Neurosurg Focus
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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. ⋯ 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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Endoscopic expanded endonasal approaches (EEAs) to the skull base are increasingly being used to address a variety of skull base pathologies. Postoperative CSF leakage from the large skull base defects has been well described as one of the most common complications of EEAs. ⋯ The authors describe two cases of EEAs in which complications related to rapid, large-volume CSF egress through the skull base surgical defect were detected in the immediate postoperative period. Preventive measures to reduce the likelihood of these immediate complications are presented.
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The interpeduncular cistern, including the retrochiasmatic area, is one of the most challenging regions to approach surgically. Various conventional approaches to this region have been described; however, only the endoscopic endonasal approach via the dorsum sellae and the transpetrosal approach provide ideal exposure with a caudal-cranial view. The authors compared these 2 approaches to clarify their limitations and intrinsic advantages for access to the interpeduncular cistern. ⋯ Both approaches are valid surgical options for retrochiasmatic lesions such as craniopharyngiomas. The endoscopic endonasal approach via the dorsum sellae provides a direct and wide exposure of the interpeduncular cistern with negligible neurovascular manipulation. The transpetrosal approach also allows direct access to the interpeduncular cistern without pituitary manipulation; however, the surgical corridor is narrow due to the surrounding neurovascular structures and affords poor contralateral visibility. Conversely, in the presence of large or giant tumors in the interpeduncular cistern, which widen the spaces between neurovascular structures, the transpetrosal approach becomes a superior route, whereas the endoscopic endonasal approach may provide limited freedom of movement in the lateral extension.
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Because multiple anatomical compartments are involved, the surgical management of trigeminal schwannomas requires a spectrum of cranial base approaches. The endoscopic endonasal approach to Meckel's cave provides a minimal access corridor for surgery, but few reports have assessed outcomes of the procedure or provided guidelines for case selection. ⋯ Endoscopic endonasal approaches appear to be well suited for trigeminal schwannomas restricted to Meckel's cave and/or extracranial segments of the nerve. Lateral transcranial skull base approaches should be considered for patients with posterior fossa disease. Further multiinstitutional studies will be necessary for adequate power to help determine relative indications between endoscopic and transcranial skull base approaches.
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Case Reports
An endoscopic assisted retrosigmoid approach to the cerebello-pontine angle for resection of an epidermoid cyst.
Epidermoid cysts are rare lesions accounting for 1% of intracranial tumors with approximately 50% located within the cerebello-pontine angle (CPA). Resection is complicated by their close anatomical relation to critical neurovascular structures and their tendency to be densely adherent making complete removal a significant neurosurgical challenge. ⋯ A 30-degree endoscope was used to assist in removal of unseen tumor in Meckel's cave, medial to the lower cranial nerves, and along the ventral pons. The video can be found here: http://youtu.be/bv0lMPbX7BY .