Research

12 pages, 983 KiB

Open AccessArticle

Endoscopic Treatment of Rathke’s Cleft Cysts: The Case for Simple Fenestration

by Matthias Millesi, Carolyn Lai, Ruth Lau, Vincent Chen Ye, Kaiyun Yang, Matheus Leite, Nilesh Mohan, Ozgur Mete, Shereen Ezzat, Fred Gentili, Gelareh Zadeh and Aristotelis Kalyvas

Brain Sci. 2022, 12(11), 1482; https://doi.org/10.3390/brainsci12111482 - 01 Nov 2022

Viewed by 2295

Abstract

Background: Rathke’s cleft cysts (RCC) arise from the pars intermedia because of incomplete regression of the embryologic Rathke pouch. A subset of RCC becomes symptomatic causing headaches, visual and endocrinological disturbances such that surgical intervention is indicated. Several points in surgical management remain [...] Read more.

Background: Rathke’s cleft cysts (RCC) arise from the pars intermedia because of incomplete regression of the embryologic Rathke pouch. A subset of RCC becomes symptomatic causing headaches, visual and endocrinological disturbances such that surgical intervention is indicated. Several points in surgical management remain controversial including operative strategy (simple fenestration (SF) vs complete cyst wall resection (CWR)) as well as reconstructive techniques. Methods: A retrospective analysis was conducted of pathologically confirmed RCC operated on by endoscopic endonasal approach from 2006 to 2019. Pre-operative symptoms, imaging characteristics, operative strategy, symptom response, complications and recurrences were recorded. Results: Thirty-nine patients were identified. Thirty-three underwent SF and six underwent CWR. Worsening pituitary function was significantly increased with CWR (50%) compared to SF (3%) (p = 0.008). All patients underwent “closed” reconstruction with a post-operative CSF leak rate of 5% (3% SF vs 16% CWR, p = 0.287). Six (15%) recurrences necessitating surgery were reported. Recurrence rates stratified by surgical technique (18% SF vs 0% CWR, p = 0.564) were not found to be significantly different. Conclusions: The current series illustrates variability in the surgical management of RCCs. SF with closed reconstruction is a reasonable operative strategy for most symptomatic RCCs cases while CWR can be reserved for selected cases. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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8 pages, 659 KiB

Open AccessArticle

Surgical and Clinical Outcomes of Microvascular Decompression: A Comparative Study between Young and Elderly Patients

by Grazia Menna, Alessandro Rapisarda, Alessandro Izzo, Manuela D’Ercole, Quintino Giorgio D’Alessandris, Alessandro Olivi and Nicola Montano

Brain Sci. 2022, 12(9), 1216; https://doi.org/10.3390/brainsci12091216 - 09 Sep 2022

Cited by 3 | Viewed by 1459

Abstract

Microvascular decompression (MVD) is the only etiological technique for the treatment of trigeminal neuralgia (TN). Whilst there is a consensus MVD is likely effective regardless of age, the elderly population is thought to be more prone to have a higher rate of surgical [...] Read more.

Microvascular decompression (MVD) is the only etiological technique for the treatment of trigeminal neuralgia (TN). Whilst there is a consensus MVD is likely effective regardless of age, the elderly population is thought to be more prone to have a higher rate of surgical complication, morbidity, and mortality. The main objective of our single-center, retrospective study was to analyze the surgical and clinical outcomes of MVD in TN elderly patients. From a surgical series of patients with TN who had undergone MVD from April 2018 to April 2022, 76 patients who matched the inclusion criteria were divided into two groups: twenty-five (32.9%) patients were older than 65 years and included in the elderly group, while the remaining fifty-one (61.1%) patients were below 65 years included in the non-elderly one. There were no differences between the groups in terms of acute pain relief (APR), Barrow Neurological Index (BNI) at follow-up, complications, and recurrence rate. In multivariate analysis (Cox proportional hazards regression analysis) the presence of an offending artery with nerve root distortion/indentation emerged as the only independent prognostic factor for pain-free survival (p = 0.0001). Our data endorse MVD as a safe and effective surgical procedure also for elderly patients with TN. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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Review

