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Open access

Ming-Ying Lan and Wei-Hsin Wang

This is a 37-year-old woman who presented with weight gain, a moon-shaped face, and muscle weakness for 4 months. Cushing’s disease was confirmed after a series of diagnostic tests. MRI demonstrated a pituitary macroadenoma with right cavernous sinus invasion and encasement of the right ICA. An endoscopic endonasal approach was performed, and gross-total resection could be achieved without injury of the cranial nerves. The Cushing’s syndrome improved gradually after the surgery. Histopathology revealed a corticotroph adenoma. In this surgical video, we demonstrate the strategies of tumor resection according to a surgical anatomy-based classification of the cavernous sinus from an endonasal perspective.

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

Open access

Joao Paulo Almeida, Zachary Cappello, Hamid Borghei-Razavi, Pablo F. Recinos, Raj Sindwani and Varun R. Kshettry

Petroclival chondrosarcomas are a formidable surgical challenge given the close relationship to critical neurovascular structures. The endoscopic endonasal approach can be utilized for many petroclival chondrosarcomas. However, tumors that extend to the inferior petrous apex require working behind the internal carotid artery (ICA). We present a case of a 33-year-old with a 1-year history of complete abducens palsy, with imaging showing an enhancing mass centered at the left petroclival fissure and inferior petrous apex behind the paraclival carotid artery and extending down into the nasopharynx abutting the cervical ICA. In this video, we describe the surgical steps of the endoscopic endonasal translacerum approach with ICA skeletonization and mobilization. We also highlight the relevant surgical anatomy with anatomical dissections to supplement the surgical video. The patient did well without complications. Postoperative MRI demonstrated complete resection and pathology revealed grade II chondrosarcoma. He underwent adjuvant proton beam radiotherapy.

The video can be found here: https://youtu.be/80QXALJW9ME.

Open access

Rodrigo Navarro-Ramirez, Oded Rabau, Alisson Teles, Susan Ge, Abdulaziz Bin Shebreen, Neil Saran and Jean Ouellet

Early-onset scoliosis (EOS) correction techniques have evolved slowly over the past 40 years and still remain a challenge for the spine surgeon. Avoiding spinal fusion in these patients is key to decreasing morbidity and mortality in this population.

Current treatments for EOS include both conservative and surgical options. The authors present the modified Luqué technique that has been performed at their institution for the past decade. This modified technique relies on Luqué’s principle, but with newer “gliding” implants through a less disruptive approach. The goal of this technique is to delay fusion as long as possible, with the intent to prevent deformity progression while preserving maximal growth.

Normally, these patients will have definitive fusion surgery once they have reached skeletal maturity or as close as possible. Out of 23 patients until present (close to 4-year follow-up), the authors have not performed any revision due to implant failure. Three patients have undergone final fusion as the curve progressed (one patient, 4 years out, had final fusion at age 12 years; two other patients had final fusion at 3 years). These implants, which have the CE mark in Europe, are available in Canada via a special access process with Health Canada. The implants have not yet been submitted to the FDA, as they are waiting on clinical data out of Europe and Canada.

In the following video the authors describe the modified Luqué technique step-by-step.

The video can be found here: https://youtu.be/k0AuFa9lYXY.

Open access

Ezequiel Goldschmidt, Philippe Lavigne, Carl Snyderman and Paul A. Gardner

This video depicts the case of a 59-year-old woman that presented to the emergency department with the worst headache of her life. CT showed subarachnoid hemorrhage and digital subtraction angiogram demonstrated a right-side posterior inferior cerebellar artery (PICA) aneurysm. Given the medial and ventral position of the aneurysm, deep to the lower cranial nerves, which obviated distal control from an open approach, and the absence of an endovascular option able to reliably preserve the PICA, an endonasal approach was offered. A far medial approach was performed, and the aneurysm was successfully clipped. The patient developed a postoperative CSF leak with persistent posthemorrhagic hydrocephalus treated with reexploration and an eventual ventriculoperitoneal shunt. The patient was discharged without neurological deficits.

The video can be found here: https://youtu.be/_9hsM2CaMow.

Open access

Ahmed Mohyeldin, Peter Hwang, Gerald A. Grant and Juan C. Fernandez-Miranda

Pediatric craniopharyngiomas that were once thought to be inoperable or considered only for salvage medical therapy are now being reconsidered for aggressive surgical resection via endoscopic endonasal approaches. Here we review the operative video case of an 11-year-old with a giant complex craniopharyngioma that was resected via an endoscopic endonasal approach. Due to the extent of tumor burden near the basilar apex, a transclival approach was necessary. To accomplish this, a wide sphenoidotomy, posterior ethmoidectomy, and resection of the middle turbinate were necessary to create enough working space for the resection. We also highlight several key innovations in pediatric endoscopic endonasal surgery management and underscore a multidisciplinary approach that allows for the safe and successful treatment of these lesions. Our multidisciplinary team involves an experienced fellowship-trained endoscopic skull base surgeon and otolaryngologist, as well as a pediatric neurosurgeon, pediatric endocrinologist, pediatric anesthesiologist, and pediatric intensivists who play important roles in the preoperative, intraoperative, and postoperative phases of care of the patient. Finally, we discuss critical surgical decision points including pituitary transposition, which has a lot of conceptual appeal when it is anatomically feasible but unfortunately, in our experience, has low functional preservation rates. Initially, we always aim to utilize pituitary transposition for tuberoinfundibular craniopharyngiomas, and once the relationship between the tumor and the stalk is determined, a decision on whether to preserve or sacrifice the stalk and pituitary gland is made. In this particular case, there was a salvageable stalk and the transposition was performed knowing that the chances for functional preservation were low.

