Surgery for clival lesions: open resection versus the expanded endoscopic endonasal approach

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Clival lesions pose significant challenges with regard to their surgical management. The expanded endoscopic endonasal (EEE) approach is a promising minimally invasive technique for lesions of the central skull base. The authors' aim in the current paper was to discuss the surgical treatment of clival lesions and to present the technical details, indications, and limitations of the EEE approach. Data from a recent endoscopically treated group will be compared with findings in a previous cohort of patients treated via classic open anterior and lateral approaches.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Since June 2005, 17 patients with clival lesions underwent surgery via the EEE approach. Suitable candidates were chosen according to lesion characteristics, clinical parameters, and surgical goals. Neurological outcomes, Karnofsky Performance Scale scores, the extent of lesion resection, and complications were evaluated among these patients. Eighteen percent of the patients in the endoscopic group presented with recurrent disease. Another series of 43 patients, who had undergone resection of clival lesions via an anterior (rhinotomy, maxillectomy, microscopic transsphenoidal surgery, or transoral surgery) or lateral (pterional, frontoorbitozygomatic, or combined suprainfratentorial retrosigmoid) approach, was similarly reviewed. Twenty-three of these patients (53%) presented with recurrent disease and thus had undergone prior surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Following the EEE approach, 11 (79%) of 14 patients who had presented with neurological symptoms experienced improvement, and gross-total resection was achieved in 59% of the patients and subtotal removal in 41%. Complications included CSF leakage (24%), tension pneumocephalus (6%), and intracranial hematoma (6%). The patient with the latter complication was the only one who experienced permanent neurological worsening. In the open resection group, neurological worsening occurred in 33% of the patients (14 of 43). Total and grosstotal removals were achieved in 84% of patients and subtotal removal in 14%.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The EEE approach has been shown to be a safe and effective technique for the resection of clival lesions with limited lateral extension. The choice of surgical approach must be tailored according to both patient and tumor characteristics. Although the 2 patient series featured in this paper are not comparable—because of a selection bias—higher rates of neurological morbidity and total and gross-total resections were observed in the open resection group. Given the long survival of some patients, the EEE approach should be favored whenever reasonable.</jats:p></jats:sec>

Hadad-Bassagasteguy flap in reconstruction of skull base defects after endonasal skull base surgery

“…Carrabba et al reported that the incidence of CSF leakage was 24% after EEA. 7 Therefore, the reconstruction of skull base defect is of paramount importance to prevent CSF leakage after endoscopic endonasal surgery. 8,9 In patients with large dural defects of anterior and ventral skull base, there is a significant risk of post-operative cerebrospinal fluid (CSF) leak after reconstruction.…”

Transsphenoidal endoscopic skull base surgery: state of the art and future perspective

“…Stippler et al [ 117 ] and Dehdashti et al [ 27 ] reported GTR resection rates for clival chordomas of 67% and 58% with CSF leak rates of 25% and 33%, respectively. Carrabba et al [ 11 ] found reduced levels of postoperative morbidity in patients treated via an endonasal endoscopic approach for clival lesions as compared to those who underwent open resection. Contraindications to this approach occur in cases with tumor primarily located posterior and lateral to critical neurovascular structures [ 73 ].…”

Defining the “edge of the envelope”: patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy

“…Moderate-sized chordomas or chondrosarcomas, without significant lateral extension or encasement of the posterior circulation vessels, can often be grossly resected via transsphenoidal-transclival approaches. 12,16,41,58 Transposition of the pituitary gland, and the use of extended transpterygoid and transmaxillary approaches as a means of providing control and mobilization of the ICA, have also been reported as successful adjunctive techniques for accessing retrosellar and retroclival lesions. 35,58 These procedures generally require a significant degree of bone removal, and in some cases planning a staged endoscopic or subsequent far-lateral approach may be beneficial, as reported in 20% of cases in a major series for clival chordomas.…”

“…Not infrequently, patients may require staged operations or a combined transpetrosal approach to achieve radical resection or adequate tumor debulking. 24,39 Although extended endoscopic techniques have improved access to these regions and have been frequently used in recent years to approach clival and retrosellar tumors, 12,58 substantial risk of injury to the infundibulum, optic tracts, and posterior arterial circulation, especially the perforating vessels, exists in many of these cases. Moderate-sized chordomas or chondrosarcomas, without significant lateral extension or encasement of the posterior circulation vessels, can often be grossly resected via transsphenoidal-transclival approaches.…”

“…Skull base tumors with marked retrosellar or retroclival extension are some of the most challenging tumors to access via extended endoscopic or open skull base approaches. 3 Tumors with attachment to, or encasement of, the posterior circulation vessels and perforators deserve significant consideration prior to attempting endoscopic approaches (as in Cases 6,8,9,10,and 12), especially in cases of reoperation in which increased adhesions or scar tissue can be anticipated. Not infrequently, patients may require staged operations or a combined transpetrosal approach to achieve radical resection or adequate tumor debulking.…”