Jump to: Research, Other

27 pages, 1118 KiB

Open AccessReview

Frontiers of Cranial Base Surgery: Integrating Technique, Technology, and Teamwork for the Future of Neurosurgery

by Corneliu Toader, Lucian Eva, Catalina-Ioana Tataru, Razvan-Adrian Covache-Busuioc, Bogdan-Gabriel Bratu, David-Ioan Dumitrascu, Horia Petre Costin, Luca-Andrei Glavan and Alexandru Vlad Ciurea

Brain Sci. 2023, 13(10), 1495; https://doi.org/10.3390/brainsci13101495 - 23 Oct 2023

Cited by 2 | Viewed by 1620

Abstract

The landscape of cranial base surgery has undergone monumental transformations over the past several decades. This article serves as a comprehensive survey, detailing both the historical and current techniques and technologies that have propelled this field into an era of unprecedented capabilities and [...] Read more.

The landscape of cranial base surgery has undergone monumental transformations over the past several decades. This article serves as a comprehensive survey, detailing both the historical and current techniques and technologies that have propelled this field into an era of unprecedented capabilities and sophistication. In the prologue, we traverse the historical evolution from rudimentary interventions to the state-of-the-art neurosurgical methodologies that define today’s practice. Subsequent sections delve into the anatomical complexities of the anterior, middle, and posterior cranial fossa, shedding light on the intricacies that dictate surgical approaches. In a section dedicated to advanced techniques and modalities, we explore cutting-edge evolutions in minimally invasive procedures, pituitary surgery, and cranial base reconstruction. Here, we highlight the seamless integration of endocrinology, biomaterial science, and engineering into neurosurgical craftsmanship. The article emphasizes the paradigm shift towards “Functionally” Guided Surgery facilitated by intraoperative neuromonitoring. We explore its historical origins, current technologies, and its invaluable role in tailoring surgical interventions across diverse pathologies. Additionally, the digital era’s contributions to cranial base surgery are examined. This includes breakthroughs in endoscopic technology, robotics, augmented reality, and the potential of machine learning and AI-assisted diagnostic and surgical planning. The discussion extends to radiosurgery and radiotherapy, focusing on the harmonization of precision and efficacy through advanced modalities such as Gamma Knife and CyberKnife. The article also evaluates newer protocols that optimize tumor control while preserving neural structures. In acknowledging the holistic nature of cranial base surgery, we advocate for an interdisciplinary approach. The ecosystem of this surgical field is presented as an amalgamation of various medical disciplines, including neurology, radiology, oncology, and rehabilitation, and is further enriched by insights from patient narratives and quality-of-life metrics. The epilogue contemplates future challenges and opportunities, pinpointing potential breakthroughs in stem cell research, regenerative medicine, and genomic tailoring. Ultimately, the article reaffirms the ethos of continuous learning, global collaboration, and patient-first principles, projecting an optimistic trajectory for the field of cranial base surgery in the coming decade. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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22 pages, 1149 KiB

Open AccessReview

Surgical Morbidity in Relation to the Surgical Approach for Olfactory Groove Meningiomas—A Pooled Analysis of 1016 Patients and Proposal of a New Reporting System

by Ekkehard M. Kasper, Farhan A. Mirza, Serdar Kaya, Robert Walker, Daniele Starnoni, Roy T. Daniel, Ramesh Nair and Fred C. Lam

Brain Sci. 2023, 13(6), 896; https://doi.org/10.3390/brainsci13060896 - 01 Jun 2023

Viewed by 1390

Abstract

Background: There is currently no consensus in the field regarding whether a frontal or lateral approach is superior for microsurgical resection of olfactory groove meningiomas (OGM). Due to the lack of uniformity in classifying lesions and inherent differences in reporting outcomes after [...] Read more.

