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Letter to the Editor: Endoscopic endonasal posterior clinoidectomy

Danilo Silva, Moshe Attia, and Theodore H. Schwartz

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Endoscopic endonasal skull base surgery in the pediatric population

Clinical article

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

Object

The use of endoscopic endonasal surgery (EES) for skull base pathologies in the pediatric population presents unique challenges and has not been well described. The authors reviewed their experience with endoscopic endonasal approaches in pediatric skull base surgery to assess surgical outcomes and complications in the context of presenting patient demographics and pathologies.

Methods

A retrospective review of 133 pediatric patients who underwent EES at our institution from July 1999 to May 2011 was performed.

Results

A total of 171 EESs were performed for skull base tumors in 112 patients and bony lesions in 21. Eighty-five patients (63.9%) were male, and the mean age at the time of surgery was 12.7 years (range 2.3–18.0 years). Skull base tumors included angiofibromas (n = 24), craniopharyngiomas (n = 16), Rathke cleft cysts (n = 12), pituitary adenomas (n = 11), chordomas/chondrosarcomas (n = 10), dermoid/epidermoid tumors (n = 9), and 30 other pathologies. In total, 19 tumors were malignant (17.0%). Among patients with follow-up data, gross-total resection was achieved in 16 cases of angiofibromas (76.2%), 9 of craniopharyngiomas (56.2%), 8 of Rathke cleft cysts (72.7%), 7 of pituitary adenomas (70%), 5 of chordomas/chondrosarcomas (50%), 6 of dermoid/epidermoid tumors (85.7%), and 9 cases of other pathologies (31%). Fourteen patients received adjuvant radiotherapy, and 5 received chemotherapy. Sixteen patients (15.4%) showed tumor recurrence and underwent reoperation. Bony abnormalities included skull base defects (n = 12), basilar invagination (n = 4), optic nerve compression (n = 3) and trauma (n = 2); preexisting neurological dysfunction resolved in 12 patients (57.1%), improved in 7 (33.3%), and remained unchanged in 2 (9.5%). Overall, complications included CSF leak in 14 cases (10.5%), meningitis in 5 (3.8%), transient diabetes insipidus in 8 patients (6.0%), and permanent diabetes insipidus in 12 (9.0%). Five patients (3.8%) had transient and 3 (2.3%) had permanent cranial nerve palsies. The mean follow-up time was 22.7 months (range 1–122 months); 5 patients were lost to follow-up.

Conclusions

Endoscopic endonasal surgery has proved to be a safe and feasible approach for the management of a variety of pediatric skull base pathologies. When appropriately indicated, EES may achieve optimal outcomes in the pediatric population.

Open access

Approach selection for resection of petroclival meningioma

Christina Jackson, Kent S. Tadokoro, Eric W. Wang, Georgios A. Zenonos, Carl H. Snyderman, and Paul A. Gardner

Petroclival meningiomas are surgically challenging tumors because of their deep location and involvement of critical neurovascular structures. A variety of approaches have been described, and selection of approach should be tailored to the location of the tumor relative to neurovascular structures and surgical experience. The authors present two patients with petroclival meningiomas with varying relationships to cranial nerves and skull base anatomy who underwent endoscopic endonasal and open petrosectomy approaches, to demonstrate the complementarity of the endonasal transpetrous and open transpetrosal corridors. Proficiency in both open and endonasal approaches is critical to appropriate approach selection and maximal safe resection.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21252

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Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica

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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Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum

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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Endoneurosurgical hemostasis techniques: lessons learned from 400 cases

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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Evolution of reconstructive techniques following endoscopic expanded endonasal approaches

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

Harvey Cushing first popularized the transsphenoidal route to the sella turcica, and Jules Hardy subsequently refined it by adding the operating microscope. Over the ensuing decades, attempts at extending the application of this approach have been advanced by Edward Laws and others. With the evolution of endoscopic approaches, the natural expansion of their use to intradural lesions followed. For the expanded endonasal approach to become a viable option, the paramount concerns surrounding consistent reconstruction of the dura mater must be overcome. In this review the authors chronicle the evolution of the reconstruction technique they currently use after performing expanded endonasal approaches. They also report the use of a balloon stent to buttress the reconstruction and counter the effects of graft migration and cerebrospinal fluid fistula formation. The technique described in this report represents an important step forward in the reconstruction of defects resulting from expanded endonasal approaches.