The video can be found here: https://youtu.be/ClL73FU5QIU.

Open access

Mostafa Shahein, Thiago Albonette-Felicio, Giuliano Silveira-Bertazzo, Rafael Martinez-Perez, Marcus Zachariah, Ricardo L. Carrau and Daniel M. Prevedello

Chordomas are rare tumors that occur at an incidence rate of 0.8 per 100,000. Thirty-five percent of chordomas occur in the spheno-occipital region. We present a case of a clival chordoma that had severe brainstem compression. The patient had a 1-year history of slurred speech and left facial weakness (House-Brackmann 3). The endoscopic endonasal transclival approach gave a panoramic view of the region without the necessity of brain retraction or manipulation of the surrounding cranial nerves. Gross-total resection was achieved and no CSF leak was encountered postoperatively. The left facial weakness improved to House-Brackmann 1.

The video can be found here: https://youtu.be/DzW9Q6ckTHw.

Open access

Joao Paulo Almeida, Dennis Tang, Varun R. Kshettry, Raj Sindwani and Pablo F. Recinos

This is the case of a 25-year-old woman who had had a previous rupture of a dermoid cyst and now presented with recent MRI scans suggesting further growth of her dermoid cyst. Her lesion was located in the suprasellar space and extended into the interpeduncular fossa and prepontine cistern. Considering the location of the tumor, an endoscopic pituitary hemitransposition was selected for its resection. In this video we present the technical nuances and illustrate the anatomy used for an endoscopic endonasal pituitary hemitransposition for resection of a suprasellar dermoid cyst with extension into the interpeduncular fossa. In this case, a near-total resection was achieved, with no complications and no additional hormonal deficit after surgery.

The video can be found here: https://youtu.be/BHtNf5invUI.

Open access

James K. Liu, Kevin Zhao and Jean Anderson Eloy

Craniopharyngioma is a rare and benign intracranial tumor of the sellar and suprasellar region. Historically, these tumors were mostly accessed through transcranial corridors and resected with microsurgical techniques. Endoscopic endonasal surgery has recently gained popularity in the treatment of these tumors and has shown at least comparable results to transcranial approaches. The endoscopic endonasal approach provides direct midline access through a transplanum transtuberculum corridor and gives excellent visualization of the undersurface of the optic chiasm to allow safe bimanual sharp dissection of the tumor from the hypothalamus. In this operative video, we demonstrate the case of a 56-year-old female who had a complex craniopharyngioma with solid and cystic components extending superolaterally into the right frontal lobe. This lesion was invasive and partially encased the right optic nerve, optic chiasm, and anterior communicating artery complex. Although a traditional transcranial approach could have been utilized, we elected for an endoscopic endonasal approach for a maximal safe near-total resection, preserving the neurovascular structures. The patient underwent radiation therapy with favorable regression of the residual tumor on subsequent imaging studies. This case illustrates the feasibility of a combined strategy of maximal safe endoscopic endonasal resection followed by early radiation therapy for a complex, invasive cystic and solid craniopharyngioma. The technical nuances of safe bimanual microsurgical dissection of tumor adhesions off of critical neurovascular structures are demonstrated.

The video can be found here: https://youtu.be/z0AINLpRZGs.

Open access

James K. Liu, Kevin Zhao, Alejandro Vazquez and Jean Anderson Eloy

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker’s approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct “head-on” trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript.

The video can be found here: https://youtu.be/gy-pkjLdDgE.

Open access

Ahmed Mohyeldin, Jayakar V. Nayak and Juan C. Fernandez-Miranda

Over the past three decades, endoscopic endonasal surgery has unlocked new corridors to treat a wide spectrum of ventral skull base lesions. Tuberculum sella meningiomas represent one of the most ideal pathologies for ventral skull base access. Traditionally, these lesions were approached primarily through various subfrontal and frontal-lateral transcranial approaches that have unfortunately been shown to be associated with worsening visual decline postoperatively. The endoscopic endonasal approach is now being attempted by more surgeons and leverages an infrachiasmatic trajectory that provides direct access to the tuberculum sella where most of the vascular supply for these lesions can be taken early, facilitating more efficient surgical resection and mitigating the risk of optic nerve injury. Here we review a challenging case of a large (∼3 cm) tuberculum sella meningioma, encasing critical vessels off the circle of Willis and resected via an endoscopic endonasal approach. We discuss the technical nuances and relevant surgical anatomy of this approach and highlight important considerations in the safe and successful removal of these meningiomas. We show that certain tumors that appear to encase the supraclinoidal carotid artery can be fully resected via an endonasal approach with precise surgical technique and adequate exposure. Furthermore, this case illustrates the risk of injuring a key perforating vessel from the anterior communicating artery complex, called the subcallosal artery. Injury to this vessel is highly associated with tumors like the one presented here that extend into the suprachiasmatic space between the optic chiasm and the anterior communicating complex. Meticulous surgical dissection is required to preserve this perforating vessel as well as branches from the superior hypophyseal artery. Finally, we review our current closure techniques for these challenging approaches and discuss the use of a lumbar drain for 3 days to lower CSF leak rates.

The video can be found here: https://youtu.be/mafyXi5B0MA.