Background: There is currently no consensus in the field regarding whether a frontal or lateral approach is superior for microsurgical resection of olfactory groove meningiomas (OGM). Due to the lack of uniformity in classifying lesions and inherent differences in reporting outcomes after varying operative approaches, the best practice for approaching these lesions is yet to be determined. Objective: This study aimed to assess various surgical approaches undertaken for OGMs, investigate procedural aspects influencing the extent of resection, and analyze the respective complication rate associated with each approach. We performed a comprehensive literature review of presenting signs and symptoms in OGM patients, their surgical management, and the reported surgical outcomes. To address the lack of uniform data reporting across studies and to take more recent translational studies into account, we developed a new classification system for OGMs that can remedy the existing deficiencies in comparability of reporting. Methods: We conducted a PRISMA-guided literature search for surgical reports on OGMs published in the MRI era using broad search terms such as ‘olfactory groove meningioma’ and ‘surgery’, which yielded 20,672 results. After title screening and removal of duplicates, we assessed 871 studies on the specific surgical management of olfactory groove meningiomas. Following the application of exclusion criteria and abstract screening, a set of 27 studies was chosen for the final analysis of a pooled cohort of these reported patient outcomes. Results: The final twenty-seven studies included in our in-depth analysis identified a total of 1016 individual patients who underwent open microsurgical resection of OGMs. The approaches used included: pterional/unilateral, bifrontal with variations, and anterior interhemispheric approaches. Across all studies, gross total resection (Simpson Grades I or II) was achieved in 91.4% of cases, and subtotal resection (Grades III and IV) was reported in 8.6% of cases. A cumulative twenty-seven percent of surgical OGM patients sustained some form of complications. Minor issues accounted for 22.2% (CSF leak, seizures, infection, transient cranial nerve palsies, hydrocephalus), whereas major issues comprised 4.7% (hemorrhage, ischemic infarct, malignant cerebral edema). We then examined the correlation between these complications and the surgical approach chosen. Among pooled cohort of 426 patients who underwent unilateral approaches, 14% experienced minor complications, and 2.1% experienced major complications. For the mixed cohort of 410 patients who underwent bifrontal approaches, 24.6% experienced minor complications, and 7% experienced major complications. Conclusions: Unilateral approaches appear to have lower complication rates for the resection of OGMs compared to bilateral approaches. However, the extent of resection is not uniformly reported, making it difficult to identify differences. The use of an improved preoperative classification and scoring system can help establish a more coherent system to select the most suitable approach and to uniformly report surgical outcomes, such as EOR and complication rates specific to a given OGM and its surgical approach. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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18 pages, 521 KiB

Open AccessReview

Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review

by Jose L. Porras, Nicholas R. Rowan and Debraj Mukherjee

Brain Sci. 2022, 12(12), 1685; https://doi.org/10.3390/brainsci12121685 - 08 Dec 2022

Cited by 5 | Viewed by 2208

Abstract

The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published [...] Read more.

The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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15 pages, 11288 KiB

Open AccessReview

The Current State of Visualization Techniques in Endoscopic Skull Base Surgery

by Jakub Jarmula, Erion Junior de Andrade, Varun R. Kshettry and Pablo F. Recinos

Brain Sci. 2022, 12(10), 1337; https://doi.org/10.3390/brainsci12101337 - 03 Oct 2022

Cited by 5 | Viewed by 1886

Abstract

Skull base surgery has undergone significant progress following key technological developments. From early candle-lit devices to the modern endoscope, refinements in visualization techniques have made endoscopic skull base surgery (ESBS) a standard practice for treating a variety of conditions. The endoscope has also [...] Read more.

Skull base surgery has undergone significant progress following key technological developments. From early candle-lit devices to the modern endoscope, refinements in visualization techniques have made endoscopic skull base surgery (ESBS) a standard practice for treating a variety of conditions. The endoscope has also been integrated with other technologies to enhance visualization, including fluorescence agents, intraoperative neuronavigation with augmented reality, and the exoscope. Endoscopic approaches have allowed neurosurgeons to reevaluate skull base neuroanatomy from new perspectives. These advances now serve as the foundation for future developments in ESBS. In this narrative review, we discuss the history and development of ESBS, current visualization techniques, and future innovations. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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9 pages, 260 KiB

Open AccessReview

Hypogonadism in Male Patients with Pituitary Adenoma and Its Related Mechanism: A Review of Literature

by Zisheng Yan and Ting Lei

Brain Sci. 2022, 12(6), 796; https://doi.org/10.3390/brainsci12060796 - 17 Jun 2022

Cited by 4 | Viewed by 1787

Abstract

Maintaining normal gonadal axis hormone levels is important for improving the condition of male patients with pituitary adenoma. The current literature is somewhat divided on the results of evaluations of gonadal axis function in male patients with pituitary adenoma before and after treatment, [...] Read more.

