✓Craniopharyngiomas have always been an extremely challenging type of tumor to treat. The transsphenoidal route has been used for resection of these lesions since its introduction. The authors present a historical review of the literature from the introduction of the endonasal route for resection of craniopharyngiomas until the present. Abandoned early due to technological limitations, this approach has been expanded both in its application and in its anatomical boundaries with subsequent progressive improvements in outcomes. This expansion has coincided with advances in visualization devices, imaging guidance techniques, and anatomical understanding. The progression from the use of headlights, to microscopy, to endoscopy and fluoroscopy, and finally to modern intraoperative magnetic resonance–guided techniques, combined with collaboration between otolaryngologists and neurosurgeons, has provided the framework for the development of current techniques for the resection of sellar and suprasellar craniopharyngiomas.
Paul A. Gardner, Daniel M. Prevedello, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau and Arlan H. Mintz
Ricky Madhok, Daniel M. Prevedello, Paul Gardner, Ricardo L. Carrau, Carl H. Snyderman and Amin B. Kassam
Rathke cleft cysts (RCCs) are benign lesions that can be diagnosed as an incidental finding associated with headaches, pituitary dysfunction, or vision deterioration. Typically, they occur in a sellar or suprasellar location. The aim of this study was to review the clinical presentation and outcomes associated with endoscopic endonasal resection of these lesions.
The authors retrospectively reviewed a series of 35 patients with a diagnosis of RCC after endoscopic endonasal resection at the University of Pittsburgh between January 1998 and July 2008.
All 35 patients underwent a purely endoscopic endonasal approach (EEA). The average patient age was 34 years (range 12–67 years), and the average follow-up was 19 months (range 1–60 months). Clinical follow-up data were available for 32 patients, and radiographic follow-up data were accessible for 33 patients. All of the patients underwent complete removal of the cyst contents, and according to radiography studies 2 patients had a recurrence, neither of which required reoperation. The mean cyst volume was 1052.7 mm3 (range 114–6044 mm3). Headache was a presenting symptom in 26 (81.2%) of 32 patients, with 25 (96.1%) of 26 having postoperative improvement in their headaches. Fifteen (57.7%) of the 26 patients had complete pain resolution, and 10 (38.5%) had a > 50% reduction in their pain scores. Six (18.8%) of 32 patients initially presented with pituitary dysfunction, although 2 (33.3%) had postoperative improvement. Three (9.4%) of 32 patients had temporary pituitary dysfunction postoperatively, although there was no permanent pituitary dysfunction. Neither were there any intraoperative complications, postoperative CSF leaks, or new neurological deficits. The average hospital stay was 1.8 days (range 1–5 days).
The EEA is a safe and effective approach in the treatment of RCCs. None of the patients in this study experienced any worsening of their preoperative symptoms or pituitary function, and 96% of the patients who had presented with headache experienced complete or significant pain relief following treatment.
Amin B. Kassam, Paul A. Gardner, Carl H. Snyderman, Ricardo L. Carrau, Arlan H. Mintz and Daniel M. Prevedello
Craniopharyngiomas are notoriously difficult to treat. Surgeons must weigh the risks of aggressive resection against the long-term challenges of recurrence. Because of their parasellar location, often extending well beyond the sella, these tumors challenge vision and pituitary and hypothalamic function. New techniques are needed to improve outcomes in patients with these tumors while decreasing treatment morbidity. An endoscopic expanded endonasal approach (EEA) is one such technique that warrants understanding and evaluation. The authors explain the techniques and approach used for the endoscopic endonasal resection of suprasellar craniopharyngiomas and introduce a tumor classification scheme.
The techniques and approach used for the endoscopic, endonasal resection of suprasellar craniopharyngiomas is explained, including the introduction of a tumor classification scheme. This scheme is helpful for understanding both the appropriate expanded approach as well as relevant involved anatomy.
The classification scheme divides tumors according to their suprasellar extension: Type I is preinfundibular; Type II is transinfundibular (extending into the stalk); Type III is retroinfundibular, extending behind the gland and stalk, and has 2 subdivisions (IIIa, extending into the third ventricle; and IIIb, extending into the interpeduncular cistern); and Type IV is isolated to the third ventricle and/or optic recess and is not accessible via an endonasal approach.
The endoscopic EEA requires a thorough understanding of both sinus and skull base anatomy. Moreover, in its application for craniopharyngiomas, an understanding of tumor growth and extension with respect to the optic chiasm and infundibulum is critical to safely approach the lesion via an endonasal route.
Amin B. Kassam, Allan D. Vescan, Ricardo L. Carrau, Daniel M. Prevedello, Paul Gardner, Arlan H. Mintz, Carl H. Snyderman and Albert L. Rhoton Jr.
✓ The purpose of this study was to describe the technique used to safely identify the petrous carotid artery during expanded endonasal approaches to the skull base. A series of 20 cadaveric studies was undertaken to isolate the vidian artery and nerve and to use them as landmarks to the petrous internal carotid artery (ICA). Twenty-five consecutive paraclival endoscopic cases were also reviewed to determine the consistency of the vidian artery in vivo as an intraoperative landmark to the ICA. These data were then correlated with results from a separate study in which computed tomography scans from 44 patients were evaluated to delineate the course of the vidian canal and its relationship to the petrous ICA. In all 20 cadaveric dissections and all 25 surgical cases, the vidian artery was consistently identified and could be reliably used as a landmark to the ICA. The correlation between anatomical and clinical data in this paper supports the consistent use of the vidian artery as an important landmark to the petrous ICA.
