Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and ...the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection.
Introduction
Endonasal endoscopic surgery has changed the treatment perspectives for different lesions of the hypothalamic–pituitary region. The metastases of the hypothalamic–pituitary region ...represent 0.4% of all intracranial metastatic tumors and account for only 1.8% of surgically managed pituitary lesions. The aim of tshis study is to describe a single-center institutional experience with 13 cases of hypothalamic–pituitary metastasis focused on presurgical workup, the evolution of the surgical technique, and postsurgical management according to our protocols, showing effects on progression-free and overall survival rates for this relatively uncommon location.
Material and Methods
We retrospectively reviewed the whole series of patients that received the endoscopic endonasal approach at the Division of Neurosurgery at the University of Naples “Federico II” undergoing surgery from January 1997 to December 2021. We identified 13 cases whose pathology reports revealed a metastatic lesion. Statistical analysis was performed to determine the Kaplan–Meier survival function and assess for log-rank differences in survival based on gender, surgical treatment, and postoperative therapy (
p
-value < 0.02*).
Results
The pathology report disclosed lung adenocarcinoma (six cases, 46%), breast adenocarcinoma (two cases, 15.4%), clear cell renal carcinoma (one case, 7%), melanoma (one case, 7%), colorectal adenocarcinoma (one case, 7%), uterine cervix carcinoma (one case, 7%), and follicular thyroid carcinoma (one case, 7%). A standard endoscopic endonasal approach was performed in 10 patients (76.9%), while an extended endonasal procedure was performed in only three cases (23%). Biopsy was the surgical choice in five patients with infiltrative and invasive lesions and a poor performance status (38%), while in the cases where neurovascular decompression was necessary, a subtotal resection was achieved in five patients (38%) and partial resection in three patients (23%). Recovery of visual field defect was observed in six of seven patients with visual loss (85.7%), improvement of oculomotor nerve palsy occurred in four of seven patients with this defect (57.1%), while the impairment of oculomotor palsy was observed in three patients (42.9%). Visual function was stable in the other patients. The median progression-free survival and overall survival were 14 and 18 months, respectively. There were statistically significant differences in PFS and OS in patients who underwent adjuvant radiotherapy (p=0.019 is referred to OS and p=0.017 to PFS, respectively;
p
-value = 0.02).
Conclusions
The endoscopic endonasal approach is a viable approach for the management of hypothalamic–pituitary metastases as this surgery provides an adequate opportunity to obtain tissue sample and neurovascular decompression, both being crucial for continuing the integrated adjuvant therapy protocols.
The transorbital route has been proposed for addressing orbital and paramedian skull base lesions. It can be complemented by further marginotomies, as per "extended-transorbital approach" and ...combined with others ventro-basal approaches featuring the concept of "multiportal surgery". Nevertheless, it cannot address some anatomical regions like the clinoid, carotid bifurcation and the Sylvian fissure. Therefore, we propose a combined transorbital and a supraorbital approach, attainable by a single infra-brow incision, and we called it "Uniportal multicorridor" approach.
The aim of our study is to verify its feasibility and deep anatomical targets through a cadaveric study.
Anatomic dissections were performed at the Laboratory of ICLO Teaching and Research Center (Verona, Italy) on four formalin-fixed cadaveric heads injected with colored neoprene latex (8 sides). A stepwise dissection of the supraorbital and transorbital approaches (with an infra-brow skin incision) to the anterior tentorial incisura, clinoid area, lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure is described.
We analyzed the anatomic areas reached by the transorbital corridor dividing them as follow: lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure; while the anatomic areas addressed by the supraorbital craniotomy were the clinoid area and the anterior tentorial incisura.
The described uniportal multi-corridor approach combines a transorbital corridor and a supraorbital craniotomy, providing a unique intra and extradural control over the anterior, middle, and posterior fossa, tentorial incisura and the Sylvian fissure, via an infra-brow skin incision.
