Endoscopic endonasal resection of skull base meningiomas: the significance of a “cortical cuff” and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>This paper describes a consecutive series of skull base meningiomas resected using an endoscopic endonasal approach through various corridors at a single institution over 7 years. The impact of case selection and experience, the presence of a cortical cuff between the tumor and surrounding vessels, and brain edema on morbidity and rates of gross-total resection (GTR) were examined.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A retrospective review of a series of 46 skull base meningiomas from a prospective database was conducted. The series of cases were divided by location: olfactory groove (n = 15), tuberculum and planum (n = 20), sellar/cavernous (n = 9) and petroclival (n = 2). Gross-total resection was never intended in the sellar/cavernous tumors, which generally invaded the cavernous sinus. Clinical charts, volumetric imaging, and pathology were reviewed to assess the extent of resection and complications. Cases were divided based on a time point in which surgical technique and case selection improved into Group 1 (surgery prior to June 2008; n = 21) and Group 2 (surgery after June 2008; n = 25) and into those with and without a cortical cuff and with and without brain edema.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Improved case selection had the greatest impact on extent of resection. For the entire cohort, rates of GTR went from 38% to 76% (p = 0.02), and for cases in which GTR was the intent, the rates went from 63% to 84% (not significant), which was mostly driven by the planum and tuberculum meningiomas, which went from 75% to 91.7 % (nonsignificant difference). The presence of a cortical cuff and brain edema had no impact on outcomes. There were 3 CSF leaks (6.5%) but all were in Group 1. Hence, CSF leak improved from 14.2% to 0% with surgical experience. Lessons learned for optimal case selection are discussed.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Surgical outcome for endonasal endoscopic resection of skull base meningiomas depends mostly on careful case selection and surgical experience. Imaging criteria such as the presence of a cortical cuff or brain edema are less important.</jats:p></jats:sec>

ICAR: endoscopic skull‐base surgery

“…These factors have been flagged as relative contraindications, the importance of which having often been left to the discretion of the surgeon. Thus, although some authors consider the absence of cortical cuff and vascular encasement as an absolute contraindication, others have deemed them not as important in predicting outcomes when compared to proper patient selection and surgeon experience . In the largest series of 50 presented by Koutourousiou et al., absence of cortical cuff, tumor calcifications, and tumor size >4 cm were shown to be statistically significant limitations for GTR.…”

Results of surgical treatment of anterior clinoidal meningiomas – our experiences

“…There is a paucity of literature data regarding anterior clinoidal meningiomas removal using this approach [26], unlike the literature on removal of e.g. tuberculum sellae, planum sphenoidale or olfactory meningiomas [25,[27][28][29]. The use of endoscopic endonasal approach for anterior clinoidal meningiomas has been controversial due to dural attachment of these tumors laterally from the midline [29].…”

Endoscopic Endonasal Approach for Olfactory Groove Meningiomas

“…3 Recently, there has been increased interest in the use of the endoscopic endonasal approach (EEA) via the transcribriform corridor for resection of olfactory groove meningiomas. 1,[23][24][25][26][27][28][29][30][31] Nevertheless, this continues to be a topic of debate. 32 Because these tumors originate at the ventral skull base, the endonasal route provides direct access to the tumor blood supply (ethmoidal arteries) for early devascularization, and removal of the underlying hyperostotic bone at the cranial base so that radical Simpson grade I resection can be achieved.…”