Multilayered macular hemorrhages as an unusual complication of transorbital neuroendoscopic surgery

Surgical risk of CSF leakage following endoscopic transorbital approach for anterior and middle skull base pathologies: a systematic review and meta-analysis

The endoscopic superior eyelid transorbital approach (SETOA) has demonstrated considerable versatility and effectiveness in managing various paramedian anterior and middle skull base pathologies. However, as with any relatively new technique, potential complications remain. We conducted an extensive literature search in MEDLINE and Embase in accordance with PRISMA guidelines including case reports and surgical series reporting cerebrospinal fluid (CSF) leak rate following SETOA for intracranial pathologies. Factors analyzed included lesion location (extra- or intra-axial), reconstruction techniques, and complication management. ROBINS-I tool was employed to assess the risk of bias. Twenty-five studies including 240 cases were eligible. The majority of lesions were intradural extra-axial (68.3%), while trigeminal schwannomas comprised all extradural cases (25.0%). Sixteen patients (6.6%) presented intradural intra-axial tumors. Osteodural reconstruction involved dural substitutes in one third of the cases (32.5%) either alone (14.2%) or combined with fat free graft (18.3%). CSF leak occurred in 6 patients (2.50%), mostly resolving via conservative management (66.6%). The risk of postoperative CSF leak was found to be significantly higher in patients undergoing resection for intra-axial tumors (OR 0.13, 95% CI: 0.04-0.49) compared to those undergoing resection for extra-axial (OR 0.01, 95% CI: 0.00-0.02; I2 = 0%; p < 0.001). Key limitations include the retrospective nature and small sample sizes among included studies as well as data heterogeneity and lack of standardized protocols for reconstruction across studies. SETOA appears safe for addressing selected extradural and intradural skull base pathologies with a low postoperative CSF leak rate. The natural repositioning of the orbital content to its original position may be instrumental in preventing its postoperative occurrence. The investigation followed a prespecified protocol registered on PROSPERO (PROSPERO 2024 CRD42024614111).

Endoscopic transorbital decompression for traumatic superior orbital fissure syndrome: from cadaveric study to clinical application

PURPOSE

The endoscopic endonasal approach (EEA) is a minimally invasive and promising modality for treating traumatic superior orbital fissure (SOF) syndrome (tSOFS). Recently, the endoscopic transorbital approach (ETOA) has been considered an alternative method for reaching the anterolateral skull base. This study accessed the practicality of using the ETOA to treat SOF decompression using both cadaveric dissection and clinical application.

METHODS

Bilateral anatomic dissections were performed on four adult cadaveric heads using the ETOA and EEA to address SOF decompression. The ETOA procedure for SOF decompression is described, and the extent of SOF decompression was compared between the ETOA and EEA. The clinical feasibility of the ETOA for treating SOF decompression was performed in two patients diagnosed with tSOFS.

RESULTS

ETOA allowed for decompression over the lateral aspect of the SOF, from the meningo-orbital band superolaterally to the maxillary strut inferomedially. By contrast, the EEA allowed for decompression over the medial aspect of the SOF, from the lateral opticocarotid recess superiorly to the maxillary strut inferiorly. In both patients treated using the ETOA and SOF decompression, the severity of ophthalmoplegia got obvious improvement.

CONCLUSIONS

Based on the cadaveric findings, ETOA provided a feasible access pathway for SOF decompression with reliable outcomes, and our patients confirmed the clinical efficacy of the ETOA for managing tSOFS.

Complications of the Superior Eyelid Endoscopic Transorbital Approach to the Skull Base: Preliminary Experience With Specific Focus on Orbital Outcome

BACKGROUND

The endoscopic superior eyelid approach is a relatively novel mini-invasive technique that is currently investigating for skull base cancers. However, questions remain regarding specific approach-related complications when treating different skull base tumors. This study aims to analyze any surgical complications that occurred in our preliminary consecutive experience, with specific focus on orbital outcome.

METHODS

A retrospective and consecutive cohort of patients treated via a superior eyelid endoscopic transorbital approach at the Division of Neurosurgery of the Hospital Clinic in Barcelona was analyzed. Patients features were described in detail. Complications were divided into 2 groups to analyze separately the approach-related complications, and those resulting from tumor removal. The ocular complications were subdivided into early ocular status (<3 weeks), late ocular status (3-8 weeks), and persistent ocular complications. The "Park questionnaire" was used to determine patient's satisfaction related to the transorbital approach.

