Endoscopic Endonasal and Supraorbital Removal of Tuberculum Sellae Meningiomas: Anatomic Guides and Operative Nuances for Keyhole Approach Selection

Mallari, Regin Jay; Thakur, Jai Deep; Rhee, John; Eisenberg, Amy; Krauss, H; Griffiths, Chester F; Sivakumar, Walavan; Barkhoudarian, Garni; Kelly, Daniel F.

doi:10.1093/ons/opab138

Cited by 20 publications

(33 citation statements)

References 41 publications

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“…Contrariwise, unilateral frontal and orbitofrontal craniotomies exploit a subfrontal route, avoiding the downsides related to superior sagittal sinus ligation and bilateral frontal lobe retraction [ 69 ]. Moreover, the supraorbital keyhole approach, either purely microsurgical or endoscope-assisted, spares frontal sinus opening, further helping in reducing CSF leak rate [ 70 , 71 , 72 ].…”

Section: Discussionmentioning

confidence: 99%

“…The “low route” enables early access to the hyperostotic and dural attachment consenting to immediate tumor devascularization, direct exposure of the subchiasmatic area without brain retraction, and a wide decompression of the optic canals without nerve manipulation [ 64 , 72 , 87 , 88 ].…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, in a limited number of cases with a high degree of pneumatization superolateral decompression can be achieved [ 90 ]. Concerning the removal rates, GTR has been reported in modern series, ranging from 80 to 95% [ 62 , 72 , 87 , 88 ].…”

Section: Discussionmentioning

confidence: 99%

“…Likewise, the opening of suprasellar and lamina terminalis cisterns via the extended approach exposes a greater amount of CSF leak to be sealed, and in case of repair failure, the risk of pneumocephalus and meningitis increases [ 92 ]. The introduction of multilayer reconstruction techniques accounting for autologous materials (above all, the Hadad–Bassagasteguy flap), along with clinical strategies aimed at counteracting CSF pulsation [ 53 , 93 , 94 ], markedly the reduced rate of complications (from 22% to 4%) [ 44 , 62 , 72 , 87 , 88 , 95 ].…”

Section: Discussionmentioning

confidence: 99%

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Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

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et al. 2022

Cancers

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

Mastantuoni

Cavallo

Esposito

et al. 2022

Cancers

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“…For over a decade, we have used several minimally invasive approaches for brain tumors, particularly for skull base and parafalcine meningiomas that eliminate the need for fixed brain retraction by relying on gravity assistance and endoscopic visualization [ 27 – 35 ]. Except for our recent report on elderly meningioma patients and that by Burks et al, to our knowledge, there are no prior studies with over 40 patients treated with a minimally invasive keyhole paradigm for all intracranial meningiomas [ 26 , 33 ].…”

Section: Introductionmentioning

confidence: 99%

Critical appraisal of minimally invasive keyhole surgery for intracranial meningioma in a large case series

et al. 2022

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Background Meningioma surgery has evolved over the last 20 years with increased use of minimally invasive approaches including the endoscopic endonasal route and endoscope-assisted and gravity-assisted transcranial approaches. As the “keyhole” concept remains controversial, we present detailed outcomes in a cohort series. Methods Retrospective analysis was done for all patients undergoing meningioma removal at a tertiary brain tumor referral center from 2008–2021. Keyhole approaches were defined as: use of a minimally invasive “retractorless” approach for a given meningioma in which a traditional larger approach is often used instead. The surgical goal was maximal safe removal including conservative (subtotal) removal for some invasive locations. Primary outcomes were resection rates, complications, length of stay and Karnofsky Performance Scale (KPS). Secondary outcomes were endoscopy use, perioperative treatments, tumor control and acute MRI FLAIR/T2 changes to assess for brain manipulation and retraction injury. Results Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30 (15.5%) had prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal (n = 74,35%), supraorbital (n = 73,34%), retromastoid (n = 38,18%), mini-pterional (n = 20,9%), suboccipital (n = 4,2%), and contralateral transfalcine (n = 4,2%). Primary outcomes: Gross total/near total (>90%) resection was achieved in 125(59%) (5% for petroclival, cavernous sinus/Meckel’s cave, spheno-cavernous locations vs 77% for all other locations). Major complications included: permanent neurological worsening 12(6%), CSF leak 2(1%) meningitis 2(1%). There were no DVTs, PEs, MIs or 30-day mortality. Median LOS decreased from 3 to 2 days in the last 2 years; 94% were discharged to home with favorable 90-day KPS in 176(96%) patients. Secondary outcomes: Increased FLAIR/T2 changes were noted on POD#1/2 MRI in 36/213(17%) cases, resolving in all but 11 (5.2%). Endoscopy was used in 87/139(63%) craniotomies, facilitating additional tumor removal in 55%. Tumor progression occurred in 26(13%) patients, mean follow-up 42±36 months. Conclusions & relevance Our experience suggests minimally invasive keyhole transcranial and endoscopic endonasal meningioma removal is associated with comparable resection rates and low complication rates, short hospitalizations and high 90-day performance scores in comparison to prior reports using traditional skull base approaches. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid neurological deficits and other post-operative complications, although longer follow-up is needed. With careful patient selection and requisite experience, these approaches may be considered reasonable alternatives to traditional transcranial approaches.

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