Endoscopic Endonasal Resection of Suprasellar Meningiomas: The Importance of Case Selection and Experience in Determining Extent of Resection, Visual Improvement, and Complications

Object 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. Methods 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. Results 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. Conclusions 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.

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“…Some of these patients were included in earlier studies but without investigation of the presence of a cortical cuff or brain edema. 2,33,43 …”

Section: Study Populationmentioning

confidence: 99%

“…2,[32][33][34]43 However, there are certain specifics that are worth discussing with respect to patient selection and technique that inform our results. Meningiomas are given 3 antibiotics preoperatively: vancomycin, ceftriaxone, and metronidazole.…”

Section: Operative Approachmentioning

confidence: 99%

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

Khan

Anand

Schwartz

2014

FOC

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“…(34,35,53,54) Clark et al (55) performed a meta-analysis assessing the endonasal endoscopic route vs transcranial approaches for tuberculum sellae meningiomas, and found higher rates of visual improvement (87% vs 59%) in the endoscopic cohort but with significantly higher CSF leak rates (21% vs 5%). The meta-analysis showed no significant difference in gross total resection rates between the endoscopic and open cohorts (88% vs 87%, respectively).…”

Section: Tuberculum Sellae Meningiomamentioning

confidence: 99%

Role of Endoscopic Skull Base and Keyhole Surgery for Pituitary and Parasellar Tumors Impacting Vision

Kelly

Griffiths

Takasumi

et al. 2015

Journal of Neuro-Ophthalmology

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Significant advances over the last 2 decades in imaging technology, instrumentation, anatomical knowledge, and reconstructive techniques have resulted in the endonasal endoscopic approach becoming an integral part of modern skull base surgery. With growing use and greater experience, surgical outcomes continue to incrementally improve across many skull base pathologies, including those tumors that impact vision and ocular motility. The importance of the learning curve and use of a multi-disciplinary approach is critical to maximizing success, minimizing complications, and enhancing quality of life in these patients. Realizing the limits of the endonasal route and reasonable use of transcranial approaches such as the supraorbital eyebrow craniotomy, it may br appropriate to consider nonsurgical therapy including various forms of radiotherapy [corrected] and medical treatment options.

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“…The largest cases series on the expanded endonasal approaches (EEA) for resection of TSMs are summarized in Table 2 [23][24][25][26][27]. These case series selected small TSMs (majority smaller than 3-4 cm) with limited medial optic canal involvement, with or without arterial encasement.…”

Section: Selected Case Series: Extent Of Resection Complications Oumentioning

confidence: 99%

Tuberculum Sellae Meningiomas: Evolving Surgical Strategies

2014

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Tuberculum sella meningiomas represent a unique set of surgical challenges due to their three-dimensional relationship with the optic apparatus, critical vasculature, and the pituitary stalk. These challenges are encountered with the context of a surgical goal that provides long-term tumor control, preservation or improvement of visual function and minimal morbidity. Advancements in skull base surgery with improvements in transcranial (TCR) approaches and endoscopic endonasal approaches have added to the surgical strategies available. We review the modern literature and compare techniques and their outcomes in an effort to determine the relative merits and indications of TCR and endoscopic endonasal approaches in the management of this set of tumors.Keywords Tuberculum sellae Á Meningioma Á Skull base Á Open skull base Á Endoscopic endonasal skull base Á Minimally invasive Á Surgery Abbreviations TSM Tuberculum sella meningiomas TCR Transcranial EEA Expanded endonasal approaches

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Endoscopic Endonasal Resection of Suprasellar Meningiomas: The Importance of Case Selection and Experience in Determining Extent of Resection, Visual Improvement, and Complications

Cited by 58 publications

References 13 publications

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

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

Role of Endoscopic Skull Base and Keyhole Surgery for Pituitary and Parasellar Tumors Impacting Vision

Tuberculum Sellae Meningiomas: Evolving Surgical Strategies

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