Maintaining normal gonadal axis hormone levels is important for improving the condition of male patients with pituitary adenoma. The current literature is somewhat divided on the results of evaluations of gonadal axis function in male patients with pituitary adenoma before and after treatment, and the increasing demand for better quality of life has provided motivation for this research to continue. In this article, we summarize the feasibility of using testosterone as an indicator for assessing male function and discuss the changes reported in various studies for gonadal hormones before and after treatment in male patients with pituitary adenoma. It is important for clinicians to understand the advantages of each treatment option and the effectiveness of assessing gonadal function. The rationale behind the theory that pituitary adenomas affect gonadal function and the criteria for evaluating pituitary–gonadal axis hormones should be explored in more depth. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

11 pages, 3187 KiB

Open AccessReview

by Grazia Menna, Marco Battistelli, Alessandro Rapisarda, Alessandro Izzo, Manuela D’Ercole, Alessandro Olivi and Nicola Montano

Brain Sci. 2022, 12(5), 583; https://doi.org/10.3390/brainsci12050583 - 29 Apr 2022

Cited by 5 | Viewed by 2040

Abstract

There is a lack of knowledge about the factors associated with the recurrence of hemifacial spam (HFS) following an initially successful microvascular decompression (MVD) surgery. The aim of the present study was to systematically review the pertinent literature and carry out a meta-analysis [...] Read more.

There is a lack of knowledge about the factors associated with the recurrence of hemifacial spam (HFS) following an initially successful microvascular decompression (MVD) surgery. The aim of the present study was to systematically review the pertinent literature and carry out a meta-analysis of factors linked to HFS recurrence in patients undergoing initially successful MVD treatment. An online literature search was launched on the PubMed/Medline and Scopus databases. The following data were collected: sex, age at surgery, affected side, reported improvement after surgery, presence of post-operatory facial weakness, symptom duration, offender vessels, and data obtained from intraoperative neurophysiological monitoring. Upon full-text review, eight articles were included, studying 1105 patients, of which 64 (5.7%) reported recurrence after MVD surgery for hemifacial spasm. There was a statistically significant increased incidence of HFS recurrence in patients with the persistence of lateral spread response (LSR after surgery (OR 9.44 (95% CI 1.69–52.58) p 0.01), while those patients experiencing a shorter disease duration before going to surgery were significantly less prone to experiencing disease recurrence (OR 0.11 (95% CI 0.03–0.46) p 0.002). The remaining examined factors did not result as significantly associated with the risk of recurrence. The funnel plots were largely symmetrical for each variable studied. Taken together, the results of our meta-analysis seem to suggest that short-term symptom duration is a protective factor against HFS recurrence after MVD surgery, while LSR persistence is a negative prognostic factor. Well-designed randomized controlled clinical trials with a long follow-up are expected to further explore therapeutic alternatives for HFS recurrence. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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17 pages, 8614 KiB

Open AccessReview

Cranio-Orbito-Zygomatic Approach: Core Techniques for Tailoring Target Exposure and Surgical Freedom

by Sabino Luzzi, Alice Giotta Lucifero, Alfio Spina, Matías Baldoncini, Alvaro Campero, Samer K. Elbabaa and Renato Galzio

Brain Sci. 2022, 12(3), 405; https://doi.org/10.3390/brainsci12030405 - 18 Mar 2022

Cited by 7 | Viewed by 2994

Abstract

Background: The cranio-orbito-zygomatic (COZ) approach is a workhorse of skull base surgery, and each of its steps has a precise effect on target exposure and surgical freedom. The present study overviews the key techniques for execution and tailoring of the COZ approach, focusing [...] Read more.