RESULTS

A total of 20 patients (5 spheno-orbital meningiomas, 1 intradiploic Meningioma, 2 intraconal lesions, 1 temporal pole lesion, 2 trigeminal schwannoma, 3 cavernous sinus lesions, and 6 petroclival lesions) were included in the period 2017-2022. Regarding early ocular status, upper eyelid edema was detected in all cases (100%) associated with diplopia in the lateral gaze in 30% of cases, and periorbital edema in 15% of cases. These aspects tend to resolve at late ocular follow-up (3-8 weeks) in most cases. Regarding persistent ocular complications, in one case of intraconal lesion, a limitation of eye abduction was detected (5%). In another patient with intraconal lesion, an ocular neuropathic pain was reported (5%). In 2 cases of petroclival menigioma, who were also treated with a ventriculo-peritoneal shunt, slight enophthalmus was observed as a persistent complication (10%). According to the Park questionnaire, no cosmetic complaints, no head pain, no palpable cranial irregularities, and no limited mouth opening were reported, and an average of 89% of general satisfaction was encountered.

CONCLUSIONS

The superior eyelid endoscopic transorbital approach is a safe and satisfactory technique for a diversity of skull base tumors. At late follow-up, upper eyelid edema, diplopia, and periorbital edema tend to resolve. Persistent ocular complications are more frequent after treating intraconal lesions. Enophthalmus may occur in patients with associated ventriculo-peritoneal shunt. According to patient's satisfaction, fairly acceptable results are attained.

The Endoscopic Lateral Transorbital Approach for the Removal of Select Sphenoid Wing and Middle Fossa Meningiomas. Surgical Technique and Short-Term Outcomes

BACKGROUND AND OBJECTIVE

The endoscopic lateral transorbital approach (eLTOA) is a relatively new approach to the skull base that has only recently been applied in vivo in the management of complex skull base pathology. Most meningiomas removed with this approach have been in the spheno-orbital location. We present a series of select purely sphenoid wing and middle fossa meningiomas removed through eLTOA. The objective here was to describe the selection criteria and results of eLTOA for a subset of sphenoid wing and middle fossa meningiomas.

METHODS

This is a retrospective study based on a prospectively maintained database of consecutive cases of eLTOA operated on at our institution by the lead author. The cohort's clinical and radiographic characteristics and outcome are presented.

RESULTS

Five patients underwent eLTOA to remove 3 sphenoid wing and 2 middle fossa meningiomas. The mean tumor volume was 11.9 cm 3 . Gross total resection was achieved in all cases. There were no intraoperative complications. Postoperatively, there was one case of subretinal hemorrhage, which was corrected by open vitrectomy repair, and one case of cerebrospinal fluid leak, which resolved with lumbar drainage. Three patients presented with visual impairment, 1 improved, 1 remained stable, and 1 worsened, but returned to stable after vitrectomy repair. All patients have been free of disease at a median follow-up of 8.9 months.

CONCLUSION

eLTOA provides a direct minimal access corridor to certain well-selected sphenoid wing and middle fossa meningiomas. eLTOA minimizes brain retraction and provides a high rate of gross total resection. Meningiomas appropriately selected based on size, type, and location of dural attachment, and the eLTOA is a safe, rapid, and highly effective procedure with acceptable morbidity.

Endoscopic Transorbital Approach for Spheno-Orbital Tumors: Case Series and Systematic Review of Literature

BACKGROUND

Transorbital neuroendoscopic surgery (TONES) comprises a group of approaches with indications expanding from orbital tumors to more complex skull base lesions. We analyzed the role of the endoscopic transorbital approach (eTOA) for spheno-orbital tumors, reporting the results of our clinical series and of a systematic review of the literature.

MATERIALS AND METHODS

All patients operated on from 2016 to 2022 at our institution for a spheno-orbital tumor through an eTOA were included in a clinical series, and a systematic review of the literature was performed.

RESULTS

Our series consisted of 22 patients (16 females, mean age 57 ± 13 years). Gross tumor removal was achieved in 8 patients (36.4%) after the eTOA and in 11 (50.0%) after a multistaged strategy combining the eTOA with the endoscopic endonasal approach. Complications included 1 chronic subdural hematoma and 1 permanent extrinsic ocular muscle deficit. Patients were discharged after 2.4 ± 1.3 days. The most common histotype was meningioma (86.4%). Proptosis improved in all cases, visual deficit in 66.6%, and diplopia in 76.9%. These results were confirmed by the review of the 127 cases reported in the literature.

CONCLUSIONS

Despite its recent introduction, a significant number of spheno-orbital lesions treated with an eTOA are being reported. Its main advantages are favorable patient outcome and optimal cosmetic results, with minimal morbidity and quick recovery. This approach can be combined with other surgical routes or adjuvant therapies for complex tumors. However, it is a technically demanding procedure, requiring specific skills in endoscopic surgery, that should be reserved to dedicated centers.