeon creates the surgical corridor by removing nasal tissue (for example, by creating a posterior septectomy or posterior ethmoidectomy) to accommodate the endoscope and dissectors. Despite the widespread adoption of endoscopic transsphenoidal surgery for sellar pathology and other more extensive skull base lesions, the sinonasal morbidity and QOL of

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Jun Muto, Daniel M. Prevedello, Leo F. S. Ditzel Filho, Ing Ping Tang, Kenichi Oyama, Edward E. Kerr, Bradley A. Otto, Takeshi Kawase, Kazunari Yoshida and Ricardo L. Carrau

bone window between both paraclival ICAs. We reiterate the growing sentiment in the skull base community that the EEA merely represents an approach that may be more appropriate than traditional open approaches under select conditions, and it must be considered as an option, but not the only option, for addressing skull base lesions. Mastering open and endoscopic endonasal approaches allows the skull base surgical team to better serve their patients and minimize morbidity by offering either approach or a combination of them for complex lesions. References 1

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

O ver 2 decades ago, Kawase et al. pioneered the extended middle fossa approach, also known as the anterior transpetrosal approach (ATPA), allowing for adequate exposure of challenging areas of the skull base, including the petrous apex, anterior cerebellopontine angle, and the upper clival region. 19 Since its inception, this technique has been well studied and broadly reported in the literature. 2 , 12 , 23 , 30 Moreover, its use has been widespread for managing a broad spectrum of skull base lesions, including not only tumors such as meningiomas