Background: The cranio-orbito-zygomatic (COZ) approach is a workhorse of skull base surgery, and each of its steps has a precise effect on target exposure and surgical freedom. The present study overviews the key techniques for execution and tailoring of the COZ approach, focusing on the quantitative effects resulting from removal of the orbitozygomatic (OZ) bar, orbital rim, and zygomatic arch. Methods: A PRISMA-based literature review was performed on the PubMed/Medline and Web of Science databases using the main keywords associated with the COZ approach. Articles in English without temporal restriction were included. Eligibility was limited to neurosurgical relevance. Results: A total of 78 articles were selected. The range of variants of the COZ approach involves a one-piece, two-piece, and three-piece technique, with a decreasing level of complexity and risk of complications. The two-piece technique includes an OZ and orbitopterional variant. Superolateral orbitotomy expands the subfrontal and transsylvian corridors, increasing surgical freedom to the basal forebrain, hypothalamic region, interpeduncular fossa, and basilar apex. Zygomatic osteotomy shortens the working distance of the pretemporal and subtemporal routes. Conclusion: Subtraction of the OZ bar causes a tremendous increase in angular exposure of the subfrontal, transsylvian, pretemporal, and subtemporal perspectives avoiding brain retraction, allowing for multiangled trajectories, and shortening the working distance. The COZ approach can be tailored based on the location of the lesion, thus optimizing the target exposure and surgical freedom and decreasing the risk of complications. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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Other

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18 pages, 1688 KiB

Open AccessSystematic Review

Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach

by Luisa F. Figueredo, Andrea L. Martínez, Paola Suarez-Meade, Lina Marenco-Hillembrand, Andrés Felipe Salazar, Daniela Pabon, Juan Guzmán, Renata Murguiondo-Perez, Hana Hallak, Alex Godo, Carolina Sandoval-Garcia, Edgar G. Ordoñez-Rubiano, Angela Donaldson, Kaisorn L. Chaichana, María Peris-Celda, Bernard R. Bendok, Susan L. Samson, Alfredo Quinones-Hinojosa and Joao Paulo Almeida

Brain Sci. 2023, 13(6), 842; https://doi.org/10.3390/brainsci13060842 - 23 May 2023

Cited by 2 | Viewed by 1730

Abstract

In recent years, the endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal branches when compared to the Transcranial [...] Read more.

In recent years, the endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal branches when compared to the Transcranial Approach (TCA). However, there is an ongoing debate regarding the criteria for selecting different approaches. To explore the current results of EEA and discuss its role in the management of craniopharyngiomas, we performed MEDLINE, Embase, and LILACS searches from 2012 to 2022. Baseline characteristics, the extent of resection, and clinical outcomes were evaluated. Statistical analysis was performed through an X² and Fisher exact test, and a comparison between quantitative variables through a Kruskal–Wallis and verified with post hoc Bonferroni. The tumor volume was similar in both groups (EEA 11.92 cm³, -TCA 13.23 cm³). The mean follow-up in months was 39.9 for EEA and 43.94 for TCA, p = 0.76). The EEA group presented a higher visual improvement rate (41.96% vs. 25% for TCA, p < 0.0001, OR 7.7). Permanent DI was less frequent with EEA (29.20% vs. 67.40% for TCA, p < 0.0001, OR 0.2). CSF Leaks occurred more frequently with EEA (9.94% vs. 0.70% for TCA, p < 0.0001, OR 15.8). Recurrence rates were lower in the EEA group (EEA 15.50% vs. for TCA 21.20%, p = 0.04, OR 0.7). Our results demonstrate that, in selected cases, EEA for resection of craniopharyngiomas is associated with better results regarding visual preservation and extent of tumor resection. Postoperative CSF leak rates associated with EEA have improved compared to the historical series. The decision-making process should consider each person’s characteristics; however, it is noticeable that recent data regarding EEA justify its widespread application as a first-line approach in centers of excellence for skull base surgery. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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22 pages, 1394 KiB

Open AccessSystematic Review

Machine Learning Models to Forecast Outcomes of Pituitary Surgery: A Systematic Review in Quality of Reporting and Current Evidence

by Matheus M. Rech, Leonardo de Macedo Filho, Alexandra J. White, Carlos Perez-Vega, Susan L. Samson, Kaisorn L. Chaichana, Osarenoma U. Olomu, Alfredo Quinones-Hinojosa and Joao Paulo Almeida

Brain Sci. 2023, 13(3), 495; https://doi.org/10.3390/brainsci13030495 - 15 Mar 2023

Cited by 2 | Viewed by 1698

Abstract

Background: The complex nature and heterogeneity involving pituitary surgery results have increased interest in machine learning (ML) applications for prediction of outcomes over the last decade. This study aims to systematically review the characteristics of ML models involving pituitary surgery outcome prediction and [...] Read more.