Different tumors can be encountered in the paraventricular regions, and whereas their deep location often make them difficult to access surgically, they may be amenable to chemotherapy and/or ...radiotherapy. Therefore, tumor biopsy and histologic diagnosis are mandatory to optimize treatment. Different technical procedures have been recommended; the neuroendoscopic approach is accepted and widely used, in particular with an enlarged ventricular system. However, specifically with paraventricular tumors, tissue sampling may be challenging. In such a scenario, the use of intraoperative ultrasonography technique can add some advantages regarding diagnostic accuracy and procedure safety. Accordingly, in this study we describe a novel technical procedure in 7 selected patients in whom tumor tissue biopsy was performed in a coupled neuroendoscopic and ultrasound-guided environment. We define a neuroendoscopic intraoperative ultrasound technique. The main advantages of this technique are the identification of the tumor that may not been clearly identified underneath the ventricular ependymal through the neuroendoscopic window alone, and furthermore, that this technique gives the possibility to detect the depth of the needle advance∖ment in the selected tissue while labeling the lesion beneath the ventricular ependyma. Moreover, intraoperative ultrasonography can reveal in a real-time fashion intracranial hemorrhages that may occur after tissue biopsy, therefore providing a useful tool to achieve valid and directed hemostasis when needed.
Abstract Background Primary intraventricular meningiomas (IVMs) make up 0.5-5% of all intracranial meningiomas and represent one of the most challenging lesions in neurosurgery. Methods Between 1990 ...and 2013, 42 patients (30 female, 12 male, mean age of 43.6 years) underwent the resection of their IVM. The removal was performed by posterior-parietal approach in 19 of the 40 lateral ventricle tumors, and one in the third ventricle meningioma. The transcallosal approach was used for three meningiomas, while other lesions underwent temporal (7 cases) and temporo-parietal approaches (12 pts) respectively. Results The most common presenting signs were increased intracranial pressure (83.3%), visual impairment (78.6%) and cognitive changes (50%). Concerning tumor location, forty lesions (95.2%) were arising in the lateral ventricles, and two (4.8%) in the third ventricle, ranging in sizes from 3 to 10 cm. Total removal was achieved in 39 cases and the pathology report disclosed WHO grade I lesions in 41 cases. Hydrocephalus, CSF leakage and cerebral edema were the postoperative complications (7.15%); one patient died of respiratory problems not directly related to surgery. Thirty-five patients (83.3%) showed a six-months Glasgow outcome scale (GOS) of 5. One patient, that underwent partial resection, presented a recurrence after 1 year that remained stable until last follow-up. Conclusions IVMs usually reach a large size before being diagnosed. The surgical treatment is the most suitable option and total removal should represent the main goal of the procedure. The posterior-parietal transulcal approach and the temporo-parietal approach are the most common surgical routes used in our series.
The management of giant and large pituitary adenomas with wide intracranial extension or infrasellar involvement of nasal and paranasal cavities is a big challenge for neurosurgeons and the best ...surgical approach indications are still controversial. Endoscopic extended endonasal approaches have been proposed as a new surgical technique for the treatment of such selected pituitary adenomas. Surgical series coming from many centers all around the world are flourishing and results in terms of outcomes and complications seem encouraging. This technique could be considered a valid alternative to the transcranial route for the management of giant and large pituitary adenomas.
Abstract Background and aims Various surgical routes have been used to decompress the intracanalicular optic nerve. Historically, a transcranial corridor was used, but more recently ventral ...approaches (endonasal and/or transorbital) have been proposed, individually or in combination. The present study aims to detail and quantify the amount of bony optic canal removal one may achieve via transcranial, transorbital and endonasal pathways. Additionally, the surgical freedom of each approach was analyzed. Methods In 10 cadaveric specimens (20 canals), optic canals were decompressed via pterional, endoscopic endonasal, and endoscopic superior eyelid transorbital corridors. The surgical freedom and circumferential optic canal decompression afforded by each approach was quantitatively analyzed. Statistical comparison was carried using a non-paired Student t-test. Results An open pterional transcranial approach allowed the greatest area of surgical freedom (transcranial: 10.9 ± 3.4 cm2; transorbital 3.7 ± 0.5 cm2; endonasal homolateral 1.1 ± 0.6 cm2 and endonasal contralateral 1.1 ± 0.5 cm2) with widest optic canal decompression when compared with the other two ventral routes (transcranial: 245.2°; transorbital: 177.9°; endonasal: 144.6°). These differences reached statistical significance for the transcranial approach. Conclusions This anatomical contribution provides a comprehensive evaluation of surgical access to the optic canal via three distinct, but complementary, approaches: transcranial, transorbital and endonasal. Our results show that, as expected, a transcranial approach achieved the widest degree of circumferential optic canal decompression and the greatest surgical freedom for manipulation of surgical instruments. Further surgical experience is necessary to determine the proper surgical indication for the transorbital approach to this pathology.
