A panoramic view of the skull base: systematic review of open and endoscopic endonasal approaches to four tumors

Abstract

Endoscopic endonasal surgery has been established as the safest approach to pituitary tumors, yet its role in other common skull base lesions has not been established. To answer this question, we carried out a systematic review of reported series of open and endoscopic endonasal approaches to four major skull base tumors: olfactory groove meningiomas (OGM), tuberculum sellae meningiomas (TSM), craniopharyngiomas (CRA), and clival chordomas (CHO). Data from 162 studies containing 5,701 patients were combined and compared for differences in perioperative mortality, gross total resection (GTR), cerebrospinal fluid (CSF) leak, neurological morbidity, post-operative visual function, post-operative anosmia, post-operative diabetes insipidus (DI), and post-operative obesity/hyperphagia. Weighted average rates for each outcome were calculated using relative study size. Our findings indicate similar rates of GTR and perioperative mortality between open and endoscopic approaches for all tumor types. CSF leak was increased after endoscopic surgery. Visual function symptoms were more likely to improve after endoscopic surgery for TSM, CRA, and CHO. Post-operative DI and obesity/hyperphagia were significantly increased after open resection in CRA. Recurrence rates per 1,000 patient-years of follow-up were higher in endoscopy for OGM, TSM, and CHO. Trends for open and endoscopic surgery suggested modest improvement in all outcomes over time. Our observations suggest that endonasal endoscopy is a safe alternative to craniotomy and may be preferred for certain tumor types. However, endoscopic surgery is associated with higher rates of CSF leak, and possibly increased recurrence rates. Prospective study with long-term follow-up is required to verify these preliminary observations.

ICAR: endoscopic skull‐base surgery

“…Three prior systematic reviews that focused on outcomes following EEA for suprasellar meningiomas reported outcomes similar to our findings . Specifically, rates of GTR in these reviews ranged from 77.2% to 79.9% and rates of postsurgical vision improvement ranged from 79.5% to 87.0%, similar to the findings in our study.…”

“…Benefit‐Harm Assessment: Greater operative experience with EEA seems to be associated with decreased harm and improved rates of extensive resection . Use of a vascularized NSF has been associated with decreased rates of cerebrospinal fluid leak Value Judgments: Use of EEA for suprasellar meningiomas allows for (1) direct extradural access to the tumor's meningeal origin and osseous attachment; (2) upfront devascularization of the tumor's meningeal blood supply; (3) early, extradural, bilateral, and wide optic nerve decompression; (4) direct identification and access to the paraclinoidal ICA, the medial aspect of optic canal, the diaphragm, and the pituitary stalk; (5) minimization of brain and optic nerve manipulation; (6) tumor debulking prior to approaching the optic apparatus; and (7) a potentially better cosmetic result. Policy Level: Opinion Intervention: Use of EEA for suprasellar meningiomas is likely the preferred surgical approach for small‐size to medium‐size tuberculum sellae meningioma with inferomedial optic canal invasion. …”

“…Eleven studies met our inclusion criteria, 4 of which were systematic reviews . Reviewed studies with clinical endpoints and conclusions are summarized in Table .…”

Transsphenoidal surgery and diabetes mellitus: An analysis of inpatient data and complications

“…). This result may be attributed to the minimally invasive nature of TSS relative to open craniotomy, although definitively concluding the reason for this is beyond the scope of our analysis. In general, documented risk factors of CSF rhinorrhea after TSS include prior history of TSS; radiotherapy; tumor size, consistency, and type of tumor; and surgical margins .…”

Endoscopic Endonasal Approach for Removal of Tuberculum Sellae Meningiomas

“…In groups of patients with similar tumor dimensions, they found that although related to a higher rate of CSF leak (21% vs 5%, P<.05) the endoscopic cohort was also associated with a significantly higher rate of visual improvement (50%-100% vs 25%-78%, P<.05); in this study, both groups presented similar gross total resection rates. Finally, Graffeo and colleagues 35 performed a systematic review of open and endoscopic approaches. Once again, the endoscopic cohort was associated with a higher CSF leak rate (21.5% vs 4.4%, P<.001) but also with higher visual improvement (87% vs 61%, P<.001) and lower visual deterioration (2.1% vs 11.4%, P 5 .009) rates.…”