Endoscopic Endonasal Transclival Approaches: Case Series and Outcomes for Different Clival Regions

Abstract

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution's experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Middle-Inferior Clivectomy, Odontoidectomy, and Far-Medial Approach

“…53 Complications of the EETCAs are mainly due to the risk of injuring the paraclival ICAs, the basilar artery and its pontine perforators, and the abducens nerve in the prepontine cistern as it enters Dorello's canal. 9,27,28,42 The risk of injury to the paraclival ICAs can increase if the bone covering the ICA is removed to improve the surgical access laterally. 58 In order to reduce the risk of injury to the intracranial vessels, careful study of preoperative imaging and intraoperative Doppler ultrasound may help identify the precise location of the underlying vasculature prior to opening the dura.…”

“…19 Several lesions of the posterior fossa may be amenable to EETCAs, including tumors, vascular malformations, and craniocervical junction abnormalities. 27,28 Benefits of the EETCA to lesions of the posterior fossa include a working corridor mostly medial to involved neurovasculature, adequate illumination and magnification of the operative field, and potentially early devascularization of the lesions' blood supply in case of meningiomas. 27 EETCAs are now commonly utilized for most chordomas of the clivus as the tumor's usually soft consistency facilitates its dissection away from involved neurovasculature.…”

“…27 Another drawback of the EETCAs is the increased risk of CSF leak. 28,59 To mitigate the risk of postoperative CSF leak, robust multilayered skull base reconstruction is required. For posterior fossa defects, reconstruction often includes autologous fat, fascia lata, and a pedicled nasoseptal flap.…”

Internal Carotid Injury during Skull Base Surgery—Case Report and a Review of the Literature

“…The ICA cavernous segment is most prone to injury in transnasal approaches to the skull base and in endoscopic sinus surgery [ 3 , 15 ]. The C2 (petrous) and C3 (lacerum) segments might also be injured during extended approaches [ 16 , 17 ]. Cavernous segment injuries occur most frequently, due to the higher frequency of transsphenoidal approaches and the high incidence of lateral sphenoid sinus wall dehiscence.…”

Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review

“…Posterior cranial fossa defects are considered to be the highest risk location for post-operative CSF leak given the high-flow nature of the prepontine cistern. Rates of CSF leak for clival defects are reported between 6.7% to 32.7% [ 9 , 13 , 22 , 27 , 33 , 34 , 35 ]. Limited data is available for craniocervical (odontoid) lesions, of which many are extradural (i.e., basilar invagination, rheumatoid pannus).…”