Background
Meningitis occurs in 0.8–1.5% of patients undergoing neurosurgery. The aim of the study was to evaluate the characteristics of meningitis after endoscopic endonasal transsphenoidal surgery ...(EETS) comparing the findings retrieved to those highlighted by literature search.
Materials and methods
Patients treated by EETS during an 18-year period in the Department of Neurosurgery of ‘Federico II’ University of Naples were evaluated and included in the study if they fulfilled criteria for meningitis. Epidemiological, demographic, laboratory, and microbiological findings were evaluated. A literature research according to PRISMA methodology completed the study.
Results
EETS was performed on 1450 patients, 8 of them (0.6%) had meningitis median age 46 years (range 33–73). Endoscopic surgery was performed 1–15 days (median 4 days) before diagnosis. Meningeal signs were always present. CSF examination revealed elevated cells median 501 cells/μL (range 30–5728), high protein median 445 mg/dL (range 230–1210), and low glucose median 10 mg/dL (range 1–39). CSF culture revealed Gram-negative bacteria in four cases (
Klebsiella pneumoniae
,
Escherichia coli
,
Alcaligenes
spp., and
Haemophilus influenzae
),
Streptococcus pneumoniae
in two cases,
Aspergillus fumigatus
in one case. An abscess occupying the surgical site was observed in two cases. Six cases reported a favorable outcome; two died. Incidence of meningitis approached to 2%, as assessed by the literature search.
Conclusions
Incidence of meningitis after EETS is low despite endoscope goes through non-sterile structures; microorganisms retrieved are those present within sinus microenvironment. Meningitis must be suspected in patients with persistent fever and impaired conscience status after EETS.
Abstract
OBJECTIVE:
The aim of the present study was to compare the anatomy of the cavernous sinus via an endoscopic transnasal route with the anatomy of the same region explored by the transcranial ...route. The purpose was to identify and correlate the corresponding anatomic landmarks both through the endoscopic transnasal transsphenoidal and the microscopic transcranial views.
METHODS:
Five fresh injected heads (10 specimens) were dissected by the endoscopic transnasal and microsurgical transcranial approaches. A comparison of different microsurgical corridors of the cavernous sinus with the corresponding endoscopic transnasal ones was performed.
RESULTS:
Through the endoscopic transnasal approach, it is possible to explore only some of the parasellar and middle cranial fossa subregions. Because of the complex multilevel architecture of the cavernous sinus, there is not always a correspondence between the surgical corridors bounded through the transcranial route and those exposed through the endoscopic transnasal approach. Nevertheless, some surgical corridors specific to the endoscopic transnasal route are evident: a C-shaped corridor is identifiable medial to the “intracavernous” internal carotid artery, whereas a wider triangular area is delineable lateral to the internal carotid artery; inside the latter, three more surgical corridors (a superior triangular space, a superior quadrangular space, and an inferior quadrangular space) can be described.
CONCLUSION:
Different surgical corridors can be defined during the endoscopic transnasal approach to the anteroinferior portion of the cavernous sinus, as already established for the transcranial route as well. Knowledge of these could be useful in decreasing morbidity and mortality during surgery in this region, these approaches being reserved to experienced transsphenoidal surgeons only.
The aim of the present study is to evaluate a neurocognitive outcome in patients affected by late-onset idiopathic aqueductal stenosis (LIAS) who underwent endoscopic third ventriculostomy (ETV).
A ...prospective study was conducted between January 2015 and December 2017 in a series of 10 consecutive adult patients referred to the Neurosurgery Department of IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy. All the adult patients admitted with absence of CSF flow through the aqueduct in phase-contrast (PC)-MRI sequences or a turbulence void signal in T2-weighted images in midsagittal thin-slice MR sequences underwent a specific neuroradiological, neurological, and neurocognitive assessment pre- and postoperatively.
All patients affected by gait and sphincter disturbances improved after ETV. Attentive and executive functions as well as visuo-spatial memory and verbal executive functions improved in several patients. Similarly, the affective and behavioral scales improved in almost 50% of the patients. No major complications have been recorded, and no patients required a second surgery for shunt placement.
Endoscopic third ventriculostomy represents a safe and effective surgical procedure for the treatment of LIAS. In addition to neurological improvement, we demonstrated also postoperative neurocognitive improvement mainly in attentive and executive functions, visuo-spatial memory, verbal executive functions, and behavioral and affective domains.
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