Letter to the Editor. Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas: unanswered questions

Nitish Agarwal MBBS and Deepak Gupta MCh
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  • All India Institute of Medical Sciences, New Delhi, India
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TO THE EDITOR: We read with keen interest the article by Bander et al.1 (Bander ED, Singh H, Ogilvie CB, et al: Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients. J Neurosurg 128:40–48, January 2018). In their small single-institution study of similar cohorts of patients with tuberculum sellae and planum sphenoidale meningiomas they highlighted the benefits of the endoscopic endonasal approach (EEA) over the transcranial approach (TCA) in that there were fewer overall complications and better visual outcomes. We have some questions regarding their findings.

First, when was postoperative MRI done? A mention of the timing of postoperative MRI holds importance because findings on diffusion-weighted imaging (DWI) in the same patient may resolve over a period of time. In their study of 44 consecutive patients with newly diagnosed gliomas, Smith et al. prospectively investigated the incidence, time course, and ultimate outcome of postoperative DWI abnormalities by using serial MRI. In 24 of 28 patients with reduced diffusion on immediate postoperative DW MRI, complete resolution of this reduced diffusion was noted within 90 days.6

Second, it would be interesting to know the length of hospital stay in the 2 patients with CSF leakage following EEA. In the present study, the mean length of hospital stay is longer in patients undergoing EEA compared to those undergoing TCA (4.6 vs 4.3 days), although this difference did not reach statistical significance. Whether the patients with CSF leakage had an effect on these results is of significant interest.

Last, were prophylactic anticonvulsants given to patients in the TCA group during the early postoperative period? There is conflicting evidence in the literature regarding use of prophylactic anticonvulsants in the postoperative period.3,4,7 Sayegh et al.,5 in their review of 6 meta-analyses published between 1996 and 2011, have concluded that this management strategy should not be used. However, many studies included in the meta-analyses did not differentiate between early and late postoperative seizures. Also, the use of prophylactic anticonvulsants during the first week after surgery, and then tapering and stopping thereafter, is consistent with American Academy of Neurology guidelines.2 This uncertainty raises a question—could anticonvulsants decrease the incidence of early postoperative seizures, if not in all patients, then at least in patients with significantly higher DWI signal following craniotomy? Further research should be directed toward answering this question.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Bander ED, Singh H, Ogilvie CB, Cusic RC, Pisapia DJ, Tsiouris AJ, et al.: Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients. J Neurosurg 128:4048, 2018

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  • 2

    Glantz MJ, Cole BF, Forsyth PA, Recht LD, Wen PY, Chamberlain MC, et al.: Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 54:18861893, 2000

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  • 3

    Komotar RJ, Raper DMS, Starke RM, Iorgulescu JB, Gutin PH: Prophylactic antiepileptic drug therapy in patients undergoing supratentorial meningioma resection: a systematic analysis of efficacy. J Neurosurg 115:483490, 2011

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  • 4

    Perry J, Zinman L, Chambers A, Spithoff K, Lloyd N, Laperriere N: The use of prophylactic anticonvulsants in patients with brain tumours—a systematic review. Curr Oncol 13:222229, 2006

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  • 5

    Sayegh ET, Fakurnejad S, Oh T, Bloch O, Parsa AT: Anticonvulsant prophylaxis for brain tumor surgery: determining the current best available evidence. J Neurosurg 121:11391147, 2014

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  • 6

    Smith JS, Cha S, Mayo MC, McDermott MW, Parsa AT, Chang SM, et al.: Serial diffusion-weighted magnetic resonance imaging in cases of glioma: distinguishing tumor recurrence from postresection injury. J Neurosurg 103:428438, 2005

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  • 7

    Temkin NR: Prophylactic anticonvulsants after neurosurgery. Epilepsy Curr 2:105107, 2002

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  • Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY

Response

In response to your questions we propose the following answers. First, postoperative MRI scans were generally done within 2–3 days after surgery during the patients’ first admission. Although we admit that DWI changes can resolve over time, it is a marker of brain injury at the time of surgery. We used DWI to compare the amount of brain trauma at the time of surgery. We are not drawing conclusions about long-term brain injury or even cognitive sequelae because we do not have data to support such a claim. Also, I would caution the authors that DWI after glioma surgery may not be the same as DWI after meningioma surgery. Second, the length of hospital stay in the patients with CSF leakage was clearly longer than if they did not have a leak. One had an initial stay of 5 days, was readmitted with a leak, and stayed an extra 5 days after lumbar drain placement. The second stayed a total of 11 days. Even with these 2 patients, there was no statistically significant difference in length of stay between the 2 groups. If these patients are eliminated, the patients who underwent EEA stayed for a shorter period of time. This implies that as CSF leak rates are reduced, eventually the length of stay may be shorter for patients treated with the EEA. As for postoperative antiepileptic drug usage, these were only given to the patients who underwent a TCA and not to the EEA patients. In spite of this fact, the rate of seizure was higher for the TCA patients.

  • 1

    Bander ED, Singh H, Ogilvie CB, Cusic RC, Pisapia DJ, Tsiouris AJ, et al.: Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients. J Neurosurg 128:4048, 2018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Glantz MJ, Cole BF, Forsyth PA, Recht LD, Wen PY, Chamberlain MC, et al.: Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 54:18861893, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Komotar RJ, Raper DMS, Starke RM, Iorgulescu JB, Gutin PH: Prophylactic antiepileptic drug therapy in patients undergoing supratentorial meningioma resection: a systematic analysis of efficacy. J Neurosurg 115:483490, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Perry J, Zinman L, Chambers A, Spithoff K, Lloyd N, Laperriere N: The use of prophylactic anticonvulsants in patients with brain tumours—a systematic review. Curr Oncol 13:222229, 2006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Sayegh ET, Fakurnejad S, Oh T, Bloch O, Parsa AT: Anticonvulsant prophylaxis for brain tumor surgery: determining the current best available evidence. J Neurosurg 121:11391147, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Smith JS, Cha S, Mayo MC, McDermott MW, Parsa AT, Chang SM, et al.: Serial diffusion-weighted magnetic resonance imaging in cases of glioma: distinguishing tumor recurrence from postresection injury. J Neurosurg 103:428438, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Temkin NR: Prophylactic anticonvulsants after neurosurgery. Epilepsy Curr 2:105107, 2002

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