The Importance and Timing of Optic Canal Exploration and Decompression During Endoscopic Endonasal Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas

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

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“…While decompression in traumatic optic neuropathy has been widely investigated, 11,13,[18][19][20]24,28,29,36,37,40,47,48,[52][53][54][55][56][57][58][59]61 indeed with debatable results, decompression for nontraumatic optic neuropathies (NONs) is still insufficiently studied. 2,3,5,12,15,17,[21][22][23][25][26][27]33,35,36,39,41,42,45,46,51 We hypothesize that the minimally invasive endoscopic endonasal approach will be more widely used in decompressions for nontraumatic pathologies of the orbital apex. We present our preliminary series of 11 optic nerve decompressions performed for NONs.…”

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confidence: 99%

Endoscopic endonasal optic nerve and orbital apex decompression for nontraumatic optic neuropathy: surgical nuances and review of the literature

Berhouma

Jacquesson

Abouaf³

et al. 2014

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Object While several approaches have been described for optic nerve decompression, the endoscopic endonasal route is gaining favor because it provides excellent exposure of the optic canal and the orbital apex in a minimally invasive manner. Very few studies have detailed the experience with nontraumatic optic nerve decompressions, whereas traumatic cases have been widely documented. Herein, the authors describe their preliminary experience with endoscopic endonasal decompression for nontraumatic optic neuropathies (NONs) to determine the procedure’s efficacy and delineate its potential indications and limits. Methods The medical reports of patients who had undergone endoscopic endonasal optic nerve and orbital apex decompression for NONs at the Lyon University Neurosurgical Hospital in the period from January 2012 to March 2014 were reviewed. For all cases, clinical and imaging data on the underlying pathology and the patient, including demographics, preoperative and 6-month postoperative ophthalmological assessment results, symptom duration, operative details with video debriefing, as well as the immediate and delayed postoperative course, were collected from the medical records. Results Eleven patients underwent endoscopic endonasal decompression for NON in the multidisciplinary skull base surgery unit of the Lyon University Neurosurgical Hospital during the 27-month study period. The mean patient age was 53.4 years, and there was a clear female predominance (8 females and 3 males). Among the underlying pathologies were 4 sphenoorbital meningiomas (36%), 3 optic nerve meningiomas (27%), and 1 each of trigeminal neuroma (9%), orbital apex meningioma (9%), ossifying fibroma (9%), and inflammatory pseudotumor of the orbit (9%). Fifty-four percent of the patients had improved visual acuity at the 6-month follow-up. Only 1 patient whose sphenoorbital meningioma had been treated at the optic nerve atrophy stage continued to worsen despite surgical decompression. The 2 patients presenting with preoperative papilledema totally recovered. One case of postoperative epistaxis was successfully treated using balloon inflation, and 1 case of air swelling of the orbit spontaneously resolved. Conclusions Endoscopic endonasal optic nerve decompression is a safe, effective, and minimally invasive technique affording the restoration of visual function in patients with nontraumatic compressive processes of the orbital apex and optic nerve. The timing of decompression remains crucial, and patients should undergo such a procedure early in the disease course before optic atrophy.

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confidence: 99%

“…24 An endoscopic endonasal approach theoretically avoids similar manipulation by approaching the meningioma through its dural base, thereby minimizing retraction of the optic nerve and decreasing the risk for postoperative visual deterioration. 1,27 The other benefits to endoscopic endonasal surgery-minimal invasiveness leading to improved patient comfort and shorter hospitalizations-are often criticized as being offset by a higher rate of CSF leakage. 2 However, modern closure techniques, when performed by experienced hands, result in very low rates of CSF leakage for suprasellar lesions, 18 and recent data suggest that for a select group of lesions, the endoscopic endonasal approach might be optimal and should be entertained as having broader applications.…”

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Endoscopic extended transsphenoidal resection of tuberculum sellae meningiomas: nuances of neurosurgical technique

Kulwin

Schwartz

Cohen-Gadol

2013

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Over the past decade, advances in endoscopic microsurgical techniques have resulted in an increasingly aggressive endonasal approach to tumors of the midline skull base. Meningiomas of the tuberculum sellae are often closely associated with cerebrovascular structures, and their removal has traditionally required a transcranial approach. An endonasal approach offers many advantages, including early tumor devascularization and tumor debulking (without manipulation of the optic apparatus), direct access to the medial optic canal, and a minimal-access corridor. Although recent articles have focused on techniques for reaching and approaching the area of the pathology (how to get there), the authors of this report discuss the technical nuances of endoscopic microsurgery when the operator is already “there.” They describe their 6-step technique for endoscopic skull base bone removal, tumor dissection/resection, and closure. They also augment their description with elaborate illustrations.

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The Importance and Timing of Optic Canal Exploration and Decompression During Endoscopic Endonasal Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas

Cited by 47 publications

References 27 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

Endoscopic endonasal optic nerve and orbital apex decompression for nontraumatic optic neuropathy: surgical nuances and review of the literature

Endoscopic extended transsphenoidal resection of tuberculum sellae meningiomas: nuances of neurosurgical technique

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