Background: The complex nature and heterogeneity involving pituitary surgery results have increased interest in machine learning (ML) applications for prediction of outcomes over the last decade. This study aims to systematically review the characteristics of ML models involving pituitary surgery outcome prediction and assess their reporting quality. Methods: We searched the PubMed, Scopus, and Web of Knowledge databases for publications on the use of ML to predict pituitary surgery outcomes. We used the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) to assess report quality. Our search strategy was based on the terms “artificial intelligence”, “machine learning”, and “pituitary”. Results: 20 studies were included in this review. The principal models reported in each article were post-surgical endocrine outcomes (n = 10), tumor management (n = 3), and intra- and postoperative complications (n = 7). Overall, the included studies adhered to a median of 65% (IQR = 60–72%) of TRIPOD criteria, ranging from 43% to 83%. The median reported AUC was 0.84 (IQR = 0.80–0.91). The most popular algorithms were support vector machine (n = 5) and random forest (n = 5). Only two studies reported external validation and adherence to any reporting guideline. Calibration methods were not reported in 15 studies. No model achieved the phase of actual clinical applicability. Conclusion: Applications of ML in the prediction of pituitary outcomes are still nascent, as evidenced by the lack of any model validated for clinical practice. Although studies have demonstrated promising results, greater transparency in model development and reporting is needed to enable their use in clinical practice. Further adherence to reporting guidelines can help increase AI’s real-world utility and improve clinical practice. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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9 pages, 980 KiB

Open AccessSystematic Review

Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus and Its Impact on Outcomes of Pituitary Surgery: A Systematic Review and Meta-Analysis

by Leonardo J. M. de Macêdo Filho, Ana Vitória G. Diógenes, Esther G. Barreto, Bhavya Pahwa, Susan L. Samson, Kaisorn Chaichana, Alfredo Quinones-Hinojosa and Joao Paulo Almeida

Brain Sci. 2022, 12(10), 1354; https://doi.org/10.3390/brainsci12101354 - 06 Oct 2022

Cited by 3 | Viewed by 1643

Abstract

Introduction. Pituitary adenomas have the potential to infiltrate the dura mater, skull, and the venous sinuses. Tumor extension into the cavernous sinus is often observed in pituitary adenomas and techniques and results of surgery in this region are vastly discussed in the literature. [...] Read more.

Introduction. Pituitary adenomas have the potential to infiltrate the dura mater, skull, and the venous sinuses. Tumor extension into the cavernous sinus is often observed in pituitary adenomas and techniques and results of surgery in this region are vastly discussed in the literature. Infiltration of parasellar dura and its impact for pituitary surgery outcomes is significantly less studied but recent studies have suggested a role of endoscopic resection of the medial wall of the cavernous sinus, in selected cases. In this study, we discuss the techniques and outcomes of recently proposed techniques for selective resection of the medial wall of the cavernous sinus in endoscopic pituitary surgery. Methods. We performed a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and protocol and a total of 4 studies with 106 patients that underwent an endoscopic approach for resection of pituitary tumors with resection of medial wall from cavernous sinus were included. Clinical and radiological data were extracted (sex, mean age, Knosp, prior surgery, tumor size and type, complication rate, and remission) and a meta-analysis using the RevMan 5.4 software was performed. Results. A total of 5 studies with 208 patients were included in this analysis. The mean age of the study population was 48.87 years (range 25–82) with a female/male ratio of 1:1.36. Majority of the patients had Knosp Grade 1 (n = 77, 37.02%) and Grade 2 (n = 53, 25.48%). The complication rate was 4.81% (n = 33/106) and the most common complication observed was a new transient CN dysfunction and diplopia. Early disease remission was observed in 94.69% of the patients (n = 196/207). The prevalence rate of CS medial wall invasion varied from 10.4 % up to 36.7%. This invasion rate increased in frequency with higher Knosp Grade. The forest plot of persistent disease vs. remission in this surgery approach showed a p < 0.00001 and heterogeneity (I^2 = 0%). Discussion. Techniques to achieve resection of the medial wall of the cavernous sinus via the endoscopic endonasal approach include the “anterior to posterior” technique (opening of the anterior wall of the cavernous sinus) and the “medial to lateral” technique (opening of the inferior intercavernous sinus and). Although potentially related with improved endocrinological outcomes, these are advanced surgical techniques and require extensive anatomical knowledge and extensive surgical experience. Furthermore, to avoid procedure complications, extensive study of the patient’s configuration of cavernous ICA, Doppler-guided intraoperative imaging, surgical navigation system, and blunt tip knives to dissect the ICA’s plane are recommended. Conclusion. Endoscopic resection of the medial wall of the cavernous sinus has been associated with reports of high rates of postoperative hormonal control in functioning pituitary adenomas. However, it represents a more complex approach and requires advanced experience in endoscopic skull base surgery. Additional studies addressing case selection and studies evaluating long term results of this technique are still necessary. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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7 pages, 2089 KiB