Luigi M. Cavallo, Daniel M. Prevedello, Domenico Solari, Paul A. Gardner, Felice Esposito, Carl H. Snyderman, Ricardo L. Carrau, Amin B. Kassam and Paolo Cappabianca
The management of recurrent or residual craniopharyngiomas remains controversial. Although possible, revision surgery is more challenging than primary surgery, and more often results in incomplete resection and an increased risk of death and complications. The extended (also called expanded) endoscopic endonasal transsphenoidal approach through the planum sphenoidale has been proposed over the past decade as an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas. In this study, the authors describe the feasibility and advantages of this technique in recurrent or symptomatic residual craniopharyngiomas.
Between January 2004 and June 2008, 22 patients underwent surgery via the extended endoscopic transsphenoidal approach for the treatment of recurrent or residual symptomatic craniopharyngiomas at either the University of Pittsburgh or the Universita degli Studi di Napoli. The lesions included 12 purely suprasellar craniopharyngiomas, 9 with both intra- and suprasellar extensions, and 1 arising from a remnant in the Meckel cave. To better evaluate the features of the extended endonasal approach for recurrent or residual craniopharyngiomas, each patient was assigned to 1 of 3 subgroups depending on the original surgical treatment: transcranial pterional route (13 patients), transphenoidal approach (3 patients; 2 microsurgically and 1 with the standard endoscopic technique), or extended endonasal endoscopic approach (6 patients).
Total removal was achieved in 9 patients (40.9%), and in 8 patients (36.4%) near-total removal (defined as > 95% removal) was possible. Subtotal removal (> 70%) was attained in 4 patients (18.2%), and tumor removal was partial (< 50%) in only 1 case (4.5%). There were no deaths or major complications, including behavior changes. Postoperative CSF leaks developed in 2 patients in the transcranial subgroup, and 1 in the transsphenoidal subgroup (overall rate 13.6%), requiring early successful endoscopic revision surgery for the cranial base defect.
Most of the advantages of the endoscopic endonasal technique were noted during tumor dissection from the inferior aspect of the chiasm, the infundibulum, the third ventricle, and/or the retro- and parasellar areas. These benefits were best appreciated in patients who had originally undergone transcranial surgery, since in such cases the authors' endoscopic endonasal approach was a virgin route. However, the extended endoscopic endonasal technique can also be safely used in patients who originally underwent transsphenoidal surgery. The endoscopic endonasal technique should be considered as a therapeutic option in selected cases of recurrent or symptomatic residual craniopharyngiomas.
Daniel M. Prevedello, Amin B. Kassam, Ricardo L. Carrau, Carl H. Snyderman, Ajith Thomas, Paul Gardner, Arlan Mintz, Lisa Vecchione and Joseph Losee
✓Teratomas are neoplasms composed of tissues from all three germ layers with varying degrees of differentiation. They are most commonly found in the sacrococcygeal and gonadal regions and rarely occur in the head and neck region. A teratoma is termed “epignathus” when it arises from the skull base or hard palate and is located in the oral cavity. The authors describe a case of a giant epignathus teratoma originating in the skull base of a neonate, extending bilaterally via two pedicles throughout the hard palate and protruding through the oral cavity. The tumor was completely resected using a transpalatal endoscopic endonasal approach. The excised tumor proved to be an immature teratoma with well-differentiated yolk sac elements. At the 1-year follow-up the patient showed no evidence of tumor recurrence and the child remains neurologically intact.
This report demonstrates the use of a transpalatal endonasal corridor in a preterm infant. This approach provided an ample corridor into the ventral skull base without the need for external excisions and/or disruption of osseous elements.
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
The development of endoscopic endonasal approaches, albeit in the early stages, represents part of the continuous evolution of skull base surgery. During this early period, it is important to determine the safety of these approaches by analyzing surgical complications to identify and eliminate their causes.
The authors reviewed all perioperative complications associated with endoscopic endonasal skull base surgeries performed between July 1998 and June 2007 at the University of Pittsburgh Medical Center.
This study includes the data for the authors' first 800 patients, comprising 399 male (49.9%) and 401 female (50.1%) patients with a mean age of 49.21 years (range 3–96 years). Pituitary adenomas (39.1%) and meningiomas (11.8%) were the 2 most common pathologies. A postoperative CSF leak represented the most common complication, occurring in 15.9% of the patients. All patients with a postoperative CSF leak were successfully treated with a lumbar drain and/or another endoscopic approach, except for 1 patient who required a transcranial repair. The incidence of postoperative CSF leaks decreased significantly with the adoption of vascularized tissue for reconstruction of the skull base (< 6%). Transient neurological deficits occurred in 20 patients (2.5%) and permanent neurological deficits in 14 patients (1.8%). Intracranial infection and systemic complications were encountered and successfully treated in 13 (1.6%) and 17 (2.1%) patients, respectively. Seven patients died during the 30-day perioperative period, 6 of systemic illness and 1 of infection (overall mortality 0.9%).
Endoscopic endonasal skull base surgery provides a viable median corridor based on anatomical landmarks and is customized according to the specific pathological process. This corridor should be considered as the sole access or may be combined with traditional approaches. With the incremental acquisition of skills and experience, endoscopic endonasal approaches have an acceptable safety profile in select patients presenting with various skull base pathologies.