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Endoscopic endonasal repair of spontaneous CSF fistulae

Matthew J. Tormenti, Alessandro Paluzzi, Carlos D. Pinheiro-Neto, Juan C. Fernandez-Miranda, Carl H. Snyderman, and Paul A. Gardner

The authors present a fully endoscopic endonasal repair of a spontaneous CSF leak caused by a defect in the anterior fossa floor. Patients were positioned supine in a Mayfield headholder in slight extension. A complete ethmoidectomy was performed to expose the defect. The middle turbinate was removed to increase visualization and allow for more working room. The defect was identified and exposed. A nasoseptal flap was raised and placed over the defect. A free-mucosal graft fashioned from the removed middle turbinate was placed on the nasoseptal donor site.

The video can be found here: http://youtu.be/gAN2cvQVXCE.

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Endoscopic endonasal approach for a tuberculum sellae meningioma

Juan C. Fernandez-Miranda, Carlos D. Pinheiro-Neto, Paul A. Gardner, and Carl H. Snyderman

The authors present the technical and anatomical nuances needed to perform an endoscopic endonasal removal of a tuberculum sellae meningioma. The patient is a 47-year-old female with headaches and an incidental finding of a small tuberculum sellae meningioma with no vascular encasement, no optic canal invasion, but mild inferior to superior compression of the cisternal segment of the left optic nerve. Neuroophthalmology assessment revealed no visual defects. Treatment options included clinical observation with imaging follow-up studies, radiosurgery, and resection. The patient elected to undergo surgical removal and an endonasal endoscopic approach was the preferred surgical option.

Preoperative radiological studies showed the presence of an osseous ring between the left middle and anterior clinoids, the so-called carotico-clinoidal ring. The surgical implications of this finding and its management are illustrated. The surgical anatomy of the suprasellar region is reviewed, including concepts such as the chiasmatic sulcus and limbus sphenoidale, medial and lateral optico-carotid recesses, and the paraclinoidal and supraclinoidal segments of the internal carotid artery. Emphasis is made in the importance of exposing the distal dural ring of the internal carotid artery and the precanalicular segment of the optic nerve for adequate intradural dissection. The endonasal route allows for early coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without any manipulation of the optic nerve. The lateral limit of dural removal is formed by the distal dural ring, which is gently coagulated after the tumor is resected. A 45° scope is used to inspect for any residual tumor, in particular at the entrance of the optic nerve into the optic canal and at the most anterior margin of the exposure (limbus sphenoidale). The steps for reconstruction are detailed and include intradural placement of dural substitute and extradural placement of the nasoseptal flap. The nuances for proper harvesting, positioning, and reinforcement of the flap are described. No lumbar drain was used.

The patient had an uneventful recovery with no CSF leak or any other complications. Imaging follow-up at 6 months showed complete removal of the tumor. The patient had no sinonasal or neurological symptoms, and olfaction was fully preserved.

The video can be found here: http://youtu.be/kkuV-yyEHMg.

Open access

Management of arterial injuries in endoscopic endonasal approaches

Michael M. McDowell, Georgios Zenonos, Eric Wang, Carl H. Snyderman, and Paul A. Gardner

This is the case of a 76-year-old woman presenting with progressive right vision loss consisting of a right eye temporal field cut and severe visual acuity loss. An MRI was performed showing a suprasellar mass for which she had been referred to our center for an endoscopic endonasal approach. The tumor was found to be densely adherent to adjacent structures, and an ophthalmic artery and A1–A2 junction injury were sustained during resection. The management of intraoperative vascular injuries is described.

The video can be found here: https://youtu.be/JJY6nYKTCSg.