Endoscopic Endonasal Minimal Access Approach to the Clivus

Fraser, Justin F.; Nyquist, Gurston; Moore, Nicholas; Anand, Vijay K.; Schwartz, Theodore H.

doi:10.1227/01.neu.0000383130.80179.41

Cited by 64 publications

(68 citation statements)

References 25 publications

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“…[3][4][5]10 Other groups have demonstrated reproducible results with the gasket seal technique. 30,31 Despite its advantages, the gasket seal technique poses some technical difficulties for the surgeon. Manipulating two independent graft materials into place within the skull base defect may require multiple attempts, thus increasing the operative time, before the fascia graft and buttress are properly situated within the epidural space.…”

Section: Discussionmentioning

confidence: 99%

One-Piece Modified Gasket Seal Technique

Wessell¹,

Singh²,

Litvack³

2013

J Neurol Surg B

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Section: Discussionmentioning

confidence: 99%

One-Piece Modified Gasket Seal Technique

Wessell¹,

Singh²,

Litvack³

2013

J Neurol Surg B

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“…Crockard et al [10] exclusively used the midline anterior approach, and good operative results were reported. On the other hand, lateral approaches are indicated for tumors with lateral extension to the ICA [22,23]. Lateral approaches are also preferred for tumors that present with cavernous sinus invasion extending to the ICA encasement or subdural invasion with involvement of the basilar artery and brainstem.…”

Section: Discussionmentioning

confidence: 99%

Surgical results of an endoscopic endonasal approach for clival chordomas

et al. 2012

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“…Detailed descriptions of the surgical technique are provided in our previous articles. 7,9,11,12,30 For statistical power, we divided the approaches into 4 subtypes: 1) transsellar; 2) transplanum; 3) transcribriform, transpterygoid, or transethmoidal; and 4) transcavernous and transclival.…”

Section: Operative Technique and Closure Methodsmentioning

confidence: 99%

Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

Banu

Szentirmai

Mascarenhas

et al. 2014

JNS

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Object Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS. Methods The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1–10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0–4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak. Results The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed “suspicious” pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as “benign” pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0–4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of “suspicious” pneumocephalus provides the best overall prediction for postoperative CSF leaks. Conclusions Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A “suspicious” pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of “suspicious” pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.

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Endoscopic Endonasal Minimal Access Approach to the Clivus

Abstract: The endonasal endoscopic transclival approach provides a minimal-access approach to the ventral midline posterior fossa skull base. The risk of CSF leak is low if appropriate closure techniques are applied.

Cited by 64 publications

References 25 publications

One-Piece Modified Gasket Seal Technique

One-Piece Modified Gasket Seal Technique

Surgical results of an endoscopic endonasal approach for clival chordomas

Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

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