Extended Endoscopic Transsphenoidal Approach for Tuberculum Sellae Meningiomas

Divitiis, Enrico de; Cavallo, Luigi Maria; Esposito, Felice; Stella, L; Messina, A.

doi:10.1227/01.neu.0000303221.63016.f2

Cited by 87 publications

(58 citation statements)

References 21 publications

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“…24 Authors laud the TNE approach for early decompression of the optic canal and 270° release compared with transcranial approaches. [4][5][6] Typically, visual improvement is reported in 70%-80% of patients who had deterioration of vision preoperatively, and 7%-12% of patients experience worsening of vision postoperatively. [8][9][10] Regarding transcranial approaches for parasellar meningiomas, deterioration of vision has been reported as occurring in 19% of cases.…”

Section: Discussionmentioning

confidence: 99%

Expanded endonasal endoscopic resection of anterior fossa meningiomas: report of 13 cases and meta-analysis of the literature

Gompel

Frank

Pasquini

et al. 2011

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Object Transnasal endoscopic (TNE) approaches have been proposed for the resection of anterior cranial base meningiomas. The purpose of this article was to evaluate the results of endoscopic resection of anterior cranial fossa meningiomas by reviewing available published data in addition to the authors' experience with 13 cases. Methods The literature was searched via OVID to identify all available disaggregate data pertaining to anterior fossa meningiomas treated primarily by TNE. In addition, the authors reviewed the records of a personal series of 13 patients who underwent TNE removal of parasellar meningiomas through a pure TNE approach. Results Meta-analysis from studies included a total of 69 patients with adequate disaggregated data to summarize. Mean age (± SD) at surgery was 53.3 ± 13.0 years (range 27–80 years); 78% of the patients were women. Tumor size was skewed toward smaller lesions, with a mean volume of 24.4 ± 2.9 cm3. Intraoperative impressions were of gross-total resection in 76% of cases. The most common complication reported was CSF leakage, occurring in 32% of the cases (22 of 69). The rate of CSF leakage was not affected by size (p = 0.52), location of tumor (p = 0.9), or age (p = 0.56). There was 1 death overall. The mean duration of follow-up was 21 ± 18 months. Conclusions Transnasal endoscopic resection of anterior cranial base meningiomas is feasible in selected cases. Reported resection rates are adequate, although the follow-up in the reported series is too short (mean 21 months) to make definitive conclusions regarding the long-term effectiveness. Cerebrospinal fluid leakage is a common complication, although it appears not to be associated with additional morbidity except for the need for reoperation. Long-term results are necessary before considering TNE resection as a valid alternative, in selected cases, to the more established transcranial techniques.

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Section: Discussionmentioning

confidence: 99%

Expanded endonasal endoscopic resection of anterior fossa meningiomas: report of 13 cases and meta-analysis of the literature

Gompel

Frank

Pasquini

et al. 2011

FOC

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“…22 In the endoscopic endonasal series, the CSF leak rate has ranged from 10% to 28%. 15,37 However, these results did not incorporate the use of a vascularized nasoseptal flap for reconstruction. 28,33 The latter technique is an important innovation in endoscopic endonasal skull base surgery, which offers robust, vascularized tissue for coverage of skull base defects to optimize tissue healing and prevention of CSF leaks.…”

Section: Limitations Of the Endoscopic Endonasal Approachmentioning

confidence: 99%

“…26 The otolaryngologist performs the initial endonasal exposure to the sphenoid sinus using a 4-mm-diameter, 18-cm-long, 30° endoscope (Karl Storz). Although most authors report using a 0° endoscope for the exposure and resection, 7,8,[15][16][17]26,37 we prefer to use a 30° endoscope because of its versatility in providing the same degree of surgical exposure as with a 0° endoscope, but with the benefits of additional angled viewing capabilities around corners, without having to repeatedly exchange the 2 endoscopes. After injecting the nasal septum and the tail and anterosuperior attachment of the middle turbinates with 1% lidocaine with epinephrine (1:100,000 dilution), both middle and inferior turbinates are lateralized using a Goldman elevator.…”

Section: Endoscopic Endonasal Transsphenoidal Approachmentioning

confidence: 99%

“…3,5,11,23,24,29,36,43,[46][47][48][49][50]55 More recently, there has been interest in endonasal extended transsphenoidal approaches (microscopic, microscopic with endoscopic assistance, and purely endoscopic) to remove tuberculum sellae meningiomas. 7,8,12,13,15,16,21,25,31,32,35,37,58,59 The purely endoscopic endonasal extended transsphenoidal route via a transplanum transtuberculum corridor offers direct and immediate exposure to the tumor without having to apply brain retraction and manipulation of neurovascular structures. Because the dural origin is adjacent to the paranasal sinuses, early devascularization of the tumor and subsequent radical resection of the involved hyperostotic bone, dural attachment, and optic canal involvement can be achieved.…”

