Surgical strategies in the removal of malignant tumors and benign lesions of the anterior skull base

Abstract

The choice of surgical approaches to the tumors of the anterior skull base is determined by the location, dimensions of such lesions and their relations to the surrounding structures. Furthermore, the need for the reconstruction of the dura and skull base structures has an important influence on the decision about the surgical procedure. Transfacial approaches provide limited exposure, especially when tumors damage the floor of the anterior cranial fossa and involve the frontobasal dura and brain. Transcranial, craniofacial and subcranial approaches in particular may aid a surgeon in the removal of such lesions, and often these surgical procedures are the only beneficial methods. Our study comprised 15 patients. Transcranial approaches were used in ten cases. In five further cases, we adopted craniofacial or subcranial approaches. Total removal of these lesions was possible in 13 cases. Neither important complications nor death after surgery was observed except for two cases (craniofacial/subcranial approach) where the CSF leak and CNS infection were reported. We deem that the transcranial approach creates a good possibility for total removal of anterior skull base tumors, particularly of the benign lesions, and permits reconstruction of the skull base damaged by the tumor. However, in patients with large malignant tumors, the en bloc resection via the combined craniofacial/subcranial approach achieved better outcome.

A review of 59 consecutive patients with lesions of the anterior cranial base operated on using the subcranial approach

“…Even though it is generally accepted that brain damage can be avoided by gentle elevation of the frontal lobe, risks of such complications as brain oedema and contusion related to frontal lobe retraction still exist (Shah et al, 1997;Kellman and Marentette, 2001). Using the classic transfacial approach, like a lateral rhinotomy, with or without a Weber-Ferguson facial flap, the facial incisions leave scars and may have other aesthetic sequelae (Raveh et al, 1995(Raveh et al, , 1998Fliss et al, 1999;Hendryk et al, 2004). Raveh and Vuillemin (1988a) introduced the subcranial approach as an alternative procedure in cases of complex traumatic injuries or neoplasms involving the anterior skull base (Raveh et al, 1995).…”

“…However, the development of surgical approaches to the skull base has improved the treatment of tumours, traumatic injuries and cerebrospinal fluid (CSF) leakage (Raveh et al, 1988a(Raveh et al, , b, 1995Fliss et al, 1999;Aitasalo and Grenman, 2004;Hendryk et al, 2004).…”

“…Furthermore, the procedure allows intradural and extradural tumour removal, repair of fractures with dural tears, optic nerve decompression, and repair of CSF leakage. The subcranial approach is performed with minimal frontal lobe manipulation, and external facial incisions can be avoided (Raveh et al, 1995;Fliss et al, 1999;Kellman and Marentette, 2001;Hendryk et al, 2004).…”

Tailored Extended Bifrontal Craniotomy for Anterior Skull Base Tumors: Anatomic Description of a Modified Surgical Technique and Case Series

“…Contemporary approaches to this region include subfrontal (through bilateral or unilateral craniotomy), pterional, supraorbital, and endoscopic approaches including extended variations such as orbitozygomatic or bilateral orbital osteotomies. [2][3][4][5][6][7][8][9] These adjunct osteotomies help serve one of the critical tenets of skull base surgery, which is to remove bone along the cranial base in order to limit the need for brain retraction and maximize safe surgical resection. 10 OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2017 | 1…”

Quality of Life following Surgery for Malignancies of the Anterior Skull Base

“…Sekhar and Moller, 1 among others, [2][3][4][5] recommended radical surgery combined with postoperative radiation to maximize outcomes in patients suffering from malignant anterior skull base tumors. Advances in combined transcranial and transfacial approaches has improved survival for patients with these tumors.…”