Open AccessCase Report

Staged Surgery for Intra-Extracranial Communicating Jugular Foramen Paraganglioma: A Case Report and Systematic Review

by Qiang Li, Yanbing Yu, Li Zhang, Jiang Liu, Hongxiang Ren and Xueke Zhen

Brain Sci. 2022, 12(9), 1257; https://doi.org/10.3390/brainsci12091257 - 16 Sep 2022

Cited by 1 | Viewed by 1591

Abstract

Staged surgery strategy was preferred for patients with intra-extracranial communicating jugular foramen paraganglioma (IECJFP). A female patient who presented mild tinnitus, headache, and dizziness, together with preoperative related imaging, was diagnosed with a left intra-extracranial communicating jugular foramen lesion in November 2015 and [...] Read more.

Staged surgery strategy was preferred for patients with intra-extracranial communicating jugular foramen paraganglioma (IECJFP). A female patient who presented mild tinnitus, headache, and dizziness, together with preoperative related imaging, was diagnosed with a left intra-extracranial communicating jugular foramen lesion in November 2015 and accepted an initial operation for the intracranial tumor by retrosigmoid approach. The pathologic report was paraganglioma. In November 2021, a subtotal resection of the extracranial tumor was conducted for prominent lower cranial nerves (LCNs) deficit and middle ear involvement by infratemporal approach. In patients with IECJFP accompanied by LCNs deficit and middle ear involvement, an initial surgery for extracranial lesion and a second procedure for intracranial tumor were appropriate. However, the first operation for the intracranial lesion was preferred in IECJFP cases without LCNs deficit and middle ear involvement, as it could remove compression to the neurovascular structure and brain stem, clarify a pathological diagnosis, avoid a CSF leak, and prevent a severe neurological disorder from extracranial lesion excision. Subtotal resection of the extracranial tumor would be performed when lesion became larger combined with obvious LCNs disorder and tympanic cavity involvement. Consideration of specific staged surgical strategy for IECJFP in accordance with preoperative LCNs deficit and tympanic cavity involvement could prevent critical postoperative neurological deficit and improve quality of life in the long term. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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12 pages, 3911 KiB

Open AccessOpinion

Giant Non-Functioning Pituitary Adenomas: Treatment Considerations

by Domenico Solari, Luigi Maria Cavallo, Chiara Graziadio, Sergio Corvino, Ilaria Bove, Felice Esposito and Paolo Cappabianca

Brain Sci. 2022, 12(9), 1256; https://doi.org/10.3390/brainsci12091256 - 16 Sep 2022

Cited by 2 | Viewed by 3262

Abstract

Giant pituitary adenomas are a subgroup of pituitary adenomas defined by a diameter greater than 4 cm, and they account for 5–14% of adenomas in surgical series. Because of their growth patterns and locations, often involving critical neurovascular structures, they represent a true [...] Read more.

