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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

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Salomon Cohen-Cohen, Paul A. Gardner, Joao T. Alves-Belo, Huy Q. Truong, Carl H. Snyderman, Eric W. Wang and Juan C. Fernandez-Miranda

both pituitary and nonpituitary tumors, including complex skull base lesions that often require endonasal transcavernous approaches, as previously described. 4 , 5 , 10 , 11 , 24 , 26 In addition, the use of the 2-surgeon, 4-hand technique is critical for performing the delicate maneuvers required to safely resect the medial CS wall. The number of cases required for such surgery is not well established, but progressive levels of training have been proposed, with these cases considered as level V/V given the ICA dissection and management necessary. 24 As such, it is

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Wei-Hsin Wang, Stefan Lieber, Roger Neves Mathias, Xicai Sun, Paul A. Gardner, Carl H. Snyderman, Eric W. Wang and Juan C. Fernandez-Miranda

demonstrated. GKS = Gamma Knife surgery. Copyright Juan C. Fernandez-Miranda. Published with permission. Click here to view. Pathology confirmed chondrosarcoma grade II with a Ki-67 index of 1%. Gamma Knife radiosurgery has been recommended for treatment of residual tumor at the jugular foramen. Case Illustration 2: Chordoma A 37-year-old man with new onset of progressive palsy of the sixth cranial nerve and a skull base lesion compatible with clival chordoma underwent partial resection at an outside institution via a transcranial approach, with significant residual tumor

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Wei-Hsin Wang, Stefan Lieber, Roger Neves Mathias, Xicai Sun, Paul A. Gardner, Carl H. Snyderman, Eric W. Wang and Juan C. Fernandez-Miranda

demonstrated. GKS = Gamma Knife surgery. Copyright Juan C. Fernandez-Miranda. Published with permission. Click here to view. Pathology confirmed chondrosarcoma grade II with a Ki-67 index of 1%. Gamma Knife radiosurgery has been recommended for treatment of residual tumor at the jugular foramen. Case Illustration 2: Chordoma A 37-year-old man with new onset of progressive palsy of the sixth cranial nerve and a skull base lesion compatible with clival chordoma underwent partial resection at an outside institution via a transcranial approach, with significant residual tumor