Elke Butterbrod, Karin Gehring, Eduard H. Voormolen, Paul R. A. M. Depauw, Willy-Anne Nieuwlaat, Geert-Jan M. Rutten and Margriet M. Sitskoorn
Patients with nonfunctioning pituitary adenomas (NFPAs) can suffer from cognitive dysfunction. However, the literature on longitudinal cognitive follow-up of patients undergoing endoscopic endonasal transsphenoidal surgery (EETS) is limited. This study was performed to investigate perioperative cognitive status and course in patients with NFPAs.
Patients underwent computerized neuropsychological assessment 1 day before (n = 45) and 3 months after (n = 36) EETS. Performance in 7 domains was measured with a computerized test battery (CNS Vital Signs) and standardized using data from a healthy control group. The authors conducted analyses of cognitive performance at both time points and changes pre- to post-ETSS on a group and an individual level. Linear multiple regression analyses were employed to investigate predictors of cognitive performance.
On average, patients scored significantly lower in 6 of 7 cognitive domains before and after surgery than controls. Impairment proportions were significantly higher among patients (56% before surgery, 63% after surgery) than among controls. Patients showed no change over time in group-level (mean) performance, but 28% of individual patients exhibited cognitive improvement and 28% exhibited cognitive decline after surgery. Hormonal deficiency showed a positive correlation with verbal memory before surgery. Postoperative performances in all cognitive domains were predicted by preoperative performances.
Cognitive impairment was present before and after EETS in over half of NFPA patients. Individual patients showed diverse postoperative cognitive courses. Monitoring of cognitive functioning in clinical trajectories and further identification of disease-related and psychological predictors of cognition are warranted.
Kenichi Oyama, Kentaro Watanabe, Shunya Hanakita, Pierre-Olivier Champagne, Thibault Passeri, Eduard H. Voormolen, Anne Laure Bernat, Nicolas Penet, Takanori Fukushima and Sébastien Froelich
The anteromedial triangle (AMT) is the triangle formed by the ophthalmic (V1) and maxillary (V2) nerves. Opening of this bony space offers a limited access to the sphenoid sinus (SphS). This study aims to demonstrate the utility of the orbitopterygopalatine corridor (OPC), obtained by enlarging the AMT and transposing the contents of the pterygopalatine fossa (PPF) and V2, as an entrance to the SphS, maxillary sinus (MaxS), and nasal cavity.
Five formalin-injected cadaveric specimens were used for this study (10 approaches). A classic pterional approach was performed. An OPC was created through the inferior orbital fissure, between the orbit and the PPF, by transposing the PPF inferiorly. The extent of the OPC was measured using neuronavigation and manual measurements. Two illustrative cases using the OPC to access skull base tumors are presented in the body of the article.
Via the OPC, the SphS, MaxS, ethmoid sinus (EthS), and nasal cavity could be accessed. The use of endoscopic assistance through the OPC achieved better visualization of the EthS, SphS, MaxS, clivus, and nasal cavity. A significant gain in the area of exposure could be achieved using the OPC compared to the AMT (22.4 mm2 vs 504.1 mm2).
Opening of the AMT and transposition of V2 and the contents of the PPF creates the OPC, a potentially useful deep keyhole to access the paranasal sinuses and clival region through a middle fossa approach. It is a valuable alternative approach to reach deep-seated skull base lesions infiltrating the cavernous sinus and middle cranial fossa and extending into the paranasal sinus.
Cristian Gragnaniello, Remi Nader, Tristan van Doormaal, Mahmoud Kamel, Eduard H. J. Voormolen, Giovanni Lasio, Emad Aboud, Luca Regli, Cornelius A. F. Tulleken and Ossama Al-Mefty
Resident duty-hours restrictions have now been instituted in many countries worldwide. Shortened training times and increased public scrutiny of surgical competency have led to a move away from the traditional apprenticeship model of training. The development of educational models for brain anatomy is a fascinating innovation allowing neurosurgeons to train without the need to practice on real patients and it may be a solution to achieve competency within a shortened training period. The authors describe the use of Stratathane resin ST-504 polymer (SRSP), which is inserted at different intracranial locations to closely mimic meningiomas and other pathological entities of the skull base, in a cadaveric model, for use in neurosurgical training.
Silicone-injected and pressurized cadaveric heads were used for studying the SRSP model. The SRSP presents unique intrinsic metamorphic characteristics: liquid at first, it expands and foams when injected into the desired area of the brain, forming a solid tumorlike structure. The authors injected SRSP via different passages that did not influence routes used for the surgical approach for resection of the simulated lesion. For example, SRSP injection routes included endonasal transsphenoidal or transoral approaches if lesions were to be removed through standard skull base approach, or, alternatively, SRSP was injected via a cranial approach if the removal was planned to be via the transsphenoidal or transoral route. The model was set in place in 3 countries (US, Italy, and The Netherlands), and a pool of 13 physicians from 4 different institutions (all surgeons and surgeons in training) participated in evaluating it and provided feedback.
All 13 evaluating physicians had overall positive impressions of the model. The overall score on 9 components evaluated—including comparison between the tumor model and real tumor cases, perioperative requirements, general impression, and applicability—was 88% (100% being the best possible achievable score where the evaluator strongly agreed with the proposed factor). Individual components had scores at or above 80% (except for 1). The only score that was below 80% was related to radiographic visibility of the model for adequate surgical planning (score of 74%). The highest score was given to usefulness in neurosurgical training (98%).
The skull base tumor model is an effective tool to provide more practice in preoperative planning and technical skills.