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confidence: 99%

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Surgical nuances for removal of tuberculum sellae meningiomas with optic canal involvement using the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach

Liu¹,

Christiano²,

Patel³

et al. 2011

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Tuberculum sellae meningiomas frequently extend into the optic canals. Radical tumor resection including the involved dural attachment, underlying hyperostotic bone, and intracanalicular tumor in the optic canal offers the best chance of a Simpson Grade I resection to minimize recurrence. Decompression of the optic canal with removal of the intracanalicular tumor also improves visual outcome since this portion of the tumor is usually the cause of asymmetrical visual loss. The purely endoscopic endonasal extended transsphenoidal approach offers a direct midline trajectory and immediate access to tuberculum sellae meningiomas without brain retraction and manipulation of neurovascular structures. Although the endoscopic approach has been previously criticized for its inability to remove tumor within the optic canals, complete Simpson Grade I tumor removal including intracanalicular tumor, dural attachment, and involved hyperostotic bone can be achieved in properly selected patients. Excellent visualization of the suprasellar region and the inferomedial aspects of both optic canals allows for extracapsular, extraarachnoid dissection of the tumor from the critical structures using bimanual microsurgical dissection. In this report, the authors describe the operative nuances for removal of tuberculum sellae meningiomas with optic canal involvement using a purely endoscopic endonasal extended transsphenoidal (transplanum transtuberculum) approach. They specifically highlight the technique for endonasal bilateral optic nerve decompression and removal of intracanalicular tumor to improve postoperative visual function, as demonstrated in 2 illustrative cases. Special attention is also given to cranial base reconstruction to prevent CSF leakage using the vascularized pedicled nasoseptal flap.

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“…The expanded endonasal approaches to relevant portions of the cranial base have been described extensively (4,5,7,10,20), and some nuances of our approach are described below.…”

Section: Surgical Techniquementioning

confidence: 99%

Results with expanded endonasal resection of skull base meningiomas: technical nuances and approach selection based on an early experience

Hayhurst

Sughrue

Gore³

et al. 2016

Turkish Neurosurgery

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ABSTRACTvascularized mucosal flap reconstruction, rates of cerebrospinal fluid (CSF) leak have dropped to between 3-5% (8,11,12,17), which is comparable to the reported 3.9% leak rate following standard microscopic transsphenoidal pituitary surgery (3).These advancements in reconstruction techniques have led to renewed enthusiasm for the expanded endonasal approach (EEA) at many centers. However, while the endonasal approach yields some advantages over transcranial surgery, it is not always possible or even advisable to attempt to resect all █ INTRODUCTION E xperience with endonasal transsphenoidal pituitary procedures has taught us that whenever anatomically feasible, surgery through the nose is better tolerated than transcranial surgery. Initial clinical reports of the utility of the endonasal approach for midline skull base meningiomas were published more than a decade ago (14,15,18). However, the widespread acceptance of the expanded endonasal route has only been made possible with advances in skull base reconstruction. With the introduction of multilayered closure and a AIM: Reconstruction technique advances have created renewed enthusiasm for the expanded endonasal approach (EEA). However, as with any new technique, early experiences inevitably lead to more selective use of these techniques. We reviewed our experience of the expanded endonasal endoscopic approach for skull base meningiomas and place it in context of the literature. MATERIAL and METhODS:We performed retrospective review of all endonasal cases performed at our center for histologically proven meningioma. Tumor locations in 26 patients included the olfactory groove (n=9), tuberculum sellae (n=7), optic nerve sheath (n=1), planum sphenoidale (n=2), clival (n=1) petroclival (n=3), cavernous sinus (n=2) and extensive pan-basal meningioma (n=1). RESULTS:The median follow-up was 38.6 months. Excluding 3 patients with tumors found incidentally, pre-operative symptoms improved in 14 of 23 (61%), were the same in 8 of 23 (35%) and worsened in one of 23 patients (4%) at time of last follow-up. Of all 26 patients, 16 (62%) had complete macroscopic resection of their tumor, 5 (19%) underwent at least 90% resection, and 5 (19%) underwent subtotal resection. There were two neurological complications and one cerebrospinal fluid leak. CONCLUSION:This study presents outcomes of patients treated with endonasal endoscopic meningioma surgery. We believe that very low rates of morbidity can be achieved in carefully selected patients, thus avoiding brain manipulation.

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Extended Endoscopic Transsphenoidal Approach for Tuberculum Sellae Meningiomas

Cited by 87 publications

References 21 publications

Expanded endonasal endoscopic resection of anterior fossa meningiomas: report of 13 cases and meta-analysis of the literature

Expanded endonasal endoscopic resection of anterior fossa meningiomas: report of 13 cases and meta-analysis of the literature

Surgical nuances for removal of tuberculum sellae meningiomas with optic canal involvement using the endoscopic endonasal extended transsphenoidal transplanum transtuberculum approach

Results with expanded endonasal resection of skull base meningiomas: technical nuances and approach selection based on an early experience

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