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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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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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Alessandro Paluzzi, Paul Gardner, Juan C. Fernandez-Miranda, Carlos D. Pinheiro-Neto, Tiago Fernando Scopel, Maria Koutourousiou and Carl H. Snyderman

recollection. This can be accomplished through different “open” surgical routes including the transcanal infracochlear, infralabyrinthine, suboccipital, and middle cranial fossa approaches. 3 We here present the results of a series of 17 petrous apex CGs treated at our center via an EEA. Methods Patient Sample Cases with a confirmed diagnosis of petrous apex CG were selected from a database of more than 1600 patients who had undergone an EEA to skull base lesions at our institution in the period from 1998 to 2011. The patients' medical records, imaging studies

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Srinivas Chivukula, Maria Koutourousiou, Carl H. Snyderman, Juan C. Fernandez-Miranda, Paul A. Gardner and Elizabeth C. Tyler-Kabara

approaches to the anterior skull base. 6 , 35 , 55 Expansion of EES has extended its spectrum of indications and has enabled surgical access not only to clival, sellar, and parasellar lesions, but also to suprasellar pathologies, without brain retraction. 7 , 11 , 12 , 15 , 34 , 37 , 40 Furthermore, since many childhood skull base lesions occur in the midline, EES is particularly advantageous, providing direct access without neural or vascular manipulation with optimal visualization provided by the rod lens endoscope. 8 , 36 However, unique challenges to the

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Maria Koutourousiou, Juan C. Fernandez-Miranda, S. Tonya Stefko, Eric W. Wang, Carl H. Snyderman and Paul A. Gardner

management of suprasellar meningiomas. Endoscopic endonasal surgery is a less externally invasive and more direct route to the suprasellar area. It is ideal for midline anterior skull base lesions such as tuberculum sellae and planum sphenoidale meningiomas, and converts these tumors into endonasal “convexity” meningiomas. Removal of involved bone, early tumor devascularization, resection of dural attachments, tumor debulking and dissection following the arachnoid planes with no brain retraction, preservation of optic apparatus vascularization, and no manipulation of

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Shannon Fraser, Paul A. Gardner, Maria Koutourousiou, Mark Kubik, Juan C. Fernandez-Miranda, Carl H. Snyderman and Eric W. Wang

OBJECTIVE

The aim in this paper was to determine risk factors for the development of a postoperative CSF leak after an endoscopic endonasal approach (EEA) for resection of skull base tumors.

METHODS

A retrospective review of patients who underwent EEA for the resection of intradural pathology between January 1997 and June 2012 was performed. Basic demographic data were collected, along with patient body mass index (BMI), tumor pathology, reconstruction technique, lumbar drainage, and outcomes.

RESULTS

Of the 615 patients studied, 103 developed a postoperative CSF leak (16.7%). Sex and perioperative lumbar drainage did not affect CSF leakage rates. Posterior fossa tumors had the highest rate of CSF leakage (32.6%), followed by anterior skull base lesions (21.0%) and sellar/suprasellar lesions (9.9%) (p < 0.0001). There was a higher leakage rate for overweight and obese patients (BMI > 25 kg/m2) than for those with a healthy-weight BMI (18.7% vs 11.5%; p = 0.04). Patients in whom a pedicled vascularized flap was used for reconstruction had a lower leakage rate than those in whom a free graft was used (13.5% vs 27.8%; p = 0.0015). In patients with a BMI > 25 kg/m2, the use of a pedicled flap reduced the rate of CSF leakage from 29.5% to 15.0% (p = 0.001); in patients of normal weight, this reduction did not reach statistical significance (21.9% [pedicled flap] vs 9.2% [free graft]; p = 0.09).

CONCLUSIONS

Preoperative BMI > 25 kg/m2 and tumor location in the posterior fossa were associated with higher rates of postoperative CSF leak. Use of a pedicled vascularized flap may be associated with reduced risk of a CSF leak, particularly in overweight patients.

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Joseph D. Chabot, Chirag R. Patel, Marion A. Hughes, Eric W. Wang, Carl H. Snyderman, Paul A. Gardner and Juan C. Fernandez-Miranda

T he endoscopic endonasal approach (EEA) has become increasingly more common in the management of ventral skull base lesions. Originally developed for resection of intrasellar lesions, anterior, posterior, and lateral extension of EEA provides access to lesions of the ventral skull base from the frontal sinus to the superior cervical spine, and laterally to the medial middle cranial fossa. 10 , 19 , 21 , 23 , 24 , 29 , 34 , 43 , 44 Compared with traditional microscopic approaches, EEA may avoid brain manipulation and cosmetic defects, but it was originally