Giant pituitary adenomas are a subgroup of pituitary adenomas defined by a diameter greater than 4 cm, and they account for 5–14% of adenomas in surgical series. Because of their growth patterns and locations, often involving critical neurovascular structures, they represent a true surgical challenge, and gross total resection is difficult to achieve. There is no consensus on the optimal surgical strategy for giant pituitary adenomas, and, often, integrated multi-staged treatment strategies have been considered. Transcranial or transsphenoidal approaches, alone or combined, according to tumor and patient features are the two main routes. Each of these strategies has pros and cons. The conventional transcranial approach has for a long time been considered the first choice for the removal of giant pituitary adenomas. Currently, with endoscopic techniques, it is also possible to remove lesions that involve the intradural compartment and the adjacent neurovascular structures with the use of extended approaches. Our policy for the management of these lesions is to adopt the endoscopic endonasal approach as the first choice unless the tumor presents significant intracranial extension that results in it being outside the visibility and maneuverability of the endoscopic endonasal route. In these latter cases, we agree that the transcranial approach is more appropriate. However, accurate preoperative evaluation and refined treatment plans for each patient are mandatory to define a proper strategy in order to achieve the most effective long-term result. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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8 pages, 1518 KiB

Open AccessCase Report

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

by Petr Matoušek, Tomáš Krejčí, Eva Misiorzová, Radim Lipina, Václav Procházka, Jakub Lubojacký, Lenka Čábalová and Pavel Komínek

Brain Sci. 2022, 12(9), 1254; https://doi.org/10.3390/brainsci12091254 - 16 Sep 2022

Cited by 1 | Viewed by 1568

Abstract

Iatrogenic injury of the internal carotid artery (ICA) is a rare, and probably underreported, complication of transnasal endoscopic skull base surgery. Although treatment algorithms have been suggested, there is no definite consensus or guideline for the management of this severe complication. We describe [...] Read more.

Iatrogenic injury of the internal carotid artery (ICA) is a rare, and probably underreported, complication of transnasal endoscopic skull base surgery. Although treatment algorithms have been suggested, there is no definite consensus or guideline for the management of this severe complication. We describe a case of ICA injury that occurred during a transsphenoidal biopsy of a tumor in the cavernous sinus and we present a treatment algorithm for managing this complication. We reviewed the articles published from 1998 to 2021, reporting on major vascular injury during transnasal endoscopic skull base surgery and endonasal endoscopic surgery, and we compare the methods and results of ICA injury management reported in the literature with the presented case. The most promising treatment for ICA injury might be packing with a muscle graft initially, then performing an endovascular intervention. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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13 pages, 2707 KiB

Open AccessTechnical Note

Tailored Approach and Multimodal Intraoperative Neuromonitoring in Cerebellopontine Angle Surgery

by Alessandro Izzo, Vito Stifano, Giuseppe Maria Della Pepa, Michele Di Domenico, Quintino Giorgio D'Alessandris, Grazia Menna, Manuela D'Ercole, Liverana Lauretti, Alessandro Olivi and Nicola Montano

Brain Sci. 2022, 12(9), 1167; https://doi.org/10.3390/brainsci12091167 - 31 Aug 2022

Cited by 3 | Viewed by 2682

Abstract

The cerebellopontine angle (CPA) is a highly complex anatomical compartment consisting of numerous nervous and vascular structures that present mutual and intricate spatial relationships. CPA surgery represents, therefore, a constant challenge for neurosurgeons. Over the years, neurosurgeons have developed and refined several solutions [...] Read more.

The cerebellopontine angle (CPA) is a highly complex anatomical compartment consisting of numerous nervous and vascular structures that present mutual and intricate spatial relationships. CPA surgery represents, therefore, a constant challenge for neurosurgeons. Over the years, neurosurgeons have developed and refined several solutions with the aim of maximizing the surgical treatment effects while minimizing the invasiveness and risks for the patient. In this paper, we present our integrated approach to CPA surgery, describing its advantages in treating pathologies in this anatomical district. Our approach incorporates the use of technology, such as neuronavigation, along with advanced and multimodal intraoperative neuromonitoring (IONM) techniques, with the final goal of making this surgery safe and effective. Full article

(This article belongs to the Special Issue Improving Outcomes and Preventing Complications in Cranial Base Surgery)

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