The technical development in skull base surgery, especially to the anterior cranial fossa, has allowed for improvement in the quality of life and the long-term prognosis of patients suffering from different types of tumors that can affect this anatomical area. Applying these advanced techniques requires a thorough understanding of the skull base anatomy and surrounding structures to perform surgery without potential intraoperative complications related to the pathology itself as well as potential complications related to the surgical approach that has been chosen to treat this pathology. The purpose of this paper is to offer a comprehensive review of the surgical anatomy of the anterior skull base and the technical nuances of the surgical approaches that are more frequently used in this region. Detailed knowledge of these aspects is essential both for the choice of the surgical approach and for its correct execution when an anterior cranial fossa lesion need to be resected.Abstract: The anterior cranial fossa (ACF) is a complex anatomical region that can be affected by a broad spectrum of pathology. For the surgical treatment of these lesions, many approaches have been described, each of them with different scope and potential surgical complications, often associated with significant morbidity. Traditionally, tumors involving the ACF have been operated by transcranial approaches; however, in the last two decades, endoscopic endonasal approaches (EEAs) have been gaining popularity. In this work, the authors review and describe the anatomical aspects of the ACF and the technical nuances of transcranial and endoscopic approaches for tumors located in this region. Four approaches were performed in embalmed cadaveric specimens and the key steps were documented. Four illustrative cases of ACF tumors were selected to demonstrate the clinical application of anatomical and technical knowledge, which are essential in the preoperative decision-making process.
Background and Objective Surgical resection of brain metastases (BM) offers the highest rates of local control and survival; however, it is reserved for patients with good functional status. In particular, the presence of BM tends to oversize the detriment of the overall functional status, causing neurologic deterioration, potentially reversible following symptomatic pharmacological treatment. Thus, a timely indication of surgical resection may be dismissed. We propose to identify and quantify these variations in the functional status of patients with symptomatic BM to optimize the indication of surgical resection.
Patients and Methods Historic, retrospective cohort analysis of adult patients undergoing BM microsurgical resection, consecutively from January 2012 to May 2016, was conducted. The Karnofsky performance status (KPS) variation was recorded according to the symptomatic evolution of each patient at specific moments of the diagnostic–therapeutic algorithm. Finally, survival curves were delineated for the main identified factors.
Results One hundred and nineteen resection surgeries were performed. The median overall survival was 243 days, while on average it was 305.7 (95% confidence interval [CI]: 250.6–360.9) days. The indication of surgical resection of 10% of the symptomatic patients in our series (7.5% of overall) could have been initially rejected due to pharmacologically reversible neurologic impairment. Survival curves showed statistically significant differences when KPS was stratified following pharmacological symptomatic treatment (p < 0.0001), unlike when they were estimated at the time of BM diagnosis (p = 0.1128).
Conclusion The preoperative determination of the functional status by KPS as an evolutive parameter after the nononcologic symptomatic pharmacological treatment allowed us to optimize the surgical indication of patients with symptomatic BM.
Background:
Meningiomas are slow-growing neoplasms, accounting for 20% of all primary intracranial neoplasms and 25% of all intraspinal tumors. Atypical and anaplastic meningiomas are infrequent, representing fewer than 5% of all meningiomas. Unusually, they can show aggressive behavior, and extracranial metastases are extremely rare, representing approximately 0.1% of all reported cases.
Case Description:
Fifty-six-year-old male patient diagnosed with atypical basal frontal meningioma with multiple resections, both endoscopic endonasal and transcranial. After hypofractionated radiosurgery, the patient showed new tumor recurrence associated to right cervical level II ganglionic metastasis. We opted for complete resection of the meningioma and reconstruction with anterior rectus abdominis muscle flap, as well as selective cervical ganglionectomy. Anatomical pathology showed neoplastic proliferation of meningothelial cells in syncytial cytoplasm, oval or spherical nuclei with slight anisocariosis and hyperchromasia, and intranuclear vacuoles, all compatible with anaplastic meningioma.
Conclusion:
Due to a lack of consensus on how to treat a metastatic malignant meningioma, this pathology requires a multidisciplinary approach, and treatment needs to be adapted to each particular case. Complete resection of the lesion is the primary goal, and this requires complex procedures involving endocranial as well as extracranial surgeries, which result in composite defects difficult to resolve. Microvascular free flaps are considered the gold standard in reconstructions of large skull base defects, with high success rates and few complications.
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